Le consommateur et les services publics au Québec

Au Québec, le droit des services publics est caractérisé par une importante dispersion législative. Celle-ci pose un problème de cohérence juridique dès lors qu’il s’agit de préciser le statut des parties à un contrat ayant pour objet la prestation d’un service public. Cela a pour effet de soumettre chaque service public à une pluralité de registres juridiques, ce qui pose ainsi un obstacle à une approche permettant d’appréhender le thème du consommateur et des services publics de manière transversale. En raison de la configuration particulière de cet amalgame de droit public et de droit privé, force est de conclure que le « droit des services publics » n’est toujours pas, au Québec, une discipline ayant acquis son autonomie.In Québec the law governing public services is impeded by significant statutory dispersal. Legal consistency is difficult to attain as one attempts to determine the status of parties to a contract involving the performance of a public service. Each public servic is subjected to a variety of legal regimes thereby hampering a global approach in which consumer and public service issues may be addressed directly. Owing to this peculiar mixture of public and private law, one must conclude that the law governing public services in Québec has yet to become an autonomous discipline

Effectiveness of interprofessional manikin-based simulation training on teamwork among real teams during trauma resuscitation in adult emergency departments : a systematic review

This systematic review synthesizes the relevant evidence about the effectiveness of interprofessional manikin-based simulation training on teamwork among real teams during trauma resuscitation in adult civilian emergency departments. A systematic literature search was conducted in MEDLINE, CINAHL, EMBASE, EBM reviews, PsycINFO, and Web of Science with no time limit. Only experimental and quasi-experimental studies were included. Effects of the simulation intervention on teamwork were categorized according to a modified version of the Kirkpatrick's model. From the 1120 studies found, 11 studies were included for synthesis. All studies showed immediate improvement in teamwork after training, but divergent results were found regarding skills retention. Although this review focused on interprofessional manikin-based simulations in real trauma teams, the results are similar to previous systematic reviews including different types of simulation. This raises significant questions regarding the importance of simulation design characteristics to improve teamwork in trauma care

Effect of simulation on cognitive load in health care professionals and students : protocol for a systematic review and meta-analysis

Objective: The objective of this review is to assess the effect of simulation activities and their design features on cognitive load in health care professionals and students. Introduction: Simulation activities are now widely implemented in health care professionals’ education. However, the mechanisms by which simulations and their design features lead to health care professionals’ and students’ learning remains unclear. Still, because of their high interactivity and complexity, simulation activities have the potential to impact the cognitive load of learners. Synthesizing evidence regarding this phenomenon could help simulation educators identify the design features that affect learners’ cognitive load, and explain why some simulation activities are more effective than others. Inclusion criteria: This review will consider experimental and quasi-experimental studies in which the effect of a simulation activity on cognitive load in health care professionals or students from any discipline or level of practice is evaluated. All academic and health settings will be included. Methods: Following the guidelines of the JBI methods for systematic reviews of effectiveness, CINAHL, Embase, ERIC, MEDLINE, PsycINFO, and Web of Science will be searched for studies published in English or French, without a date limit. Retrieved studies will be independently screened for inclusion, then critically appraised for methodological quality by two reviewers using standardized JBI tools. Data extraction will be done independently using adapted tools from JBI. Where possible, data will be pooled using meta-analytical methods

Towards a better understanding of increased sleep duration in the chronic phase of moderate to severe traumatic brain injury : an actigraphy study

Introduction Most adults with moderate to severe traumatic brain injury (TBI) report persistent sleep-wake disturbances. Whether these complaints are either associated with abnormal sleep-wake patterns or can be explained by TBI-related characteristics is unclear. The present study aimed at characterising the subjective and objective sleep-wake patterns in TBI adults by taking into consideration the influence of TBI severity, common comorbidities and psychoactive medication. Methods Overall, 34 adults with moderate-severe TBI (one to four years post-injury) were compared to 34 controls. Sleepiness, fatigue, sleep quality, mood, and pain were assessed with questionnaires. A seven day sleep diary and actigraphy was used to document sleep and wake patterns. Results Compared to controls, TBI participants reported more sleepiness and fatigue, as well as poorer sleep quality. On actigraphy, they had earlier bedtime and longer time spent in bed, but equivalent sleep efficiency during the nighttime episode compared to controls. TBI participants also took more naps and accumulated more time asleep over the 24 h period than controls. These group differences were accentuated when only TBI adults using psychoactive medication were included. More comorbidities, more severe injuries and longer hospital stay were positively correlated with fatigue, sleepiness and sleep duration. Conclusions Our results showed that despite complaints regarding sleep and diurnal functioning, TBI survivors have very marginal changes in their objective sleep-wake schedules. Prolonged time spent in bed may reflect an attempt to increase their sleep duration in response to fatigue and sleepiness. TBI adults who use psychoactive medication are those with more evident changes in their sleep-wake schedules

