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Achats stratégiques des soins et intervention communautaire : une approche collaborative et innovante d'amélioration de l'utilisation des services des soins maternels et infantiles au Tchad
No full textChad continues to experience some of the highest maternal and child mortality rates in the world. In response to this critical public health issue, a multi-year intervention (2016–2019) was implemented in three rural health districts in the southern part of the country. The intervention combined a user fee exemption policy with strong community engagement, aiming to improve both the supply and demand for maternal and child health services. This thesis seeks to assess the effects of the intervention on service utilization and to explore the underlying factors contributing to the observed results. A mixed-methods approach was adopted. The quantitative component involved an interrupted time series analysis with a control group, using monthly attendance data from 36 health centers (18 intervention and 18 control sites) over a 42-month period (18 months pre-intervention and 24 months post-intervention). Results indicate a statistically significant increase in service utilization in the intervention sites, with an average of 10.98 additional pediatric consultations and 0.68 more facility-based deliveries per month compared to control sites (p < 0.001). Community involvement played a pivotal role in achieving these outcomes. The qualitative component consisted of a multiple-case study in four health centers with contrasting performance levels. Data were collected through 26 in-depth interviews and 22 focus group discussions with service users, community health workers, and healthcare providers. Analysis using QDA Miner software revealed that differences in organizational and managerial capacity among health providers and community actors, as well as contextual factors such as geographical remoteness and poor road conditions, contributed to the heterogeneous outcomes observed across sites. Overall, this thesis highlights the critical importance of community participation, decentralized governance, and context-sensitive implementation for improving access to essential health services and advancing toward universal health coverage. It underscores the value of combining quantitative and qualitative methods in health policy evaluation.Le Tchad demeure l’un des pays présentant les taux de mortalité maternelle et infantile les plus élevés au monde. Pour répondre à cette problématique, une intervention pluriannuelle (2016–2019) a été mise en œuvre dans trois districts sanitaires ruraux du sud du pays. Elle associait une politique d’exemption du paiement des soins à une forte implication des communautés, avec pour objectif de renforcer simultanément l’offre et la demande de services de santé maternelle et infantile. Cette thèse vise à évaluer les effets de cette intervention sur l’utilisation des services, tout en analysant les facteurs contextuels et organisationnels susceptibles d’expliquer la variabilité des résultats observés. Une approche méthodologique mixte a été adoptée. La composante quantitative repose sur une analyse de séries chronologiques interrompues avec groupe contrôle, à partir de données mensuelles issues de 36 centres de santé (18 bénéficiant de l’intervention et 18 centres témoins), sur une période de 42 mois (18 mois avant et 24 mois après le début de l’intervention). Les résultats révèlent une augmentation statistiquement significative de l’utilisation des services dans les centres appuyés, avec en moyenne 10,98 consultations pédiatriques et 0,68 accouchement supplémentaires par mois, comparativement aux centres témoins (p < 0,001). Cette progression est étroitement liée à la mobilisation communautaire. La composante qualitative, fondée sur une étude de cas multiples contrastés, a été conduite dans quatre centres de santé. Les données ont été recueillies par le biais de 26 entretiens individuels et de 22 groupes de discussion avec des femmes bénéficiaires, des agents de santé communautaire et des prestataires. L’analyse, effectuée à l’aide du logiciel QDA Miner, montre que les différences de résultats s’expliquent par les capacités organisationnelles et managériales des acteurs locaux, ainsi que par des facteurs contextuels tels que l’éloignement géographique et la dégradation des infrastructures routières. Les résultats de cette recherche mettent en évidence le rôle essentiel de la gouvernance locale, de l’engagement communautaire et de l’adaptation aux contextes locaux pour améliorer l’accès aux soins et progresser vers la couverture santé universelle. Ils soulignent l’importance de combiner des approches quantitatives et qualitatives pour l’évaluation des politiques publiques de santé
Acute heart failure in non-cardiac surgery
