Face au handicap: action syndicale et cadrages juridiques

peer reviewedLes travailleurs en situation de handicap forment une catégorie invisibilisée et discriminée. Cet article examine la façon dont les militants syndicaux, en France, utilisent le droit et la justice pour défendre les travailleurs handicapés et, par ce biais, pour rendre ce public visible, aux yeux des employeurs et de leurs propres organisations syndicales. Il montre tout d’abord comment les syndicalistes font émerger la cause des travailleurs handicapés. Ensuite, il examine leurs usages du droit, très contrastés en fonction des arènes mobilisées et des buts poursuivis. Il met enfin en évidence les cadrages pluriels du handicap au sein des organisations syndicales, qui allient leur action pour la protection des emplois des salariés à des revendications d'égalité professionnelle. Plus généralement, cette étude renouvelle les travaux sur les usages syndicaux du droit en portant attention aux rôles du droit dans la visibilisation d’un public.Workers with disabilities are invisible and discriminated against. This article examines how labor unions representatives, in France, mobilize the law and the labor court to make this public visible among employers and members of unions. First, it shows how labor unions started to make the cause of disabled workers visible in their mobilization. Then, it examines their mobilization of the law and the court and how it varies according to the arenas and goals. Through this analysis, it shows the various framings of disability within labor unions, which combine mobilization to protect their members’ rights and claims for equal opportunity. More broadly, this study suggests new ways to analyze labor unions’ mobilization, by examining the role of the law in making a public visible.Handicap et aménagements raisonnables au travail: importation et usages d'une catégorie juridique en France et en Belgiqu

Logiques, contraintes et effets du recours aux comparutions immédiates. Etude de cinq juridictions de la Cour d’appel de Douai.

La comparution immédiate (CI) a connu une forte croissance de son usage au cours des années 2000. La procédure s’est par ailleurs largement diffusée dans l’ensemble des juridictions, alors qu’elle a longtemps été surtout mobilisée dans les grandes juridictions. Une telle croissance interroge sur les ressorts du recours aux comparutions immédiates. Plusieurs réformes ont été adoptées au cours de cette décennie mais ne suffisent pas à expliquer la diffusion de la procédure. Par ailleurs, le volume de jugements en CI invite à mieux caractériser la procédure, ses cibles et ses effets en termes de peine, dans la mesure où elle concerne aujourd’hui un nombre relativement important de cas. Etudier les comparutions immédiates est ainsi une façon de questionner les pratiques judiciaires et leur évolution de façon plus large. Trois objectifs ont ainsi été fixés à la recherche, au-delà de l’analyse de la croissance du nombre de comparutions immédiates : préciser le profil des individus jugés en comparution immédiate, tester l’hypothèse selon laquelle les comparutions immédiates conduisent à des peines plus sévères, identifier et expliquer la variété des pratiques. Ce dernier point visait notamment à dépasser une analyse en termes de critères présidant au choix de la CI, ou de telle peine dans le cadre de la CI, pour tenter de saisir les contraintes ou conditions spécifiques façonnant l’usage de la procédure. L’analyse s’appuie sur l’étude de 5 juridictions de la Cour d’appel de Douai (Lille, Béthune, Arras, Hazebrouck et Avesnes-sur-Helpe). Un échantillon de minutes de jugement (7882 affaires) a fait l’objet d’une analyse statistique, en vue de l’analyse des peines et du profil des prévenus. Une trentaine d’entretiens a par ailleurs été réalisé auprès de magistrats et d’avocats, et des observations ont été réalisées dans deux salles de permanence du parquet.Les résultats relatifs au profil des prévenus et aux peines prononcées à l’issue d’un jugement en CI confirment largement ceux d’autres travaux portant sur d’autres juridictions. Un autre résultat important de la recherche est la mise en évidence de la variabilité des pratiques, pour ce qui est de la fréquence du recours aux comparutions immédiates, des affaires susceptibles d’être traitées par la voie de cette procédure et des jugements prononcés. Ce deuxième résultat renforce paradoxalement le premier : les différences constatées dans l’usage des comparutions immédiates n’empêchent pas que cette procédure concerne un « public » aux caractéristiques bien identifiables (individus ayant un « passé pénal » et/ou en situation de précarité) ; elles ne contrecarrent pas non plus un effet propre de la procédure, qui favorise le prononcé de peines plus sévères que d’autres procédures.L’attention portée aux variations observables d’une juridiction à l’autre met en évidence des profils de magistrats, des conditions matérielles et des configurations locales freinant ou encourageant le recours aux comparutions immédiates. Par ailleurs, l’analyse localisée de pratiques met en évidence un certain nombre de facteurs structurant le recours aux comparutions immédiate : ainsi la logique de « l’ordre public », principe dont le contenu est défini localement, ou encore l’attractivité et la taille des juridictions, qui ont des effets sur le profil des magistrats en poste et sur la nature des relations entre les professionnels qui interviennent en matière de CI

