[Impact of precariousness on breast cancer care in the Île-de-France region: Results of the DESSEIN study]. / Impact de la précarité sur la prise en charge du cancer du sein en Île-de-France : résultats de l'étude DESSEIN.

INTRODUCTION: Precariousness has been associated with an increase in breast cancer mortality, but the links between precariousness, stage at diagnosis and care pathways are little explored. The objective of the DESSEIN study was to assess the impact of precariousness on disease and care pathways. METHODS: Prospective observational study in Île-de-France comparing precarious and non-precarious patients consulting for breast cancer and followed for 1 year. RESULTS: In total, 875 patients were included between 2016 and 2019 in 19 institutions: 543 non-precarious patients and 332 precarious patients. Precarious patients had a more advanced stage at diagnosis (55% T1 vs. 63%, 30% N+ vs 19%, P=0.0006), had a higher risk of not receiving initially planned treatment (4 vs. 1%, P=0.004), and participated less in clinical trials (5 vs. 9%, P=0.03). Non-use of supportive oncology care was 2 times more frequent among patients in precarious situations (P<0.001). During treatment, 33% of deprived patients reported a loss of income, compared with 24% of non-deprived patients (P<0.001). At 12 months from diagnosis, lay-offs were 2 times more frequent in precarious patients (P=0.0001). DISCUSSION: Precariousness affects all stages of the cancer history and care pathway. Particular attention needs to be paid to vulnerable populations, considering issues of accessibility and affordability of care, health literacy and possible implicit bias from the care providers.

[COPD - An Underestimated Disease]. / COPD ­ eine unterschätzte Erkrankung.

COPD - An Underestimated Disease Abstract: Chronic obstructive pulmonary disease (COPD) is a heterogeneous lung condition with a complex clinical picture. The diagnosis is not easy to make because COPD can develop insidiously and remain unnoticed for a long time. Therefore, general practitioners play a central role in the early detection of the disease. Suspected COPD can be confirmed by special examinations in collaboration with pulmonologists. The new GOLD guideline defines three COPD risk groups (A-B-E) which should guide the personalized treatment concept. A short- or long-acting bronchodilator (SAMA/SABA or LAMA/LABA) is recommended for group A, and a dual long-acting bronchodilator therapy (LABA+LAMA) is recommended for group B and E. In case of blood eosinophilia (≥300 cells/µl) and/or recent hospitalization for COPD exacerbation, triple therapy (LABA+LAMA+ICS) is recommended. General practitioners are important in implementing non-pharmacological measures (smoking cessation, regular exercise, vaccinations, patient selfmanagement education). However, this also underlines the high demands of the implementation of the GOLD guideline in daily practice.

Factors Associated With Initiation of Antidepressant Medication in Adults With Type 1 and Type 2 Diabetes: A Primary Care Retrospective Cohort Study in Ontario, Canada.

OBJECTIVES: Depression in patients with diabetes mellitus is common and associated with poorer outcomes. This study aims to identify demographic, socioeconomic and medical factors associated with the initiation of antidepressant medication after a diagnosis of diabetes in adult patients without a previous prescription for antidepressants. We also examined frequency of primary care visits in the year after antidepressant initiation compared with the year before treatment began. METHODS: This was a retrospective cohort study using routinely collected electronic medical record data spanning January 2011 to December 2019 from the University of Toronto Practice-based Research Network (UTOPIAN) Data Safe Haven. Our primary outcome was a first prescription for an antidepressant in patients with diabetes. We used a mixed-effects logistic regression model to identify sociodemographic and medical factors associated with this event. RESULTS: Among 22,750 patients with diabetes mellitus, 3,055 patients (13.4%) began taking an antidepressant medication. Increased odds of antidepressant initiation were observed in younger patients (odds ratio [OR], 1.77; 95% confidence interval [CI], 1.39 to 2.26), females (OR, 1.60; 95% CI, 1.46 to 1.7), those receiving insulin treatment (OR, 1.59; 95% CI, 1.43 to 1.78) and cases of polypharmacy (OR, 3.67; 95% CI, 3.29 to 4.11). There was an increase in the mean number of primary care visits from 4.6 to 5.9 per year after antidepressant initiation. CONCLUSIONS: In patients with diabetes, age, sex and medical characteristics were associated with the initiation of antidepressants. These patients accessed primary care more frequently. Screening and prevention of depression, particularly in these subgroups, could reduce its personal and systemic burdens.

[Gynecological care among women reporting sexual violence: a qualitative study]. / Recours au soin gynécologique chez les femmes rapportant des violences sexuelles : étude qualitative.

