Construire des savoirs issus de l'expérience à l'ère de l'Evidence-Based Medicine : une enquête anthropologique auprès des sages-femmes indépendantes en Suisse romande

Partant d'une préoccupation, qui concerne les influences de l'Evidence-­‐Based Medecine (EBM) sur l'évolution de l'accompagnement de la naissance, cette thèse interroge tout d'abord plusieurs enjeux sous-­‐tendant le développement de ce mouvement social à travers une revue de littérature et plusieurs analyses documentaires. L'EBM, conçue pour réguler des problèmes récurrents en médecine, dont font partie la disparité des pratiques et les inégalités d'accès à des soins adaptés, fait néanmoins l'objet de critiques en sciences sociales. Ce modèle qui valorise les méthodes de recherche quantitatives, dont l'Essai Contrôlé Randomisé, déconsidère les savoirs construits par les professionnel-­‐le-­‐s de la santé au cours de leur activité. Le coeur de la thèse consiste par conséquent à se pencher sur ces savoirs déconsidérés et à interroger ce que leur mise à l'écart implique pour l'accompagnement de la naissance. A partir d'une enquête de terrain, conduite auprès d'une communauté de pratique de sages-­‐femmes indépendantes et, qui comporte une triangulation de méthodes, dont en particulier des observations de consultations postnatales à domicile, les processus et les contenus participant à la construction de savoirs sont identifiés. Le regard porté, inspiré d'une anthropologie des habiletés, intéressée par les détails et les circonstances de l'activité, fait ressortir une grande diversité des sources -­‐communautaires, contextuelles, socioculturelles et personnelles-­‐ participant à l'interprétation que les praticiennes portent sur l'expérience de la naissance. Les sages-­‐femmes partagent une praxis et un ethos communautaires caractérisés par la temporalité centrée sur les besoins et la tonalité affective de leur accompagnement. La situation écologique de leur activité, exercée au domicile des familles, dévoile en particulier comment la naissance s'inscrit dans la vie et ses contraintes et est parfois entachée d'une souffrance sociale et de ses expressions multiples. Pour répondre aux détresses conséquentes, les praticiennes, prises dans les aléas de fonctionnement du réseau interprofessionnel, en partie impuissantes, sortent de l'obstétrique ordinaire et réinventent leur rôle au quotidien, tout en questionnant ses nouvelles limites. Au final, la mise en miroir des savoirs issus de l'EBM et de l'expérience, détaille la dimension non standardisable de l'accompagnement, intervenant notamment dans les situations de souffrance sociale, et qui consiste en une forme de lutte impensée contre les inégalités d'accès aux prestations du système socio-­‐sanitaire. -- From a concern about the implications of Evidence-­‐Based Medicine (EBM) on the evolution of care around birth, this thesis firstly questions what is at stake along the development of this social movement, using a literature review and a content analysis of EBM productions. EBM has been developed to address recurrent issues met by medicine, among which a disparity of practices and an inequality of access to adequate care, but has nevertheless been the target of critics from the social sciences. This model of knowledge-­‐making favors quantitative methods in research, in particular the Randomized Controlled Trial and, consequently, tends to dismiss knowledge made by health professionals through their practice. The core of the thesis hence consists of an exploration of these discredited expressions of knowledge-­‐making and also questions the implication of their dismissal for the care of women and families around birth. The ensuing fieldwork enquires about processes and elements of content which participate to the knowledge-­‐making of community midwives, in particular during postnatal home visits. The interpretation, inspired by anthropologists dedicated to the study of skills and human knowledge-­‐making, stresses the importance of details and circumstances framing practice, thus highlighting a great diversity of sources and processes used for the understanding of birth and care by midwives. These practitioners share a common praxis and ethos built through legitimate participation in their association and, expressed through a temporality driven by families' needs and through the expression of different signs of affection towards families. The ecological setting of their activity, performed at the home of families, shows how the experience of birth is entangled with larger circumstances of life itself and is sometimes rooted in social suffering. To respond to the subsequent distress of women and families, midwives deal with the sometimes whimsical functioning of the interprofessional network, experiment some powerlessness and thus recreate their practice while questioning the new boundaries of their role. Finally, the confrontation of two forms of knowledge-­‐making, through the model of EBM on one hand and situated practice on the other hand, highlights the dimension of midwives' care which cannot be standardized. These contingent responses to social suffering, made of loneliness, poverty, or violence, form an implicit struggle against the inequal access to services provided by the social and health system

Levetiracetam circulating concentrations and response in status epilepticus.

Intravenous levetiracetam (LEV) is broadly used in the treatment of status epilepticus (SE). A loading dose is usually infused, aiming to reach quickly the range of plasma concentrations considered as therapeutic (12-46 mg/l). The aim of the study was to evaluate the response to LEV in SE, correlated exposure assessed by plasma concentration monitoring, as well as calculated exposure parameters. We retrospectively analyzed a SE registry, including patients since 2015 with at least one available LEV plasma level measured less than 36 h after loading. A Bayesian maximum likelihood approach based on a population pharmacokinetic model was used to estimate LEV exposure parameters. We compared plasma levels and pharmacokinetics parameter estimates between responders and nonresponders. Therapeutic response was defined as SE cessation within 24 h following LEV introduction without a need for additional antiepileptic drug (AED). We included 29 patients (45 plasma levels). Variability was salient in LEV loading doses (ranging between 17 and 38 mg/kg) and monitoring practice. There was no difference in median plasma concentrations (19.5 versus 21.5 mg/l; p = 0.71), median estimated LEV exposure (25.8 versus 37.0 mg/l; p = 0.61), peak (30.4 versus 41.5 mg/l; p = 0.36), or residual levels after loading dose (14.4 versus 20.5 mg/l; p = 0.07) between responders and nonresponders. Levetiracetam exposure does not seem to differ significantly between responders and nonresponders; greater exposure was not associated with better outcome. Loading doses of 30 mg/kg seem, however, appropriate to quickly reach the target exposure level. The short LEV half-life makes standardized sampling measurement necessary to obtain directly interpretable LEV levels

Studying changes in the practice of two teachers developing assessment for learning

This paper describes changes in the practice of two teachers, observed over an eighteen month period, who were participating in a study intended to support teachers in developing their use of assessment in support of learning. The design of the intervention allowed each teacher to choose for themselves which aspects of their practice to develop. Analysis of lesson observations, journal entries and interviews indicate that both teachers were keen to change their practice, but were concerned about the disruption to their established routines, and in particular about the potential for loss of control of their classes. Both teachers did effect significant changes in their classrooms, but these tended to be developments of existing preferred ways of working, rather than radical innovations. In conclusion, it is suggested that to be most effective, teacher professional development needs to be structured strongly enough to afford teacher growth, but flexible enough to allow different teachers to take their practice in different ways