Publications Collection HAL

Teledentistry consultations are an effective way to increase access to care. Whether it be for a screening, referral or even an adapted treatment plan for a certain number of patients whose access to care is complicated, demonstrating the reliability of remote consultations is essential in allowing the technique to become generalised. Aim: This study aimed to determine if teledentistry consultations using fluorescence are of the same quality as regular consultations in the diagnosis of caries. Methods: Patients were seen in consultation in the dental care centre at the Montpellier University Hospital (France) and in the centre at Kyushu Dental University Hospital (Japan). The protocol was broken down into three parts: the regular consultation, the recording of videos with the Soprocare camera and the remote consultation. The regular consultation and the remote consultation were blinded and carried out by two different dentists. The recording of videos was carried out by a third dentist. The carious diagnosis was based on the International Caries Detection and Assessment System: a clinical rating system for the detection and assessment of caries. Results: One hundred and ninety-five patients met the predefined inclusion criteria. Most patients had at least one surface at stage 3 or higher (73%) with a higher proportion amongst French patients (81% compared to 66%). However, they had good dental hygiene, given that dental hygiene was only deemed unsatisfactory for 10.8% (19% for French patients and 2% for Japanese patients). The odontogram (presence/absence of each tooth) seemed to be correctly identified during the remote consultation (reinterpretation). Out of the 195 patients, 168 (86.2%) were identified without error. Conclusions Teledentistry consultations can represent acceptable diagnostic performance with regard to the detection of dental caries. The Soprocare camera enables an early diagnosis of carious lesions with optimal efficiency. Several areas still need to be improved, however, so that the use of the camera during remote consultations is as coherent and effective as possible, especially with regard to the organisational aspects of remote consultations.

Objectives: The objective was to describe the epidemiology of dyspnea presenting to emergency departments (EDs) in the Asia-Pacific region, to understand how it is investigated and treated and its outcome. Methods: Prospective interrupted time series cohort study conducted at three time points in EDs in Australia, New Zealand, Singapore, Hong Kong, and Malaysia of adult patients presenting to the ED with dyspnea as a main symptom. Data were collected over three 72-hour periods and included demographics, comorbidities, mode of arrival, usual medications, prehospital treatment, initial assessment, ED investigations, treatment in the ED, ED diagnosis, disposition from ED, in-hospital outcome, and final hospital diagnosis. The primary outcomes of interest are the epidemiology, investigation, treatment, and outcome of patients presenting to ED with dyspnea. Results: A total of 3,044 patients were studied. Patients with dyspnea made up 5.2% (3,105/60,059, 95% confidence interval [CI] = 5.0% to 5.4%) of ED presentations, 11.4% of ward admissions (1,956/17,184, 95% CI = 10.9% to 11.9%), and 19.9% of intensive care unit (ICU) admissions (104/523, 95% CI = 16.7% to 23.5%). The most common diagnoses were lower respiratory tract infection (20.2%), heart failure (14.9%), chronic obstructive pulmonary disease (13.6%), and asthma (12.7%). Hospital ward admission was required for 64% of patients (95% CI = 62% to 66%) with 3.3% (95% CI = 2.8% to 4.1%) requiring ICU admission. In-hospital mortality was 6% (95% CI = 5.0% to 7.2%). Conclusion: Dyspnea is a common symptom in ED patients contributing substantially to ED, hospital, and ICU workload. It is also associated with significant mortality. There are a wide variety of causes however chronic disease accounts for a large proportion.

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Introduction: Fetal growth restricted fetuses are less likely to receive evidence-based care; a previous work demonstrated an improvement in neonatal prognosis when fetuses with intrauterine growth restriction (IUGR) received minimum evidence based-care.Objective: The objective of the study was to evaluate the impact of a standardized healthcare pathway on the implementation of the recommended clinical practice in the antenatal management of IUGR fetuses, in comparison to a traditional pathway. The quality of the implementation of practice has been defined whether or not minimum evidence-based care (MEC), defined according to the recommendations of the French college of gynecologists and obstetricians (CNGOF), has been implemented.Study design: From a historical cohort of 31,052 children, born at the Femme Mère Enfant Hospital (Lyon, France) between January 1st, 2011 and December 31st, 2017, we selected the population of IUGR fetuses. We compared the rate of MEC between the IUGR fetuses followed-up in the traditional healthcare pathway versus the IUGR fetuses followed-up in a standardized healthcare pathway between 2015 and 2017.Results: A total of 245 IUGR were tracked between 2015 and 2017. Over this period, 120 fetuses were followed within the traditional pathway and 125 within the IUGR pathway. The standardized pathway resulted in a higher rate of MEC (86,4%) when compared to IUGR fetuses followed-up in the traditional pathway (27,5% (OR* 20 (95 % CI 10.0-39.7). Among early-onset IUGR: 31 % received MEC in the traditional pathway versus 83 % in the standardized pathway (p<0.001). Among late-onset IUGR: 22 % received MEC in the traditional pathway versus 92 % in the standardized pathway (p<0.001). The provided care in the standardized pathway resulted in an increase of complete antenatal corticosteroid therapy (92,8 %) when compared to the traditional pathway (50.0 %; p<0.001) and a reduction of the rate of caesarean sections before labor for non-reassuring fetal heart rate (15 %) when compared to the traditional pathway (41.3 % p=0.007).Conclusion: The standardized pathway improves the implementation of the local recommendations in the management of early- and late-onset IUGR. This study is the first to suggest a standardized care pathway in prenatal medicine. A medico-economic study could estimate the health care savings that such a pathway would provide by allowing a medical management in accordance with the recommendations.

