L'appropriation du dispositif de contractualisation interne à l'hôpital de V. : évolution conjointe de la stratégie et du contrôle de gestion

Cette communication étudie les rapports entre stratégie et contrôle de gestion, dans le cas de l'implémentation d'un système de contrôle de gestion, au sein d'un hôpital public de taille moyenne. Plus particulièrement, nous étudions le dialogue entre l'intention stratégique et sa traduction instrumentale, dans la mise en place d'un système de contrôle de gestion. Le cas de l'hôpital de V. est intéressant à deux égards. Il permet de voir comment une stratégie et des outils de contrôle de gestion se construisent progressivement et mutuellement, dans un système de contrôle en évolution permanente. Il permet de voir également quel rôle jouent les outils de gestion dans la dynamique mise en place : notamment, leurs imperfections et leurs limites sont-elles importantes ?contrôle de gestion ; hôpital ; nouvelle gouvernance ; appropriation ; outils de gestion

0015: High LDL cholesterol decreases life expectancy in primary prevention

BackgroundThe 2012 ESC guidelines recommend a LDL-cholesterol (LDL-C) lower than 3mmol/L for subjects at low or moderate risk with a class I/A and a strong grade. According to ESC, statins should be used as the drugs of first choice. The aim of this study was to assess the association between elevated LDL-C with total and cardiovascular (CV) mortality in primary prevention.MethodsOur study population consisted in patients who had been admitted from 1995 to 2011 in a preventive cardiology unit of a large French university hospital. We excluded patients whose age was less than 30 and all patients with previous ischemic heart disease. Vital status in 2011 was checked through the death national database.Results4885 patients were included (59% men; 53±10 yrs). After a mean follow-up of 8.6 years, 129 deaths, including 31 CV deaths, were recorded. The mean LDL-C was 3.98±1.18mmol/L (3.90 in men and 4.11 in women). Among these 4885 patients, 2648 (54.2%) had LDL-C lower than 4mmol/L, 1890 (38.7%) had LDL-C between 4 and 6mmol/L, 347 (7.1%) had LDL-C higher than 6mmol/L, and 1833 (37.5%) were on current lipid-lowering treatment. After adjustment for age, gender, smoking, hypertension and diabetes, an increased LDL-C > 4mmol/L was significantly associated with all cause mortality (hazard ratio (HR) 2.06; 95% confidence interval (CI) [1.42-3.00], p=0.001) and with CV mortality (HR 2.18; 95% CI [1.04-4.57], p=0.04). After adjustment for these classical risk factors and for lipid-lowering treatment, LDL-C remained significantly associated with an increasing risk of all cause mortality; with LDL-C < 4mmol/L as a reference class, LDL-C levels between 4 and 6mmol/L were associated with an increased all cause mortality (HR 1.72; 95% CI [1.17-2.54], p=0.006) as well as LDL-C > 6mmol/L (HR 2.60; 95% CI [1.49-4.85], p=0.001).ConclusionsLDL-C levels higher than 4mmol/L were significantly associated with all-cause and cardiovascular mortality in primary prevention

Delayed reconstruction and high BMI z score increase the risk of meniscal tear in paediatric and adolescent anterior cruciate ligament injury

PURPOSE: The purpose of this study was to identify epidemiologic risk factors for secondary meniscal tears in paediatric and adolescent patients who sustain an anterior cruciate ligament (ACL) tear. The hypothesis was that delayed reconstruction and elevated BMI z score, increase the risk for secondary meniscal tears. METHODS: A prospective, descriptive and analytical study of consecutively accrued children and adolescents with an ACL tear was performed. One hundred and sixty subjects (114 males and 46 females) were identified between 2006 and 2015 at one institution. The age range was between 7 and 19 years. Fifteen parameters were recorded and analysed: age at initial trauma, initial trauma circumstance, sex, BMI z score, affected side, type of sport, Tegner score, athletic level, time to MRI, time to first referral, time to surgery, age at surgery, attempted non-operative treatment, operative report and associated meniscal tear. These meniscal lesions could be diagnosed by an MRI and / or during surgery. RESULTS: Out of the 160 cases, 143 were treated surgically and 17 cases non-operatively. Median corrected BMI z score was 0.5 (range - 1.8 to 4.7). 41.9% had one or more meniscal lesions. 55 patients were initially treated non-operatively, of which 39 patients were secondarily operated. There was a positive relationship between meniscal lesion and: BMI z score (p = 0.0364), attempted non-operative treatment (p = 0.001) and time to surgery (p = 0.002). The median time to ACL reconstruction was 229 days for patients with secondary meniscal lesions. CONCLUSIONS: Patients with ACL tears treated non-operatively developed secondary meniscal lesions requiring delayed surgical management. There was a positive correlation between BMI z score and secondary meniscal lesions. Thus, early ACL reconstruction is advocated in young athletes