Handicap et aménagements raisonnables: importation et usages d'une catégorie juridique en France et en Belgique

La notion d’aménagement raisonnable désigne toute tentative, dans une société, de s’accommoder ou de s’ajuster aux besoins d’un individu qui découlent de son appartenance à une minorité, dans le respect de l’égalité de traitement entre tous les êtres humains et des libertés fondamentales. Centrée sur les aménagements à destination des travailleurs en situation de handicap, cette enquête interroge l’émergence de cette catégorie en droit, ainsi que les usages qu’en font les acteurs sociaux dans le domaine du travail. Ce rapport examine les législations en vigueur, la jurisprudence et la doctrine. Il donne à voir les conditions d’importation de cette catégorie juridique en France et en Belgique et son articulation avec d’autres législations qui encadrent les relations de travail (obligation de reclassement, bien-être au travail, etc.). Il présente, ensuite, les résultats d’une enquête inédite menée auprès de professionnels – syndicalistes, avocats et agents des organismes publics de lutte contre les discriminations –, d’employeurs et de travailleurs avec un handicap, et met en lumière la façon dont cette catégorie juridique est mobilisée, contournée ou évitée. Les mobilisations syndicales et professionnelles, ainsi que les expériences du handicap au travail, s’inscrivent dans des configurations de relations professionnelles et des catégorisations administratives et juridiques du handicap différentes en France et en Belgique. Plus généralement, cette recherche montre les effets produits par l’introduction de cette obligation légale. Les acteurs du monde du travail se réfèrent peu aux législations en matière d’aménagement raisonnable, le pouvoir contraignant de ces normes étant contrebalancé par d’autres impératifs et logiques : discours managérial, droit du travail, etc. Néanmoins, ceci ne veut pas dire que le droit aux aménagements raisonnables n’a aucune effectivité, ni qu’il ne produit aucun effet. Les discours changent, les employeurs et les travailleurs se saisissent des cadres juridiques existants, les intègrent dans leurs discours et parfois dans leurs pratiques, lui donnent sens, et contribuent ainsi à remodeler les contours des normes juridiques

Association between administration of IL-6 antagonists and mortality among patients hospitalized for COVID-19 : a meta-analysis