Introduction: Despite various efforts to improve human papillomavirus (HPV) vaccine coverage in France, it has always been lower than in most other high-income countries. The health authorities launched in 2018 the national PrevHPV research programme to (1) co-develop with stakeholders and (2) evaluate the impact of a multicomponent complex intervention aimed at improving HPV vaccine coverage amongst French adolescents. Objective: To describe the development process of the PrevHPV intervention using the GUIDance for rEporting of intervention Development framework as a guide. Methods: To develop the intervention, we used findings from (1) published evidence on effective strategies to improve vaccination uptake and on theoretical frameworks of health behaviour change; (2) primary data on target populations' knowledge, beliefs, attitudes, preferences, behaviours and practices as well as the facilitators and barriers to HPV vaccination collected as part of the PrevHPV Programme and (3) the advice of working groups involving stakeholders in a participatory approach. We paid attention to developing an intervention that would maximise reach, adoption, implementation and maintenance in real-world contexts. Results: We co-developed three components: (1) adolescents' and parents' education and motivation using eHealth tools (web conferences, videos, and a serious video game) and participatory learning at school; (2) general practitioners' e-learning training on HPV using motivational interviewing techniques and provision of a decision aid tool and (3) easier access to vaccination through vaccination days organised on participating middle schools' premises to propose free of charge initiation of the HPV vaccination. Conclusion: We co-developed a multicomponent intervention that addresses a range of barriers and enablers of HPV vaccination. The next step is to build on the results of its evaluation to refine it before scaling it up if proven efficient. If so, it will add to the small number of multicomponent interventions aimed at improving HPV vaccination worldwide. Patient or Public Contribution: The public (adolescents, their parents, school staff and health professionals) participated in the needs assessment using a mixed methods approach. The public was also involved in the components' development process to generate ideas about potential activities/tools, critically revise the successive versions of the tools and provide advice about the intervention practicalities, feasibility and maintenance.

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Background: Health literacy is a critical health determinant. To implement initiatives aiming at improving health literacy among children, adapted measurement tools are needed. Objective: This study aimed to translate, adapt, and test the Health Literacy Survey Child Questionnaire-15 (HLS-Child-Q15) to assess health literacy among French-speaking 8- to 11-year-old pupils. Methods: The HLS-Child-Q15 was translated and adapted to the French context to become the HLS-Child-Q15-FR. A cross-sectional survey was carried out using a written, self-reported questionnaire to assess the psychometric properties of the HLS-Child-Q15-FR. Key Results: Translation and adaptation of the HLS-Child-Q15 German-French translated versions were cross-referenced. Back-translation led to minor refinements. Qualitative pre-test among children led to simplifications in wording and structure. Validation of the HLS-Child-Q15-FR. Four trained interviewers collected data among 3,107 pupils in 74 elementary schools of the Auvergne-Rhône-Alpes region. HLS-Child-Q15-FR showed good reliability (alpha = 0.83). Exploratory factor analysis showed a two-factor model related to health care and primary prevention. Construct validity analyses suggested removing 3 items. External validity analyses indicated a significant and moderate relationship with perceived self-efficacy. Conclusion: This study aimed to address the issue of measuring health literacy among French-speaking 8- to 11-year-old pupils. The HLS-Child-Q15-FR showed a high internal consistency. Statistics suggested a two-dimensional thematic scale. These findings should be further investigated. [ HLRP: Health Literacy Research and Practice . 2023;7(3):e144–e153. ]

Background: Health literacy is a critical health determinant. To implement initiatives aiming at improving health literacy among children, adapted measurement tools are needed.

