Enjeux et usages des recommandations de bonne pratique : application à la médecine générale et à l'hypertension artérielle

Best practice recommendations, stemming from evidence based medicine, are part of a well versed process aiming to claim medical legitimacy based on science and are used as policy tools in practice. How do they relate to professional values, and to the practice of medicine?This question is examined within the framework of recommendations regarding the treatment, control and prevention of arterial hypertension (AH) in general practice which can be said to exemplify the construction of a public health risk.The first part of this work is centred on the origins of evidence based medicine, and the way in which it brings continuity as well as change to the relationships between: medical professionals; the institution of medicine and the state; doctors and patients.The second part, a microsociological study of GP consultations with hypertensive patients, shows that recommendations are used to reinforce the doctor’s efforts to increase patients’ awareness of AH and the ensuing cardiovascular risks. However, GPs use their influence over a long time period and, influenced by their patients, they negotiate, compromise and even disregard some of the best practice recommendations, considering that what may not be achievable in the present, may be achievable in the long term. Recommendations are therefore used in practice in hybrid form, where science is merged with an adaptation to each unique situation. The ‘average patient’ as the basic unit of evidence based medicine is opposed with the social reality of an individual with a certain level of autonomy and resources whose trust the doctor needs to gain and maintain.Les recommandations de bonne pratique, issues de la médecine des preuves, s’insèrent dans un processus ancien visant à asseoir la légitimité médicale sur la science et se sont déployées en tant qu’instrument politique de rationalisation des pratiques.Comment rencontrent-elles les valeurs professionnelles et l’exercice de la médecine ?La question est traitée dans le cadre de la médecine générale et de l’hypertension artérielle (HTA) dont la mise en recommandations est exemplaire de la construction d’un risque en santé publique.La première partie s’intéresse à l’origine de la médecine des preuves et en quoi ce mouvement est porteur de continuité et de modification dans les relations entre Médecine et État, au sein de la profession, entre médecin et patient.La seconde partie, centrée sur une microsociologie des consultations de patients hypertendus, montre que les recommandations constituent un appui pour le travail médical de prise de conscience par le patient de la réalité pathologique de l’HTA et des risques cardiovasculaires associés. Mais le généraliste inscrit son action dans la durée et, sous influence du patient, négocie et fait des compromis voire déroge aux « bonnes pratiques », considérant que ce qui n’est pas réalisable aujourd’hui le sera demain.Les recommandations sont intégrées dans les pratiques sous forme d’un modèle hybride associant la référence aux données scientifiques et l’adaptation à la singularité de la situation. La figure du patient statistique porté par la médecine des preuves est confrontée à la réalité sociale de l’individu plus ou moins doté d’autonomie et de ressources dont il s’agit pour le médecin d’acquérir la confiance et de la conserver

The REVERE project:Experiments with the application of probabilistic NLP to systems engineering

Despite natural language’s well-documented shortcomings as a medium for precise technical description, its use in software-intensive systems engineering remains inescapable. This poses many problems for engineers who must derive problem understanding and synthesise precise solution descriptions from free text. This is true both for the largely unstructured textual descriptions from which system requirements are derived, and for more formal documents, such as standards, which impose requirements on system development processes. This paper describes experiments that we have carried out in the REVERE1 project to investigate the use of probabilistic natural language processing techniques to provide systems engineering support

'L'éducation' du patient en médecine générale : une activité périphérique ou spécifique de la relation de soin ?

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Increase in Tomato Locule Number Is Controlled by Two Single-Nucleotide Polymorphisms Located

In tomato (Solanum lycopersicum) fruit, the number of locules (cavities containing seeds that are derived from carpels) varies from two to up to 10 or more. Locule number affects fruit shape and size and is controlled by several quantitative trait loci(QTLs). The large majority of the phenotypic variation is explained by two of these QTLs, fasciated (fas) and locule number (lc), that interact epistatically with one another. FAS has been cloned, and mutations in the gene are described as key factors leading to the increase in fruit size in modern varieties. Here, we report the map-based cloning of lc. The lc QTL includes a 1,600-bp region that is located 1,080 bp from the 3# end of WUSCHEL, which encodes a homeodomain protein that regulates stem cell fate in plants. The molecular evolution of lc showed a reduction of diversity in cultivated accessions with the exception of two single-nucleotide polymorphisms. These two single-nucleotide polymorphisms were shown to be responsible for the increase in locule number. An evolutionary model of locule number is proposed herein, suggesting that the fas mutation appeared after the mutation in the lc locus to confer the extreme high-locule-number phenotype