IMPORTANCE Clinical trials assessing the efficacy of IL-6 antagonists in patients hospitalized for COVID-19 have variously reported benefit, no effect, and harm. OBJECTIVE To estimate the association between administration of IL-6 antagonists compared with usual care or placebo and 28-day all-cause mortality and other outcomes. DATA SOURCES Trials were identified through systematic searches of electronic databases between October 2020 and January 2021. Searches were not restricted by trial status or language. Additional trials were identified through contact with experts. STUDY SELECTION Eligible trials randomly assigned patients hospitalized for COVID-19 to a group in whom IL-6 antagonists were administered and to a group in whom neither IL-6 antagonists nor any other immunomodulators except corticosteroids were administered. Among 72 potentially eligible trials, 27 (37.5%) met study selection criteria. DATA EXTRACTION AND SYNTHESIS In this prospectivemeta-analysis, risk of biaswas assessed using the Cochrane Risk of Bias Assessment Tool. Inconsistency among trial results was assessed using the I-2 statistic. The primary analysis was an inverse variance-weighted fixed-effects meta-analysis of odds ratios (ORs) for 28-day all-cause mortality. MAIN OUTCOMES AND MEASURES The primary outcome measurewas all-cause mortality at 28 days after randomization. There were 9 secondary outcomes including progression to invasive mechanical ventilation or death and risk of secondary infection by 28 days. RESULTS A total of 10 930 patients (median age, 61 years [range of medians, 52-68 years]; 3560 [33%] were women) participating in 27 trials were included. By 28 days, there were 1407 deaths among 6449 patients randomized to IL-6 antagonists and 1158 deaths among 4481 patients randomized to usual care or placebo (summary OR, 0.86 [95% CI, 0.79-0.95]; P =.003 based on a fixed-effects meta-analysis). This corresponds to an absolute mortality risk of 22% for IL-6 antagonists compared with an assumed mortality risk of 25% for usual care or placebo. The corresponding summary ORs were 0.83 (95% CI, 0.74-0.92; P <.001) for tocilizumab and 1.08 (95% CI, 0.86-1.36; P =.52) for sarilumab. The summary ORs for the association with mortality compared with usual care or placebo in those receiving corticosteroids were 0.77 (95% CI, 0.68-0.87) for tocilizumab and 0.92 (95% CI, 0.61-1.38) for sarilumab. The ORs for the association with progression to invasive mechanical ventilation or death, compared with usual care or placebo, were 0.77 (95% CI, 0.70-0.85) for all IL-6 antagonists, 0.74 (95% CI, 0.66-0.82) for tocilizumab, and 1.00 (95% CI, 0.74-1.34) for sarilumab. Secondary infections by 28 days occurred in 21.9% of patients treated with IL-6 antagonists vs 17.6% of patients treated with usual care or placebo (OR accounting for trial sample sizes, 0.99; 95% CI, 0.85-1.16). CONCLUSIONS AND RELEVANCE In this prospectivemeta-analysis of clinical trials of patients hospitalized for COVID-19, administration of IL-6 antagonists, compared with usual care or placebo, was associated with lower 28-day all-cause mortality

Efficacy and safety of baricitinib in hospitalized adults with severe or critical COVID-19 (Bari-SolidAct): a randomised, double-blind, placebo-controlled phase 3 trial

International audienceAbstract Background Baricitinib has shown efficacy in hospitalized patients with COVID-19, but no placebo-controlled trials have focused specifically on severe/critical COVID, including vaccinated participants. Methods Bari-SolidAct is a phase-3, multicentre, randomised, double-blind, placebo-controlled trial, enrolling participants from June 3, 2021 to March 7, 2022, stopped prematurely for external evidence. Patients with severe/critical COVID-19 were randomised to Baricitinib 4 mg once daily or placebo, added to standard of care. The primary endpoint was all-cause mortality within 60 days. Participants were remotely followed to day 90 for safety and patient related outcome measures. Results Two hundred ninety-nine patients were screened, 284 randomised, and 275 received study drug or placebo and were included in the modified intent-to-treat analyses (139 receiving baricitinib and 136 placebo). Median age was 60 (IQR 49–69) years, 77% were male and 35% had received at least one dose of SARS-CoV2 vaccine. There were 21 deaths at day 60 in each group, 15.1% in the baricitinib group and 15.4% in the placebo group (adjusted absolute difference and 95% CI − 0.1% [− 8·3 to 8·0]). In sensitivity analysis censoring observations after drug discontinuation or rescue therapy (tocilizumab/increased steroid dose), proportions of death were 5.8% versus 8.8% (− 3.2% [− 9.0 to 2.7]), respectively. There were 148 serious adverse events in 46 participants (33.1%) receiving baricitinib and 155 in 51 participants (37.5%) receiving placebo. In subgroup analyses, there was a potential interaction between vaccination status and treatment allocation on 60-day mortality. In a subsequent post hoc analysis there was a significant interaction between vaccination status and treatment allocation on the occurrence of serious adverse events, with more respiratory complications and severe infections in vaccinated participants treated with baricitinib. Vaccinated participants were on average 11 years older, with more comorbidities. Conclusion This clinical trial was prematurely stopped for external evidence and therefore underpowered to conclude on a potential survival benefit of baricitinib in severe/critical COVID-19. We observed a possible safety signal in vaccinated participants, who were older with more comorbidities. Although based on a post-hoc analysis, these findings warrant further investigation in other trials and real-world studies. Trial registration Bari-SolidAct is registered at NCT04891133 (registered May 18, 2021) and EUClinicalTrials.eu ( 2022-500385-99-00 )