The idea that intelligence is embedded not only in a single brain network, but instead in a complex, well-optimized system of complementary networks, has led to the development of whole brain network analysis. Using graph theory to analyze resting-state functional MRI data, we investigated the brain graph networks (or brain networks) of high intelligence quotient (HIQ) children. To this end, we computed the "hub disruption index κ," an index sensitive to graph network modifications. We found significant topological differences in the integration and segregation properties of brain networks in HIQ compared to standard IQ children, not only for the whole brain graph, but also for each hemispheric graph, and for the homotopic connectivity. Moreover, two profiles of HIQ children, homogenous and heterogeneous, based on the differences between the two main IQ subscales [verbal comprehension index (VCI) and perceptual reasoning index (PRI)], were compared. Brain network changes were more pronounced in the heterogeneous than in the homogeneous HIQ subgroups. Finally, we found significant correlations between the graph networks' changes and the full-scale IQ (FSIQ), as well as the subscales VCI and PRI. Specifically, the higher the FSIQ the greater was the brain organization modification in the whole brain, the left hemisphere, and the homotopic connectivity. These results shed new light on the relation between functional connectivity topology and high intelligence, as well as on different intelligence profiles.

Background: The progression of periodontitis, induced by polymicrobial dysbiosis, can be modified by systemic or environmental factors such as stress or anxiety affecting host response. The purpose of this study is to evaluate the potential associations between psychosocial factors scores or salivary cortisol levels with clinical periodontal parameters and bacterial environment in patients with periodontitis; (2) Methods: Subgingival microbiota was collected in two pathological and one healthy sites from thirty diseased patients (before/after scaling and root planing (SRP)) and from one healthy site from thirty control patients. Usual clinical periodontal parameters were recorded, and a saliva sample was harvested. Patients completed stress and anxiety self-assessment questionnaires. Cortisol concentrations were determined by ELISA and bacteria were identified by PCR; (3) Results: No correlation between salivary cortisol and the stress-anxiety self-declared was found (p > 0.05), but high concentrations of this molecule were associated positively and linearly with periodontal pocket depth (p = 0.04). It appeared that certain psychosocial stressors are associated with a modulation of the bacterial colonization of pockets of diseased group (before/after SRP), notably concerning Tannerella forsythia (p = 0.02), Porphyromonas gingivalis (p = 0.03), Fusobacterium nucleatum (p = 0.049) and Campylobacter rectus (p = 0.01). (4) Conclusion: This study reveals associations between bacteria colonization and psychosocial parameters in periodontitis that needs to be further investigated.

Background: Epinephrine effectiveness and safety are still questioned. It is well known that the effect of epinephrine varies depending on patients' rhythm and time to injection.Objective: We aimed to assess the association between epinephrine use during out-of-hospital cardiac arrest (OHCA) care and patient 30-day (D30) survival.Methods: Between 2011 and 2017, 27,008 OHCA patients were included from the French OHCA registry. We adjusted populations using a time-dependent propensity score matching. Analyses were stratified according to patient's first rhythm. After matching, 2837 pairs of patients with a shockable rhythm were created and 20,950 with a nonshockable rhythm.Results: Whatever the patient's rhythm (shockable or nonshockable), epinephrine use was associated with less D30 survival (odds ratio [OR] 0.508; 95% confidence interval [CI] 0.440-0.586] and OR 0.645; 95% CI 0.549-0.759, respectively). In shockable rhythms, on all outcomes, epinephrine use was deleterious. In nonshockable rhythms, no difference was observed regarding return of spontaneous circulation and survival at hospital admission. However, epinephrine use was associated with worse neurological prognosis (OR 0.646; 95% CI 0.549-0.759).Conclusions: In shockable and nonshockable rhythms, epinephrine does not seem to have any benefit on D30 survival. These results underscore the need to perform further studies to define the optimal conditions for using epinephrine in patients with OHCA.

Abstract Background Thanks to advancements in medical care, a majority of patients with sickle cell disease (SCD) worldwide live beyond 18 years of age, and therefore, patients initially followed in paediatric departments are then transferred to adult departments. This paediatric-adult care transition is a period with an increased risk of discontinuity of care and subsequent morbidity and mortality. During this period, the patient will have to manage new interlocutors and places of care, and personal issues related to the period of adolescence. To take into consideration all these aspects, an interesting approach is to use the whole system approach to the patient, as presented in the biopsychosocial approach. The aim of this trial is to evaluate the impact of the proposed biopsychosocial paediatric-adult transition programme. Methods The DREPADO study is a multicentre randomised control trial comparing a control group (Arm A) to an interventional group with a paediatric-adult transition programme based on a biopsychosocial approach (Arm B). To be included, patients should have the SS, SC, or Sβ form of sickle cell disease and be aged between 16 and 17 years. The randomisation in a 1:1 ratio assigns to Arm A or B. The primary outcome is the number of hospital admissions and emergencies for complications in the index hospital, in the 2 years after the first consultation in the adult department of care. Secondary outcomes consider the quality of life, but also include coping skills such as sense of self-efficacy and disease knowledge. To provide patient and parent knowledge and coping skills, the transition programme is composed of three axes: educational, psychological, and social, conducted individually and in groups. Discussion By providing self-care knowledge and coping skills related to SCD and therapeutics, helping empower patientsin relation to pain management and emotions, and facilitating the relationship to oneself, others, and care in Arm B of the DREPADO study, we believe that the morbidity and mortality of patients with SCD may be reduced after the proposed paediatric-adult transition programme. Trial registration ClinicalTrials.gov, ID: NCT03786549; registered on 17 December 2018; https://clinicaltrials.gov/ .

