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Chapitre 23. Environnements de travail
No full textInternational audience23.1. Le milieu de travail : un déterminant majeur de la santé 23.2. Lésions professionnelles et indicateurs de santé 23.3. Principaux facteurs de risque pour les travailleurs 23.3.1. Agents chimiques 23.3.2. Agents biologiques 23.3.3. Agents physiques 23.3.4. Contraintes du travail associées aux troubles musculo-squelettiques (TMS) 23.3.5. Organisation du travail 23.4. Prévention et gestion du risque professionnel 23.4.1. Interventions en santé au travail 23.4.2. Surveillance des milieux de travail 23.4.3. Surveillance médicale individuelle 23.4.4. Surveillance épidémiologique 23.5. Perspective
Evaluation of maternal and child care continuum in Guinea: a secondary analysis of two demographic and health surveys using the composite coverage index (CCI)
No full textInternational audienceIntroduction: The composite coverage index (CCI) is the weighted average coverage of eight preventive and curative interventions received along the maternal and childcare continuum. This study aimed to analyse maternal and child health indicators using CCI.Methods: We performed a secondary analysis of demographic and health surveys (DHS) focused on women aged 15 to 49 and their children aged 1 to 4. This study took place in Guinea. The CCI (meeting the need for planning, childbirth assisted by qualified healthcare workers, antenatal care assisted by qualified healthcare workers, vaccination against diphtheria, pertussis, tetanus, measles and Bacillus Calmette-Guérin, taking oral rehydration salts during diarrhoea and seeking care for pneumonia) is optimal if the weighted proportion of interventions is > 50%; otherwise, it is partial. We identified the factors associated with CCI using the descriptive association tests, the spatial autocorrelation statistic and multivariate logistic regression.Results: The analyses involved two DHS surveys, with 3034 included in 2012 and 4212 in 2018. The optimal coverage of the CCI has increased from 43% in 2012 to 61% in 2018. In multivariate analysis, in 2012: the poor had a lower probability of having an optimal CCI than the richest; OR = 0.11 [95% CI; 0.07, 0.18]. Those who had done four antenatal care visits (ANC) were 2.78 times more likely to have an optimal CCI than those with less OR = 2.78 [95% CI;2.24, 3.45]. In 2018: the poor had a lower probability of having an optimal CCI than the richest OR = 0.27 [95% CI; 0.19, 0.38]. Women who planned their pregnancies were 28% more likely to have an optimal CCI than those who had not planned OR = 1.28 [95% CI;1.05, 1.56]. Finally, women with more than 4 ANC were 2.43 times more likely to have an optimal CCI than those with the least OR = 2.43 [95% CI; 2.03, 2.90]. The spatial analysis reveals significant disparities with an aggregation of high partial CCI in Labé between 2012 and 2018.Conclusion: This study showed an increase in CCI between 2012 and 2018. Policies should improve access to care and information for poor women. Besides, strengthening ANC visits and reducing regional inequalities increases optimal CCI
L’intersectorialité négociée « par le bas ». Quand une institution médico-sociale s’inscrit dans les murs d’un collège
No full textInternational audienceThe right to mainstream education for children with disabilities has been recognized in law since 2005. This article is based on a study carried out within a project designed to enhance their inclusion within schools. In so doing, it explores the ways in which sectoral boundaries can be crossed ‘from below’. The arrival of professionals and pupils from the French “medical-social” sector within a mainstream school aroused professional reticences within the latter. It was only after a succession of inter-professional negotiations that this crossing eventually reached a form of stability. The resulting negotiated local order has nonetheless still been rendered fragile by bureaucratic rivalries.Le droit à l’éducation en milieu ordinaire des enfants en situation de handicap est reconnu par la loi depuis 2005. En faisant évoluer les catégories de l’action publique, la logique inclusive met sous tension la partition historiquement construite entre écoles ordinaires et institutions médico-sociales. À partir d’une enquête menée au sein d’un dispositif qui permet à des élèves handicapés et aux professionnels qui les accompagnent d’inscrire leurs activités quotidiennes dans un collège, cet article s’intéresse aux modalités d’un franchissement des frontières sectorielles « par le bas ». L’irruption de professionnels et d’élèves du médico-social suscite des réticences professionnelles au sein de l’établissement scolaire. C’est dès lors par de multiples négociations professionnelles que ce franchissement trouve une forme de stabilité, ordre local négocié rendu fragile par les rivalités bureaucratiques entre les tutelles sectorielle
Are Nurse Coordinators Really Performing Coordination Pathway Activities? A Comparative Analysis of Case Studies in Oncology
