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International audience; We present the evolution of patient-centered care (PCC) and shared decision-making (SDM) in France since 2017, highlighting advantages and drawbacks of their implementation at the macro level. We then focus on several key policy and legislative milestones that are aimed to develop PCC and SDM. These milestones underline the importance of patient movements to support and fund the development of research and practice in the field. We shall conclude by presenting the growing research agenda and selected key topics. These key topics notably include the increase in both patient and healthcare professional trainings on PCC and SDM provided by healthcare users' and patients' representatives. PCC and SDM continue to be central preoccupations at the macro level, supported by public health policies and patients/healthcare users' actions. This overview, however, suggests that although implementation initiatives have increased since 2017, implementation remains scarce in routine clinical practice. Funding, not only for research projects, but for the implementation of PCC and SDM in real-life settings (e-decision aids, clinical guidelines integrating PCC/SDM, human resources dedicated to PCC/SDM, etc.) are needed to promote sustained adoption. More systematic training for both healthcare professionals and patients is also warranted for a true acculturation to occur.

International audience; It has been reported that decision making is impaired in suicide attempters. Decision making is a complex process and little is known about its different components. Yet, this information would help to understand the functioning of suicidal minds. In this study, the Prospect Valence-Learning (PVL) computational model was applied to the Iowa Gambling Task (IGT) to investigate and compare decision-making components in patients with affective disorder and with/without history of suicide attempts and in healthy controls. To this aim, 116 inpatients with current major depressive episode (among whom 62 suicide attempters) and 38 healthy controls were recruited. Decision-making performance was measured using the IGT. The Bayesian computational PVL model was applied to compare the feedback sensitivity, loss aversion, learning/memory, and choice consistency components of decision making in the different groups. Depressive symptomatology was assessed using the Beck Depression Inventory short form (BDI-SF). The total IGT net score and the loss aversion and learning/memory scores were lower in suicide attempters than in healthy controls. The choice consistency score was low in all patients (with/without suicide history) compared with healthy controls. Moreover, patients with high BDI score showed a positive relationship between the choice consistency score and suicide attempt. These findings suggest that decision-making impairment in depressed patients with and without suicidal history might be the result of underlying problems in feedback processing and task learning, which influence the building of long-term strategies. All these impairments should be targeted in therapeutic strategies for suicidal patients.

La première molaire permanente, dite dent de 6 ans, est une dent « pilier » de l’appareil manducateur ; elle joue un rôle clé dans l’établissement de l’occlusion et assure plus du ¼ du coefficient masticatoire. Cependant, la dent de 6 ans présente un haut risque carieux. Ceci s’explique par l’immaturité des tissus qui la composent pendant les 3 premières années suivant son éruption, son émergence précoce dans la cavité buccale, sa situation postérieure sur l’arcade, ainsi que sa morphologie occlusale complexe. De plus, la première molaire permanente est « sensible » aux anomalies de structure, en particulier l’hypominéralisation incisives-molaires. La perte prématurée de la vitalité pulpaire engendre d’une part un arrêt de l’élongation radiculaire et la fermeture apicale, et d’autre part l’arrêt de l’épaississement des parois radiculaires par apposition physiologique de dentine. Lorsque les techniques de prévention primaire et secondaire ont échoué, le traitement de la dent immature est basé sur son potentiel de réparation grâce à sa vascularisation pulpaire très importante et grâce à l’activité physiologique spécifique de la rhizagenèse en cours. Ainsi, en présence d’une pathologie pulpaire, nos thérapeutiques visent à permettre la poursuite de l’édification radiculaire physiologique jusqu’à la fermeture apicale, ou au traitement endodontique de la dent, dans le but de maintenir la dent sur l’arcade. Lorsque la dent n’est plus conservable sur l’arcade dentaire, l’extraction guidée peut être une alternative de choix, à condition qu’elle soit envisagée dans un plan de traitement global.

