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Optimising trial design for cardiogenic shock: insights from the sixth Critical Care Clinical Trialists Workshop
No full textInternational audienceDespite substantial advancements in the management of cardiogenic shock, mortality rates remain greater than 40%. Trials have shown that increasing survival rates in cardiogenic shock is challenging. Even the most successful trials show 5-15% reductions in mortality, and gains have been restricted to acute myocardial infarction cardiogenic shock, representing approximately 5% of the population with cardiogenic shock. Trials studying pharmacological strategies in all populations with cardiogenic shock have been consistently neutral or negative. The reasons are complex and include heterogeneity in cardiogenic shock phenotypes, timing of patient inclusion, high prevalence of multiorgan failure and cardiac arrest, and unrealistic estimated treatment effects that restrict sample size with sometimes inadequate funding leading to underpowered trials. In June, 2024, international experts from the fields of cardiology, anaesthesiology, critical care medicine, biostatistics, government regulation of trials, and patient advocacy convened at the sixth Critical Care Clinical Trialists Workshop to reflect on how to improve the design of future randomised clinical trials in cardiogenic shock. This Position Paper summarises the results of discussions regarding what an optimal randomised controlled trial on cardiogenic shock should entail in terms of population selection, primary objectives, statistical analysis, and incorporation of the patient's perspective
Three Body-Worn Accelerometers in the French NutriNet-Santé Cohort: Feasibility and Acceptability Study
No full textInternational audienceAccurate assessment of physical activity (PA) in large population-based cohorts remains a major methodological challenge. Self-reported questionnaires, although commonly used due to low cost and simplicity, are prone to recall and social desirability biases, causing misclassification and weakened associations with health outcomes. Body-worn accelerometers provide more objective and reliable measurements, but their acceptability and feasibility in large-scale epidemiological studies must be carefully evaluated to ensure compliance, data quality, and scalability. Objective The primary objective was to assess the acceptability of using 3 body-worn accelerometer devices (Fitbit, ActivPAL, and ActiGraph) among healthy middle-aged adults participating in the NutriNet-Santé cohort. The secondary objective was to assess the feasibility of these devices in terms of wear-time compliance under free-living conditions. Methods This is an ancillary study of the European WEALTH (WEarable sensor Assessment of physicaL and eaTing beHaviors) project that was conducted between 2023 and 2024 in a subsample of participants of the NutriNet-Santé surveillance in France. This sample included 126 healthy participants (62 men), with a mean age of 46.3 (SD 11.3) years. Participants wore simultaneously 3 body-worn accelerometer devices (Fitbit [wrist], ActivPAL [thigh], and ActiGraph [waist]) for 7 consecutive days. After the wear period, participants completed a specific 22-item web-based questionnaire, regarding their acceptability of using each device. This questionnaire was based on the Technology Acceptance Model, which identifies perceived usefulness and ease of use as key determinants of technology acceptance. Items were rated on a 5-point Likert scale (1=strongly disagree to 5=strongly agree). Feasibility was assessed based on the accelerometer wear time data reported in a log diary by participants. A valid day was defined as ≥600 minutes per day of wear time, and a valid week as at least 4 of such days. Acceptability scores were compared between devices using ANOVA, and feasibility outcomes were compared using Kruskal-Wallis tests. Results The acceptability assessment based on the questionnaire revealed significant differences among the 3 devices (P<.001). The Fitbit achieved the highest acceptability score (mean 80.5/100, SD 8.13) across most criteria such as comfort, ease of use, and social acceptability, while the ActiGraph received the lowest score (mean 71.7, SD 8.68), mainly due to challenges with stability and interference during PA. In terms of feasibility, the 3 accelerometers demonstrated high compliance, with the ActivPAL recording the highest daily wear time, followed by the Fitbit and the ActiGraph (P<.001). Conclusions Results from our study showed that the Fitbit watch appears as the most accepted device for measuring PA in free-living conditions in the NutriNet-Santé study. The large-scale use of such a device must now be evaluated in terms of logistics, cost, and data privacy
Dette publique et stabilité financière, une question de soutenabilité ? Le cas de la crise des fonds de pension britanniques de septembre 2022
No full textThis paper discusses the role of public debt in the financial system, and its implication for financial stability. To this effect, we look at the UK pension funds turmoil of September 2022, which was, so the story goes, caused by Liz Truss' government "mini-budget" announcement of September 23, 2022. In taking a closer look, we show that financial instability arose not from excessive deficits, but from vulnerabilities in sovereign debt markets. Specifically, liability-driven investment (LDI) strategies employed by pension funds, which relied on repo financing of gilt inventories, precipitated a liquidity spiral when yields rose abruptly around the time of the announcement. This challenges both the prevailing description of the events of September and October 2022, and mainstream accounts of the link between public debt and financial instability, as both accounts insist on the role of unreasonable public deficits. Our analysis highlights the need to study this link through the lens of market practices rather than fiscal "fundamentals" alone.</div
Global Health Initiatives and Universal Health Coverage in Pakistan‐Aligned for the Future?