No full textInternational audiencePatient Pathway Coordination (PPC) improves patient care quality and safety, particularly in oncology. PPC roles, such as nurse coordinators (NCs), have positively impacted the quality of patient care and reduced financial costs. However, NCs and their real activities in Health Care Organizations (HCOs) are unclear. Our aim was to identify, quantify, and compare all activities performed by NCs in oncology care settings from an organizational approach. Methods: We used qualitative and quantitative approaches based on case study principles. We accumulated 325 observation hours by shadowing and timing the activities of 14 NCs in four French HCO in oncology. Data analysis was conducted using an analytical framework to investigate the Activity of PAtient PAthway Nurse Coordinators in Oncology (APANCO). Results: Our research generated important findings: (1) NC roles and job titles are not standardized. (2) Non-coordination related activities are important in NC work content. Non-coordination times were consistent with distribution times between ward NCs and NCs in centralized structures. Ward NCs had higher non-coordination activities when compared with NCs in centralized structures. (3) PPC times varied for both ward NCs and NCs in centralized structures. Ward NCs performed less design coordination when compared with NCs in centralized structures, and this latter group also performed more external coordination than ward NCs. Conclusions: NCs do not just perform PPC activities. Their position in HCO structures, wards, or centralized structures, influence their work content. Centralized structures allow NCs to focus on their PPC roles. We also highlight different dimensions of NC work and training requirements. Our study could help managers and decision-makers develop PPC roles in oncology
A new cure model that corrects for increased risk of non-cancer death: analysis of reliability and robustness, and application to real-life data
No full textInternational audienceBACKGROUND: Non-cancer mortality in cancer patients may be higher than overall mortality in the general population due to a combination of factors, such as long-term adverse effects of treatments, and genetic, environmental or lifestyle-related factors. If so, conventional indicators may underestimate net survival and cure fraction. Our aim was to propose and evaluate a mixture cure survival model that takes into account the increased risk of non-cancer death for cancer patients. METHODS: We assessed the performance of a corrected mixture cure survival model derived from a conventional mixture cure model to estimate the cure fraction, the survival of uncured patients, and the increased risk of non-cancer death in two settings of net survival estimation, grouped life-table data and individual patients’ data. We measured the model’s performance in terms of bias, standard deviation of the estimates and coverage rate, using an extensive simulation study. This study included reliability assessments through violation of some of the model’s assumptions. We also applied the models to colon cancer data from the FRANCIM network. RESULTS: When the assumptions were satisfied, the corrected cure model provided unbiased estimates of parameters expressing the increased risk of non-cancer death, the cure fraction, and net survival in uncured patients. No major difference was found when the model was applied to individual or grouped data. The absolute bias was < 1% for all parameters, while coverage ranged from 89 to 97%. When some of the assumptions were violated, parameter estimates appeared more robust when obtained from grouped than from individual data. As expected, the uncorrected cure model performed poorly and underestimated net survival and cure fractions in the simulation study. When applied to colon cancer real-life data, cure fractions estimated using the proposed model were higher than those in the conventional model, e.g. 5% higher in males at age 60 (57% vs. 52%). CONCLUSIONS: The present analysis supports the use of the corrected mixture cure model, with the inclusion of increased risk of non-cancer death for cancer patients to provide better estimates of indicators based on cancer survival. These are important to public health decision-making; they improve patients’ awareness and facilitate their return to normal life
Le projet stratégique hospitalier à l'ère de chatgpt : quelques conseils pour garder son emploi de directeur
No full textNational audienceL'introduction de l'IA dans les hôpitaux n'est pas récente. Au début, simple moyen informatique amélioré d'aide à la décision médicale ou à la planification opérationnelle, il propose des évolutions récentes conversationnelles dans des domaines variés. Ceci nous interroge sur le potentiel de l'outil à concevoir et poser une architecture de pilotage. Après avoir rappelé les racines de l'implantation de l'IA à l'hôpital, puis les modalités de production et de structuration d'un plan stratégique hospitalier, nous invitons ici un outil de grande notoriété (ChatGPT, de la société OpenAI) à nous proposer ses propres vues organisatrices sur un hôpital réel pour essayer d'en améliorer la gestion