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In this paper, we tackle the problem of quantifying the closeness of a newly observed curve to a given sample of random functions, supposed to have been sampled from the same distribution. We define a probabilistic criterion for such a purpose, based on the marginal density functions of an underlying random process. For practical applications, a class of estimators based on the aggregation of multivariate density estimators is introduced and proved to be consistent. We illustrate the effectiveness of our estimators, as well as the practical usefulness of the proposed criterion, by applying our method to a dataset of real aircraft trajectories.

BACKGROUND: The exact overall incidence of sarcoma and sarcoma subtypes is not known. The objective of the present population-based study was to determine this incidence in a European region (Rhone-Alpes) of six million inhabitants, based on a central pathological review of the cases. METHODOLOGY/PRINCIPAL FINDINGS: From March 2005 to February 2007, pathology reports and tumor blocks were prospectively collected from the 158 pathologists of the Rhone-Alpes region. All diagnosed or suspected cases of sarcoma were collected, reviewed centrally, examined for molecular alterations and classified according to the 2002 World Health Organization classification. Of the 1287 patients screened during the study period, 748 met the criteria for inclusion in the study. The overall crude and world age-standardized incidence rates were respectively 6.2 and 4.8 per 100,000/year. Incidence rates for soft tissue, visceral and bone sarcomas were respectively 3.6, 2.0 and 0.6 per 100,000. The most frequent histological subtypes were gastrointestinal stromal tumor (18%; 1.1/100,000), unclassified sarcoma (16%; 1/100,000), liposarcoma (15%; 0.9/100,000) and leiomyosarcoma (11%; 0.7/100,000). CONCLUSIONS/SIGNIFICANCE: The observed incidence of sarcomas was higher than expected. This study is the first detailed investigation of the crude incidence of histological and molecular subtypes of sarcomas.

<b><i>Background:</i></b> Secondary prevention is inadequate in the first 2 years after stroke but what happens after that is less documented. The aim of this study was to assess the use and the adherence to preventive drugs 3 and 6 years after experiencing a transient ischemic attack (TIA) or an ischemic stroke (IS). <b><i>Methods:</i></b> The population study was from the AVC69 cohort (IS or TIA admitted in an emergency or stroke unit in the Rhône area, France, for an IS or a TIA during a 7-month period). Medication use was defined as ≥1 purchase during the studied year and adherence as Continuous Measure of Medication Acquisition ≥0.8 using the French medical insurance health care funding database. <b><i>Results:</i></b> The study population consisted of 210 patients at 3 years and 163 patients at 6 years. Medication use at 3 and 6 years was, respectively, 80.9 and 79.8% for antithrombotics, 69.1 and 66.3% for antihypertensives, 60.5 and 55.2% for statins and 48.6 and 46.6% for optimal treatment defined as the treatment achieved by the use of the 3 drugs. Adherence to each class was good at 3 years and tends to decrease at 6 years. <b><i>Conclusions:</i></b> More than one patient out of 2 do not use the optimal preventive treatment.

BACKGROUND: The European Society of Clinical Nutrition and Metabolism (ESPEN) has developed a consensus definition of malnutrition. This study aimed to determine the prevalence of malnutrition according to the ESPEN definition in otherwise healthy community-dwelling older women and to explore its value for predicting long-term mortality in this population. METHODS: This prospective population-based cohort study included 181 women (age ≥75 years) from a subsample of the EPIDémiologie de l'OStéoporose (EPIDOS) study participants from Toulouse. Inclusion criteria were the availability of the data on variables required to apply the ESPEN definition and survival after 7 years of follow-up. Primary outcome was mortality at 12-year follow-up; main covariates were malnutrition assessment according to the ESPEN consensus and its components (unintentional weight loss, BMI, and FFMI). Body composition was assessed by dual-energy X-ray absorptiometry at baseline and at 7-year follow-up. Kaplan-Meier survival curves and adjusted Cox regressions were performed. Analysis was adjusted for age, hypertension, diabetes mellitus, and coronary heart disease as potential confounders. RESULTS: Complete data were available for 179 of the 181 women in the EPIDOS-Toulouse cohort (83.1 ± 2.2 years) and 13 (7.3%) fulfilled the ESPEN definition for malnutrition at 7-year follow-up. Malnutrition was associated with increased risk of mortality (adjusted HR = 4.4 [95%CI: 1.7-11.3]). Among the ESPEN components, only BMI was associated with increased mortality (adjusted HR=0.6 [95%CI: 0.4-0.9]). CONCLUSIONS: Although malnutrition prevalence according to the ESPEN definition was relatively low (7.3%) in this sample of otherwise healthy community-dwelling older French women, malnutrition was associated with 4.4-fold higher mortality risk at 12-year follow-up.