Emotional feedback, such as faces showing emotions, can influence decision making. Decision making and emotional face processing, mainly mediated by the prefrontal and cingulate cortices, are impaired in suicide attempters. Here, we used functional MRI (fMRI) to study prefrontal activation in suicide attempters during a modified version of the Iowa Gambling Task (IGT) that included emotional face feedback. We randomly distributed the 116 euthymic women (n = 45 suicide attempters, n = 41 affective controls with history of depression without suicide attempt, and n = 30 healthy controls) included in the study in three emotional IGT groups: concordant (safe and risky choices followed by happy and angry faces, respectively), discordant (safe and risky choices followed by angry and happy faces, respectively), and neutral condition (safe and risky choices followed by neutral faces). Considering the two IGT phases (ambiguous and risky), we then analyzed five regions of interest during the risky vs. safe choices: orbitofrontal (OFC), anterior cingulate (ACC), ventrolateral (VLPFC), medial (MPFC) and dorsal prefrontal (DPFC) cortices. We found: (1) impaired decision making and increased DPFC and OFC activation in suicide attempters vs. controls in the discordant condition during the risky phase; (2) reduced VLPFC activation in suicide attempters in the concordant condition during the ambiguous phase; and (3) decreased OFC, ACC and DPFC activation in both control groups in the concordant condition during the ambiguous phase. Suicide attempters showed prefrontal alterations during reward-learning decision making with emotional feedback. Suicide attempters may guide their decisions to avoid social negative feedback despite the expected outcome.

International audience

International audience; Objectives: To comprehensively assess the effect of a living will on end-of-life care.Design: Systematic review with narrative analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology.Participants: All interventional and observational studies were included, excepting those with fictive cases. Included studies were conducted in adults with and without living wills, excluding individuals with specific psychiatric living wills.Measurements: Two authors independently extracted study and participant characteristics and outcomes related to end-of-life care (place of death, hospitalization and intensive care unit management, life-sustaining treatments, restricted care). Risk of bias was assessed using the Risk Of Bias In Non-randomized Studies of Interventions tool.Results: From 7,596 records identified, 28 observational studies were included, 19 conducted in the United States, 7 in Europe, and 1 each in Canada and Australia. Place of death was assessed in 14 studies, life-sustaining treatments in 13, decision for restricted care in 12, and hospitalization in 8. Risk of bias was serious for 26 studies and moderate for 2. Twenty-one studies reported significantly less medical management for individuals with a living will, 3 reported more medical management, and the difference was not significant in 37.Conclusion: Methodological quality of included studies was insufficient to offer reliable results. The effect of living wills appears limited in view of the importance and direction of potential biases. Further studies including larger populations, considering main confounding factors, and documenting the real presence of a living will in medical records are necessary to reach stronger conclusions on the effect of living wills on end-of-life care.

The aetiology of psychiatric disorders remains poorly understood, despite significant progress in neurosciences and psychopharmacology. These approaches might be limited by their lack of causal account linking psychiatric symptoms and neurobiological data. This dissertation presents a new theoretical approach of psychopathology, i.e. computational psychiatry, that aims to develop and test hypotheses about the algorithms that the brain implements to produce observable behavior. To that purpose, we review two major computational models. First, models from reinforcement learning and neuro-economics give a novel account of symptoms as a decision making process gone awry (such as addiction, impulsiveness, compulsions or apathy). Then, we examine how Bayesian modeling of probabilistic inference enlightens psychotic symptoms. Finally, we discuss the limitations and future applications of computational approaches in psychiatry.; L’étiologie des maladies psychiatriques est encore mal connue, malgré d’importants progrès en neurosciences et en psychopharmacologie. La limite que rencontrent ces approches tient probablement à l’absence de modèles explicatifs permettant de lier causalement les symptômes psychiatriques et les données neurobiologiques. Cette thèse aborde une nouvelle approche théorique de la psychopathologie, la psychiatrie computationnelle, dont l’objectif est de proposer et de tester empiriquement des hypothèses quant aux algorithmes implémentés par le cerveau, à l’origine des comportements observés. Pour cela, nous présentons deux grands types de modèles computationnels. Premièrement, les modèles issus de l’apprentissage par renforcement et de la neuro-économie, permettent de redéfinir les symptômes traduisant une altération de la prise de décision (addiction, impulsivité, compulsions, apathie). Deuxièmement, nous examinons en quoi les modèles bayésiens d’inférence probabiliste apportent un éclairage sur les symptômes psychotiques. Enfin, nous discutons dans un troisième temps les limites et perspectives de l’approche computationnelle en psychiatrie.