No full textInternational audienceABSTRACT There is increasing global discourse on Global Health Initiatives' (GHIs) role and the need for better alignment with universal health coverage (UHC), which is particularly salient given recent rapid reductions in global aid. However, tensions within national ecosystems of GHI assistance and country alignment towards UHC are less well understood. We identify challenges and leverage points for aligning GHIs' assistance towards UHC‐focused health systems in Pakistan, drawing from the perspective of country stakeholders. A political economy approach was applied to unpack the context of national aid architecture, country discourse on strengths and weakness of GHI country ecosystem and stakeholders' power, positioning and interests for future reforms. Key informant interviews were conducted with constituencies of country‐based stakeholders in federal and provincial health systems, supplemented by a desk review of health financing data and policy‐programmatic documents. The findings highlight a context of expanding GHI mandate, despite Pakistan's trajectory towards middle income country status, but weak alignment with national primary health care (PHC) budgeting and planning processes. Country discourse acknowledged improved disease coverage but surfaced tensions with the off‐budget parallel grant model, comprising of several GHI intermediaries, headquarters‐driven planning and selective system support, that was not positioned to build sustainability resulting in duplicative resourcing, questionable value for money, clouding of accountability roles and poor preparedness for transition. Competing interests between federal and provincial governments, and between disease managers and PHC planners, was perceived to further weaken country stewardship of GHI assistance. The prospect of an impending decline in aid funding was a common interest for change across all stakeholder constituencies. Stakeholders were positioned for a continuation of GHI assistance but with fundamental changes involving integration with national PHC budgeting, re‐balancing power through shared accountability, and calibrated federal‐provincial incentives for coordinated working, but most felt disempowered to bring about change. We conclude that addressing power imbalances must be at the centre of paradigm shifts in country assistance by GHIs, although contextual modalities will differ across LMICs. Direct engagement with UHC stakeholders under the ambit of national PHC reforms, fewer intermediaries, on‐budget incentives to sustainably grow domestic financing and PFM technical assistance for aid management emerged as key areas for efficient, sustainable alignment in Pakistan and similar LMICs. Urgent actions are required within the current context of changes in global aid to build local capability for systematically easing dependence on GHIs while protecting equitable gains in disease outcomes
Le vécu de l’électroconvulsivothérapie par les professionnels de santé
No full textInternational audienceThe objective of this study is to explore the experiences of health care providers with electroconvulsive therapy (ECT). Seven participants from diverse professional and geographical backgrounds were recruited and interviewed between November 2021 and May 2022. Analysis of the interviews revealed four meta-themes: 1) Despite their initial preconceptions of ECT, health care providers report significant treatment effectiveness and good patient tolerance. 2)Their apprehensions about administering the treatment generally subside with experience. 3)Their empathetic stance is crucial in building a trusting relationship, facilitating the smooth course of ECT. 4)The issue of responsibility remains a major concern. This study contextualizes the administration of ECT based on the lived experience of the health care providers who perform it. It offers an experiential perspective—still little explored to date—complementing that of patients who have received the treatmentL’objectif de cette étude est d’explorer le vécu de l’électroconvulsivothérapie (ECT) par des soignants. Sept participants d’origines professionnelle et géographique variées ont été recrutés puis rencontrés entre novembre 2021 et mai 2022. Les analyses des entretiens ont révélé 4 méta-thèmes : 1) Malgré les représentations a priori que les soignants ont de l’ECT, ils font l’expérience d’une efficacité importante du traitement et d’une bonne tolérance par les patients. 2) Leurs appréhensions pour la réalisation du traitement s’apaisent généralement par l’expérience. 3) Leur posture empathique est un pilier pour la construction d’une relation de confiance, permettant le bon déroulement de l’ECT. 4) La question de la responsabilité reste une préoccupation importante. Cette étude contextualise la réalisation du traitement par ECT à partir du vécu des soignants qui le réalisent. Elle offre un angle de vue expérientiel des soignants, peu exploré à ce jour, par rapport à celui des patients ayant reçu ce traitement
Assessment of Knowledge and Practices Related to Children's Physical Fitness and Health Among French PE Teachers