INTRODUCTION: Sexual violence can be followed by different levels of gynecological care. Our objective was to characterise gynecological care and to identify the related factors among women who had reported sexual violence. METHODS: Twenty-five semi-structured interviews were conducted among adult women who reported sexual violence during childhood or as adults. Topics addressed included gynecological health, gynecological care and experienced violence, RESULTS: Interviewed women, aged 20-60, had a good professional integration and a high level of education. The violence had often been committed by a relative or acquaintance. For the women interviewed, the least use of gynecological care was motivated by a desire to avoid the gynecological examination. Among women who had regular check-ups, the desire to conform to the norm explained their need for gynecological check-ups, which was similar to that of women who had never been subjected to violence. Lastly, some care pathways were characterised by multiple recourse of gynecological care for complaints with identical motives. The women interviewed expected professionals to spontaneously identify the violence they had suffered and the gynecological consequences attributed to such violence. CONCLUSION: Individual and interpersonal differences in levels of gynecological care use were related to the characteristics of the violence and its perceived effects on gynecological health. It would be interesting to extend this research by examining the care pathways of women with other socioeconomic characteristics. A quantitative study would measure the association between violence and the use of gynecological care.

[Identification of factors associated with low access to psychiatric care. Concerning 516 psychiatric assessments carried out in the framework of the local medical committee of Martinique]. / Identification de facteurs associés à un faible recours aux soins spécialisés en psychiatrie. À propos de 516 cas d'expertises psychiatriques réalisées dans le cadre du Comité médical départemental de Martinique.

OBJECTIVE: Mental illness is noted for being in one of the first places in global burden of disease in terms of years lived with disability (YLDs). Notably, absences due to mental health problems greatly affect the world of work, and mental illness is one of the most economically important diseases. However, there is a high rate of those not seeking care in mental health, both in the general population but also in workers in private and public sectors with significant economic impacts. The aim of our study was to identify factors associated with low access to specialized psychiatric care among French Public Sector employees referred to a psychiatric expertise upon request from the Departmental Medical Board of Martinique (Comité médical départemental [CMD] de Martinique), between 2000 and 2013. METHODS: We carried out an observational and transversal study, analyzing sociodemographic and clinical data from psychiatric assessments done to help the CMD give notification on the medico-administrative situation of Public Sector employees, a large majority of whom had been on sick leave due to mental health for at least 6 months. The variable of interest - low access to psychiatric care - was defined as the absence of consultation at the time of the assessment provided by a psychiatrist since at least 12 months. Descriptive analyses were performed first, then univariate analysis using a non-adjusted binary logistic regression model, to identify factors associated with low access to psychiatric care. Finally, multivariate analyses using a binary logistic regression model were performed after excluding non-relevant factors (with significance level above 5%) during the univariate analysis. A significance threshold of 0.05 was adopted for all of the statistical analyses. RESULTS: We retrospectively analysed the records of 516 Public Sector employees. Two hundred and ninety-three subjects (57% of the population) had a low access to psychiatric care as part of their regular clinical follow-up, even the 81% who were identified has having had psychiatric antecedents (55% with 'mood disorders', and 17% with 'neurotic, stress-related and somatoform disorders'). Moreover, psychiatric expertise found a psychiatric diagnostic in 96 % of cases, mostly 'mood disorders', 'neurotic, stress-related and somatoform disorders' and 'personality disorders'. For mood disorders, clinical characteristics of episodes were defined as 'severe' or 'with psychotic symptoms' in many cases. Suicidal thoughts were found in 96 subjects (18%) during the expertise. Fewer than half of the subjects (43%) had a specialized psychiatric care (mostly subjects with 'mood disorders' and 'psychotic disorders') and 41% only had care by a general practitioner (mostly subjects with 'neurotic, stress-related and somatoform disorders'). In most of the cases, psychotropic drugs were insufficiently and inadequately prescribed. Using multivariate analysis, we found a significant association between low access to psychiatric care and: being masculine, having had more than two children, having had personal life events (in particular chronic somatic diseases), and having had no history of mental illness or of psychiatric hospitalization. It appears that chronic somatic diseases are frequently associated with psychiatric diseases, and the association worsens the prognosis of the two disorders. However, even if employees with mental disorders associated with chronic somatic diseases are unfit for work, many of them do not have access to mental health care and only have care by a general practitioner. CONCLUSION: More than half of French Public Sector employees referred to the Departmental Medical Board of Martinique for a medico-administrative decision relevant to sick leave due to mental diseases, had low access to specialized psychiatric care. By identifying barriers to care and reasons for not seeking specialized mental health care, we would be able to prevent disability claims and days off work (predicting malaise in the workplace and health-related limitations). Our results demonstrate the need to strengthen existing partnerships, and thus enhancing cooperation between public psychiatric sectors and primary healthcare players, facilitating access to mental healthcare and decreasing the stigma about mental disorders.

