PIXE (Particle Induced X-ray Emission) et PIGE (Particle Induced Gamma-ray Emission) sont des méthodes d’analyse par faisceau d’ions, multiélémentaires et non destructives. Elles sont basées sur la détection des rayons X et gamma caractéristiques émis suite à l’interaction de particules chargées avec la matière. La méthode PIXE permet de quantifier les éléments de numéro atomique Z>11 avec une limite de détection au niveau du μg/g (ppm). Les rayons X émis par les éléments légers (Z<11) sont fortement atténués par la matière, limitant la sensibilité de PIXE pour cette gamme de numéro atomique. Ces éléments peuvent légers être analysés, simultanément, par la méthode PIGE. Un des nombreux avantages de la méthode PIXE/PIGE est sa capacité à pouvoir effectuer différentes analyses (cartographie des concentrations, analyse en profondeur, objets précieux). Il est possible d’analyser des échantillons aussi bien homogènes que non homogènes. La méthode PIXE à haute énergie a été développée au cyclotron ARRONAX avec des faisceaux de particules pouvant atteindre 70 MeV. La technique PIXE à haute énergie permet, notamment, l’analyse d’échantillons épais et limite les risques d’endommagement. Premièrement la plateforme PIXE/PIGE à haute énergie est décrite. Ensuite une étude de la méthode PIGE à haute énergie ainsi que la mise en place d’un protocole de mesure de sections efficaces sont présentées. Pour finir les méthodes mises en place ainsi que les résultats obtenus lors de l’analyse de plusieurs types d’échantillons non homogènes (multicouches et granulaires) sont présentés et discutés. / Particle Induced X-ray Emission (PIXE) and Particle Induced Gamma-ray Emission (PIGE) are multi-elemental and non-destructives techniques. They are based on the detection of characteristic X-ray and gamma emission induced by the interaction of accelerated charged particles with matter. Elements with an atomic number Z> 11 can be quantified reaching a limit of detection in the order of μg/g (ppm). X-rays from light elements are strongly attenuate by matter. Therefore, PIXE shows little sensitivity for lights elements. Those elements are analyzed simultaneously using PIGE. One of the benefits of PIXE/PIGE is its ability to perform analysis with different requirement (elemental concentration mapping, in-depth analysis, valuable objects). Homogeneous and non-homogenous samples can be studied thanks to PIXE/PIGE. High energy PIXE (HEPIXE) has been developed at the ARRONAX cyclotron using particles beams up to 70 MeV. Thus analysis of thick samples is achievable using HEPIXE. Using high energy beams can also reduce the risk of damaging the sample. First of all, the high energy PIXE/PIGE platform develop at ARRONAX is described. Then the results given by high energy PIGE analysis and the experimental procedure for gamma emission cross section measurements are discussed. Finally, the methods developed and the results obtained during the analysis of inhomogeneous samples (multi-layer and granular samples) are presented and discussed.

Background: Brazil has high frequency of inappropriate obstetric practices and cesarean sections. This procedure may be associated with increased maternal and perinatal morbidity. Objective: to describe practices and interventions used during labor and childbirth and factors associated with such practices and to evaluate the impact of mode of delivery in breastfeeding incentive practices and in neonatal and maternal complications. Methods: A Cohort study was conducted, between june 2015 and april 2017, at the 11 maternity hospitals in Sergipe with 768 puerperal women, interviewed in the first 24 hours after delivery, 45-60 days and 6-8 months after delivery. The associations between good practices and interventions used during labor and delivery with exposure variables were described by simple frequencies, percentages, crude and adjusted odds ratios (ORA) with the confidence interval and the association between breastfeeding incentive practices, neonatal and maternal, both short term and late complications and the exposure variables were evaluated by the relative risk (95% IC) and the Fisher exact test. Results: were fed 10.6% of women and 27.8% moved during labor; non-pharmacological measures for pain relief were performed in 26.1%; the partograph was filled in 39.4% of the charts and the companion was present in 40.6% of deliveries. Oxytocin, amniotomy and analgesia occurred in 59.1%, 49.3% and 4.2% of women, respectively. The delivery occurred in the lithotomy position in 95.2% of the cases, there was episiotomy in 43.9% and Kristeller's maneuver in 31.7%. The factors most associated with cesarean section were the private health sector (ORA = 4.27,95% CI: 2.44-7.47), had higher education (ORA = 4.54,95%CI 2.56 -8.3) and high obstetric risk (ORA = 1.9,95%CI: 1.31-2.74). Private-sector users had a greater presence of the companion (ORA = 2.12,95% CI:1.18-3.79) and analgesia (ORA = 4.96,95% CI:1.7-14.5). The C-section delivery resulted in less skin-to-skin contact immediately after delivery (intrapartum c-section: RR=0.18;95%CI:0.1-0.31 and elective c-section: RR=0.36;95%CI:0.27-0.47) and less breastfeeding within one hour of birth (intrapartum