No full textInternational audienceObjectives: To assess PE teachers' knowledge of physical fitness and its link to children's health and identify barriers and facilitators for its management in schools. Methods: A total of 2,378 PE teachers (56% men) completed an online questionnaire on their knowledge, perceived barriers, and facilitators regarding physical fitness. Results: Most of teachers reported being aware of the associations between cardiorespiratory fitness (CRF) (96%) and muscular strength (MS) (88%) with current health in youth. A smaller proportion of teachers acknowledged knowing the potential associations of these fitness components with future health in adulthood, specifically 40% for CRF and 22% for MS. The majority of teachers (80%) reported being sufficiently trained during their training courses to assess and develop the CRF. Only 50% of teachers reported feeling sufficiently trained to assess MS, while 58% reported being adequately trained to develop this component. Among the teachers, 82% reported that insufficient practice time, large class sizes, and high heterogeneity are key obstacles. Less than 50% identified other prioritized objectives as barriers, while 30% reported a lack of material resources as a significant limitation. Then, 84% of teachers reported being interested in participating in continued professional development focused on the promotion of physical fitness in youth through PE. Conclusions: Barriers such as limited training, structural constraints, and low awareness of MS recommendations hinder effective fitness management. Addressing these through improved curricula, teacher training, and resources is crucial to enhancing youth fitness and health in France
Comment on “Performance and Reproducibility of Large Language Models in Named Entity Recognition: Considerations for the Use in Controlled Environments”
No full textSuhasini Vincent. Earth Polyphonies: Law, Ecocriticism, Eco-activism in Postcolonial India
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Les transformations de l'intérêt à agir et de l'intérêt à intervenir devant le juge administratif face aux transitions
No full textInternational audienceLa contribution étudie la mutation de l’intérêt des associations dans le cadre de l’activité contentieuse développée en matière de droit public économique. D’abord, l’impératif de sécurisation des activités économiques favorise la redirection des associations vers une vocation, non plus perturbatrice, mais contributrice. Apparaît ensuite une mutation tenant à la substance de l’intérêt défendu. L’interpénétration entre logique économique et enjeux environnementaux se traduit, du point de vue contentieux, par une combinaison, voire une fusion, des intérêts écologique et économique pour accéder au prétoire
Antenatal care interventions in Afghanistan from 2000 to 2024: a rapid realist review
No full textInternational audienceIntroduction In response to the high maternal mortality in Afghanistan, the government emphasised enhancing antenatal care (ANC) coverage to improve skilled birth attendance and reduce maternal mortality. This study aimed to explain how and why ANC interventions worked, for whom, and under what circumstances in Afghanistan between 2000 and 2024. Methods A rapid realist review was conducted to identify underlying programme theories and examine contextual factors and key mechanisms influencing ANC outcomes, with input from a panel of national experts. Data were extracted using context–mechanism–outcome (CMO) configurations to develop and refine theories for policy recommendations. Results From 3502 papers, 1860 duplicates were removed, 63 were screened for full text and 25 were included in the final review. In total, 29 CMOs were inferred across nine interventions, classified at individual, interpersonal, community and institutional levels. We found that ANC interventions could work best by empowering women and healthcare workers (HCWs), involving husbands, hiring female community health workers (CHWs), ensuring regular contact with the same HCWs, endorsing health messages by the government, incentivising CHWs and designing and implementing interventions using participatory approaches. Interventions are less successful when there is a lack of community trust in service quality or HCW qualifications, low decision-making ability among women, discomfort during travel to health facilities, adherence to traditional practices and beliefs, hiring CHWs from outside the community, chronic stress and lack of support among HCWs and unrecognised incentives. Conclusion Our evidence synthesis can inform donors, policymakers and implementers on how to design more effective ANC interventions to achieve better health outcomes in Afghanistan. By emphasising intervention evaluation and ANC quality improvement, it highlights the importance of key social elements, such as cultural norms, power dynamics, relationships, beliefs and trust, which are likely to maximise impact. Community involvement is essential for designing and implementing effective and sustainable ANC interventions