[Community pharmacists are also first aid actors. Results of the survey on unscheduled care in pharmacies in the Grand Est region]. / Les pharmaciens d'officine sont aussi des acteurs du 1er recours. Résultats de l'enquête demandes de soins non programmés dans les officines du Grand Est.

INTRODUCTION: According to the Public Healthcare Code, contributing to primary care is one of the pharmacist's key missions. Accessibility without appointment and the territorial network of pharmacies make the pharmacist an essential player in the management of unscheduled care, which remains an important gateway for users into the primary care system. This type of requests, daily in pharmacies, has not been yet the subject of a qualitative or quantitative evaluation. The Grand-Est Region, regrouping nearly 8% of French pharmacies, wanted to conduct a specific survey to quantify and assess the unscheduled care requests addressed to pharmacists on its territory. METHODS: The survey by URPS Pharmacists and ARS Grand-Est was conducted by Tous Pour la Santé over a period of 12months from November 2020 to November 2021. Participation in the study was on a voluntary basis. The main objective of this study was to define the typology of unscheduled care requests addressed to the Region pharmacies and to characterize the responses provided. RESULTS: One hundred and eighty-nine pharmacies (nearly 12% of Grand Est pharmacies, the participation rate could certainly have been higher if the study had not been conducted during the COVID-19 pandemic), representing 11,010 unscheduled care requests, took part in the survey. Despite the profession's massive desire to get involved in handling unscheduled care requests, the survey revealed a lack of specific training for pharmacists on this subject and an all-too-rare update from the AFGSU. User requests concern both daily healthcare needs and more specific chronic patients' needs. They evolve according to the profile of the applicant, the seasons, the days of the week and the type of pharmacy concerned. All ages are represented, including young adults. The average duration of care by the pharmacy team was 8minutes per request, even though in 20% of cases this did not lead to any delivery of product and in 11% of cases to no remuneration for the pharmacist. CONCLUSION: This survey confirmed the role of the pharmacist in responding to unscheduled care requests as a first-line actor and referral agent in the health system. The implementation of shared multiprofessional protocols, including first and foremost general practionners, and the recognition of the contribution of pharmacy teams would allow to define a framework to optimize the patient's journey through the healthcare system.

[Emergency in oncologic patient's pathway]. / La consultation médicale en urgence dans le parcours du patient en oncologie.

BACKGROUND: Medical emergencies are defined at the medical level, whereas the use of emergency consultations is decided by the patient. Urgent oncology cares are specific due to clinical, therapeutic, technic and psychologic complexity. METHODS: This descriptive retrospective study about 142 consultations carried out at the unplanned medical unit, with an analyse of demographics, clinical characteristics, reason for medical appeal, deployed resources and oncological pathway for six months. RESULTS: Breast (48 %) and lung (21 %) cancer are the most common. 68 % of patients present with a disease at a non-curative stage and 83 % have received a cancer treatment within the previous two months. Pain is the main reason for consultation (19 ). 91 % of patients benefit from diagnostic and therapeutic procedures. At three month, half of patients use an emergency system again. At six months, the tumour progression rate is 54 %. The mortality rate is 33 % regardless of the risk of immediate aggravation. CONCLUSION: The use of emergency consultation mainly concerns patients in a palliative situation, sometimes announcing the change of the trajectory towards the advanced phase. The organization of the emergency care pathway should evolve to better consider the needs of this population, by formalizing longitudinal monitoring, collaboration with palliative care teams and coordination with care providers in the city.

[Predictors Of The Use Of Prenatal Care Among Women Who Have Given Birth In Burundi: A Multilevel Analysis]. / Predicteurs Du Recours Aux Soins Prenataux Chez Les Femmes Ayant Accouchees Au Burundi : Une Analyse Multiniveau.