C-section: RR=0.43;95%CI:0.29-0.63 and elective C-section: RR=0.44;95%CI:0.33-0.59). Newborns from elective c-section were less frequently breastfed in the delivery room (RR=0.42;95%CI:0.2-0.88) and stayed less in rooming- in (RR=0.85;95%CI:0.77-0.95). Women who were submitted to intrapartum c-section had greater risk of early complications (RR=1.3;95%CI:1.04-1.64; p=0.037) and sexual dysfunction (RR=1.68;95%CI:1.14-2.48; p=0.027). There was no difference in the frequency of neonatal complications, urinary incontinence and depression according to the mode of delivery. Conclusions: good obstetric practices are poorly performed and unnecessary interventions are frequent, and the factors most associated with cesarean delivery have been the private health sector, higher schooling and high obstetric risk. C-section was negatively associated to breastfeeding incentive practices. C-section after labor increased the risk of early maternal complications and sexual dysfunction, six to eight months after delivery. / Introdução: No Brasil, verifica-se elevada frequência de práticas obstétricas inadequadas e de cesáreas. Este procedimento pode associar-se a aumento de risco de morbidade materna e neonatal. Objetivo: descrever as práticas utilizadas durante o trabalho de parto e parto e fatores associados e avaliar práticas de incentivo à amamentação, complicações neonatais e maternas precoces e tardias segundo tipo de parto. Pacientes e Métodos: estudo tipo coorte, no período de junho de 2015 a abril e 2016, nas 11 maternidades de Sergipe, com 768 puérperas entrevistadas após 6h do parto, 45 a 60 dias e 6 a 8 meses após o parto e análise de dados do prontuário das puérperas e dos recém-nascidos. As associações entre as boas práticas e intervenções utilizadas durante o trabalho de parto e parto com as variáveis de exposição foram descritas em frequências simples, percentuais, razões de chances brutas (OR) e ajustadas (ORA) com o intervalo de confiança e as associações entre as práticas de incentivo à amamentação, as complicações neonatais e maternas precoces e tardias e as variáveis de exposição foram descrias por risco relativo (IC=95%) e pelo teste exato de Fisher. Resultados: alimentaram-se 10,6% das mulheres e 27,8% movimentaram-se durante o trabalho de parto; medidas não farmacológicas para alívio da dor foram realizadas em 26,1%; o partograma estava preenchido em 39,4% dos prontuários e o acompanhante esteve presente em 40,6% dos partos. Ocitocina, amniotomia e analgesia ocorreram em 59,1%, 49,3% e 4,2% das mulheres, respectivamente. O parto ocorreu na posição de litotomia em 95,2% dos casos, houve episiotomia em 43,9% e manobra de Kristeller em 31,7%. Os fatores mais associados à cesárea foram ser do setor privado de saúde (ORA=4,27;95%CI:2,44-7,47), ter maior escolaridade (ORA=4,54;95%CI:2,56-8,3) e alto risco obstétrico (ORA=1,9;95%CI:1,31-2,74). Usuárias do setor privado tiveram maior presença do acompanhante (ORA=2,12;95%CI:1,18-3,79) e analgesia (ORA=4,96;95%CI: 1,7-14,5). Os recém-nascidos de puérperas que se submeteram a cesárea tiveram menor frequência de contato pele a pele com suas mães imediatamente após o parto (cesárea intraparto: RR=0,18;95%CI:0,1-0,31 e cesárea eletiva: RR=0,36;95%CI:0,27-0,47) e mamaram menos na primeira hora de vida (cesárea intraparto: RR=0,43;95%CI:0,29-0,63 e cesárea eletiva: RR=0,44; 95%CI:0,33-0,59). Recém-nascidos de cesárea eletiva foram menos frequentemente colocados para mamar na sala de parto (RR=0,42;95%CI:0,2-0,88) e ficaram em menor frequência em alojamento conjunto (RR=0,85;95%CI:0,77-0,95). As mulheres submetidas a cesárea intraparto tiveram maior risco de complicações precoces (RR=1,3;95%CI:1,04-1,64; p=0,037) e de disfunção sexual (RR=1,68;95%CI:1,14-2,48; p=0,027). Não houve diferença nas frequências de complicações neonatais, incontinência urinária e de depressão segundo tipo de parto. Conclusões: boas práticas obstétricas são pouco utilizadas e intervenções desnecessárias são frequentes e os fatores mais associados à operação cesariana foram ser do setor privado de saúde, ter maior escolaridade e alto risco obstétrico. A cesárea associou-se negativamente às práticas de incentivo à amamentação. A cesárea após trabalho de parto associou-se a maior risco de complicações maternas precoces e a disfunção sexual seis a oito meses pós-parto. / São Cristóvão, SE

Submitted by Renata Lopes (renatasil82@gmail.com) on 2018-07-20T15:48:26Z No. of bitstreams: 1 mateusclovisdesouzacosta.pdf: 2901250 bytes, checksum: 8af7b5baf07040748804059716275b90 (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2018-09-03T16:18:14Z (GMT) No. of bitstreams: 1 mateusclovisdesouzacosta.pdf: 2901250 bytes, checksum: 8af7b5baf07040748804059716275b90 (MD5) / Made available in DSpace on 2018-09-03T16:18:14Z (GMT). No. of bitstreams: 1 mateusclovisdesouzacosta.pdf: 2901250 bytes, checksum: 8af7b5baf07040748804059716275b90 (MD5) Previous issue date: 2018-06-29 / A tese tem por objetivo estimular a discussão, por meio de três estudos independentes, sobre os impactos econômico-financeiros das cesarianas desnecessárias no Brasil, estimando os custos, propondo estratégias para redução do procedimento quando desnecessário e