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Background: Pre-eclampsia, the second most frequent direct source of maternal mortality, is a multisystem gestational disorder characterized by proteinuria and maternal hypertension after the 20th gestational week. Although the causes of pre-eclampsia are still discussed, research has suggested that the placenta has a central place in the pathogenesis of this disease. Moreover, current surveys indicated that periodontal disorders observed during the pregnancy and more particularly, periodontal pathogens could be link to the risk of pre-eclampsia. Objectives: This article aims to review recent studies focusing on periodontal conditions and pathogens associated with pre-eclampsia. Methods: The process followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. Results: Metabolic conditions, immunological changes, fluctuating progesterone and estrogen levels of the pregnant woman induce a dysbiosis of the oral microbiota and contribute to increase inflammation of periodontal tissues. Periodontal pathogens could diffuse through the bloodstream inducing a placenta inflammatory response as well as inflammatory molecules produced in response to periodontopathogens could migrate through the bloodstream leading to a placenta inflammatory response. Also, periodontopathogens can colonize the vaginal microbiota through the gastrointestinal tract or during oro-genital contacts. Conclusion: A cumulative bi-directional relationship between periodontal conditions, pathogens and the pre-eclampsia exists.

Dans les rhumatismes inflammatoires chroniques (RIC), l’efficacité des traitements n’est plus à démontrer. Toutefois, il existe un défaut d’adhésion médicamenteuse dans ces pathologies qui a pour conséquence une diminution de l’efficacité des traitements et une augmentation de l’activité de la maladie et des coûts de santé. Plusieurs facteurs de non-adhésion existent dont l’absence de continuité des soins entre la ville et l’hôpital et le faible niveau de connaissances des patients. Face à ce constat, nous nous sommes intéressés au parcours de soins des patients atteints de RIC afin d’optimiser leur accompagnement thérapeutique. L’objectif de ce travail de thèse était (1) auprès du patient atteint de RIC, d’évaluer son niveau de littératie en santé (c’est-à-dire la capacité du patient à accéder à l'information, la comprendre, l'évaluer et la communiquer ; ceci afin de promouvoir, maintenir et améliorer sa santé) et d’analyser le lien entre littératie et adhésion médicamenteuse ; (2) à l’hôpital, d’analyser l’intérêt des activités de pharmacie clinique centrées sur le patient avec prise en charge rhumatologique ; et (3) en ville, d’explorer les leviers et les freins des pharmaciens de ville et des médecins généralistes pour développer des collaborations dans les RIC. (1) Le lien entre l’adhésion médicamenteuse et la littératie en santé est peu étudié dans les pathologies chroniques. Dans les RIC, le niveau de littératie en santé des patients est insuffisant. Si l’association retrouvée entre la littératie et l'adhésion est modérée, les niveaux de littératie devraient néanmoins être détectés et pris en compte systématiquement pour adapter l'information aux patients. (2) A l’hôpital, les activités de pharmacie clinique déjà développées (analyse de prescriptions, conciliation des traitements médicamenteux (CTM)) ont montré leur efficacité. Face au difficile déploiement de la CTM pour un nombre de patients important, les entretiens pharmaceutiques ciblant l’historique médicamenteux menés à l’entrée des patients pourraient être une alternative à un processus complet de CTM dans des situations ciblées. (3) En ville, les pharmaciens officinaux sont motivés pour développer des entretiens pharmaceutiques pour les patients atteints de polyarthrite rhumatoïde (PR), ils ont évoqué néanmoins certains freins (nécessité de formation et financement). Les médecins généralistes pourraient s’impliquer davantage dans la prise en charge des patients atteints de PR, ils semblent privilégier un lien plus fort avec l’hôpital. Ces différents travaux exploratoires (patient, hôpital, ville) ont permis de concevoir de façon multidisciplinaire le protocole de l’étude REMEDIA (RhEumatoid arthritis MEDIcation Adherence). Il s’agit d’un essai clinique randomisé, contrôlé, en ouvert, à 2 bras parallèles, multicentrique dont l’objectif principal est d’évaluer l’impact de soins pharmaceutiques réalisés en collaboration médico-pharmaceutique ville-hôpital sur l’adhésion médicamenteuse aux traitements de fond des patients présentant une PR par rapport à une prise en charge habituelle sans accompagnement pharmaceutique et collaboration pluriprofessionnelle spécifique.