No full textInternational audienceMore than 64 million people worldwide have heart failure (HF), and these numbers are expected to rise. Acute HF (AHF) is the leading cause of hospitalization in patients over 65 years old and is linked to high mortality and readmission rates. AHF may also be a frequent complication in patients hospitalized for other medical reasons as well as after cardiac or non-cardiac surgery. These three entities are summarized as secondary AHF. As secondary AHF has been largely overlooked by medical research and education, little is known about its pathophysiology, phenotypes, diagnosis, management, and prognosis. Secondary AHF occurring after non-cardiac surgery warrants particular attention due to its very high mortality rates of up to 44% within 1 year and is therefore the focus of this review. The scope of this document is to summarize the available evidence regarding the pathophysiology, prevention, diagnosis, treatment, and prognosis of AHF after non-cardiac surgery. Key to prevention is understanding and addressing the pathophysiology of AHF after non-cardiac surgery, which involves close monitoring of fluid status to avoid volume overload and/or hypovolemia, avoiding hypo- and/or hypertension, treating pain and anaemia to prevent tachycardia, and avoiding electrolyte disturbances to prevent arrhythmias. Cardiac biomarkers, such as cardiac troponins and natriuretic peptides, serve as important diagnostic tools and enhance risk stratification in the perioperative setting. A low threshold to perform echocardiography in this population is suggested. Vigilant post-operative care is essential for the early recognition and treatment of AHF after non-cardiac surgery, which could help improve outcomes for patients
Exploring individual and structural factors influencing healthcare seeking behavior in the context of the Senegal’s Universal Health Coverage program: a multilevel analysis from the ANRS-12399 Soignants Sénégal study
No full textInternational audienceBackground Although Senegal's Universal Health Coverage (UHC) program has improved access to care, it has sometimes led to overuse of health services. Moreover, the program's substantial financial debt to health facilities (HFs) has exposed them to organizational and financial problems, making it difficult to renew drug stocks and pay salaries on time. The multiple effects of the UHC program, both on individuals and on HFs, may discourage individuals from seeking for care in HFs. This study analyzed structural and individual factors associated with healthcare-seeking behavior in the context of Senegal's UHC program. MethodsWe used data from six HFs in the mostly rural Fatick region that participated in two different two surveys: ANRS 12399 Soignants Sénégal and CMUtuelleS. We performed a multilevel logistic regression model to identify individual and structural factors influencing healthcare-seeking behavior.Results Among the 313 individuals included, 63.3% were female and median age was 52 years (IQR [41⎯63]). Half the participants (50.5%) sought health services after experiencing a health problem in the two months prior to the survey. HFs, which the National Agency managing the UHC program (33.3%) owed most to, were better equipped and staffed, but also the most negatively affected by UHC implementation. Despite this, individuals sought care in these facilities just as frequently as in others, suggesting that being better equipped and staffed helped them to be more resilient to the negative effects of the UHC program. Individuals were less likely to seek care in smaller HFs. Instead, they were more likely to seek care in HFs providing HIV and tuberculosis care. Voluntary (i.e., paying) members (vs. other members) of community-based health insurance organizations, and individuals with a chronic illness (vs. without), were more likely to seek care. Persons with a disability (vs. without) and those experiencing food insecurity (vs. no food insecurity) were less likely to seek care. ConclusionBoth the financial support provided to individuals by the UHC program and structural characteristics of the healthcare system were associated with seeking healthcare. Taking greater account of these structural aspects when implementing UHC could enhance the program's effectiveness and help achieve its objectives.</div
Lire entre les lignes : Un cadre robuste de détection de fraude dans les états financiers
No full textInternational audienceFinancial statement fraud detection (FSFD) is crucial for market integrity but faces challenges from increasingly sophisticated schemes and under-utilized textual data in financial reports. Existing methods often rely on random data splits, leading to overoptimistic performance estimates that do not reflect real-world generalization to new companies or future periods. This paper proposes a robust FSFD framework leveraging Large Language Models (LLMs) to integrate both structured financial data and unstructured textual information from financial reports. To provide a more realistic evaluation, we introduce a novel and challenging benchmark task called Company-Isolated FSFD (CI-FSFD). We construct and make publicly available a comprehensive U.S. company dataset combining financial statements, summarized MD&A text, and fraud labels. Our LLM-based approach achieves the best performance on the challenging CI-FSFD task, demonstrating the critical value of textual data and robust evaluation for reliable financial fraud detection.La détection des fraudes dans les états financiers (FSFD) est essentielle à l'intégrité des marchés, mais se heurte à la sophistication croissante des schémas frauduleux et à la sous-exploitation des données textuelles contenues dans les rapports financiers. Les méthodes existantes reposent souvent sur des divisions aléatoires des données, ce