investigando a hipótese de que obstetras induzem a demanda por cesariana. A epidemia de cesariana é um problema de saúde pública que onera financeiramente os sistemas público e privado de saúde e que desperdiça recursos que poderiam ser utilizados de maneira mais eficiente. O primeiro estudo estima o custo da cesariana desnecessária no Brasil. Tendo como base dados da pesquisa Nascer no Brasil, DATASUS, SIGTAP, UNIDAS e estimando por regressão logística, foi possível concluir que o custo da cesariana desnecessária é no mínimo R$ 10,5 milhões no setor público e R$ 17,6 milhões no setor privado, o que representa 1,6% a 6% dos gastos públicos com cesariana. O segundo estudo propõe mudança no modelo de assistência obstétrica que envolve alteração na jornada de trabalho, na forma de remuneração e no aumento da punição aos obstetras, como forma de inibir a prática de indução de demanda. A partir de referências na literatura, dados da AMB, DATASUS e da pesquisa Nascer no Brasil, atribuíram-se métricas para a utilidade do obstetra e utilizou-se uma simulação para sensibilizar as métricas de remuneração e ética profissional, permitindo observar o efeito na decisão do obstetra. Concluise que remunerar obstetras com salário fixo, introduzi-los na jornada de trabalho sob regime plantão e em equipe colaborativa e aumentar da punição pela prática antiética de indução de demanda são ações que podem somar a outros esforços para o combate à epidemia da cirurgia no Brasil. O terceiro estudo investigou a hipótese de indução de demanda por cesariana no Brasil. Com dados do DATASUS, CFM e da pesquisa Nascer no Brasil, foi possível descrever comportamentos da assistência obstétrica brasileira no que diz respeito ao volume de nascimentos por hora, processos éticos contra obstetras e a probabilidade de haver cesariana sem indicação clínica. As conclusões são de que o volume de nascimentos por cesariana no Brasil supera aos do parto vaginal em horários comerciais, que ginecologia-obstetrícia é a especialidade com maior volume processos ético-disciplinares no CFM, que a maioria das decisões dos CRM’s/CFM tem caráter reservado e que quando o trabalho de parto de mulheres de risco habitual, que se iniciou espontaneamente, é acompanhando só por médico obstetra, ocorre em dia de semana e o obstetra decidiu a via de nascimento no final da gestação, houve maior chance de cesariana, levando à suspeita da prática de medicina defensiva. / This thesis aims to stimulate the discussion, by means of three independent studies, of the economic-financial impacts of unnecessary cesarean sections in Brazil, estimating the costs, suggesting strategies to decrease this procedure when unnecessary and investigating the hypothesis that obstetricians induces the demand for this surgery. The cesarean sections epidemic is a public health issue that financially burdens both public and private health systems, wasting resources that could be used in a more efficient way. The first study estimates the cost of unnecessary cesarean section in Brazil. Basing on Birth in Brazil research, DATASUS, SIGTAP and UNIDAS data and estimating by logistic regression, it was possible to conclude that the cost of unnecessary cesarean sections is at least R$ 10,5 million in the public sector and R$ 17,6 million in the private sector, representing 1.6% to 6 % of public expenses with this procedure. The second study proposes a change in the obstetric assistance model that involves alteration in the working hours, in the remuneration forms and the increase of penalties to obstetricians, as way to inhibit the practice of demand induction. Starting from literature references, AMB, DATASUS and Birth in Brazil research data, a metric for the obstetrician utility has been attributed and a simulation to sensetize the metrics for remuneration and professional ethics has been used, allowing to observe the effects in the obstetrician decisions. It was concluded that remunerating obstetricians with a fixed wage, puting them in a on call working journey with a collaborative team and increasing penalties for the unethical practice of demand induction are means that can be added to other efforts to fight the epidemic of this surgery in Brazil. The third study has investigated the hypothesis of demand induction for cesarean sections in Brazil. With DATASUS, CFM and Birth in Brazil research data, it was possible to describe behaviors of Brazilian obstetric assistance regarding the amount of births per hour, ethical law suits against obstetricians and the probability of a cesarean section without clinical indication. The conclusions are that the amount of births by cesarean section in Brazil exceeds those of vaginal delivery during business hours, that gynecology-obstetrics is the specialty with the greatest amount of ethical-disciplinary law suits in the CFM, that most CRMs/CFM decisions have a reserved character and that when the labor of women on habitual risk, which started spontaneously, occurs on weekdays and is followed only by an obstetrician, and the obstetrician decided the birth path at the end of gestation, there was a higher chance of a cesarean section, leading to the suspicion of the defensive medicine practice.