Background In spite of their extensive use, the ecological relevance of tasks dedicated to assessing real-world decision-making in a laboratory setting remains unclear. Objectives Our study aimed to evaluate the relationship between decision-making and behavioral competency and awareness of limitations. Methods A total of 20 patients with Alzheimer's disease (AD), 20 with amnestic mild cognitive impairment (aMCI) and 20 healthy controls (HC) were assessed for decision-making using the Iowa Gambling Task (IGT). Behavioral competency was evaluated by the Patient Competency Rating Scale (PCRS), which requires each participant and a relative to answer the same 30 questions on participant's competency and to rate each item, while awareness of limitations was evaluated by subtracting the self-rated score from the relative-rated score. Results Using the median-split approach, the proportion of disadvantageous decision-makers was higher in both the MCI and AD groups than in HC (P = 0.02 and P = 0.03, respectively), with no differences between clinical groups. The percentage of participants with poorer behavioral competency was also higher in the MCI and AD than in the HC (self-rated: P = 0.025 and P = 0.01, respectively; relative-rated: P = 0.008 and P = 0.008, respectively), again with no differences between MCI and AD. All groups were comparable in awareness. For all participants, disadvantageous decision-making was associated with both reduced behavioral competency and poor awareness of limitations (OR: 3.47, P = 0.03 and OR: 5.4, P = 0.004, respectively). Conclusion Our findings support the ecological relevance of the IGT. Behavioral competency integrity and awareness of limitations are both associated with advantageous decision-making profiles.