OBJECTIVE: Identify the predictors of the use of antenatal care in Burundi. DATA AND METHODS: This were an analysis of secondary data from the 2016 - 2017 demographic and health surveys in Burundi. The survey population was women who gave birth in the last five (05) years prior to the survey and gave their informed consent. Our sample consisted of 7,372 women. The data were analyzed with Stata 15.1 software. In bivariate analysis, the Chi-2 test, and simple logistic regression allowed us to identify the candidate variables for modelling at the 20% threshold. Multilevel ordinal logistic regression identified individual and contextual predictors of prenatal care use. RESULTS: The use of antenatal care by women who gave birth in Burundi was influenced by the area of residence (rural area : OR=1.25; 95% CI [1.05 - 1.49]), level of education (secondary level: OR=1.36; 95% CI [1.12 - 1.65]), parity (OR=0.77; 95% CI [0.68 - 0.87]), HIV transmission during pregnancy (OR=1.22; 95% CI [1.06 - 1.41]) and internet use frequency (OR=1.60; 95% CI [1.16 - 2.20]). The intraclass correlation coefficient was (Ii 3 = 0.0050083). CONCLUSION: Consideration of these determinants in the development of strategies to improve antenatal care utilization is necessary.

OBJECTIF: Identifier les facteurs prédictifs du recours aux soins prénatals au Burundi. DONNÉES ET MÉTHODES: Il s'agissait d'une analyse de données secondaires provenant des enquêtes de démographie et de santé 2016 ­ 2017 du Burundi. Notre échantillon était constitué de 7372 femmes. Les données ont été analysées avec le logiciel stata 15.1. La régression logistique ordinale multiniveau a permis d'identifier les prédicteurs individuels et contextuels du recours aux soins prénatals. RÉSULTATS: Le recours aux soins prénataux par les femmes ayant accouché au Burundi était influencé par le milieu de résidence (milieu rural : OR=1.25 ; IC 95% [1.05 ­ 1.49]), le niveau d'éducation (niveau secondaire : OR=1.36 ; IC 95% [1.12 ­ 1.65]), la parité (OR=0.77 ; IC 95% [0.68 ­ 0.87]), la transmission du VIH pendant la grossesse (OR=1.22 ; IC 95% [1.06 ­ 1.41]) et la fréquence d'utilisation de l'internet (OR=1.60 ; IC 95% [1.16 ­ 2.20]). Le coefficient de corrélation intraclasse était (Ii 3 = 0.0050083). CONCLUSION: La prise en compte de ces déterminants dans l'élaboration des stratégies d'amélioration de l'utilisation des soins prénataux s'avère nécessaire.

[Novelties in the Treatment of Asthma]. / Neues in der Asthma-Grundversorgung.

Novelties in the Treatment of Asthma Abstract. For general practitioners there have been important novelties in the treatment of asthma due to recent modifications of the international guidelines from Global Initiative for Asthma (GINA). Step 1 no longer recommends the use of short-acting ß2-agonists (SABA) without concomitant inhaled corticosteroids (ICS) as a controller because of the lack of efficacy and for safety reasons. Instead, low dose ICS-formoterol as needed is recommended. GINA step 5 recommends targeted biologic therapies like interleukin antibodies in patients with severe uncontrolled asthma. Asthma patients presenting simultaneously with symptoms of chronic obstructive pulmonary disease (COPD) should receive treatment containing ICS. Independent of the current corona pandemic, GINA recommendations stay in place. Recent data on prescriptions of SABA and oral corticosteroids (OCS) in Switzerland indicate that they still play an important role in asthma management and that GINA recommendations have not yet been sufficiently implemented into practice.

The impact of the COVID-19 epidemic on primary care in South-eastern France: implementation of a real-time monitoring system based on regional health insurance system data.

BACKGROUND: The spring 2020 COVID-19 epidemic severely impacted France's healthcare system. The associated lockdown (17 March- 11 May 2020) and the risk of exposure to SARS-CoV-2 led patients to change their use of healthcare. This article presents the development and implementation of a real-time system to monitor i) private doctors' activity in South-eastern France, and ii) changes in prescription of drugs for people with diabetes, mental health disorders and for certain vaccines from Mars 2020 to October 2020. METHODS: Data extracted from the regional healthcare insurance databases for 2019 and 2020 were used to construct indicators of healthcare use. They were calculated on a weekly basis, starting from week 2 2020 and compared for the same period between 2019 and 2020. RESULTS: Private doctors' activity decreased during the spring 2020 lockdown (by 23 % for general practitioners and 46 % for specialists), followed by an almost complete return to normal after it ended until week 41. Over the same period, a huge increase in teleconsultations was observed, accounting for 30 % of private doctors' consultations at the height of the crisis. The start of the lockdown was marked by a peak in drug prescriptions, while vaccinations declined sharply (by 39 % for the measles, mumps and rubella (MMR) vaccine in children under 5 years old, and by 54 % for human papillomavirus vaccine in girls aged 10-14 years old). CONCLUSION: The ongoing COVID-19 epidemic may lead to health consequences other than those directly attributable to the disease itself. Specifically, lockdowns and foregoing healthcare could be very harmful at the individual and population levels. The latter issue is a concern for French public authorities, which have implemented actions aimed at encouraging patients to immediately seek treatment. However, the COVID-19 crisis has also created opportunities, such as the roll-out of teleconsultation and tele-expertise. The indicators described here as part of the monitoring system can help public decision-makers to become more responsive and to implement tailored actions to better meet the general population's healthcare needs.