Rotating blades, which are the most critical components of any turbo-machinery, need to be designed to withstand forced vibrations due to accidental tip rub impact against inner surface of casing. These vibrations are typically dependent on operating conditions and geometric parameters. In the current study, a rotor test rig with a maximum tip speed capability of 144 km/hr has been developed for studying the dynamic behavior of representative jet engine compressor blades actuated by the closure of clearance between the tip of a given rotating blade and a sector of the inner lining of the casing. Ten different blade profiles are chosen in the present research. The blades are obtained by lofting NACA GOE123 airfoil cross-section along different stacking axes. Rotor test rigs which simulate transient dynamic events require high frequency data acquisition systems like slip ring arrangement or telemetric transmission. While slip rings introduce noise into the signal, the telemetric transmission works out to be rather expensive. To circumvent the stated shortcomings of data acquisition systems, a novel rotor-mounted data acquisition system has been implemented here which captures dynamic strains in vibrating blades during operation. The current data acquisition system can store data for duration of five seconds with a sampling rate of 35 kHz. It has been calibrated with four standard tests, and provides a simple and efficient mode of data capturing. Three blades with airfoil sections (a flat beam-type blade of uniform rectangular cross-section, a blade with twisted cross-sections stacked along a straight line, and a blade similar to the latter but with a curved stacking axis) are tested under controlled rub conditions at four different speeds. The maximum test speed is restricted to 800 rpm for reasons of safety although the set-up is designed to operate up to a maximum speed of 2000 rpm. For each of the rotor speeds, a blade is tested for three to four different stagger angles in the range of 0o-30o. By plotting the RMS values of measured dynamic responses with respect to stagger angle for a given rotor speed, it has been observed, perhaps for the first time in published literature, that a stagger angle of around 20o yields the maximum RMS value of strain response. A major objective of the current study has been to utilize the data generated in the tip rub impact tests for validating a predictive numerical model of the test set-up using explicit finite element analysis. To this end, a finite element model of the rotor rig inclusive of a rotor with two blades and the static frame structure is developed and analyzed using an explicit LS-DYNA solver. This model is calibrated with the test results of the three blade designs described above. In particular, it has been shown that the frequency contents of the measured dynamic strain responses agree quite well with frequencies obtained from the numerically computed responses. It has been found in the experimental responses that a given blade vibrates with two main frequencies: one corresponding to the first natural frequency of the rotor-blade system during the tip-rubbing phase (which lasts until the blade tip is in contact with the rub element which is a sector of the circular casing), and another corresponding to the first natural frequency of the blade when it vibrates freely without its tip being in contact with the rub-liner of the casing. A shortcoming of the current modeling approach is its inability to realistically represent the damping behaviors observed in the tests. For reasons of computational efficiency and consistent with the fact that there was no perceptible damage in the tested blades, an elastic constitutive behavior is specified for the blades, while the sacrificial PVC rub-liner is assumed to behave elasto-plastically. A limited study has also been carried out by assigning an elasto-plastic constitutive model to one of the blades previously represented with elastic properties only, and although incipient yielding is observed in a highly localized region at the tip of a blade (which can also be a numerical artifact), the responses under the two material behavior considerations (i.e. elastic and elasto-plastic) are found to be nearly same. Finally, this validated modeling approach is applied to the study of blades of ten distinct geometric profiles (including the three configurations already considered) at a speed of 800 rpm and the resonant speed of a given blade. Comparisons are made between the relevant responses (such as time-histories of root strain, shaft torque, blade axial displacement, bearing load and rub force) of nine blades with airfoil cross-sections (leaving aside the results for the first blade of rectangular cross-section which is only of academic interest). Based on this study, of all the blade designs, it has been found that the curve-stacked airfoils exhibit better ‘Rub-tolerant’ behavior. Both experimental and simulation results have predominantly proven the fact that adding curvature to a straight stacked blade through curve-stacked or bow result in reducing the rub induced vibration. While sweep and bow provide some aerodynamic advantages, they are not much helpful in containing the vibrations to a sustainable extent.