Context: HPV infections are a part of the most frequent sexually transmitted infections in the world. More than 80 % of women counts a genital HPV infection in their life, with a risk of evolution towards a cervical cancer. In France, this cancer represents the 11th cause of cancer, and the 12th cause of death of consequences of a cancer among women. In spite of the fact that vaccination against papillomavirus is recommended for girls since 2007, vaccine coverage remains largely insufficient in France with a rate bordering the 30 %. Objectives: identify factors influencing parents in their decision to have or not to have their daughter inoculated against the HPV, and study the effect of the representations which they can have concerning this vaccination; then examine the girls’ characteristics, allowing to specify the results obtained with the parents. Material and method: it is a quantitative, observational, descriptive and retrospective study, realized from a double questionnaire circulated between September 15th and December 30th, 2017, in Île-de-France. The first questionnaire was intended to girls between 18 and 23 years, and the second was intended for one of their parents. Main results: 159 questionnaires were analyzed. 48, 4 % of parents had decided to have their daughter inoculated and, for 57, 1 % of them, the factor which had been decisive was the recommendations of their regular doctor. The press and the media were often an information source for the parents (45, 9 %) but they led them for the greater part to refuse that their daughter was inoculated. Girls whose parents have histories of HPV infection are better inoculated. Furthermore, those who had already consulted a gynaecologist or a midwife, are inoculated 3 times as frequently against HPV than those who had not entered a circuit of care in touch with reproductive health. As for the girls whose mothers have regular gynaecological follow-up, they are almost 10 times better inoculated than the others. Finally, girls whose parents have a high socioeconomic level are better inoculated. Conclusion: From information results the decision of vaccination, hence its importance. Healthcare professionals have a major role. Falsified representations concerning vaccination, in particular about side effects, cause under-vaccination.; Contexte : les infections à HPV font partie des infections sexuellement transmissibles les plus fréquentes dans le monde. Plus de 80% des femmes auront une infection génitale à HPV dans leur vie, avec un risque d’évolution vers le cancer du col de l’utérus. En France, ce cancer représente la onzième cause de cancer et la douzième cause de mortalité des suites d’un cancer chez la femme. Malgré le fait que la vaccination contre le papillomavirus soit recommandée depuis 2007 chez les jeunes filles, la couverture vaccinale en France reste largement insuffisante avec un taux avoisinant les 30%. Objectifs : identifier des facteurs influençant les parents dans leur décision de faire ou non vacciner leur fille contre l’HPV et étudier l’effet des représentations qu’ils peuvent avoir concernant cette vaccination ; puis étudier les caractéristiques des jeunes filles, pour préciser les résultats obtenus auprès des parents. Matériel et méthode : c’est une étude quantitative, observationnelle, descriptive et rétrospective réalisée à partir d’un double questionnaire distribué entre le 15 septembre et le 30 décembre 2017, en Ile-de-France. Le premier questionnaire s’adressait à des jeunes filles de 18 à 23 ans, le second était destiné à l’un de leurs parents. Principaux résultats : 159 questionnaires ont été analysés. 48,4% des parents avaient décidé de faire vacciner leur fille, et pour 57,1% d’entre eux, le facteur décisif était les recommandations de leur médecin traitant. La presse et les médias ont aussi été souvent une source d’informations pour les parents (45,9%), mais ils les ont conduits pour la plupart à refuser que leur fille soit vaccinée. Les filles dont les parents ont des antécédents d’infection à HPV sont mieux vaccinées. Celles qui ont déjà consulté en gynécologie, sont trois fois plus vaccinées contre l’HPV que celles qui n’étaient pas entrées dans un circuit de soins en rapport avec la santé génésique. Quant aux filles dont les mères ont un suivi gynécologique régulier, elles sont 10 fois plus vaccinées. Enfin, celles dont les parents ont un niveau socio-économique élevé sont mieux vaccinées. Conclusion : de l’information découle la décision de vaccination, d’où son importance. Les professionnels de santé ont un rôle majeur. Les représentations faussées concernant la vaccination, notamment sur les effets secondaires, entraînent une sous-vaccination.

International audience; Humans can readily assess their degree of confidence in their decisions. Two models of confidence computation have been proposed: post hoc computation using post-decision variables and heuristics, versus online computation using continuous assessment of evidence throughout the decision-making process. Here, we arbitrate between these theories by continuously monitoring finger movements during a manual sequential decision-making task. Analysis of finger kinematics indicated that subjects kept separate online records of evidence and confidence: finger deviation continuously reflected the ongoing accumulation of evidence, whereas finger speed continuously reflected the momentary degree of confidence. Furthermore, end-of-trial finger speed predicted the post-decisional subjective confidence rating. These data indicate that confidence is computed on-line, throughout the decision process. Speed-confidence correlations were previously interpreted as a post-decision heuristics, whereby slow decisions decrease subjective confidence, but our results suggest an adaptive mechanism that involves the opposite causality: by slowing down when unconfident, participants gain time to improve their decisions.

Objectives: Local health technology assessment (HTA) to determine whether new health technologies should be adopted is now a common practice in many healthcare organizations worldwide. However, little is known about hospital-based HTA activities in France. The objective of this study was to explore hospital-based HTA activities in French university hospitals and to provide a picture of organizational approaches to the assessment of new and innovative medical devices.Methods: Eighteen semi-structured interviews with hospital pharmacists were conducted from October 2012 to April 2013. Six topics were discussed in depth: (i) the nature of the institution concerned; (ii) activities relating to innovative medical devices; (iii) the technology assessment and decision-making process; (iv) the methodology for technology assessment; (v) factors likely to influence decisions and (vi) suggestions for improving the current process. The interview data were coded, collated and analyzed statistically.Results: Three major types of hospital-based HTA processes were identified: medical device committees, innovation committees, and “pharmacy & management” processes. HTA units had been set up to support medical device and innovation committees for technology assessment. Slow decision making was the main limitation to both these committee-based approaches. As an alternative, “pharmacy & management” processes emerged as a means of rapidly obtaining a formal assessment.Conclusions: This study provides an overview of hospital-based HTA initiatives in France. We hope that it will help to promote hospital-based HTA activities in France and discussions about ways to improve and harmonize practices, through the development of national guidelines and/or a French mini-HTA tool, for example.

