La personne de confiance, créée par la loi du 4 mars 2002, permet au patient non communiquant, de transmettre sa parole au médecin, pour l'aider dans sa prise de décision. Dix ans après, la désignation de la personne de confiance reste rare, même en gériatrie, y compris pour les patients atteints de maladie d’Alzheimer. Plusieurs enquêtes par questionnaires et entretiens et une recherche-action ont été réalisés auprès des différents acteurs du soin gériatrique : patients, aidants, gériatres, médecins traitants et associations de patients, pour appréhender comment les professionnels de gériatrie se sont approprié la notion juridique de personne de confiance et ont modifié leurs pratique Les résultats montrent que les acteurs ne connaissent pas bien la loi et n’ont rien fait pour la mettre en œuvre, même s’ils en attendent beaucoup. Les équipes de soin peuvent cependant s’approprier le sujet et donner à la personne de confiance la place prévue par la loi. Des risques de dérives sont décrits : prise de pouvoir de la personne de confiance sur le patient, décharge de la responsabilité médicale, écartement des proches au profit de la seule personne de confiance, poids extrême pouvant peser sur cette dernière. Les professionnels trouvent que la procédure prend beaucoup de temps, qu’un document écrit n’est pas toujours adapté, que cela représente une charge supplémentaire, alors qu’ils sont déjà surchargés. Le manque de pratique entraine le manque d’utilisation. Les patients présentent parfois des difficultés de communication, limitant la possibilité de désigner. L’information sur la personne de confiance et sa désignation provoquent souvent une angoisse supplémentaire du patient face à sa possible mort prochaine. Il lui est parfois difficile de choisir entre ses enfants. Les professionnels pressentent que la personne de confiance n’a pas la même utilité pour tous. Elle est intéressante en soins d’urgence et de réanimation, mais les patients n’ont souvent pas le temps de la désigner avant d’en avoir besoin. Elle prend tout son sens dans les maladies chroniques, dont la maladie d’Alzheimer, pour lesquelles la désignation de la personne de confiance pourrait être anticipée par rapport à l’arrivée à l’hôpital. Il ne semble pas y avoir de limite, autre que celle de l’a priori moral des professionnels, à la possibilité de désigner une personne de confiance, même pour un patient atteint de maladie d’Alzheimer, la personne de confiance permettant alors au patient d’exprimer ses volontés au-delà de son handicap, en prenant au mieux en compte son ancienne personnalité et ses désirs actuels. Cette réflexion amène à certaines réserves éthiques. Le patient, sa personne de confiance et le médecin peuvent-ils conclure une alliance thérapeutique en médecine aiguë, alors que la patient est dépendant du médecin, par le fait même de sa maladie et de la proximité de la mort ? La logique des droits des patients a-t-elle une limite, puisque tous les patients n’ont pas accès à la désignation de leur personne de confiance ? Le risque de routinisation de la procédure est majeur, si le sens même de cette désignation n’est pas perçu par les différents acteurs. La réflexion autour de la prise de décision montre que le patient en semble souvent absent et pas toujours représenté par la personne de confiance. Le tuteur ne semble pas être le représentant idéal du patient, qui ne peut légalement plus désigner sa personne de confiance. Une amélioration du processus par le biais de bonnes pratiques de la désignation de la personne de confiance sont proposées : améliorer l’information de la population et des patients, former les professionnels aux conditions de désignation optimale pour le patient, informer la personne de confiance sur son rôle et sur sa responsabilité vis-à-vis du patient, de l’aidant familial et de la famille, extension de la procédure de désignation partout où il y a du soin / The Act of March 4th, 2002, has created a new actor in the doctor-patient relationship: the health care surrogate. This person can be designated by every patient at the beginning of the hospitalization, except patients under legal protection. This person can escort the patient to receive the medical information, so with a derogation of medical confidentiality. This person can also tell the doctor what the patient would want, if the patient is not able to communicate. So this health care surrogate could be the witness, who allows the patient who can no longer communicate, to advise the medical decision. Ten years after the law, few health care surrogates are designated, even in geriatric care and for people suffering from Alzheimer disease. Different studies have been done with people acting in geriatric care: patients, caregivers, geriatricians, general practioners, and patient’s associations. The aim of these studies was to appreciate how professional of geriatrics appropriated the juridical notion of health care surrogate and how they changed their practices. Results showed that the role and missions of the health care surrogate are insufficiently known by the patients and also by the professionals. But professionals can be trained and can give to the health care surrogate his right place. Some risks are described: health care surrogate taking power on the patient, discharge from medical responsibility, spacing proxies in the benefit of the health care surrogate, burden to the surrogate. Professionals found that the procedure is time consuming, that a written document is not always adapted and that it’s an additional burden, so they are already exhausted. The lack of practice leads to a lack of use. Designation is often difficult for patients that are then faced with their own death and particularly for those who had communication difficulties. Sometimes patients did not want to choose between their children, who will be their surrogate. Health care surrogate designation was interesting in acute care and emergency room but people did not have often enough time to do it. It makes sense in chronicle diseases, for which the designation may be anticipated before patient’s arrival in the hospital. It does not seem to be any limit to designate health care surrogate, other than the moral prejudices of professionals, even for patients with Alzheimer disease. Health care surrogates allowed Alzheimer patient to express himself his will, taking care of his old personality and his actual wishes. This reflexion leads to some ethical reserves. Can patient, health care surrogate and doctors make a therapeutic alliance in acute care? Thus patient is under medical power, due to his illness and the possibility to die. Do the patient’s rights have a limit, as some patients are not allowed to designate their surrogate? The risk of routine is extreme if the sense itself of the designation is lost or not seen by professionals. Patients are often excluded from the decision process. The legal protector of the patient does not seem to be the ideal health care surrogate. This could be ameliorated by good practice recommendations: improving population and patient information, improving professional’s training, informing the health care surrogates, caregivers and families. The designation’s procedure can be extended everywhere where care is done: home, networks, nursing homes… the tools for information and designation must be adapted to everyone, and be as different as patients can be. Progressive appropriation of the concept of the health care surrogate by the care system can be done, with help of the peer’s societies and patient’s associations