L'utilisation de nombreux médicaments est de plus en plus fréquente, notamment chez les personnes âgées. Cela a été attribuée à plusieurs facteurs, dont la prévalence élevée de la multi morbidité au sein de cette population ou encore l’élargissement de la palette thérapeutique avec toujours plus de recommandations de bonnes pratiques qui préconisent l'utilisation de plus d'un médicament dans la prise en charge des maladies chroniques, comme l'hypertension. Par ailleurs, la polymédication a été identifiée comme le principal déterminant de la prescription potentiellement inappropriée pour les populations âgées, elle est liée à de nombreuses conséquences cliniques négatives causées par les évènements indésirables liés aux médicaments, mais aussi à une baisse de l’efficacité des traitements ou encore, à une baisse de l’observance. Les implications sont également économiques. Elles sont liées au coût de traitements potentiellement inefficaces, auquel se rajoute le coût de la prise en charge des complications en cascade. Avec l’accélération du vieillissement de la population en France, comme dans le reste du monde, les enjeux liés à ce phénomène sont plus que jamais majeurs. Dans sa première étape, notre recherche s’est intéressée à la définition de la notion de polymédication dans la littérature pour faire le constat d’une grande variabilité en l’absence de tout consensus autour de celle-ci. Dans la seconde étape, l’objectif de notre recherche a été d’élaborer une intervention en utilisant une approche systématique guidée par les meilleures données probantes disponibles et la théorie adaptée, et impliquant les principaux intervenants dans la prescription et la délivrance de médicaments pour améliorer la prise en charge des personnes âgées exposés à la polymédication en soins primaires. Ainsi, une étude qualitative a été conçue et menée auprès des médecins généralistes et pharmaciens d’officine de la région Nouvelle-aquitaine. Modelée sur les recommandations du Medical Research Council’s (MRC) pour le développement et l'évaluation d'interventions complexes, notre approche s’est basée sur un modèle théorique combinant le cadre des domaines théoriques (Theoretical Domains Framework - TDF) et les techniques de changement de comportement (Behaviour Change Techniques - BCTs). L’analyse des résultats a permis d’identifier des mécanismes clés perçus par ces professionnels comme influençant leur prescription et leur délivrance d'une polymédication appropriée chez cette population âgée et de sélectionner cinq composantes (BCTs) à privilégier pour servir de base à la conception d’une intervention ciblant les médecins généralistes et les pharmaciens d’officine pour l’optimisation de la prise en charge de la polymédication des personnes âgées.

L’évaluation de l’impact organisationnel apporte des éléments complémentaires et éclairants aux évaluations cliniques et médico-économiques des innovations en santé. Des médicaments innovants, susceptibles d’induire un changement dans le parcours des patients sont ou vont être mis à disposition dans la prise en charge de l’hémophilie. L’objectif de ce travail de thèse était d’évaluer l’impact organisationnel d’une innovation sur le parcours de santé du patient hémophile. Pour cela, nous avons étudié l’évolution du parcours de santé du patient induite par les innovations thérapeutiques, par le passé. Puis, une modélisation du parcours actuel a été réalisée, afin d’évaluer l’impact des innovations, à venir, dans l’organisation de la prise en charge globale du patient. Ce travail a permis de réaliser une représentation schématique d’un parcours de santé complexe, et de mettre en œuvre une méthode quantitative d’analyse de décision multicritères pour évaluer un impact organisationnel. Ces données ont été complétées par la mise en place d’une étude qualitative pour intégrer le point de vue du patient et de leurs aidants à cette analyse.

Les facteurs de risque modifiables représentent des menaces émergentes pour la santé des populations mais aussi de réelles opportunités pour la prévention des maladies non transmissibles (MNT). Le rôle de la nutrition et de l’hygiène orale sur l’évolution des maladies parodontales (MP), maladies sentinelles des MNT, et sur les autres MNT est fondamental. Les applications mobiles (app) de santé représentent un levier actionnable qui peut améliorer le parcours de vie de l’usager en réduisant la survenue ou l’aggravation de facteurs de risque et donc des MNT. Elles sont très largement adoptées par le grand public. Or, il n’existe pas à ce jour de processus réglementé de la qualité des apps, de leur contenu et de leur impact sur la santé. Afin que les professionnels de santé puissent évaluer objectivement la qualité des app, l’échelle validée Mobile Apps Rating Scale (MARS) a été adaptée en langue française. Puis les apps disponibles sur le marché permettant à l’usager de maîtriser les facteurs de risque modifiables que sont la nutrition et l’hygiène orale ont été évaluées. Nos résultats ont tout d’abord souligné la faible quantité et l’hétérogénéité des apps accessibles en libre accès. La qualité des apps en lien avec la nutrition et l’hygiène orale est considérée comme satisfaisante par les professionnels de santé. Mais ce jugement est associé à l’insuffisance de référence à des normes et preuves scientifiques des contenus qui pénalise la crédibilité et la portée des connaissances affichées. A ce stade de l’expertise, même s’il est admis que les apps pourraient contribuer à favoriser la littératie et l’éducation à la santé en nutrition et en hygiène orale, des preuves en termes de contenus et de changement de comportement, sont recommandés.