Risques pour la santé humaine liés aux proliférations d’Ostreopsis spp. sur le littoral basque
No full textCitation suggérée : Anses. (2023). Risques pour la santé humaine liés aux proliférations d’Ostreopsis spp. sur le littoral basque. (saisine 2021-SA-0212). Maisons-Alfort : Anses, 244 p.Au cours des dernières décennies, les dinoflagellés du genre Ostreopsis ont été identifiés dans les eaux marines de plusieurs pays européens tels que l’Albanie, la Croatie, Chypre, l'Espagne, la France, la Grèce, l'Italie, Monaco et le Portugal . Ces microalgues sont principalement benthiques et vivent de préférence sur des substrats biotiques, comme des macrophytes (macroalgues et phanérogames marines). Elles peuvent néanmoins se retrouver en suspension dans l’eau (elles sont alors planctoniques) ou même former des agrégats en surface, on les nomme alors fleurs d’eau. Ces microalgues peuvent causer des intoxications humaines lorsque les cellules ou les toxines qu’elles produisent sont présentes dans l’eau de mer, dans les embruns et aérosols ou dans certains produits de la mer. L’exposition peut se faire :• par voie respiratoire (inhalation et/ou contact avec les aérosols lors de promenade, de surveillance des plages, des activités de baignade et nautiques, etc.) ;• par contact cutané avec de l’eau de mer ou des macrophytes, support d’Ostreopsis(lors des activités de baignade et/ou nautiques) ;• par ingestion d’eau de mer lors de la baignade ou de pratiques d’activités nautiques ou encore en cas de consommation de produits de la mer contaminés par des toxinesproduites par Ostreopsis spp.Des manifestations cliniques telles que toux, rhinorrhée, irritations de la sphère ORL et des yeux, céphalées, fièvre, difficultés respiratoires, nausées, vomissements, diarrhées, douleurs abdominales, myalgies, rougeurs ou démangeaisons sont alors observées chez les personnes exposées à Ostreopsis.En France, la présence d’Ostreopsis est identifiée de façon récurrente sur les côtesméditerranéennes depuis une quinzaine d’années. Plus récemment, 674 personnes ont développé des signes et des symptômes associés aux proliférations d’Ostreopsis sur la côte basque française durant l’été 2021. Le bilan épidémiologique de ces intoxications montre qu’il n’existe pas de différence clinique avec les effets observés lors des épisodes de prolifération d’Ostreopsis cf. ovata du pourtour méditerranéen.Les investigations menées par l’Ifremer ont mis en évidence sur la côte basque la présence de deux espèces de microalgues du genre Ostreopsis pendant les épisodes de proliférations de 2021 et 2022 : O. cf. siamensis et O. cf. ovata.Si la première, O. cf. siamensis, est présente sur cette côte depuis 2018, la seconde, O. cf. ovata, a été identifiée dans cette partie du golfe de Gascogne pour la première fois en 2021.Ostreopsis cf. ovata est connue pour produire des toxines dont la structure est proche de celle de la palytoxine (PLTX). Ces molécules pourraient être à l’origine des symptômes observés dans les populations humaines, d’autant plus que certaines d’entre elles ont été détectées dans les aérosols en Méditerranée
Can we accurately assess disease activity using automated methods in large real-life MRI databases? Insights from the OFSEP HD database.
No full textInternational audienceIntroduction: Large real-life databases (DB) of MS patients usually consist of clinical data, including limited imaging metrics. The possibility of re-analyzing images to extract a wide range of metrics is now possible through the use of AI based methods. The presence of new lesions on longitudinal MRIs for exemple is used to assess the effectiveness of treatments in real-life studies. However, the automated tools that currently identify these new lesions are designed as an aid for radiologists, potentially generating false positives. The possibility of transferring these methods to analyze DB without supervision should be assessed.Objectives/Aims: To compare the performance of an automated method to classify MS patients as “active” or “inactive” based on new lesions on FLAIR images in a large real-life multicentric DB with respect to the data provided in the clinical DB.Methods: We included 1412 pairs of brain MRI scans from 868 MS patients with both FLAIR images available in the French OFSEP HD cohort imaging DB at 2 time points, and the radiological comparison captured in the clinical DB. An automated tool based on a fully convolutional neural network (trained on 159 patients) was used to detect new lesions between the corresponding longitudinal FLAIR images. Then, 160 pairs of brain MRI scans for which the automated method output and the corresponding clinical DB comparison disagree were randomly selected and their MRI were reviewed by 2 experts to constitute a ground truth. Differences in sensitivity, specificity and