La Communauté française décide en concertation avec la Région bruxelloise et la Région wallonne, de financer un Centre d’Epidémiologie Périnatale (CEpiP). Les Communautés et Régions chargent le CEpiP de les assister dans la vérification, le remplissage et la correction des certificats concernant les naissances à partir du 1er janvier 2008. Le CEpiP est également chargé d’encoder les certificats bruxellois, les certificats wallons étant toujours encodés par un sous-traitant.<p>Un problème souvent rencontré dans l’analyse des certificats de naissance est la présence de données manquantes. Des informations manquaient sur 64.0% des certificats bruxellois de janvier 2008 (situation de base). Le renforcement de l’enregistrement par le CEpiP durant l’année 2008 est lié à une diminution des informations manquantes sur les certificats initiaux (à la sortie des maternités et services d’état civil) après la première et la deuxième année d’enregistrement :20,8% et 19,5% des naissances en décembre 2008 et 2009 respectivement. Le taux résiduel de données manquantes après correction grâce aux listes envoyées aux maternités et services d’Etat civil est faible. En particulier, la nationalité d’origine des parents était souvent manquante, jusqu’à 35% à Bruxelles (données non publiées), et ce taux est passé à 2.6% en 2008 et 0.1% en 2009. Certaines données manquantes ne sont pas distribuées de façon équivalente selon la nationalité de la mère, même après correction. Les mères d’origine sub-saharienne ont les taux de remplissage les moins élevés. Enfin, le taux de mort-nés a augmenté par rapport aux données de 2007, au profit des mort-nés avant l’âge de 28 semaines, et suggère une amélioration de l’enregistrement suite au renforcement de l’information.<p>Les données concernant l’indice de masse corporelle des patientes sont donc relevées depuis 2009 pour l’ensemble des mères qui accouchent en Belgique. L’obésité maternelle et l’immigration sont en augmentation en Belgique, et ont été rarement étudiées au travers d’études de population sur les certificats de naissance. Des études ont pourtant montré que ces mères étaient à risque de complications périnatales, comme la césarienne ou la mortalité périnatale. L’obésité et l’immigration ont en commun le fait qu’elles recouvrent des réalités médicales, sociales et relationnelles face au personnel soignant, qui les mettent à risque de complications périnatales.<p>Des différences en termes de complications obstétricales et néonatales entre populations immigrantes et autochtones ont été observées en Belgique et dans d’autres pays, mais elles sont encore mal comprises. <p>Dans un premier travail d’analyse, nous avons évalué les taux de mortalité périnatale chez les mères immigrantes, en fonction du fait qu’elles étaient naturalisées ou non.<p>Le taux de mortalité périnatale est globalement plus élevé chez les mères immigrantes (8.6‰) que non-immigrantes (6.4‰).<p>Le taux de mortalité périnatale est globalement plus élevé chez les mères non naturalisées (10.3‰) que chez les mères naturalisées (6.1‰).<p>Le taux de mortalité périnatale varie selon l’origine des mères, mais dans chaque sous-groupe étudié, les mères non naturalisées ont un taux plus élevé de mortalité périnatale.<p><p>Des études ont successivement montré davantage, ou moins de césariennes chez les mères immigrantes. Peu de facteurs confondants étaient généralement pris en compte. Dans un second travail d’analyse, nous avons comparé les taux de césarienne dans plusieurs sous-groupes de nationalités.<p>Les taux de césarienne varient selon les sous-groupes de nationalités. Les mères originaires d’Afrique sub-saharienne ont un odds ratio ajusté pour la césarienne de 2.06 (1.62-2.63) en comparaison aux mères belges. L’odds ratio ajusté n’est plus statistiquement significatif après introduction des variables anthropométriques dans le modèle multivariable pour les mères d’Europe de l’Est, et après introduction des interventions médicales pour les mères du Maghreb.<p><p>Peu d’études ont analysé la relation entre l’obésité maternelle et les complications néonatales, et la plupart de ces études n’ont pas ajusté leurs résultats pour plusieurs variables confondantes. Nous avons eu pour but dans un troisième travail d’analyse d’étudier la relation entre l’obésité maternelle et les paramètres néonatals, en tenant compte du type de travail (induit ou spontané) et du type d’accouchement (césarienne ou voie basse). Les enfants de mères obèses ont un excès de 38% d’admission en centre néonatal après ajustement pour toutes les caractéristiques du modèle multivariable (intervalle de confiance à 95% :1.22-1.56) ;les enfants de mères obèses en travail spontané et induit ont également un excès de risque de 45% (1.21-1.73) et 34% (1.10-1.63) respectivement, alors qu’après une césarienne programmée l’excès de risque est de 18% (0.86-1.63) et non statistiquement significatif.<p>Les enfants de mères obèses ont un excès de 31% de taux d’Apgar à 1 minute inférieur à 7, après ajustement pour toutes les caractéristiques du modèle mutivariable (1.15-1.49) ;les enfants de mères obèses en travail spontané et induit ont également un excès de risque de 26% (1.04-1.52) et 38% (1.12-1.69) respectivement, alors qu’après une césarienne programmée l’excès de risque est de 50% (0.96-2.36) et non statistiquement significatif.