Frequently measured turbidity was examined as a surrogate for total phosphorus (TP) and total suspended solids (TSS) loads at two locations in the Little Bear River, Utah, USA. Using regression techniques, equations were developed for TP and TSS as functions of turbidity. The equations accounted for censored data, and additional explanatory variables to represent hydrological conditions were considered for inclusion in the equations. By using the resulting surrogate relationships with high frequency turbidity measurements, high frequency estimates of TP and TSS concentrations were calculated. To examine the effect of sampling frequency, reference loads were determined from the concentration records for two water years. The concentration records were artificially decimated to represent various frequencies of manual grab sampling from which annual loads were calculated and compared to the reference loads.

Les phases de conception et de validation de pièces mécaniques nécessitent des outils de calculs rapides et fiables, permettant de faire des choix technologiques en un temps court. Dans ce cadre, il n'est pas possible de calculer la réponse exacte pour l'ensemble des configurations envisageables. Les métamodèles sont alors couramment utilisés mais nécessitent un grand nombre de réponses, notamment dans le cas où celles-ci sont non-linéaires. Une solution est alors d'exploiter plusieurs sources de données de qualité diverses pour générer un métamodèle multi-fidélité plus rapide à calculer pour une précision équivalente. Ces données multi-fidélité peuvent être extraites de modèles réduits.Les travaux présentés proposent une méthode de génération de métamodèles multi-fidélité pour l'optimisation de structures mécaniques par la mise en place d'une stratégie d'enrichissement adaptatif des informations sur la réponse de la structure, par utilisation de données issues d'un solveur LATIN-PGD permettant de générer des données de qualités adaptées, et d'accélérer le calcul par la réutilisation des données précédemment calculées. Un grand nombre de données basse-fidélité sont calculées avant un enrichissement intelligent par des données haute-fidélité.Ce manuscrit présente les contributions aux métamodèles multi-fidélité et deux approches de la méthode LATIN-PGD avec la mise en place d'une stratégie multi-paramétrique pour le réemploi des données précédemment calculées. Une implémentation parallèle des méthodes a permis de tester la méthode sur trois cas-tests, pour des gains pouvant aller jusqu'à 37x. / Engineering simulation provides the best design products by allowing many design options to be quickly explored and tested, but fast-time-to-results requirement remains a critical factor to meet aggressive time-to-market requirements. In this context, using high-fidelity direct resolution solver is not suitable for (virtual) charts generation for engineering design and optimization.Metamodels are commonly considered to explore design options without computing every possibility, but if the behavior is nonlinear, a large amount of data is still required. A possibility is to use further data sources to generate a multi-fidelity surrogate model by using model reduction. Model reduction techniques constitute one of the tools to bypass the limited calculation budget by seeking a solution to a problem on a reduced order basis (ROB).The purpose of the present work is an online method for generating a multi-fidelity metamodel nourished by calculating the quantity of interest from the basis generated on-the-fly with the LATIN-PGD framework for elasto-viscoplastic problems. Low-fidelity fields are obtained by stopping the solver before convergence, and high-fidelity information is obtained with converged solution. In addition, the solver ability to reuse information from previously calculated PGD basis is exploited.This manuscript presents the contributions to multi-fidelity metamodels and the LATIN-PGD method with the implementation of a multi-parametric strategy. This coupling strategy was tested on three test cases for calculation time savings of more than 37x.