International audience; Shaw et al argue that it's wrong to assume that patients suffering from mental health issues (including depression) cannot consent to assisted suicide. But being depressed is the strongest correlate of decision instability, of changing from acceptance of euthanasia to rejecting it at follw up. As a matter of fact, the rate of psychiatric patients who, after seeking euthanasia or assisted suicide(EAS), no longer wished to die and/or withdrew their requests is quite high. In general, caregivers should be aware of the risks for patients with a mental health issue.

International audience; Facing the consequence of a decision we made can trigger emotions like satisfaction, relief, or regret, which reflect our assessment of what was gained as compared to what would have been gained by making a different decision. These emotions are mediated by a cognitive process known as counterfactual thinking. By manipulating a simple gambling task, we characterized a subject's choices in terms of their anticipated and actual emotional impact. Normal subjects reported emotional responses consistent with counterfactual thinking; they chose to minimize future regret and learned from their emotional experience. Patients with orbitofrontal cortical lesions, however, did not report regret or anticipate negative consequences of their choices. The orbitofrontal cortex has a fundamental role in mediating the experience of regret.

The 37/67 kDa laminin receptor (LR) is a non-integrin protein, which binds both laminin-1 of the extracellular matrix and prion proteins, that hold a central role in prion diseases. The 37/67 kDa LR has been identified as interactor for the prion protein (PrPC) and to be required for pathological PrP (PrPSc) propagation in scrapie-infected neuronal cells, leading to the possibility that 37/67 kDa LR-PrPC interaction is related to the pathogenesis of prion diseases. A relationship between 37/67 kDa LR and PrPC in the presence of specific LR inhibitor compounds has not been investigated yet. We have characterized the trafficking of 37/67 kDa LR in both neuronal and non-neuronal cells, finding the receptor on the cell surface and nuclei and identified the 67 kDa LR as the almost exclusive isoform interacting with PrPC. Here, we show that the treatment with the 37/67 kDa LR inhibitor, NSC47924, affects both the direct 37/67 kDa LR-PrPC interaction in vitro and the formation of the immunocomplex in live cells, inducing a progressive internalization of 37/67 kDa LR and stabilization of PrPC on the cell surface. These data reveal NSC47924 as a useful tool to regulate PrPC and 37/67 kDa LR trafficking and degradation, representing a novel small molecule to be tested against prion diseases.

International audience; Several theoretical studies predict that informed (e.g., density-dependent) dispersal should generally result in lower emigration probabilities than uninformed (random) dispersal. In a 2012 publication, Bocedi et al. surprisingly come to the opposite conclusion. For most scenarios investigated, they found that noninformed and, particularly, less precisely informed dispersers evolve lower dispersal propensity than dispersers following "fully informed" strategies. Further, they observed that fully informed individuals evolved a steplike dispersal response-a response to local density that contradicts theoretical predictions for organisms with nonoverlapping generations. Replicating the individual-based simulations of Bocedi et al. we find that these conclusions are not justified and are based on a misinterpretation of simulation results: their controversial findings result from (i) a misleading use of the term "population density," (ii) a misconception concerning the true informative value of the different decision criteria they compared, and (iii) arbitrary constraints on the evolution of the dispersal response that prevented the evolution of strategies that allow for a fitness-enhancing utilization of available information.