[The impact of the COVID-19 pandemic on first-line primary care in southeastern France: Feedback on the implementation of a real-time monitoring system based on regional health insurance data]. / L'impact de l'épidémie de COVID-19 sur les soins de premier recours en région Provence-Alpes-Côte d'Azur : retour d'expérience sur la mise en place d'un dispositif de surveillance en temps réel à partir des données régionales de l'Assurance maladie.

BACKGROUND: Starting in spring 2020, the COVID-19 pandemic markedly impacted the French healthcare system. Lockdown and risks of exposure to the coronavirus induced patients to modify their ways of use. The objective of this article was to share feedback on the implementation of a real-time monitoring system concerning (a) the activity of private practitioners in southeastern France, and (b) the evolution of reimbursements for drugs prescribed to persons with diabetes, for treatment of mental health disorders, and for performance of some vaccines. METHODS: Data regarding 2019 and 2020 were extracted from regional health insurance databases. They were used to elaborate several indicators relative to the general health insurance scheme, which were calculated and updated each week, starting with week 2. RESULTS: We observed a drop in private physician activity during the lockdown (-23% for general practitioners; -46% for specialist doctors), followed by a return to a semblance of normalcy. Concomitantly, a boom in teleconsultations occurred: at the height of the crisis they represented 30% of medical acts. The initial stage of the lockdown was characterized by peak provisioning for drugs, whereas vaccination strongly declined (-39% regarding measles, mumps and rubella vaccine among children aged less than 5 years; -54% regarding human papillomavirus vaccine among girls aged 10 to 14 years). CONCLUSION: The COVID-19 pandemic could lead to health effects other than those directly attributable to the coronavirus itself. Renouncing care may result in healthcare delays highly deleterious for people and society. Public authorities are preoccupied with these questions; they have set up action plans aimed at encouraging patients to seek treatment without delay. That said, the COVID-19 pandemic crisis has also created opportunities, such as the expansion of telemedicine. Although partial, these indicators can provide useful information enabling public decision makers to be reactive and to implement specific actions to meet the health needs of the population.

[Patients on oral anticancer drugs and coordinated pathway: CHIMORAL, feedback from care providers]. / Patients sous anticancéreux oraux et parcours coordonné : CHIMORAL, retour des acteurs de soins.

INTRODUCTION: Oral anticancer drugs have raised the question of how to follow-up these patients and how to coordinate this follow-up. The CHIMORAL study evaluated the involvement of primary care providers and a coordination by territorial health networks. Training/information tools were provided, as well as weekly nursing follow-up at home. METHODS: The operational feasibility of this model was assessed through a qualitative/quantitative analysis of territorial health network intervention and feedback from primary care providers. RESULTS: One hundred and fifty four patients received coordinated care, with nursing follow-up for 89% of them (average 6.3 weeks). One in three nurses, one in five pharmacists and one in ten doctors used the tools provided, 41% of which were used for training and 16% for the management of an adverse event. The main reasons for using the networks concerned adverse effects (34%) and came mainly from nurses (45%) and patients and their relatives (47%). Patients felt safe, with more responsive management. DISCUSSION: This intervention has strengthened the networks' links with primary care providers. The use of the community-based care system for adverse events was more frequent, with improved detection and patient awareness, with no observed impact on compliance. A proposed evolution is to maintain an in-home assessment for all patients and to define a frequency and duration of follow-up according to the patient's profile.

[Seeking colleagues' advice when facing complex clinical situations]. / Savoir « passer la main ¼ devant une situation complexe.