Indiana University-Purdue University Indianapolis (IUPUI) / The design optimization of laminated composite structures is of relevance in automobile, naval, aerospace, construction and energy industry. While several optimization methods have been applied in the design of laminated composites, the majority of those methods are only applicable to linear or simplified nonlinear models that are unable to capture multi-body contact. Furthermore, approaches that consider composite failure still remain scarce. This work presents an optimization approach based on design and analysis of computer experiments (DACE) in which smart sampling and continuous metamodel enhancement drive the design process towards a global optimum. Kriging metamodel is used in the optimization algorithm. This metamodel enables the definition of an expected improvement function that is maximized at each iteration in order to locate new designs to update the metamodel and find optimal designs. This work uses explicit finite element analysis to study the crash behavior of composite parts that is available in the commercial code LS-DYNA. The optimization algorithm is implemented in MATLAB. Single and multi-objective optimization problems are solved in this work. The design variables considered in the optimization include the orientation of the plies as well as the size of zones that control the collapse of the composite parts. For the ease of manufacturing, the fiber orientation is defined as a discrete variable. Objective functions such as penetration, maximum displacement and maximum acceleration are defined in the optimization problems. Constraints are included in the optimization problem to guarantee the feasibility of the solutions provided by the optimization algorithm. The results of this study show that despite the brittle behavior of composite parts, they can be optimized to resist and absorb impact. In the case of single objective problems, the algorithm is able to find the global solution. When working with multi-objective problems, an enhanced Pareto is provided by the algorithm.

Indiana University-Purdue University Indianapolis (IUPUI) / Driving safety is a very important topic in vehicle development. One of the biggest threat of driving safety is road departure. Many vehicle active safety technologies have been developed to warn and mitigate road departure in recent years. In order to evaluate the performance of road departure warning and mitigation technologies, the standard testing environment need to be developed. The testing environment shall be standardized to provide consistent and repeatable features in various locations worldwide and in various seasons. The testing environment should also be safe to the vehicle under test in case the safety features do not function well. Therefore, soft, durable and reusable surrogates of roadside objects need to be used. Meanwhile, all surrogates should have the same representative characteristics of real roadside objects to di erent automotive sensors (e.g. radar, LIDAR and camera). This thesis describes the study on identifying the radar characteristics of common roadside objects, metal guardrail, grass, and concrete divider, and the development of the required radar characteristics of surrogate objects. The whole process is divided into two steps. The rst step is to nd the proper methods to measure the radar properties of those three roadside objects. The measurement result of each roadside object will be used as the requirement for making its surrogate. The second step is to create the material for developing the surrogate of each roadside object. In the experimental results demonstrate that all three surrogates satisfy their radar characteristics requirements.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第20755号 / 医博第4285号 / 新制||医||1024(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 伊佐 正, 教授 宮本 享, 教授 井上 治久 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

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The existence of trihalomethanes (THMs) in a drinking water plant of Nicaragua has been investigated in order to see whether the concentration exceeded the maximum contaminant level recommended by the environmental protection agency of the United States (USEPA) and the Nicaragua guidelines. The influence of pH, temperature, chlorine dose and contact time on the formation of THMs were studied. The contents of organic matter measured by surrogate parameters such as total organic carbon, dissolved organic carbon, ultraviolet absorbance and specific ultraviolet absorbance were also determined in order to show which type of organic matter is most reactive with chlorine to form THMs. Models developed by other researchers to predict the formation of trihalomethanes were tested to see whether they can be used to estimate the trihalomethane concentration. In addition, empirical models were development to predict the THM concentration of the drinking water plant analysed. The raw water was treated by conventional and enhanced coagulation and these processes were compared with regard to the removal of natural organic matter (NOM). The significance of the results was assessed using statistic procedures. The average concentration of THMs found at the facility is below the USEPA and Nicaragua guideline values. Nevertheless the maximum contaminant level set by USEPA is sometimes exceeded in the rainy season when the raw water is rich in humic substances. Comparison between the water treated by conventional and enhanced coagulation shows that enhanced coagulation considerably diminished the trihalomethane formation and the value after enhanced coagulation never exceeded the guidelines. This is because enhanced coagulation considerably decreases the organic matter due to the high coagulant dose applied. The study of the trihalomethane formation when varying pH, time, temperature and chlorine dose using water treated by conventional and enhanced coagulation showed that higher doses of chlorine, higher pH, higher temperature and a longer time increases the formation of THMs. However, combinations of two and three factors are the opposite. The predicted THM formation equations cannot be used for the water at this facility, since the results shown that the measured THM differs significantly from the THM concentration predicted. Two empirical models were developed from the data for enhanced coagulation, using linear and non-linear regression. These models were tested using the database obtained with conventional coagulation. The non-linear model was shown to be able to predict the formation of THMs in the Boaco drinking water plant. / QC 20101129