Ionospheric and magnetic signatures of a high speed solar wind in low latitudes on 13 October 2012

International audienceThis paper presents the impact of a fast solar wind on the ionosphere, in low latitudes, on 13 October 2012. On that day, the high speed solar wind reached the Earth around 16:00UT, during the recovery phase of a geomagnetic storm which started around 00:00UT. The solar wind speed was determined to be 580km/s, on the same day, around 17:00UT. Its impact was observed in low and equatorial latitudes, in Africa and in Eastern South America, on the F layer and on the geomagnetic field variations. Through the analysis of magnetic indices, ionosonde characteristics and the horizontal component of the geomagnetic field, we found that the 13 October 2012 event exhibited a local impact, affecting the observatories situated in a longitude sector between 315°E and 45°E. Particularly, the F layer in Africa (observed by the ionosonde at Ascension Island) did not present any lift, and there was a delay for approximately two hours of the ascent of the F layer in America (the ionosonde at Fortaleza). In this case, there was an evident inhibition on the development of spread F at the time of the Pre Reversal Enhancement (PRE) in Africa and Eastern America, while the ionograms of the days before and after presented clear spread F traces. The disturbances of the ionospheric equivalent electric current (Diono) deduced from the variations of the geomagnetic field at M'Bour near Dakar (Africa) and at Kourou (Eastern America) exhibited on the dayside, an anti Sq current which is signature of the influence of the Disturbance Dynamo Electric Field (DDEF)

Associer des itinéraires techniques de niveau d'intrants variés à des variétés rustiques de blé tendre : évaluation économique, environnementale et énergétique

International audienceL’impact de l’utilisation des engrais azotés et des pesticides (Aubertot et al., 2005) sur l’environnement ainsi que l’instabilité des prix de vente des céréales ont suscité un certain nombre de réflexions sur de nouvelles manières de produire du blé tendre d’hiver, en prenant notamment appui sur le progrès variétal. Ainsi, à partir de 1999, l’INRA, l’ITCF (puis ARVALIS-Institut du végétal), les sélectionneurs du GIE Club des Cinq et les chambres d’agriculture d’Indre-et-Loire et du Morbihan ont engagé une collaboration afin d’évaluer l’intérêt des variétés rustiques conduites avec des itinéraires techniques à niveaux d’intrants réduits. Ces variétés ont été choisies parmi celles présentant des caractères de multirésistance aux maladies et à la verse, tout en s’assurant d’un niveau de rendement comparable aux autres cultivars du catalogue. Le réseau expérimental multilocal mis en place de 2000 à 2002 a révélé des performances économiques satisfaisantes de ces itinéraires techniques au regard des recommandations locales, et ce pour le prix de vente moyen de cette période, à savoir 100 € par tonne (Loyce et al., 2001 ; Félix et al., 2002 ; Rolland et al., 2003 ; Loyce et al., accepté)

Middle and low latitude ionosphere response to 2015 St. Patrick's Day geomagnetic storm

International audienceThis paper presents a study of the St Patrick's Day storm of 2015, with its ionospheric response at middle and low latitudes. The effects of the storm in each longitudinal sector (Asian, African, American, and Pacific) are characterized using global and regional electron content. At the beginning of the storm, one or two ionospheric positive storm effects are observed depending on the longitudinal zones. After the main phase of the storm, a strong decrease in ionization is observed at all longitudes, lasting several days. The American region exhibits the most remarkable increase in vertical total electron content (vTEC), while in the Asian sector, the largest decrease in vTEC is observed. At low latitudes, using spectral analysis, we were able to separate the effects of the prompt penetration of the magnetospheric convection electric field (PPEF) and of the disturbance dynamo electric field (DDEF) on the basis of ground magnetic data. Concerning the PPEF, Earth's magnetic field oscillations occur simultaneously in the Asian, African, and American sectors, during southward magnetization of the B z component of the interplanetary magnetic field. Concerning the DDEF, diurnal magnetic oscillations in the horizontal component H of the Earth's magnetic field exhibit a behavior that is opposed to the regular one. These diurnal oscillations are recognized to last several days in all longitudinal sectors. The observational data obtained by all sensors used in the present paper can be interpreted on the basis of existing theoretical models

SIAMESE-RELATED1 Is Regulated Posttranslationally and Participates in Repression of Leaf Growth under Moderate Drought.

