Le territoire, générateur d’inégalités face aux cancers

Agir efficacement contre les inégalités géographiques face aux cancers implique une meilleure compréhension du processus aboutissant à ces inégalités. Une méthodologie interdisciplinaire, traitant conjointement les multiples dimensions par lesquelles le territoire impacte la santé et retraçant l’évolution pronostique des patients, permettrait de répondre à ce besoin. La cohorte EMS, retraçant la prise en charge de patients atteints de sarcomes (cancers rares) en Rhône-Alpes, a été analysée suivant ces principes méthodologiques. L’analyse de 15 variables géographiques ayant une influence sur la santé a permis de distinguer six types de territoires rhônalpins. Cette typologie a ensuite été croisée avec les données de la cohorte EMS pour étudier les pertes de chances propres à chaque type de territoire. La surmortalité des pôles urbains est liée à l’incidence plus importante des sarcomes, quand celle des quartiers populaires et des espaces ruraux s’expliquent davantage par des pertes de chances de survie au cours de la prise en charge.Cancers inequalities in France are among the highest in developed countries and these gaps seem to be growing in the last decades. Territorial inequalities of cancers are analyzed by mapping, which showed higher mortality rates in the North-East Regions of France. At the local scale, standardized mortality rates are two times higher in some areas in the North as other areas in the South-East. Epidemiological studies, mostly based on multilevel analysis, evidence the impact of physical environment, deprivation or health care access on health outcomes. But to identify contextual effects are not sufficient to understand how cancer inequalities are built and how patient’s life context contributes to this process. As epidemiological approach is splitting contextual effects according to health outcomes, geographical approach may have to explain how these contextual effects lead to cancer inequalities, by using territorial typology to summarize these contextual effects. Comparing health outcomes according to this territorial classification may help to understand territory’s ability to generate health inequalities. Several stages across the cancer continuum are implied in the building of the cancer inequalities. This medical process has to be reconstructed to determine whether mortality inequalities are generated by a higher incidence or a lower survival. Moreover, lower survival may be linked to the worse prognosis of patients at diagnosis or to the lower quality of management according to cancer care facilities. Evolution of patients’ prognosis may be reconstructed, thanks to clinical data, in order to identify the most influent steps during this medical process. As a result, to understand the way geographical inequalities of cancers are building requires a multidisciplinary methodology, considering the territory’s contribution as a whole and using longitudinal clinical data. But to reconstitute this medical process is quite difficult actually because few longitudinal and exhaustive data are available. The EMS cohort represents an opportunity to test and discuss this methodological approach. This cohort includes all sarcoma (rare cancer) patients diagnosed in 2005 and 2006, in the Rhône-Alpes Region, and collects clinical data from the diagnosis to the patient follow-up. For this geographical analysis of the EMS cohort, we used a territorial typology generated thanks to multivariate analysis of 15 geographical variables known for their impact on health. Strong differences are noticed in terms of environment exposures, deprivation and health care access between the six types of territory (metropolitan neighborhoods, working-class neighborhoods, urban districts, residential areas, periurban areas, rural areas). This typology seems to be relevant to study geographical inequalities because it enables to distinguish populations which are not exposed to the same risks through their life context. A logistic regression including stage, age and histological subtype, as clinical factors influencing prognosis, estimates the patients’ prognosis at diagnosis. This prognosis score seems to be quite predictive because only 7% of “good prognosis” patients will be dead five years later, whereas this five years death rate raises to 80% for the worse prognosis patients. Analysis of geographical inequalities for sarcoma patients in the Rhône-Alpes Region shows the diversity of situations leading to inequalities of mortality. Indeed, the higher mortality in three types of territories has to be attributed to three different processes. In the case of the urban hub, this high mortality is linked to the higher incidence of sarcoma, as survival rate for patients of these districts is very close to the regional average. As incidence and prognosis risk in the working-class neighborhoods are quite similar to the regional average, higher mortality is due to the loss of survival odds in the course of treatments, probably because of a less optimal management. Despite the second lower incidence among the six types of territories, the worse prognosis of patients (more late-stage diagnosis) and the loss of survival odds during cancer management explained the high mortality rated in the rural areas. Thanks to the EMS cohort’s analysis, we assess the potential of a multidisciplinary methodology studying the territory’s ability to generate geographical inequalities of cancers. Territorial typology, produced without health outcomes data, may be used for every health studies as a synthetic index of the territory and also evidence strong inequalities of health according to people’s life contexts. As public policies struggle to be successful on this issue, to identify key events in the medical process leading to cancer inequalities may improve the territorialization and the efficiency of these policies. Territories with high risk before diagnosis would be focused on prevention and early diagnosis, whereas those more disadvantage during the management would lean towards cancer care quality, access to hospitals and cancer expertise and patient compliance

