Approche anthropologique des déterminants de l'observance dans le traitement de l'hypertension artérielle

La revue Pratiques et organisation des soins (en ligne) porte le numéro ISSN : 1961 - 9391Revue en ligne et en libre accès : http://www.ameli.fr/l-assurance-maladie/statistiques-et-publications/la-revue-pratiques-et-organisation-des-soins/Article disponible en ligne sur le site de la revue : http://www.ameli.fr/fileadmin/user_upload/documents/Observance_du_traitement_de_l_hypertension_01.pdfAim: Uncontrolled hight blood pressure leads clinicians to wonder about adherence degree amongst hypertensive patients. In this context, our study aims to describe and analyse patients experience of antihypertensive drugs, in order to shed light on the multiple social and symbolic logics, forming part of the cultural factors shaping personal medication practices.Methods: The inductive and comprehensive anthropological approach implemented is based on an ethnographical survey (observations of medical consultations and interviews). Semi-structured interviews were conducted with 68 hypertensive patients (39 women and 29 men, between the ages of 40 and 95, of whom 52 were over 60) who had been receiving treatment for over a year.Results: Antihypertensive drug is reinterpreted using popular representations of pathophysiology (the body as a machine). This symbolic dimension eases acceptance of therapy, but leads to a hierarchy forming of other prescribed medicines and of certain therapeutic classes (such as diuretics). Prescription compliance does not solely depend on the patient's perception of cardiovascular risk, but also on how the patient appropriates the treatment and integrates it into his/her daily life, requiring identification with the product, building commitment and self-control of the treatment (experimentation; command of treatment; control of side effects, of intake, continuity of treatment).A relationship based on trust between the physician and patient is necessary for a prescription to be followed. We have identified three types of relationship: reasoned trust, emotional trust, conceded trust.Conclusion: Consideration and understanding of these pragmatic, symbolic issues by physicians should help practitioners support and advise patients with high blood pressure.Objectif : Les hypertensions artérielles non contrôlées conduisent les cliniciens à s'interroger sur les niveaux d'observance des hypertendus traités. Dans ce contexte, notre étude visait à décrire et à analyser l'expérience des hypotenseurs par les hypertendus, afin de mettre à jour les logiques plurielles, sociales et symboliques, permettant de comprendre ce qui construit culturellement les pratiques médicamenteuses des individus.Méthodes : La démarche anthropologique, inductive et compréhensive, mise en oeuvre reposait sur une enquête ethnographique (observations de consultations et entretiens). Nous avons interviewé 68 hypertendus (39 femmes et 29 hommes, âgés de 40 à 95 ans, 52 d'entre eux ayant plus de 60 ans) traités depuis plus d'un an.Résultats : Le médicament hypotenseur était réinterprété au travers du filtre des représentations populaires de la physiopathologie (corps machine). Cette dimension symbolique facilitait l'adhésion thérapeutique,mais conduisait à une hiérarchisation des autres médicaments prescrits, et de certaines classes thérapeutiques (diurétiques). Le suivi de l'ordonnance était conditionné par la perception du risque cardiovasculaire,mais également par l'appropriation du traitement et son intégration dans la vie quotidienne nécessitant une identification au produit, une fidélisation, et une auto-régulation du traitement (expérimentation ; maîtrise du traitement ; contrôle des effets indésirables, de l'ingestion, de la continuité du traitement). Le suivi de l'ordonnance requiert une relation de confiance entre le médecin et le patient dont nous avons relevé trois formes : la confiance raisonnée, la confiance affective, la confiance concédée.Conclusion : La prise en compte et la compréhension de ces différentes logiques pragmatiques et symboliques par le médecin traitant devraient pouvoir aider les praticiens dans leur fonction d'éducation thérapeutique des personnes hypertendues

Ecoulement dense autour d'une sphère traversant un nuage de grains

Une simulation bidimensionnelle d'une sphère se déplaçant à vitesse constante à l'intérieur d'un nuage de petits grains est présentée avec une méthode de type ?'Non-Smooth Contact Dynamic'' (sans effet de la gravité). Une zone granulaire dense, appelée ?'cluster'', à fraction volumique constante se construit progressivement autour de la sphère jusqu'à ce qu'un régime stationnaire apparaisse caractérisée par une taille constante du cluster en amont de la sphère qui augmente avec la fraction volumique initiale \phi_0 du nuage. Une analyse détaillée du champ de taux de déformation et du champ de contrainte à l'intérieur du cluster révèle que, malgré les variations spatiales de ces champs, le coefficient local de friction \mu et la fraction volumique \phi dépendent uniquement du nombre d'inertie I, ce qui signifie que la rhéologie du milieu granulaire est bien locale dans cet écoulement non parallèle. Les variations spatiales de I à l'intérieur même du cluster ne dépendent pas de la vitesse de déplacement de la sphère et explore une faible gamme allant de 0.01 à 0.1. L'influence des parois latérales sur l'écoulement et les forces est ensuite étudiée

Dense flow around a sphere moving into a cloud of grains

A bidimensional simulation of a sphere moving at constant velocity into a cloud of smaller spherical grains without gravity is presented with a non-smooth contact dynamics method. A dense granular “cluster” zone of about constant solid fraction builds progressively around the moving sphere until a stationary regime appears with a constant upstream cluster size that increases with the initial solid fraction ϕ0 of the cloud. A detailed analysis of the local strain rate and local stress fields inside the cluster reveals that, despite different spatial variations of strain and stresses, the local friction coeffcient μ appears to depend only on the local inertial number I as well as the local solid fraction ϕ, which means that a local rheology does exist in the present non parallel flow. The key point is that the spatial variations of I inside the cluster does not depend on the sphere velocity and explore only a small range between about 10−2 and 10−1. The influence of sidewalls is then investigated on the flow and the forces