<p><p>In 2008, a Centre for Perinatal Epidemiology was created inter alia to assist the Health Departments of Brussels-Capital City Region and the French Community to check birth certificates. A problem repeatedly reported in birth certificate data is the presence of missing data. The purpose of this study is to assess the changes brought by the Centre in terms of completeness of data registration for the entire population and according to immigration status. Reinforcement of data collection was associated with a decrease of missing information. The residual missing data rate was very low. Education level and employment status were missing more often in immigrant mothers compared to Belgian natives both in 2008 and 2009. Mothers from Sub-Saharan Africa had the highest missing rate of socio-economic data. The stillbirth rate increased from 4.6‰ in 2007 to 8.2‰ in 2009. All twin pairs were identified, but early loss of a co-twin before 22 weeks was rarely reported.<p>Differences in neonatal mortality among immigrants have been documented in Belgium and elsewhere, and these disparities are poorly understood. Our objective was to compare perinatal mortality rates in immigrant mothers according to citizenship status. Perinatal mortality rate varied according to the origin of the mother and her naturalization status: among immigrants, non-naturalized immigrants had a higher incidence of perinatal mortality (10.3‰) than their naturalized counterparts (6.1‰). In a country with a high frequency of naturalization, and universal access to health care, naturalized immigrant mothers experience less perinatal mortality than their not naturalized counterparts. <p>Our second objective was to provide insight into the differential effect of immigration on cesarean section rates, using Robson classification. Cesarean section rates currently vary between Robson categories in immigrant subgroups. Immigrant mothers from Sub-Saharan Africa with a term, singleton infant in cephalic position, without previous cesarean section, appear to carry the highest burden.<p>If it is well known that obesity increases morbidity for both mother and fetus and is associated with a variety of adverse reproductive outcomes, few studies have assessed the relation between obesity and neonatal outcomes. This is the aim of the last study, after taking into account type of labor and delivery, as well as social, medical and hospital characteristics in a population-based analysis. Neonatal admission to intensive care and low Apgar scores were more likely to occur in infants from obese mothers, both after spontaneous and <p> / Doctorat en Sciences médicales / info:eu-repo/semantics/nonPublished

La césarienne est une intervention obstétricale majeure qui peut sauver la vie de la mère et de l’enfant. En Afrique sub-saharienne, il persiste une grande inégalité d’accès à la césarienne et une grande variation des pratiques autour des indications d’intervention. D’un côté, des barrières financières, géographiques, culturelles privent des femmes d’une intervention qui peut sauver leur vie. De l’autre, la pratique grandissante de césariennes sans indication médicale, dans un contexte de mauvaise qualité de soins, entraine une sur-morbidité et mortalité iatrogènes et évitables. <p>L’objectif de notre thèse est de contribuer à une meilleure connaissance des déterminants d’une césarienne de qualité et de montrer comment en situation réelle (cas d’un district urbain au Burkina Faso) on peut agir sur ces déterminants pour améliorer la qualité des césariennes.<p>Dans le cadre d’un projet multidisciplinaire (santé publique, mobilisation politique et sociale, anthropologie) d’Amélioration de la QUalité et de l’Accès aux Soins Obstétricaux d’Urgence - le projet AQUASOU (2003-2006) - nous avons pu mettre en œuvre des activités visant à améliorer l’accès à une césarienne de qualité dans le district du Secteur 30) à Ouagadougou, Burkina Faso. Nous avons mené une étude Avant-Après et utilisé des méthodes d’évaluation mixtes quantitatives et qualitatives pour comprendre dans quelle mesure et comment ce type d’approche globale améliore la qualité de la césarienne. Nous avons utilisé le cadre d’analyse de Dujardin et Delvaux (1998) qui présente les différents déterminants de la césarienne pour organiser et structurer nos résultats. Cette expérience s’étant déroulée dans le cadre d’un projet pilote nous avons également évalué le degré de pérennité du projet AQUASOU quatre ans après sa clôture officielle et analysé sa diffusion au niveau région et national.<p>Le cadre d’analyse de la césarienne de qualité avec ses quatre piliers (Accès, Diagnostic, Procédure, Soins postopératoires) a permis d’aller au-delà de la simple évaluation de la qualité technique de l’acte césarienne. Il a structuré l’analyse des différentes barrières à l’accès à la césarienne comme par exemple l’acceptabilité des services par la population et le coût de la prise en charge. <p>L’analyse des discours des femmes césarisées a mis en lumière le sentiment de culpabilité des femmes d’avoir eu une césarienne - ne pas avoir été « une bonne mère » capable d’accoucher normalement. Les questionnements sur la récurrence de la césarienne pour les prochaines grossesses, les dépenses élevées à la charge du ménage, la fatigue physique et les complications médicales possibles après l’opération mettent la femme dans une situation de vulnérabilités plurielles au sein de son couple et de sa famille.<p>L’évaluation du système de partage des coûts pour les urgences obstétricales mis en place en 2005 dans le district du Secteur 30 a montré qu’il était possible de mobiliser les collectivités locales de la ville et des communes rurales pour la santé des femmes. La levée des barrières financières a pu bénéficier à la fois aux femmes du milieu urbain et rural mais l’écart d’utilisation des services entre le milieu de résidence n’a pas été comblé et cela confirme l’importance des barrières géographiques (distance, route impraticable pendant la saison des pluies, manque de moyen de transport) et socioculturelles.