Regional cerebral blood flow during wakeful rest in older subjects with mild to severe obstructive sleep apnea

Objectives: To evaluate changes in regional cerebral blood flow (rCBF) during wakeful rest in older subjects with mild to severe obstructive sleep apnea (OSA) and healthy controls, and to identify markers of OSA severity that predict altered rCBF. Design: High-resolution 99mTc-HMPAO SPECT images during wakeful rest. Setting: Research sleep laboratory affiliated with a University hospital. Participants: Fifty untreated OSA patients aged between 55 and 85 years divided into mild, moderate and severe OSA and 20 age-matched healthy controls. Interventions: N/A Measurements: Using statistical parametrical mapping, rCBF was compared between groups and correlated with clinical, respiratory and sleep variables. Results: Whereas no rCBF change was observed in mild and moderate groups, participants with severe OSA had reduced rCBF compared to controls in the left parietal lobules, precentral gyrus, bilateral postcentral gyri, and right precuneus. Reduced rCBF in these regions and in areas of the bilateral frontal and left temporal cortex was associated with more hypopneas, snoring, hypoxemia, and sleepiness. Higher apnea, micro-arousal, and body mass indexes were correlated to increased rCBF in the basal ganglia, insula, and limbic system. Conclusions: While older individuals with severe OSA had hypoperfusions in the sensorimotor and parietal areas, respiratory variables and subjective sleepiness were correlated with extended regions of hypoperfusion in the lateral cortex. Interestingly, OSA severity, sleep fragmentation and obesity correlated with increased perfusion in subcortical and medial cortical regions. Anomalies with such a distribution could result in cognitive deficits and reflect impaired vascular regulation, altered neuronal integrity, and/or undergoing neurodegenerative processes

Parallel recovery of consciousness and sleep in acute traumatic brain injury.

OBJECTIVE: To investigate whether the progressive recuperation of consciousness was associated with the reconsolidation of sleep and wake states in hospitalized patients with acute traumatic brain injury (TBI). METHODS: This study comprised 30 hospitalized patients (age 29.1 ± 13.5 years) in the acute phase of moderate or severe TBI. Testing started 21.0 ± 13.7 days postinjury. Consciousness level and cognitive functioning were assessed daily with the Rancho Los Amigos scale of cognitive functioning (RLA). Sleep and wake cycle characteristics were estimated with continuous wrist actigraphy. Mixed model analyses were performed on 233 days with the RLA (fixed effect) and sleep-wake variables (random effects). Linear contrast analyses were performed in order to verify if consolidation of the sleep and wake states improved linearly with increasing RLA score. RESULTS: Associations were found between scores on the consciousness/cognitive functioning scale and measures of sleep-wake cycle consolidation (p < 0.001), nighttime sleep duration (p = 0.018), and nighttime fragmentation index (p < 0.001). These associations showed strong linear relationships (p < 0.01 for all), revealing that consciousness and cognition improved in parallel with sleep-wake quality. Consolidated 24-hour sleep-wake cycle occurred when patients were able to give context-appropriate, goal-directed responses. CONCLUSIONS: Our results showed that when the brain has not sufficiently recovered a certain level of consciousness, it is also unable to generate a 24-hour sleep-wake cycle and consolidated nighttime sleep. This study contributes to elucidating the pathophysiology of severe sleep-wake cycle alterations in the acute phase of moderate to severe TBI