L’hématologie pédiatrique est une spécialité médicale prenant en charge des patients de 0 à 18 ans, atteints de maladies malignes comme la leucémie aigüe ou de maladies non-malignes comme la drépanocytose, et traités par diverses thérapeutiques. L’adhésion thérapeutique constituée par l’adhésion médicamenteuse et non-médicamenteuse, c’est-à-dire l’adhésion aux thérapeutiques non-médicamenteuses, aux recommandations diététiques, aux rendez-vous médicaux et d’imagerie. L’adhésion thérapeutique est influencée par de nombreux facteurs et est non-optimale, en hématologie pédiatrique comme pour d’autres spécialités médicales. Toutefois, ses enjeux individuels et collectifs sont importants; c’est pourquoi il est essentiel d’améliorer cette adhésion. Actuellement, plusieurs interventions existent, mais elles sont rares en hématologie pédiatrique. La problématique de ce travail est la suivante : Alors que l’adhésion thérapeutique en hématologie pédiatrique a des enjeux importants, comment se fait-elle qu’elle soit non-optimale ? Pour cela deux études ont été menées. Elles ont utilisé la méthodologie qualitative en explorant les représentations et les vécus vis-à-vis de l’adhésion thérapeutique. La première étude a été menée auprès d’aidants et de professionnels de santé d’enfants ayant eu une allogreffe de cellules souches hématopoïétiques. Les résultats montrent d’une part que l’adhésion médicamenteuse et non-médicamenteuse semble influencer par des facteurs similaires. D’autre part, l’entité familiale a toute sa place dans la prise en charge et l’adhésion médicamenteuse et non-médicamenteuse. En plus de la sortie d’hospitalisation, l’adolescence et les maladies non-malignes sont exprimées par les professionnels de santé comme des facteurs majeurs de non-adhésion lors d’une allo-greffe. Pour comprendre l’adhésion thérapeutique là où elle semble plus problématique, la seconde étude de ce travail est menée auprès de patients adolescents et adultes atteints de drépanocytose hors allogreffe, d’aidants et de professionnels de santé. Les résultats de cette étude ont montré qu’au moment de l’adolescence a lieu une « double transition », la « transition d’état du patient » et la transition de soins pédiatrie-adulte. Cette « double transition » fait de l’adolescence un moment particulièrement « à risque » de rupture de soins, nécessitant donc une intervention d’amélioration de l’adhésion thérapeutique. Les résultats de cette étude ont montré que cette intervention doit être multifactorielle et centrée sur le patient, en intégrant les aidants. Pour répondre à ce besoin, l’étude interventionnelle DREPADO est proposée. Il s’agit d’un programme de transition en plusieurs axes, éducatif, psychologique et social, intégré à un essai clinique contrôlé randomisé. Ce programme de transition est comparé à la prise en charge habituelle du patient. L’objectif principal de cet essai clinique est d’améliorer l’état de santé des adolescents atteints de drépanocytose dans les deux années qui suivent leur transfert en secteur adulte (mesuré sur le nombre d’hospitalisation pour complication de la maladie). Actuellement DREPADO est mis en œuvre en France métropolitaine et DOM-TOM (début octobre 2020 : 4 centres ouverts et 22 patients inclus). Ce travail de thèse a permis de mieux comprendre la problématique de l’adhésion thérapeutique en hématologie pédiatrique et de proposer une étude interventionnelle adaptée.

Le microbiote commensal de la sphère buccale, écosystème complexe, joue un rôle essentiel dans le maintien de la santé orale et systémique. Une relation homéostatique s’établit entre l’hôte et son microbiote résidant. Une perturbation de cet équilibre finement régulé, appelée dysbiose, favorise l’apparition de pathologies bucco-dentaires. A l’intérieur de cette sphère, les espaces interdentaires sont des niches écologiques riches en microorganismes commensaux et pathogènes. Ils restent un défi majeur pour la garantie d’une prophylaxie individuelle de qualité, car inaccessibles aux méthodes traditionnelles de désorganisation du biofilm par voie mécanique et/ou chimique. Notre recherche porte sur l’évaluation clinique de l’efficacité de mesures de prophylaxie orale individuelle des espaces interdentaires chez l’adulte jeune. Elle s’articule autour de deux axes : la désorganisation mécanique du biofilm et l’action chimique. Ainsi, sont évaluées l’efficacité de l’utilisation de brossettes interdentaires calibrées et l’efficacité d’un dentifrice/bain de bouche à base d’extrait de feuille de Carica papaya contenant des flavonoïdes antioxydants, sur la réduction de l’inflammation du parodonte interdentaire cliniquement sain, objectivée par l’évolution du saignement gingival. De même est évaluée la mise en oeuvre de modules d’enseignement théoriques et pratiques auprès des étudiants nécessaires à la transmission d’une connaissance de qualité. En conclusion, ce travail apporte des recommandations pour une orientation novatrice de la valorisation et de l’efficience de la prophylaxie individuelle en santé bucco-dentaire.