<p>L’étude sur le rôle des audits cliniques ou revues de cas dans l’amélioration de la qualité des soins a montré que les soignants avaient une bonne connaissance du but de l'audit et qu’ils classaient l'audit comme le premier facteur de changement dans leur pratique, comparé aux staffs matinaux, aux formations et aux guides cliniques. Cependant, l’institutionnalisation des audits se révèle difficile dans un contexte de manque de ressources qui affecte les conditions de travail et dans un environnement peu favorable à la remise en question de sa pratique professionnelle.<p>L’évaluation de la pérennité du projet pilote quatre ans après la fin du soutien financier et technique montre que les bénéfices pour la population sont toujours là en terme d’accessibilité à la césarienne :coûts directs pour les ménages de 5000 FCFA (US $ 9.8), qualité des soins maintenue avec une diminution de la mortalité périnatale précoce pour les accouchements par césarienne de 3,6% en 2004 à 1,8% en 2008.<p> \ / Doctorat en Sciences de la santé publique / info:eu-repo/semantics/nonPublished

Doctorat en sciences, Spécialisation physique / info:eu-repo/semantics/nonPublished

L'utilisation de protons dans le traitement du cancer est largement reconnue grâce au parcours fini des protons dans la matière. Pour la planification du traitement par protons, l'incertitude dans la détermination de la longueur du parcours des protons provient principalement de l'inexactitude dans la conversion des unités Hounsfield (obtenues à partir de tomographie rayons X) en pouvoir d'arrêt des protons. La tomographie proton (pCT) est une solution attrayante car cette modalité reconstruit directement la carte du pouvoir d'arrêt relatif à l'eau (RSP) de l'objet. La technique pCT classique est basée sur la mesure de la perte d'énergie des protons pour reconstruire la carte du RSP de l'objet. En plus de la perte d'énergie, les protons subissent également des diffusions coulombiennes multiples et des interactions nucléaires qui pourraient révéler d'autres propriétés intéressantes des matériaux non visibles avec les cartes de RSP. Ce travail de thèse a consisté à étudier les interactions de protons au travers de simulations Monte Carlo par le logiciel GATE et d'utiliser ces informations pour reconstruire une carte de l'objet par rétroprojection filtrée le long des chemins les plus vraisemblables des protons. Mise à part la méthode pCT conventionnelle par perte d'énergie, deux modalités de pCT ont été étudiées et mises en œuvre. La première est la pCT par atténuation qui est réalisée en utilisant l'atténuation des protons pour reconstruire le coefficient d'atténuation linéique des interactions nucléaires de l'objet. La deuxième modalité pCT est appelée pCT par diffusion qui est effectuée en mesurant la variation angulaire due à la diffusion coulombienne pour reconstruire la carte de pouvoir de diffusion, liée à la longueur de radiation du matériau. L'exactitude, la précision et la résolution spatiale des images reconstruites à partir des deux modalités de pCT ont été évaluées qualitativement et quantitativement et comparées à la pCT conventionnelle par perte d'énergie. Alors que la pCT par perte d'énergie fournit déjà les informations nécessaires pour calculer la longueur du parcours des protons pour la planification du traitement, la pCT par atténuation et par diffusion donnent des informations complémentaires sur l'objet. D'une part, les images pCT par diffusion et par atténuation fournissent une information supplémentaire intrinsèque aux matériaux de l'objet. D'autre part, dans certains des cas étudiés, les images pCT par atténuation démontrent une meilleure résolution spatiale dont l'information fournie compléterait celle de la pCT par perte d'énergie. / The use of protons in cancer treatment has been widely recognized thanks to the precise stopping range of protons in matter. In proton therapy treatment planning, the uncertainty in determining the range mainly stems from the inaccuracy in the conversion of the Hounsfield units obtained from x-ray computed tomography to proton stopping power. Proton CT (pCT) has been an attractive solution as this modality directly reconstructs the relative stopping power (RSP) map of the object. The conventional pCT technique is based on measurements of the energy loss of protons to reconstruct the RSP map of the object. In addition to energy loss, protons also undergo multiple Coulomb scattering and nuclear interactions which could reveal other interesting properties of the materials not visible with the RSP maps. This PhD work is to investigate proton interactions through Monte Carlo simulations in GATE and to use this information to reconstruct a map of the object through filtered back-projection along the most likely proton paths. Aside from the conventional energy-loss pCT, two pCT modalities have been investigated and implemented. The first one is called attenuation pCT which is carried out by using the attenuation of protons to reconstruct the linear inelastic nuclear cross-section map of the object. The second pCT modality is called scattering pCT which is performed by utilizing proton scattering by measuring the angular variance to reconstruct the relative scattering power map which is related to the radiation length of the material. The accuracy, precision and spatial resolution of the images reconstructed from the two pCT modalities were evaluated qualitatively and quantitatively and compared with the conventional energy-loss pCT. While energy-loss pCT already provides the information needed to calculate the proton range for treatment planning, attenuation pCT and scattering pCT give complementary information about the object. For one, scattering pCT and attenuation pCT images provide an additional information intrinsic to the materials in the object. Another is that, in some studied cases, attenuation pCT images demonstrate a better spatial resolution and showed features that would supplement energy-loss pCT reconstructions.