Sleep and wake disturbances following traumatic brain injury

Traumatic brain injury (TBI) is a major health concern in industrialised countries. Sleep and wake disturbances are among the most persistent and disabling sequelae after TBI. Yet, despite the widespread complaints of post-TBI sleep and wake disturbances, studies on their etiology, pathophysiology, and treatments remain inconclusive. This narrative review aims to summarise the current state of knowledge regarding the nature of sleep and wake disturbances following TBI, both subjective and objective, spanning all levels of severity and phases postinjury. A second goal is to outline the various causes of post-TBI sleep-wake disturbances. Globally, although sleep-wake complaints are reported in all studies and across all levels of severity, consensus regarding the objective nature of these disturbances is not unanimous and varies widely across studies. In order to optimize recovery in TBI survivors, further studies are required to shed light on the complexity and heterogeneity of post-TBI sleep and wake disturbances, and to fully grasp the best timing and approach for intervention

Brain white matter damage and its association with neuronal synchrony during sleep

The restorative function of sleep partly relies on its ability to deeply synchronize cerebral networks to create large slow oscillations observable with EEG. However, whether a brain can properly synchronize and produce a restorative sleep when it undergoes massive and widespread white matter damage is unknown. Here, we answer this question by testing 23 patients with various levels of white matter damage secondary to moderate to severe traumatic brain injuries (ages 18–56; 17 males, six females, 11–39 months post-injury) and compared them to 27 healthy subjects of similar age and sex. We used MRI and diffusion tensor imaging metrics (e.g. fractional anisotropy as well as mean, axial and radial diffusivities) to characterize voxel-wise white matter damage. We measured the following slow wave characteristics for all slow waves detected in N2 and N3 sleep stages: peak-to-peak amplitude, negative-to-positive slope, negative and positive phase durations, oscillation frequency, and slow wave density. Correlation analyses were performed in traumatic brain injury and control participants separately, with age as a covariate. Contrary to our hypotheses, we found that greater white matter damage mainly over the frontal and temporal brain regions was strongly correlated with a pattern of higher neuronal synchrony characterized by slow waves of larger amplitudes and steeper negative-to-positive slopes during non-rapid eye movement sleep. The same pattern of associations with white matter damage was also observed with markers of high homeostatic sleep pressure. More specifically, higher white matter damage was associated with higher slow-wave activity power, as well as with more severe complaints of cognitive fatigue. These associations between white matter damage and sleep were found only in our traumatic brain injured participants, with no such correlation in controls. Our results suggest that, contrary to previous observations in healthy controls, white matter damage does not prevent the expected high cerebral synchrony during sleep. Moreover, our observations challenge the current line of hypotheses that white matter microstructure deterioration reduces cerebral synchrony during sleep. Our results showed that the relationship between white matter and the brain’s ability to synchronize during sleep is neither linear nor simple

Visual fixation in the intensive care unit: a strong predictor of post-traumatic amnesia and long-term recovery after moderate-to-severe traumatic brain injury

Objective: We examined whether visual fixation at 24h of intensive care unit (ICU) admission is superior to the initial Glasgow Coma Scale (GCS) score to predict PTA duration and long-term TBI recovery. Design: Two-phase cohort study. Setting: Level I trauma ICU. Patients: Moderate-to-severe TBI discharged alive between 2010-2013. Interventions: None. Measurements and Main Results: Presence/absence of visual fixation at 24h of ICU-admission was determined through standard behavioral assessments in 181 TBI patients and compared to the GCS score to predict PTA duration during hospitalization (Phase 1) and performance on the Glasgow Outcome Scale-Extended (GOS-E) 10-40 months after (n=144; Phase 2a). A subgroup also completed a visual attention task (n=35; Phase 2b) and brain magnetic resonance imaging post-TBI (n=23; Phase 2c). Presence/absence of visual fixation at 24h of ICU-admission showed a sensitivity of 84%, a specificity of 82% and an AUC of 0.87 for the prediction of PTA duration. Visual fixation (AUC=0.85) was also found as performant as PTA (AUC=0.81; difference-between-AUC=0.04; 95%CI:-0.03-0.116; p=0.28) for the prediction of GOS-E scores. Conversely, the GCS score was a poor predictor of both PTA and GOS-E. Even when controlling for age/medication/CT scan findings, fixation remained a significant predictor of GOS-E scores (=-0.29, p<0.05). Poorer attention performance and increased regional brain volume deficits were also observed in participants who could not fixate 24h following ICU-admission versus those who could. Conclusions: Visual fixation within 24h of ICU-admission could be as performant as PTA for predicting TBI recovery, introducing a new variable of interest in TBI outcome research