ROHHAD syndrome without rapid-onset obesity: A diagnosis challenge

peer reviewedBackgroundROHHAD syndrome (Rapid-onset Obesity with Hypothalamic dysfunction, Hypoventilation and Autonomic Dysregulation) is rare. Rapid-onset morbid obesity is usually the first recognizable sign of this syndrome, however a subset of patients develop ROHHAD syndrome without obesity. The prevalence of this entity is currently unknown. Alteration of respiratory control as well as dysautonomic disorders often have a fatal outcome, thus early recognition of this syndrome is essential.Material and methodsA retrospective, observational, multicenter study including all cases of ROHHAD without rapid-onset obesity diagnosed in France from 2000 to 2020.ResultsFour patients were identified. Median age at diagnosis was 8 years 10 months. Median body mass index was 17.4 kg/m2. Signs of autonomic dysfunction presented first, followed by hypothalamic disorders. All four patients had sleep apnea syndrome. Hypoventilation led to the diagnosis. Three of the four children received ventilatory support, all four received hormone replacement therapy, and two received psychotropic treatment. One child in our cohort died at 2 years 10 months old. For the three surviving patients, median duration of follow-up was 7.4 years.ConclusionROHHAD syndrome without rapid-onset obesity is a particular entity, appearing later than ROHHAD with obesity. This entity should be considered in the presence of dysautonomia disorders without brain damage. Likewise, the occurrence of a hypothalamic syndrome with no identified etiology requires a sleep study to search for apnea and hypoventilation. The identification of ROHHAD syndrome without rapid-onset obesity is a clinical challenge, with major implications for patient prognosis

War and commercial exchanges in the late medieval Aegean: Investigating the metal provenance of the Chalcis Hoard

International audienc

FABRICATION AND CIRCULATION OF MEDIEVAL ARMOR: AN ARCHAEOMETRY APPROACH

International audienceAt the end of the Middle-Ages, armor is an object both for everyday military use and a luxury attire produced in prestigious European centers of production like Milan located in the north of Italy and Nuremberg or Augsburg in the south of Germany. Even if some research works have focused on that subject nevertheless several questions concerning the nature of the material employed, the technical skills of the craftsmen (quenching and tempering, presence of second phase particles, etc), depending on their uses and their location are still unanswered. Besides, at the same period, crucial changes occurred in the iron and ferrous alloy production chain with the emergence of the new indirect process, the blast furnace and finery. It allows producing great quantities of metal at low cost. Former studies have already showed specific skills for instance in the hardening of steel or in material choice depending on the center of production(Williams, 2003). However a linkage between the kind of reduction process used to obtain the metal and the mass production of armor in military use is a question left unresolved. Furthermore, while centers of production like Milan or Nuremberg are clearly identified by historical sources, very little is known about the origins of the metal employed. A first set of armor coming from Italy Germany and France were examined following the methodology developed in NIMBE/LAPA laboratory (metallography, MEB-EDS and LA-ICP-MS analyses) (Dillmann and L'Héritier, 2007), (Disser et al., 2014). However armor’s samples contain small size of inclusions (diameter 80μm). Thus a specific methodology has been developed in order to quantify trace elements. Two different equipments have been used: an inductively coupled plasma mass spectrometer, coupled with a nanosecond laser at the CEB center in Orleans, and with a femtosecond laser at IPREM laboratory in Pau. Primary results show the nature and quality of the metal employed, and the kind of reduction process used depending on their location. Furthermore it also allows making a first comparison with existing geochemical databases in order to test hypotheses on the origin of the materials employe