A Collaborative Epidemiological Investigation into the Criminal Fake Artesunate Trade in South East Asia

Paul Newton and colleagues' international, collaborative study found evidence that counterfeit artesunate was being manufactured in China, which prompted a criminal investigation

Maternal exposure to air pollution before and during pregnancy related to changes in newborn's cord blood lymphocyte subpopulations. The EDEN study cohort

<p>Abstract</p> <p>Background</p> <p>Toxicants can cross the placenta and expose the developing fetus to chemical contamination leading to possible adverse health effects, by potentially inducing alterations in immune competence. Our aim was to investigate the impacts of maternal exposure to air pollution before and during pregnancy on newborn's immune system.</p> <p>Methods</p> <p>Exposure to background particulate matter less than 10 μm in diameter (PM₁₀) and nitrogen dioxide (NO₂) was assessed in 370 women three months before and during pregnancy using monitoring stations. Personal exposure to four volatile organic compounds (VOCs) was measured in a subsample of 56 non-smoking women with a diffusive air sampler during the second trimester of pregnancy. Cord blood was analyzed at birth by multi-parameter flow cytometry to determine lymphocyte subsets.</p> <p>Results</p> <p>Among other immunophenotypic changes in cord blood, decreases in the CD4+CD25+ T-cell percentage of 0.82% (p = 0.01), 0.71% (p = 0.04), 0.88% (p = 0.02), and 0.59% (p = 0.04) for a 10 μg/m³increase in PM₁₀levels three months before and during the first, second and third trimester of pregnancy, respectively, were observed after adjusting for confounders. A similar decrease in CD4+CD25+ T-cell percentage was observed in association with personal exposure to benzene. A similar trend was observed between NO₂exposure and CD4+CD25+ T-cell percentage; however the association was stronger between NO₂exposure and an increased percentage of CD8+ T-cells.</p> <p>Conclusions</p> <p>These data suggest that maternal exposure to air pollution before and during pregnancy may alter the immune competence in offspring thus increasing the child's risk of developing health conditions later in life, including asthma and allergies.</p

Poor quality vital anti-malarials in Africa - an urgent neglected public health priority

BACKGROUND: Plasmodium falciparum malaria remains a major public health problem. A vital component of malaria control rests on the availability of good quality artemisinin-derivative based combination therapy (ACT) at the correct dose. However, there are increasing reports of poor quality anti-malarials in Africa. METHODS: Seven collections of artemisinin derivative monotherapies, ACT and halofantrine anti-malarials of suspicious quality were collected in 2002/10 in eleven African countries and in Asia en route to Africa. Packaging, chemical composition (high performance liquid chromatography, direct ionization mass spectrometry, X-ray diffractometry, stable isotope analysis) and botanical investigations were performed. RESULTS: Counterfeit artesunate containing chloroquine, counterfeit dihydroartemisinin (DHA) containing paracetamol (acetaminophen), counterfeit DHA-piperaquine containing sildenafil, counterfeit artemether-lumefantrine containing pyrimethamine, counterfeit halofantrine containing artemisinin, and substandard/counterfeit or degraded artesunate and artesunate+amodiaquine in eight countries are described. Pollen analysis was consistent with manufacture of counterfeits in eastern Asia. These data do not allow estimation of the frequency of poor quality anti-malarials in Africa. CONCLUSIONS: Criminals are producing diverse harmful anti-malarial counterfeits with important public health consequences. The presence of artesunate monotherapy, substandard and/or degraded and counterfeit medicines containing sub-therapeutic amounts of unexpected anti-malarials will engender drug resistance. With the threatening spread of artemisinin resistance to Africa, much greater investment is required to ensure the quality of ACTs and removal of artemisinin monotherapies. The International Health Regulations may need to be invoked to counter these serious public health problems

Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome associated with COVID-19: An Emulated Target Trial Analysis.

RATIONALE: Whether COVID patients may benefit from extracorporeal membrane oxygenation (ECMO) compared with conventional invasive mechanical ventilation (IMV) remains unknown. OBJECTIVES: To estimate the effect of ECMO on 90-Day mortality vs IMV only Methods: Among 4,244 critically ill adult patients with COVID-19 included in a multicenter cohort study, we emulated a target trial comparing the treatment strategies of initiating ECMO vs. no ECMO within 7 days of IMV in patients with severe acute respiratory distress syndrome (PaO2/FiO2 <80 or PaCO2 ≥60 mmHg). We controlled for confounding using a multivariable Cox model based on predefined variables. MAIN RESULTS: 1,235 patients met the full eligibility criteria for the emulated trial, among whom 164 patients initiated ECMO. The ECMO strategy had a higher survival probability at Day-7 from the onset of eligibility criteria (87% vs 83%, risk difference: 4%, 95% CI 0;9%) which decreased during follow-up (survival at Day-90: 63% vs 65%, risk difference: -2%, 95% CI -10;5%). However, ECMO was associated with higher survival when performed in high-volume ECMO centers or in regions where a specific ECMO network organization was set up to handle high demand, and when initiated within the first 4 days of MV and in profoundly hypoxemic patients. CONCLUSIONS: In an emulated trial based on a nationwide COVID-19 cohort, we found differential survival over time of an ECMO compared with a no-ECMO strategy. However, ECMO was consistently associated with better outcomes when performed in high-volume centers and in regions with ECMO capacities specifically organized to handle high demand. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/)