Seeking a second medical advice as a medical practitioner is a frequent situation that should be facilitated to best suit patients' expectations, while maintaining medical confidentiality. The patient and his relatives need to be involved with diagnostic and therapeutic procedures. The radiation oncologist should accept and help a patient who seeks a second advice, and patients will always appreciate when the physician helps them to seek such an advice. Examples that each practitioner should know include tertiary centers tumor boards, centers with access to innovation or clinical research, or with special teams to take care of specific populations such as adolescents and young adults. In some situations, no treatment can also be the best treatment, and it takes time to explain and discuss such watchful waiting strategies to patients. In case of recurrent disease after radiotherapy, salvage reirradiation must be discussed at a tertiary tumor board and weighed against other options, especially for rare and complex cases. Radiation oncology has gained multiple options with technological advances, such as proton therapy, brachytherapy, stereotactic body radiotherapy with respiratory tracking or contact therapy. Radiation oncologists must know the benefits associated with each option in terms of survival, local control or organ preservation in order to address patients to the best practitioner.

[Lack of medical or dental care: Impact on health expenditures for people with chronic disease]. / L'effet du non-recours aux soins médicaux et dentaires sur les dépenses de santé des personnes ayant une maladie chronique.

BACKGROUND: People with chronic disease often have dental (especially periodontal) disorders. Nevertheless, people with chronic disease seek dental care less often than others. We wanted to know if there is a relationship between the consumption of medical care and the consumption of dental care, and if so if the relationship is especially strong for people with chronic disease. METHODS: We conducted a longitudinal study that combined two data-sets: consumption data from the French National Health Insurance Fund and health and socioeconomic welfare data collected with a dedicated national survey. We studied healthcare expenditure and analyzed the association between healthcare consumption, health status and healthcare expenditure over a four-year period (2010-2013). RESULTS: People who did not seek medical or dental care in 2010 exhibited irregular consumer behavior thereafter. This pattern was particularly evident among those with chronic disease whose healthcare expenditures did not stabilize during the study period compared with the rest of the study population. Among people who did not seek medical care in 2010, variation in average dental care expenditure was 91% in people with chronic disease versus 42% for those without chronic disease. Lack of medical care during the first year of the study was also associated with greater expenditure-delay in people with chronic disease (77%) compared with 15% in people without chronic disease. CONCLUSION: The lack of medical or dental care in 2010 for people with chronic disease did not lead to an increase in medical and dental consumption in the following years. The catch-up delay was longer than four years. This highlights a problem of monitoring and identifies a marginalized population within the healthcare system.

Campos de ação estratégica e os recursos de poder do sistema de gestão de recuperação de direitos na bacia do Rio Doce / Strategic fields of action and power resources of the rights recovery management system in the Rio Doce basin / Campos estratégicos de acción y recursos de poder del sistema de gestión de recuperación de derechos en la cuenca del Río Doce / Les champs d'action stratégique et les ressources de puissance du système de gestion du recouvrement des droits dans le bassin du Rio Doce

O rompimento da barragem de Fundão, pertencente às empresas Samarco, BHP Billiton e Vale provocou o maior desastre socioambiental do país. A lama de rejeitos de minérios de percorreu a extensão do Rio Doce até o mar, causando diversos danos ambientais, sociais, econômicos e culturais. Este estudo analisa as estratégias de ação das comunidades atingidas no território capixaba, e as instâncias do sistema de governança do desastre para compreender quais os recursos e interações potencialmente avançam na luta por seus direitos. Em vista disso, o artigo explora aspectos jurídicos do desastre através dos dispositivos extrajudiciais que organizam a gestão da recuperação e reparação dos danos. A teoria dos campos é operacionalizada para compreender o cenário de negociação, estratégias de cooperação, coalização e contestação que foi desencadeado entre os atingidos, autoridades e agentes do mercado. A investigação foi realizada através do estudo de caso, grupos de discussão, e observação participante da tecnologia social Com Rio Com Mar Opinião Popular criada como apoio e suporte aos atingidos, e da atuação da Defensoria Pública do Estado do Espírito Santo.

The breach of the Fundão dam, belonging to Samarco, BHP Billiton and Vale companies, caused the biggest social and environmental disaster in the country. The ore tailings sludge ran the length of the Rio Doce to the sea, causing various environmental, social, economic and cultural damages. This study analyzes the strategies of action of communities affected in the state of Espírito Santo, and the instances of the disaster governance system to understand which resources and interactions potentially advance in the struggle for their rights. In face of the article explores the legal aspects of the disaster through the extrajudicial arrangements that organize the management of recovery and damage repair. Field theory is operationalized to understand the negotiation scenario, cooperation strategies, coalition and contestation that was unleashed among the affected, authorities and market agents. The investigation was conducted through case study, discussion groups, and participant observation of the social technology Com Rio Com Mar Popular Opinion created as support and support to those affected, and the performance of the Public Defender's Office of the State of Espírito Santo.