Disseminating and assessing implementation of the EULAR recommendations for patient education in inflammatory arthritis:a mixed-methods study with patients' perspectives

OBJECTIVES: To explore patients' agreement and reasons for agreement or disagreement with the EULAR recommendations for patient education (PE) for people with inflammatory arthritis (IA). METHODS: This mixed-method survey collected data using snowball sampling. The survey had been translated into 20 languages by local healthcare professionals, researchers and patient research partners. It explored the degree to which patients with IA agreed with each recommendation for PE (0=do not agree at all and 10=agree completely) and their rationale for their agreement level in free text questions. Descriptive statistics summarised participants' demographics and agreement levels. Qualitative content analysis was used to analyse the free text data. Sixteen subcategories were developed, describing the reasons for agreement or disagreement with the recommendations, which constituted the categories. RESULTS: The sample comprised 2779 participants (79% female), with a mean (SD) age 55.1 (13.1) years and disease duration 17.1 (13.3) years. Participants strongly agreed with most recommendations (median 10 (IQR: 9-10) for most recommendations). Reasons for agreement with the recommendations included the benefit of using PE to facilitate collaborative care and shared decision making, the value of flexible and tailored PE, and the value of gaining support from other patients. Reasons for disagreement included lack of resources for PE, not wanting information to be tailored by healthcare professionals and a reluctance to use telephone-based PE. CONCLUSION: The EULAR recommendations for PE have been disseminated among patients with IA. Overall, agreement levels were very high, suggesting that they reflect patients' preferences for engaging in collaborative clinical care and using PE to facilitate and supplement their own understanding of IA. Reasons for not completely agreeing with the recommendations can inform implementation strategies and education of healthcare professionals

Functional dichotomy of ribosomal proteins during the synthesis of mammalian 40S ribosomal subunits

Subsets of 40S ribosomal subunits are required for initiating rRNA processing, rRNA maturation, and nuclear export

Evaluation globale standardisée systématique des rhumatismes inflammatoires chroniques: intérêts et limites