Respiratory support in patients with severe COVID-19 in the International Severe Acute Respiratory and Emerging Infection (ISARIC) COVID-19 study: a prospective, multinational, observational study

Background: Up to 30% of hospitalised patients with COVID-19 require advanced respiratory support, including high-flow nasal cannulas (HFNC), non-invasive mechanical ventilation (NIV), or invasive mechanical ventilation (IMV). We aimed to describe the clinical characteristics, outcomes and risk factors for failing non-invasive respiratory support in patients treated with severe COVID-19 during the first two years of the pandemic in high-income countries (HICs) and low middle-income countries (LMICs). Methods: This is a multinational, multicentre, prospective cohort study embedded in the ISARIC-WHO COVID-19 Clinical Characterisation Protocol. Patients with laboratory-confirmed SARS-CoV-2 infection who required hospital admission were recruited prospectively. Patients treated with HFNC, NIV, or IMV within the first 24 h of hospital admission were included in this study. Descriptive statistics, random forest, and logistic regression analyses were used to describe clinical characteristics and compare clinical outcomes among patients treated with the different types of advanced respiratory support. Results: A total of 66,565 patients were included in this study. Overall, 82.6% of patients were treated in HIC, and 40.6% were admitted to the hospital during the first pandemic wave. During the first 24 h after hospital admission, patients in HICs were more frequently treated with HFNC (48.0%), followed by NIV (38.6%) and IMV (13.4%). In contrast, patients admitted in lower- and middle-income countries (LMICs) were less frequently treated with HFNC (16.1%) and the majority received IMV (59.1%). The failure rate of non-invasive respiratory support (i.e. HFNC or NIV) was 15.5%, of which 71.2% were from HIC and 28.8% from LMIC. The variables most strongly associated with non-invasive ventilation failure, defined as progression to IMV, were high leukocyte counts at hospital admission (OR [95%CI]; 5.86 [4.83-7.10]), treatment in an LMIC (OR [95%CI]; 2.04 [1.97-2.11]), and tachypnoea at hospital admission (OR [95%CI]; 1.16 [1.14-1.18]). Patients who failed HFNC/NIV had a higher 28-day fatality ratio (OR [95%CI]; 1.27 [1.25-1.30]). Conclusions: In the present international cohort, the most frequently used advanced respiratory support was the HFNC. However, IMV was used more often in LMIC. Higher leucocyte count, tachypnoea, and treatment in LMIC were risk factors for HFNC/NIV failure. HFNC/NIV failure was related to worse clinical outcomes, such as 28-day mortality. Trial registration This is a prospective observational study; therefore, no health care interventions were applied to participants, and trial registration is not applicable

Respiratory support in patients with severe COVID-19 in the International Severe Acute Respiratory and Emerging Infection (ISARIC) COVID-19 study: a prospective, multinational, observational study