La ruptura de la presa Fundão, perteneciente a las compañías Samarco, BHP Billiton y Vale, causó el mayor desastre social y ambiental en el país. El lodo de relaves minerales se extendía a lo largo del río Doce hasta el mar, causando varios daños ambientales, sociales, económicos y culturales. Este estudio analiza las estrategias de acción de las comunidades afectadas en el estado de Espírito Santo, y las instancias del sistema de gobernanza de desastres para comprender qué recursos e interacciones potencialmente avanzan en la lucha por sus derechos. En vista de esto, el artículo explora los aspectos legales del desastre a través de los arreglos extrajudiciales que organizan la gestión de la recuperación y reparación de daños. La teoría de campo se operacionaliza para comprender el escenario de negociación, las estrategias de cooperación, la coalición y la contestación que se desató entre los afectados, las autoridades y los agentes del mercado. La investigación se realizó a través de un estudio de caso, grupos de discusión y observación participante de la tecnología social. Opinión popular creada por Com Rio Com Mar como apoyo y apoyo a los afectados, y el desempeño de la Oficina del Defensor Público del Estado de Espírito Santo.

La rupture du barrage de Fundão, appartenant aux entreprises Samarco, BHP Billiton et Vale, a provoqué le plus grand désastre socio-environnemental du pays. La boue de rebuts de minerais a parcouru l'étendue du Rio Doce jusqu'à la mer, causant divers dommages environnementaux, sociaux, économiques et culturels. Cette étude analyse les stratégies d'action des communautés touchées sur le territoire capixaba, et les instances du système de gouvernance du désastre pour comprendre quelles ressources et interactions pourraient progresser dans la lutte pour leurs droits. Cet article explore donc les aspects juridiques de la catastrophe à travers les dispositifs extrajudiciaires qui organisent la gestion de la réparation et de la réparation des dommages. La théorie des champs est mise en place pour comprendre le scénario de négociation, les stratégies de coopération, la coercition et la contestation qui a été déclenchée parmi les touchés, les autorités et les acteurs du marché. La recherche a été réalisée par l'étude de cas, des groupes de discussion, et l'observation participante de la technologie sociale Com Rio Com Mar Opinião Popular créée comme soutien et soutien aux touchés, et de l'action du Défenseur Public de l'Etat de l'Esprit Saint.

Health care utilization by men with prostate cancer during the year before their death: A 2015 population-based study.

INTRODUCTION: To study the characteristics and health care utilization of men with prostate cancer (PCa) during their last year and last month of life, as these data have been rarely reported to date. SUBJECTS AND METHOD: Men covered by the national health Insurance general scheme (77% of the French population) treated for PCa (2014-2015), who died in 2015 were identified in the national health data system, including reimbursed hospital and outpatient care, and their causes of death. RESULTS: A total of 11,193 men (mean age: 81 years, SD: 9.6) were included. Almost 58% of these men died in a short-stay hospital (SSH), 4% died in hospital-at-home, 9% died in Rehab, 9% died in skilled nursing homes and 21% died at home. During the last year of life, almost all men were hospitalised at least once in SSH and 47% received hospital palliative care (HPC), immediately prior to death in 8% of cases. During the last month of life, 76% of men were hospitalised at least once in SSH, 43% attended an emergency department and 14% were admitted to intensive care, 7% received a chemotherapy session, and 24% received an antineoplastic agent dispensed by a retail pharmacy. Cancer was the main cause of death for 63% of men, corresponding to PCa in 40% of cases, and cardiovascular disease was the main cause of death for 13% of men with marked variations according to age, place of death, and use of HPC. The mean cost reimbursed per man during the last year of life was €38,750 (€48,601 including HPC). CONCLUSIONS: In France, end-of-life management of men with PCa, regardless of the cause of death, is centered on SSH and HPC, essentially at the time of death. Certain indicators of end-of-life management were particular high. LEVEL OF EVIDENCE: 4.

Effects of Pay-for-Performance for Primary Care Physicians on Preventable Diabetes-Related Hospitalization Costs Among Adults in New Brunswick, Canada: A Quasiexperimental Evaluation.