Introduction: National and international recommendations call for an annual standardized systematic holistic review in the management of chronic inflammatory rheumatism (CIR). This includes an assessment of disease activity and severity, as well as patient education on the disease, knowledge of pharmacological and non-pharmacological treatments, adherence to treatment and screening for comorbidities. Our study aims to recall the definition of a holistic review (HR), to present the evidence of their effectiveness and to give an overview of HR practices in France. Methods: A literature review was conducted in the Pubmed database to identify randomized controlled trials (RCTs) or meta-analyses reporting the efficacy of a multidisciplinary intervention in ICR or other chronic diseases. Two online surveys were sent to all rheumatology departments in France and to a sample of independent rheumatologists, with 34 and 19 questions respectively. These questionnaires were used to determine the profile of the responding center/rheumatologist, the existence of an HR and the obstacles or facilitators to its implementation. Results: Literature search yielded 872 articles, 24 of which were finally included: 16 RCTs and 8 meta-analyses. Only 3 articles concerned ICRs, including one meta-analysis of 10 RCTs in rheumatoid arthritis (RA). Of these 3 studies, 2 RCTs in systemic lupus and systemic sclerosis showed a favorable impact of a multidisciplinary approach on SLEDAI and grip strength and mouth opening respectively, while the meta-analysis in RA showed no benefit on disability or disease activity.The questionnaire was answered by 72 centers and 186 rheumatologists. A third of the centers had already implemented a HR during an day hospitalization. 70 % of centers estimated that they managed more than 10 patients per month, devoting an average of 35 minutes of rheumatologist time and 90 minutes of cumulative time for all other healthcare professionals (HCPs) involved in the program. Most of the HCPs involved were nurses (92 %), dieticians (56 %) and physiotherapists (56 %). The main obstacles to setting up a HR were the lack of paramedical resources, lack of economic value and lack of support from treating rheumatologists, while patient motivation was seen as a facilitating factor. Conclusion: Although HR is recommended, there is little evidence of its effectiveness in ICR. Only 36 % of responding centers have implemented such a program. This survey helps to identify the obstacles and facilitators, and to find solutions for extending this practice

Assessing acceptability and identifying barriers and facilitators to implementation of the EULAR recommendations for patient education in inflammatory arthritis: a mixed-methods study with rheumatology professionals in 23 European and Asian countries

Objectives: To disseminate and assess the level of acceptability and applicability of the EULAR recommendations for patient education among rheumatology professionals across Europe and 3 Asian countries, and identify potential barriers and facilitators to their application.Methods: A parallel convergent mixed methods research design with an inductive approach was used. A web-based survey, available in 20 different languages, was distributed to health professionals by non-probability sampling. The level of agreement and applicability of each recommendation was assessed by (0 to 10) rating scales. Barriers and facilitators to implementation were assessed using free-text responses. Quantitative data were analysed descriptively and qualitative data by content analysis and presented in 16 categories supported by quotes. Results: A total of 1159 participants completed the survey; 852 (73.5%) were women. Most of the professionals were nurses (n=487), rheumatologists (n=320), physiotherapists (n=158). For all recommendations, the level of agreement was high but applicability was lower. The four most common barriers to application were: lack of time, lack of training in how to provide patient education, not having enough staff to perform this task and lack of evaluation tools. The most common facilitators were: tailoring patient education to individual patients, using group education, linking patient education with diagnosis and treatment, and inviting patients to provide feedback on patient education delivery.Conclusions: This project has disseminated the EULAR recommendations for patient education to health professionals across 23 countries. Potential barriers to their application were identified and some are amenable to change, namely training patient education providers and developing evaluation tools

MICROSCOPE mission: first results of a space test of the equivalence principle

According to the weak equivalence principle, all bodies should fall at the same rate in a gravitational field. The MICROSCOPE satellite, launched in April 2016, aims to test its validity at the 10−15 precision level, by measuring the force required to maintain two test masses (of titanium and platinum alloys) exactly in the same orbit. A nonvanishing result would correspond to a violation of the equivalence principle, or to the discovery of a new long-range force. Analysis of the first data gives δ(Ti,Pt)=[−1±9(stat)±9(syst)]×10−15 (1σ statistical uncertainty) for the titanium-platinum Eötvös parameter characterizing the relative difference in their free-fall accelerations

Les boucles appariées et autres éléments particuliers du recodage (approche descriptive et biologique)

TOULOUSE3-BU Sciences (315552104) / SudocSudocFranceF

Le territoire, générateur d’inégalités face aux cancers. Analyse de la cohorte EMS en Région Rhône-Alpes

International audienc

Comorbidités dans le rhumatisme psoriasique : comment les évaluer en pratique ?

International audienc

Répondre aux enjeux des cancers rares. Analyse géographique de la cohorte EMS des sarcomes en région Rhône-Alpes

International audienc