How do patients and health professionals perceive the role of family members in the decision-making process regarding the choice of a dialysis method? A qualitative study

BackgroundTherapeutic decisions often seem to be the product of interaction between health professionals and patients alone. However, some realities make it essential to consider family members when examining care of patients, especially in the construction of therapeutic choices. Implementation of measures such as therapeutic patient education to make the patient an actor in his own healthcare, and the impact of disease on the patient's social and professional activities mean there is an important place for family members in a patient's care pathway. This study aims to examine the role of family members and the family environment in decision-making on treatment for patients with chronic kidney disease. It also analyzes how they contribute to the construction of patients’ choices on dialysis methods through their involvement in a therapeutic patient education program.MethodsThis study involved thirty-six semi-structured interviews: sixteen with patients and twenty with health professionals. Therapeutic patient education sessions, interactions and information exchanges between patients and health professionals, as well as participant behaviours, were also observed. Analysis was thematic.ResultsResults indicate that the factors influencing the patient's choice of dialysis methods include the family environment as the place where the disease is experienced, the need to maintain family ties, the advice provided by family members and their active participation in therapeutic patient education sessions and partnership between family members and health professionals in the decision-making process.ConclusionThis study highlights the reality of decision-making processes that can start from a non-hospital setting. Furthermore, it argues for greater consideration of the needs, values, and preferences of family members in mechanisms designed to promote patient participation in therapeutic decisions.     

Représentation des proximités entre médicaments sur des critères multiples

En evaluation médicale, on est souvent amené a comparer les propriétés de traitements voisins ou proposés pour les mêmes indications. Les méthodes habituelles, basées sur des analyses et des tests statistiques, sont mal adaptées à ce problème : elles nécessitatt des échantillons de grandes tailles et la comparaison se limite à quelques traitements et quelques critères. Nous proposons une méthode pour comparer des traitements sur des critères multiples. Ces critères peuvent être choisis par l'utilisateur dans une base de données qui regroupe la connaissance actuelle sur les médicaments étudiés : efficacité clinique, pharmacocinétique, coût, etc. Les différences ou les similitudes entre médicaments sont évaluées à partir d'indices de similarité ou de distance. En utilisant l'analyse en composantes principales sur tableaux de distance, des représentations graphiques des points medicaments sont ensuite construites pour faciliter l'interprétation. Sur ces graphiques, des proximités peuvent être interprétées comme des similitudes sur les critères de comparaison. Un prototype informatique utilisant cette méthode a été développé. II a été testé sur l'exemple de l'antibiothérapie en cas de maladie infectieuse.     

Aide à la décision de segmentation d'image par la théorie de Dempster-Shafer : application à une séquence d'images IRM

Le travail présenté clans cet article s'inscrit clans le cadre d'une collaboration avec le service radiologie de I'institut Calot de Berck sur Mer et Siemens. II vise à fournir une aide aux médecins pour le suivi des maladies de la colonne vertébrale. L'objectif est de reconstruire chaque vertébre du rachis lombaire à partir d'une série de coupes parallèles. À partir d'une segmentation initiale, on recherche une segmentation qui représente au mieux le contour anatomique de la vertébre, afin de donner aux médecins une proposition des points faisant réellement partie de la vèrtébre. La méthodologie est basée sur l'utilisation de la théorie de l'évidence pour fusionner les informations. Elle a l'avantage d'introduire la notion de doute entre les différents éléments étudiés. De plus, elle représente mieux la certitude sur la solution de segmentation calculée, et d'autre part elle permet de fusionner des données très hétérogènes. Nous présentons des résultats obtenus à la fois sur des données synthétiques et réelles en précisant les limitations de notre démarche. Nous terminons sur les perspectives à apporter, afin de rendre plus souple la modélisation de fusion employée. aide a la decision I segmentation l fusion de donnees 1 theorie de Dempster-Shafer 1 sequence d'images IRM     

Évaluation des régulateurs de débit passifs utilisés pour la perfusion intraveineuse

Objective

The aim of our study is to evaluate seven flow rate regulators (FRR) to assess the reliability of these devices compared to standard perfuser with roller clamp.