OBJECTIVES: In New Brunswick, Canada, 13.6% of the population 35 years of age and older is living with type 1 or type 2 diabetes mellitus. To address public health and clinical challenges, pay-for-performance (P4P) for family physicians was introduced in 2010 to enable comprehensive diabetes management. This study assesses the impacts of the P4P scheme on excess health-care costs. METHODS: We used a quasiexperimental study design drawing on linked population-based administrative data sets of physician billings, hospital discharge abstracts and provider and resident registrations. Prospective cohorts of patients with diabetes were identified through a validated algorithm tracing individuals' interactions with the health-care system. We applied propensity-score difference-in-differences estimation for the effects of P4P on preventable diabetes-related hospitalization costs according to patients' exposures to physicians' uptake of the incentive. RESULTS: Coverage of incentivized care peaked at less than half (44%) of adults with diabetes, who tended to be younger and less often presenting comorbid conditions compared to those whose providers did not claim incentives. The introduction of P4P was attributed to significantly lower diabetes hospitalization costs among newly diagnosed patients (-0.083; p<0.01) and improved compensation for physicians. No cost avoidance was established among medium-term and longer-term patients or for hospitalizations for conditions concordant with diabetes. CONCLUSIONS: The effects of New Brunswick's P4P for diabetes care are mixed. Results reflect the deficient evidence base on the effects of P4P on patient-oriented and policymaker-important health outcomes. The high risk for multiple morbidities among patients with diabetes and the heterogeneity of physician responses to performance incentives may be hindering the effectiveness of P4P in improving diabetes outcomes.

[Maternal deaths related to social vulnerabilities. Results from the French confidential enquiry into maternal deaths, 2010-2012]. / Mortalité maternelle chez les femmes en situation de précarité. Résultats de l'ENCMM, France 2010­2012.

The theme of deprivation is new for the ENCMM. In view of the perceived increase in the number of maternal deaths that may be related to a deprivation situation, we sought to understand the main dimensions that could contribute to maternal death in this context, in order to propose a definition. The selection of cases made a posteriori is mainly based on a qualitative judgment. Between 2010 and 2012, among the deaths evaluated by the CNEMM, one or more elements related to social vulnerability were identified in 8.6% of the cases (18 deaths). The direct criteria used were the concepts of "deprivation" or "social difficulties", difficulties of housing, language barriers and isolation. The absence of prenatal care was retained as an indirect marker. We excluded cases where psychiatric pathology and/or addiction were predominant. Of the 18 cases identified with deprivation factors, death was considered "unavoidable" in 2 cases (11%), "certainly avoidable" or "possibly avoidable" in 13 cases (72%). In 3 cases (17%), avoidability could not be determined. Avoidability was related to the content and adequacy of care in 11 cases out of 13 (85%) and the patient's interaction with the health care system in 10 of 18 cases (56%). The analysis of maternal deaths among women in precarious situations points out that the link between socio-economic deprivation and poor maternal health outcomes potentially includes a specific risk of maternal death.

Towards an integrated approach to health and medicine in Africa.

UNLABELLED: This article frames the intersections of medicine and humanities as intrinsic to understanding the practice of health care in Africa. Central to this manuscript, which draws on empirical findings on the interplay between HIV and AIDS and alternative medicine in Zimbabwe is the realisation that very limited research has been undertaken to examine 'HIV/AIDS patient behaviour' with respect to choice of therapy on the continent [Bene, M. & Darkoh, M. B. K. (2014). The Constraints of Antiretroviral Uptake in Rural Areas: The Case of Thamaga and Surrounding Villages, Botswana. SAHARA-J: Journal of Social Aspects of HIV/AIDS, 11(1), 167-177. doi: 10.1080/17290376.2014.972057 ; Chavunduka, G. (1998). Professionalisation of Traditional Medicine in Zimbabwe, Harare, Jongwe Printers; O'Brien, S. & Broom, A. (2014). HIV in (and out of) the Clinic: Biomedicine, Traditional Medicine and Spiritual Healing in Harare. SAHARA-J: Journal of Social Aspects of HIV/AIDS, 11(1), 94-104. doi: 10.1080/17290376.2014.938102 ]. As such, a social approach to health-seeking behaviour questions how decisions about alternative therapies including herbal remedies, traditional healing and faith healing are made. The paper unpacks the realities around how people living with HIV and AIDS - who span different age groups and profess various religious backgrounds, faced with an insurmountable health challenge against a background of limited resources and no cure for the virus - often experience shifts in health-seeking behaviour. Grappling with seemingly simple questions about 'when, where and how to seek medical attention', the paper provides pointers to therapy choices and health-seeking behaviour; and it serves as a route into deeper and intense healthcare practice explorations. In conclusion, the paper proposes that medicine and the humanities should engage seriously with those social aspects of HIV and AIDS which call for an integrated approach to healthcare practice in Africa. If combined, medicine and the humanities might achieve what neither would alone.