accuracy between the automated method and the clinical DB were assessed.Results: Overall, 222 out of 1412 (16%) intervals were considered active from the clinical DB, compared to 467 (35%) from the automated method. Over the 160 cases of disagrement included in the ground truth, the automated method correctly classified patients in 66% of the cases and the clinical DB in 34%. More specifically, the automated method was more sensitive than the clinical DB (p<0.001), but the clinical DB was more specific (p<0.001). Under simplified assumptions, we extrapolate from these results a sensitivity, specificity and accuracy of about 0.95, 0.99 and 0.92 for the clinical DB and 0.99, 0.69 and 0.96 for the automated method.Conclusion: The automated analysis of images collected in large real-life databases allows to correctly classify MS patients as active or inactive in a large majority of cases, and offers the possibility to extract other metrics such as lesion number or volume to analyze the efficacy of treatments in real-life
Serum persistent organic pollutants and diminished ovarian reserve: a single-exposure and mixture exposure approach from a French case-control study
No full textInternational audienceSTUDY QUESTION Are persistent organic pollutants (POPs) associated with a diminished ovarian reserve (DOR) in women of reproductive age? SUMMARY ANSWER Amongst 17 POPs detected in over 20% of serum samples, only p,p '-DDE was significantly associated with an increased risk of DOR, and beta-hexachlorocyclohexane (beta-HCH) was significantly associated with a decreased risk of DOR whilst mixture analyses yielded non-significant associations and did not detect any interactions between POPs. WHAT IS KNOWN ALREADY Animal studies have shown that several POPs can alter folliculogenesis and increase follicle depletion. However, only a few studies have been conducted in humans, with small sample sizes and inconsistent results. STUDY DESIGN, SIZE, DURATION Our study included 138 cases and 151 controls from the AROPE case-control study. Study participants were women between 18 and 40 years of age recruited amongst couples consulting for infertility in four fertility centres in western France between 2016 and 2020. PARTICIPANTS/MATERIALS, SETTING, METHODS Cases of DOR were defined as women with anti-Mullerian hormone (AMH) levels <= 1.1 ng/ml and/or antral follicle count (AFC) <7, and controls were women with AMH levels between 1.1 and 5 ng/ml and AFC >= 7, without genital malformations and with a menstrual cycle length between 26 and 35 days. A total of 43 POPs (including 15 organochlorine pesticides, 17 polychlorinated biphenyls, and 9 polybromodiphenylethers) were measured in the serum at inclusion into the study. We conducted logistic regression adjusted for potential confounders using a directed acyclic graph to study the effect of each POP on DOR as single exposures, and used Bayesian kernel machine regression (BKMR) to measure the mixture effect of POPs on DOR. MAIN RESULTS AND THE ROLE OF CHANCE Of the 43 POPs, 17 were detected in over 20% of the serum samples. In the single-exposure multivariate logistic regressions, p,p '-DDE (median 165.0 IQR 161.0 ng/l in controls) as a continuous exposure was significantly associated with an increased risk of DOR (odds ratio (OR) 1.39, 95% CI 1.10-1.77) and non-significantly associated with an increased risk of DOR for the second and third terciles (OR 1.46, 95% CI 0.74-2.87, and OR 1.72, 95% CI 0.88-3.37, respectively). beta-HCH (median 24.2 IQR 21.5 ng/l in controls) was significantly associated with a decreased risk of DOR when beta-HCH was treated as a continuous exposure (OR 0.63, 95% CI 0.44-0.89) and for the third tercile of exposure (OR 0.43, 95% CI 0.21-0.84) and non-significantly associated with a decreased risk of DOR for the second tercile (OR 0.77, 95% CI 0.42-1.42). All sensitivity analyses confirmed our results. BKMR showed similar associations for single exposures but found no significant associations for the total mixture effect. In addition, the BKMR results did not suggest any interactions between POPs. LIMITATIONS, REASONS FOR CAUTION Controls were recruited amongst infertile couples and thus may not be representative of all women of reproductive age. However, their POP concentrations were in the same range as in the general French population. WIDER IMPLICATIONS OF THE FINDINGS This study is the first to examine the associations between serum POPs and DOR. The well-recognized anti-androgenic properties of p,p '-DDE and estrogenic properties of beta-HCH could explain these associations of opposite direction. If these results are replicated elsewhere, this could have an impact on fertility prevention messages and help in understanding the impact of POPs on the female reproductive system. STUDY FUNDING/COMPETING INTEREST(S) This study was funded by the Fondation de France (grant numbers 2014-50537 and 00110196) and the French Biomedicine Agency (2016). None of the authors have any conflicts of interest to declare