Workplaces are increasingly advocated as promising places to promote a healthy lifestyle, but workers say they face many obstacles to sustain a healthy diet while at work. Among them, lack of time is one of the most frequently cited (Donaldson-Feilder et al., 2017; Grant, 2018; Karnaki, Zota, & Linos, 2009). Despite this, very little research has been dedicated to the investigation of the links between lack of time and workers’ eating habits during their workday. This thesis builds on this idea and investigates the time constraints associated with choice of lunch purchase location among French workers. It sets out to provide a better understanding of the nature and characteristics of these constraints, and to evaluate their consequences on workers’ lunchtime decisions. Three separate studies are presented in this manuscript. The first study examined French workers’ lunch habits. In the absence of available data, a survey instrument was developed specifically for this research and was used to collect data on the lunch practices of an online sample of 1139 French wage-earners. The study investigated the relationship between the workplace food environment, lunch habits, and time-related working conditions. The results revealed important differences across socioeconomic statuses in the availability of options in respondents’ workplace choice environments. Blue-collar workers (N=272) had less access to worksite cafeterias than white-collar workers (N=281) (23.2% vs 56.6%, p<0.001), and attended less places even when they had access (1.5 ±1.6 vs 2.3 ±1.6, p<0.001). These results partially replicated previous results from studies conducted in other countries (Raulio, Roos, & Prättälä, 2012). A multivariate analysis of the constraints, behaviors and factors of choice that could be related to lack of time in the survey highlighted four relevant dimensions within the context of lunchtime decisions at work: time demands, time-related determinants, autonomy, and lunch habits. The relationship between these dimensions and the attendance of food outlets for lunch was examined through logistic regressions for each type of food outlets, revealing a weak, but systematic and significant role of time dimensions in the attendance. The second study was designed to measure the willingness-to-pay of a sample of 121 workers for time-saving services in the context of lunchtime decisions, under controlled work-related time constraints. In this online experiment, the participants’ willingness-to-pay for meal delivery was elicited through a multiple-price list mechanism (Casini et al., 2019) using a 2 (time pressure) x 2 (deadline) experimental design. Drawing upon household production theory (Becker, 1965), differences in willingness to pay were hypothesized to reflect changes in the economic value of time, induced by time pressure and the existence of deadlines. Both were found to have significant influence over willingness to pay. The third study consisted in a field investigation, conducted in a company’s site in Grenoble, France, in January 2020. For a period of two weeks, 34 employees were asked to complete a daily questionnaire based on the first study’s surveying tool. These responses were linked to their actual choices of attended lunchtime location, as well as the amount of money spent for their lunch each day. This study allowed to evaluate intra-individual variability of attendance of food outlets in an identical environment for all respondents, and which was known to the researcher. Results of this case study suggest associations between time pressure and lunchtime decisions at work. This thesis highlights the complexity of the notion of time and of its examination in naturalistic as well as experimental settings. It proposes new methods of investigation and calls for greater attention to time-related working conditions, in particular when implementing interventions aimed at promoting healthy eating in the workplace

La carie dentaire est l’une des pathologies chronique d’origine multifactorielle la plus répandue dans le monde. Elle résulte d’un changement dans la composition de la plaque dentaire, avec un passage d’un état de symbiose à un état de dysbiose. Notre recherche clinique a permis de caractériser qualitativement et quantitativement, par réaction de polymérisation en chaine en temps réel, le microbiote interdentaire de 50 adolescents âgés de 15 à 17 ans en fonction du risque carieux. Parmi les 26 pathogènes analysées, aucune des bactéries cariogènes testées ne présentait de différences significatives selon le risque carieux. Seul 3 bactéries connues principalement pour leur implication dans les maladies parodontales (Streptococcus sobrinus, Eikenella corrodens et Tannerella forsythia) étaient significativement surexprimées chez les adolescents à risque carieux élevé. Ces 3 bactéries orales apparaissent comme des marqueurs prédictifs du risque carieux. Leur quantification interdentaire, permettrait d’améliorer les classifications de risque carieux, de prévenir les lésions carieuses débutantes et de stabiliser les lésions déjà établies. De plus, certains agents pathogènes oraux dont Eikenella corrodens et Tannerella forsythia sont connus pour être des facteurs de risques, des facteurs d’aggravation voir des facteurs déclencheurs de certaines maladies systémiques. Ainsi, la mise en place d’une prophylaxie interdentaire quotidienne via les brossettes interdentaires semble primordiale dès l’adolescence pour rétablir la symbiose du microbiote, prévenir les maladies orales et systémiques comme nous l’avons démontré chez des adultes âgés de 18 à 35 ans