Fabrication et circulation des armures médiévales, étude interdisciplinaire

International audienceA la fin du Moyen Âge l‘armure est un objet à double destinations : à la fois objet de grande consommation et d’usage courant dans le cas des armures de troupes, mais également dans d’autre cas, un objet de prestige élaboré dans différents centres européens de grande renommée. Du point de vue de l’histoire des techniques de nombreuses questions se posent alors quand à la nature des matériaux employés pour leur réalisation, aux gestes associés en fonction notamment de leurs usages et de leurs lieux de fabrication, ainsi qu’au type de procédé de réduction utilisé pour l’obtention du métal. Par ailleurs si les centres de production des armures comme ceux de Milan ou Nuremberg sont bien identifiés par les sources historiques on sait toutefois peu de choses sur les réseaux d’approvisionnement des armuriers.Un premier corpus composé d’un ensemble d'armures produites dans les grands centres européens et notamment ceux d’Italie du Nord et d’Allemagne du Sud a ainsi été formé grâce à la collaboration mise en place avec la Wallace Collection (Londres) et le musée Dobrée (Nantes). Ces échantillons ont été étudiés selon les modes opératoires développés au NIMBE/LAPA (métallographie, analyse MEB-EDS et LA-ICP-MS) avec toutefois une nécessité d’adaptation du protocole analytique pour la quantification des éléments traces due à la faible taille des inclusions à sonder. Pour cela deux types d’appareillages ont été testés : un spectromètre de masse à plasma induit, couplé à un laser nanoseconde au centre CEB à Orléans d’une part, et un laser femtoseconde au laboratoire IPREM à Pau d’autre part. Les résultats ont permis de préciser la nature et la qualité du métal, le type de procédé de réduction utilisé ainsi que d’effectuer des premières comparaisons avec les bases de données géochimiques déjà existantes afin de déterminer la provenance des matériaux employés

La fabrication des armures à Nuremberg : croiser les sources réglementaires et la matière

International audienc

Organisation of armor production in 16th century armorer workshops: the example of Valentin Siebenbürger

International audienceAt the end of the Middle Ages, armor was considered both an object for everyday military use and a luxury attire. Furthermore, war practices have undergone major changes both on the technological level (appearance of english longbows or firearms) as well as the organizational one (development of mercenary companies). Accordingly, defensives arms were adapted to suit these new needs. Following the wider socio-economic conditions, it became a marketed commodity with a range of diverseproducts addressing an equally diverse range of customers. Its fabrication dominated by several prestigious centers like Milan or Nürnberg, required specific technical skills to shape the ferrous alloys. Therefore, the study of armor manufacture and tradeoffers great opportunity to understand the European exchange of war materials, techniques and skills, as well as metal selection based on the artifact's purpose. In that perspective, several dozen artefacts fabricated in European centers and more precisely in Nürnberg were sampled and studied in detail. Several of them share the same famous origin, Valentin Siebenbürger's workshop. Active in the 16thc, many of this workshop’s pieces can be identified in museum collections thanks to the city’s and his own stamped markings. Through this example, the study of armor materials, manufacture and trade may provide a crucial insight into the practices of the armorers in terms of technical skills and supplies, as reflected in the preserved artefacts. Armors wereexamined following the methodology developed in NIMBE/LAPA laboratory (sampling, metallography, MEB-EDS and LA-ICP-MS analyses), (Disser et al., 2014), (Dillmann et al., 2017). With regard to V. Siebenbürger's pieces, the results show differences in the nature, quality and thermic treatment of the metal employed for a same artefact and between artefacts of similar quality. However, despite these heterogeneities, the origin of the metal employed seems close which could suggest a common supplier. These results have been integrated into a larger group of European armors for discussion in a broader context