qui conduit à des estimations de performance trop optimistes et peu pertinentes pour la généralisation à de nouvelles entreprises ou à des périodes futures. Cet article propose un cadre FSFD robuste exploitant les grands modèles de langage (LLM) pour intégrer à la fois les données financières structurées et les informations textuelles non structurées issues des rapports financiers. Afin de fournir une évaluation plus réaliste, nous introduisons une nouvelle tâche de référence exigeante : la détection des fraudes dans les états financiers par entreprise (CI-FSFD). Nous avons constitué et mis à disposition du public un ensemble de données exhaustif sur les entreprises américaines, combinant états financiers, résumés des rapports de gestion et étiquettes de fraude. Notre approche basée sur les LLM obtient les meilleures performances sur la tâche CI-FSFD, démontrant ainsi l'importance cruciale des données textuelles et la robustesse de l'évaluation pour une détection fiable des fraudes financières
Photodynamic Therapy Using Pulsed-Laser Irradiation of Gold Nanoparticles for the Treatment of Cancers with High Basal Oxidative Stress
No full textInternational audienceFor over 20 years, considerable research has been carried out on the use of nanotechnologies in cancer treatment. Beyond the photothermal effect of irradiating gold nanoparticles, the photodynamic effect with reactive oxygen species (ROS) production at the tissue level is poorly known. We showed that renal cancers had high basal ROS levels. We engineered different gold nanoparticles and optimized the irradiation parameters. Then, we intravenously injected several patient-derived xenografts with tailored gold nanorods that we irradiated using a pulsed laser. We optimized irradiation parameters to decrease toxic effects on normal tissue and showed that the local monitoring of skin temperature was an accurate marker for predicting histological toxicity. We demonstrated a significant additional effect of irradiating gold nanoparticles, with the increased activation of the autophagy pathway following irradiation, associated with the disappearance of renal cancer cells. Our study highlights the elevated ROS levels in cancers as a potential therapeutic target for ROS-mediated cytotoxicity therapies
L'innovation dans les bibliothèques : Une perspective orientée service
No full textInternational audienceThis article is devoted to the question of innovation in libraries. Ignored by ‘service studies’, this question occupies an important place in library and information science, but is all too often approached in a way that is factual and descriptive. Drawing on advances in service economics and management, this article adopts a perspective of the library as an ‘architectural’ or ‘assembled’ service bringing together a number of core and peripheral services, and mobilizing competences and different types of technology to collaboratively generate, utilities for the user or community. We discuss how such a representation of the product can systematically account for the full complexity of the forms and dynamics of innovation in libraries. We have thus identified and empirically illustrated three general innovation logics (horizontal, vertical and diagonal), which differ according to the components of the library service on which they act, and which operate according to different modalities, reflecting different innovation trajectories
Finite element modelling of the sacral soft tissues under compressive loading in the context of pressure ulcer prevention: importance of the personalization of the material parameters
No full textInternational audienceBackground: Pressure ulcers are a common occurrence in the sacrum and are frequently associated with deep tissue injury. Research has demonstrated that compression and mechanical strain contribute to tissue damage and can be employed to assess the risk of injury. Despite the existence of several finite element models based on this evidence, the experimental evaluation of localized tissue strain is rarely addressed. Methods: The objective of this study is to present a proof-of-concept protocol for creating subject-specific finite element models of sacral soft tissues under compressive loading and to compare the model predictions with experimental data based on Digital Volume Correlation of MRI data. The data was collected from one asymptomatic volunteer in four loading conditions (vertical loading of 4.3 N, 6.1 N, 8 N and 11.9 N). Findings: A comparison of DVC-derived tissue displacements with the Finite Element simulations demonstrated accurate estimations for maximum values and displacement distribution fields for all load cases, with less than 5 % discrepancy for load configurations L1-L3 and 7 % for load configuration L4. Concerning shear strains, it was observed that there were significant differences between the DVC-derived experimental tissue shear strains and the simulation predictions when generic constitutive parameters were used. The highest difference was 43 % for the highest load configuration (11.9 N). Interpretation: These results demonstrate that incorporating personalized tissue properties substantially improves model fidelity, highlighting the potential of combined imaging, mechanical testing, and FE modelling for individualized risk assessment of deep tissue injury