This thesis answers the question of how a vision recorded in Joseph Smith's journal found its home in the Doctrine and Covenants and become recognized as canonized scripture. The April 3, 1836, journal entry became known as Section 110. Section 110 serves as a foundation for the current practices and doctrines of The Church of Jesus Christ of Latter-day Saints, involving temple building and temple ordinances. Thus it is important to understand the history of this Section from journal entry to canonization because it is an example of recovering revelation. This thesis also explores contributing factors that could have led to the rediscovery of the 1836 vision. While Joseph Smith and Oliver Cowdery were in the Kirtland Temple with veils drawn around them at the Melchizedek Priesthood pulpits on April 3, 1836, they both saw Jesus Christ, Moses, Elias, and Elijah. Jesus Christ accepted the newly built temple and Moses, Elias, and Elijah committed keys to Joseph Smith and Oliver Cowdery. The vision was recorded, but as of yet, there is no evidence that the vision was publicly taught by Joseph Smith nor by Oliver Cowdery. This thesis follows the pattern established by Section 110 and the reclamation of the revelation and looks at how this section paved the way for other revelations and visions to move from handwritten pages to doctrinal levels of canonization, such as Sections 137 and 138. Joseph Smith had the vision recorded in his journal by Warren Cowdery, who served as a scribe to him. Joseph Smith also had the journal entry written in the Manuscript History of the Church. Although Joseph Smith did not publically declare that the 1836 vision had occurred to him and Oliver Cowdery, he still taught about the visitors in the vision and of their importance. After Joseph Smith's death, the leaders of the Church had his history printed in Church owned newspapers. The first time the vision was published in print was on November 6, 1852, in Salt Lake City, Utah, in the Deseret News. Outside influences of the late 1850s through the 1860s put pressure on the Church. Some of these potentially destructive influences were the Utah War, Civil War, transcontinental railroad, Spiritualism movement, and the lack of understanding of the foundational doctrines of the Church by the rising generation that had been a part of the Church from its beginnings with Joseph Smith as its Prophet. This thesis explores these potentially destructive forces on the Church and its doctrine, and looks at how the leadership of the Church responded to them and how their response influenced the canonization of the 1836 vision. Under the direction of Brigham Young, Orson Pratt oversaw the publication of the new 1876 edition of the Doctrine and Covenants. This new edition contained twenty-six new sections, including Section 110. After the death of Brigham Young in 1877, John Taylor sat at the head of the Church as president of the Quorum of the Twelve Apostles. While Orson Pratt was in England, preparing to print a new edition of the Book of Mormon on electrotype plates, he asked John Taylor about printing the Doctrine and Covenants with the electrotype plates as well. John Taylor agreed on condition that Orson Pratt add cross references and explanatory notes, as he had done with the Book of Mormon. Using the 1876 edition, Orson Pratt made the requested additions and the new edition of the Doctrine and Covenants was printed in 1880 and canonized on October 10, 1880, in a General Conference of The Church of Jesus Christ of Latter-day Saints, where all present voted unanimously to accept the 1880 edition as canonized scripture.

The Diploma thesis deals with design and static assessment of timber footbridge structural system for pedestrians and cyclist across the Trebuvka river in Lostice on the site of the existing footbridge. Structural system is designed in two alternatives and assessed according to the current standards. Spans of the bridge are 2x18 m and 1x6 m. The main beams are made of glued laminated timber, other parts of the structure are made of timber and steel elements. First alternative is designed as a simple half-through truss beam, second alternative as continuous beam with variable height where the deck is sitting on top of the girders.