The plant cell cycle is tightly regulated by factors that integrate endogenous cues and environmental signals to adapt plant growth to changing conditions. Under drought, cell division in young leaves is blocked by an active mechanism, reducing the evaporative surface and conserving energy resources. The molecular function of cyclin-dependent kinase-inhibitory proteins (CKIs) in regulating the cell cycle has already been well studied, but little is known about their involvement in cell cycle regulation under adverse growth conditions. In this study, we show that the transcript of the CKI gene SIAMESE-RELATED1 (SMR1) is quickly induced under moderate drought in young Arabidopsis thaliana leaves. Functional characterization further revealed that SMR1 inhibits cell division and affects meristem activity, thereby restricting the growth of leaves and roots. Moreover, we demonstrate that SMR1 is a short-lived protein that is degraded by the 26S proteasome after being ubiquitinated by a Cullin-RING E3 ubiquitin ligase. Consequently, overexpression of a more stable variant of the SMR1 protein leads to a much stronger phenotype than overexpression of the native SMR1. Under moderate drought, both the SMR1 transcript and SMR1 protein accumulate. Despite this induction, smr1 mutants do not show overall tolerance to drought stress but do show less growth inhibition of young leaves under drought. Surprisingly, the growth-repressive hormone ethylene promotes SMR1 induction, but the classical drought hormone abscisic acid does not

Modification des propriétés des poudres par enrobage à sec dans un mélangeur Cyclomix

International audienceNous présentons ici une étude de la modification de certaines propriétés de poudres après enrobage de fines particules sur des particules hôtes dans un mélangeur de laboratoire modèle « Cyclomix », d'une contenance de 1 litre. Ce type d'appareil présente des effets de cisaillement et d'impact, permettant de réaliser rapidement des enrobages à sec avec des volumes significatifs de poudre. De plus des possibilités d'extrapolation à des échelles supérieures (jusqu'à 500 L) existent pour préparer des quantités industrielles de poudres à surface modifiée. Plusieurs systèmes particulaires sont utilisés, avec des particules hôtes différentes : des poudres de gel de silice et d'amidon de maïs. Différents types de particules invitées ont été également examinées : stéarate de magnésium, silice hydrophile ou hydrophobe. Les caractéristiques morphologiques des poudres, et les densités du solide (mesurées par pycnomètre à hélium) ont été déterminées. Les modifications apportées aux particules hôtes par les particules invitées sont caractérisées par des tests de cinétique d'adsorption de vapeur d'eau, de mesure d'angle de contact par goutte posée, et d'évaluation de la coulabilité par mesures de densités tassées ou non tassées. Les résultats obtenus montrent que le mélangeur Cyclomix permet de réaliser des enrobages de poudres modifiant les propriétés de façon sensible

Developing an intervention to facilitate family communication about inherited genetic conditions, and training genetic counsellors in its delivery.

Many families experience difficulty in talking about an inherited genetic condition that affects one or more of them. There have now been a number of studies identifying the issues in detail, however few have developed interventions to assist families. The SPRinG collaborative have used the UK Medical Research Council's guidance on Developing and Evaluating Complex Interventions, to work with families and genetic counsellors (GCs) to co-design a psycho-educational intervention to facilitate family communication and promote better coping and adaptation to living with an inherited genetic condition for parents and their children (<18 years). The intervention is modelled on multi-family discussion groups (MFDGs) used in psychiatric settings. The MFDG was developed and tested over three phases. First focus groups with parents, young people, children and health professionals discussed whether MFDG was acceptable and proposed a suitable design. Using evidence and focus group data, the intervention and a training manual were developed and three GCs were trained in its delivery. Finally, a prototype MFDG was led by a family therapist and co-facilitated by the three GCs. Data analysis showed that families attending the focus groups and intervention thought MFDG highly beneficial, and the pilot sessions had a significant impact on their family' functioning. We also demonstrated that it is possible to train GCs to deliver the MFDG intervention. Further studies are now required to test the feasibility of undertaking a definitive randomised controlled trial to evaluate its effectiveness in improving family outcomes before implementing into genetic counselling practice.The National Institute of Health Research funded the study but any views expressed do not necessarily reflect those of the Authority. Funded by NIHR reference number: RP-DG-1211-10015