Background: Up to 30% of hospitalised patients with COVID-19 require advanced respiratory support, including high-flow nasal cannulas (HFNC), non-invasive mechanical ventilation (NIV), or invasive mechanical ventilation (IMV). We aimed to describe the clinical characteristics, outcomes and risk factors for failing non-invasive respiratory support in patients treated with severe COVID-19 during the first two years of the pandemic in high-income countries (HICs) and low middle-income countries (LMICs). Methods: This is a multinational, multicentre, prospective cohort study embedded in the ISARIC-WHO COVID-19 Clinical Characterisation Protocol. Patients with laboratory-confirmed SARS-CoV-2 infection who required hospital admission were recruited prospectively. Patients treated with HFNC, NIV, or IMV within the first 24 h of hospital admission were included in this study. Descriptive statistics, random forest, and logistic regression analyses were used to describe clinical characteristics and compare clinical outcomes among patients treated with the different types of advanced respiratory support. Results: A total of 66,565 patients were included in this study. Overall, 82.6% of patients were treated in HIC, and 40.6% were admitted to the hospital during the first pandemic wave. During the first 24 h after hospital admission, patients in HICs were more frequently treated with HFNC (48.0%), followed by NIV (38.6%) and IMV (13.4%). In contrast, patients admitted in lower- and middle-income countries (LMICs) were less frequently treated with HFNC (16.1%) and the majority received IMV (59.1%). The failure rate of non-invasive respiratory support (i.e. HFNC or NIV) was 15.5%, of which 71.2% were from HIC and 28.8% from LMIC. The variables most strongly associated with non-invasive ventilation failure, defined as progression to IMV, were high leukocyte counts at hospital admission (OR [95%CI]; 5.86 [4.83–7.10]), treatment in an LMIC (OR [95%CI]; 2.04 [1.97–2.11]), and tachypnoea at hospital admission (OR [95%CI]; 1.16 [1.14–1.18]). Patients who failed HFNC/NIV had a higher 28-day fatality ratio (OR [95%CI]; 1.27 [1.25–1.30]). Conclusions: In the present international cohort, the most frequently used advanced respiratory support was the HFNC. However, IMV was used more often in LMIC. Higher leucocyte count, tachypnoea, and treatment in LMIC were risk factors for HFNC/NIV failure. HFNC/NIV failure was related to worse clinical outcomes, such as 28-day mortality. Trial registration This is a prospective observational study; therefore, no health care interventions were applied to participants, and trial registration is not applicable

Thrombotic and hemorrhagic complications of COVID-19 in adults hospitalized in high-income countries compared with those in adults hospitalized in low- and middle-income countries in an international registry

Background: COVID-19 has been associated with a broad range of thromboembolic, ischemic, and hemorrhagic complications (coagulopathy complications). Most studies have focused on patients with severe disease from high-income countries (HICs). Objectives: The main aims were to compare the frequency of coagulopathy complications in developing countries (low- and middle-income countries [LMICs]) with those in HICs, delineate the frequency across a range of treatment levels, and determine associations with in-hospital mortality. Methods: Adult patients enrolled in an observational, multinational registry, the International Severe Acute Respiratory and Emerging Infections COVID-19 study, between January 1, 2020, and September 15, 2021, met inclusion criteria, including admission to a hospital for laboratory-confirmed, acute COVID-19 and data on complications and survival. The advanced-treatment cohort received care, such as admission to the intensive care unit, mechanical ventilation, or inotropes or vasopressors; the basic-treatment cohort did not receive any of these interventions. Results: The study population included 495,682 patients from 52 countries, with 63% from LMICs and 85% in the basic treatment cohort. The frequency of coagulopathy complications was higher in HICs (0.76%-3.4%) than in LMICs (0.09%-1.22%). Complications were more frequent in the advanced-treatment cohort than in the basic-treatment cohort. Coagulopathy complications were associated with increased in-hospital mortality (odds ratio, 1.58; 95% CI, 1.52-1.64). The increased mortality associated with these complications was higher in LMICs (58.5%) than in HICs (35.4%). After controlling for coagulopathy complications, treatment intensity, and multiple other factors, the mortality was higher among patients in LMICs than among patients in HICs (odds ratio, 1.45; 95% CI, 1.39-1.51). Conclusion: In a large, international registry of patients hospitalized for COVID-19, coagulopathy complications were more frequent in HICs than in LMICs (developing countries). Increased mortality associated with coagulopathy complications was of a greater magnitude among patients in LMICs. Additional research is needed regarding timely diagnosis of and intervention for coagulation derangements associated with COVID-19, particularly for limited-resource settings