Study design

Each FRR was tested with 5% dextrose and 0.9% sodium chloride combined with three different theoretical flow rates (30, 80 and 250 ml/h). Accuracy was compared with the theoretical value. Repeatability of flow rate was assessed thanks to variance break-up.

Results

Each FFR exhibits at least one combination “flow rate–solution” significantly different of the theoretical flow rate. Exadrop^® was the least successful of the FFR according to the accuracy. This FFR had for each combination a flow rate different of the theoretical (mean error: −24.0 ml/h). Tutodrop^® was the most successful of the FFR according to the accuracy with five combinations comparable to the theoretical value (mean error: −1.2 ml/h). The standard perfuser with roller clamp, used without FRR, reported two combinations comparable to the theoretical value and showed lowest rates for repeatability.

Conclusion

Our study exhibits the poor performances of the FRR studied: according to expected flow regulation, the reported results demonstrate the lack of accuracy. Their only one value added compare to the roller clamp is to improve the repeatability of the flow rate.     

虚拟手术设计在双颌正颌手术中的精准性研究

目的评估虚拟手术设计在双颌正颌手术中的精准性,以期为临床提供参考。方法纳入需行双颌正颌手术的患者30例,利用CT数据和牙弓平面扫描数据建立复合颅骨模型,在Dolphin Imaging 11.7 Premium软件上模拟上颌骨LeFort I型骨切开术和双侧下颌支矢状骨劈开术,必要时行颏成形术,利用3D打印的手术导板将虚拟手术设计转移到术中。选择3个平面:眶耳平面(FHP)、面中平面(垂直于FHP且通过鼻根点)和冠状面(垂直于FHP且通过蝶鞍点)。选择6个标志点:上、下颌中切牙的近中接触点(UI、LI)以及上下颌第一磨牙的近中颊尖(U6-R、U6-L、L6-R、L6-L)。在虚拟手术模型和真实术后模型上测量选定标志点和对称平面之间的距离,并计算两模型之间的线性差异和总体平均线性差异(UI、LI、U6-R、U6-L、L6-R、L6-L分别与眶耳平面、面中平面和冠状面之间距离的平均差异)。确定由咬合平面、腭平面和下颌平面分别与眶耳平面和面中平面构成的角度值,并计算虚拟手术模型和真实术后模型之间的角度差异和总体平均角度差异。结果借助3D打印手术导板,虚拟手术设计被成功转移至实际手术中,所有患者术后对面型和咬合都很满意。虚拟与真实模型间的总体平均线性差异为0.81 mm(上颌骨0.71 mm,下颌骨0.91 mm);总体平均角度差异为0.95°(相对于眶耳平面的平均角度差异为1.10°,相对于面中平面的平均角度差异为0.83°)。结论虚拟手术设计有助于牙颌面畸形的诊断和治疗计划的制定,可以增加双颌正颌手术中骨块定位的精准性。     

Conditions de prise de décision d’admission ou de non admission en réanimation chirurgicale

Objectives

To describe the condition of the decision-making of admission and non-admission in intensive care unit.

Study design

Non-interventional observational cohort.

Patients and methods

Retrospective analysis of declarative terms of decision-making of patients admitted or denied in a surgical intensive care unit. The decision-making in the two admitted or not admitted troops was compared.

Results

That it is during a non-admission (149 decisions) or of an admission (149 decisions), the decision-making process was not very different. The instruction of the files was regarded as collegial in nearly 80% of the cases by the intensivist in load. The dialogue precedent the decision utilized generally several speakers but who could be residents. The participation of the patient and/or his close relations, as that of the ancillary medical personnel was rare. No person of confidence or anticipated directive was quoted. More than 50% of the decisions were taken within a time lower than 30 minutes. The decisions of non-admission were considered to be more difficult than the decisions of admission. Traceability was not automatically given.

Conclusion

Thus, this study shows that in its current form the intensivists of the service estimate that in the majority of the cases the instruction of the files was collegial. However, the conditions of seniorisation of the decision, the collection of opinion of the patient and/or his close relations and the traceability are tracks of improvement to be implemented in certain circumstances of admission or non-admission.