International audience; Reproductive techniques such as prenatal diagnosis (PND) or preimplantation genetic diagnosis (PGD), although debated, are legally forbidden in France in case of Lynch syndrome. The preference of mutation carriers about their reproductive options is not systematically considered in France. We aimed to prospectively assess the reproductive preferences of mismatch repair mutation carriers consulting in our institution (2003-2010, n = 100). We also considered the short- and long-term post-disclosure psychological impact using the Impact of Events Scale-Revised questionnaire to measure the prevalence of posttraumatic stress disorder (PTSD) in those patients. Complete data were obtained for 34 respondents (17 males, 17 females, median age of 33.5 years [22-59]). Seventeen respondents (57 %) preferred spontaneous natural conception versus 28 % and 35 % choosing PND and PGD, respectively. At results disclosure, respondents mainly explained their distress by fear of premature death (43 %) and transmitting mutated genes (42 %). One year later, this last fear remained predominant in 55 % of subjects. None of the main socio-demographical, psychological or medical variables (including fear of transmitting mutations) was significantly associated with the reproductive preferences. Results disclosure had a real and time-decreasing psychological impact on mutation carriers. Reproductive techniques, expected to decrease the hereditary risk, were not significantly preferred to natural conception.

Decision making has been reported to be reduced in eating disorders. However, studies are sparse and have been carried out in various selected populations. In the current study we arranged to confirm previous observations and to assess the relationship between decision making and dimensions relevant to eating disorders.Patients suffering from anorexia nervosa (n = 49), bulimia nervosa (n = 38), and healthy controls (n = 83) were assessed using the Iowa Gambling Task (IGT). All patients were euthymic and free of psychotropic medication. Self-questionnaires (Eating Disorder Inventory-2; Gardner, 1991; and Eating Attitude Test; GarnerGarfinkel, 1979) were used to assess clinical dimensions relevant to eating disorders.No significant differences in IGT performance were observed between patients and healthy controls or between restrictive and purging types of anorexia nervosa. No correlations were found between IGT performance and eating disorder questionnaires.These results do not support reduced decision making in patients with eating disorders, and suggest that previously reported alterations could be related to other clinical characteristics. This should stimulate new topic-related studies designed to reach a firm conclusion.

International audience; In Sub-Saharan Africa, prevention of HIV pediatric infection due to breastfeeding requires turning to alternatives to prolonged breastfeeding: artificial feeding or exclusive breastfeeding with early weaning. Choosing a preventive option and applying it does not only depend upon the mother but also on the father and more specifically on couple interactions. To date, not enough studies have considered this question. In Abidjan, Ivory Coast, HIV-positive women and their infants were followed over two years in Ditrame Plus, a prevention of mother-to-child transmission (PMTCT) project. Using data from this project and from interviews conducted with couples and women, we analyzed the construction of decisions and practices concerning the application of preventive infant feeding options. Differences may be found between women and men in discourses regarding their attitudes, which are in part related to their conceptions of motherhood and fatherhood. We found that when men know their wife is HIV positive and are involved in the PMTCT project, they play an active role in applying the advice received. However, women do not always need the support of their spouse to undertake preventative behaviour. The project team also plays an important role in the adoption of such by women and men. The implementation of preventive options is a complex process in which three groups of actors (women, men and the project team) interact. In order to optimize PMTCT programs for couples, it is essential that this dynamic be taken into account.

International audience; In 1994, it was proposed that decision-making requires emotion-related signals, known as somatic markers. In contrast, some authors argued that conscious knowledge of contingencies is sufficient for advantageous decision-making. We aimed to investigate the respective roles of somatic markers and explicit knowledge in decision-making. Thirty healthy volunteers performed the Iowa Gambling Task (IGT). Conscious knowledge was assessed using a sensitive questionnaire and skin conductance responses (SCRs) were recorded. Most participants acquired a preference for advantageous choices during the task and generated larger anticipatory SCRs before disadvantageous relative to advantageous choices. Performance on the IGT and the autonomic response were positively correlated (r=0.38, p=0.045). Moreover, there was a statistically significant difference in performance according to conscious awareness (p=0.009). There was no significant association between level of explicit knowledge and SCR (p=0.1). Finally, we did not find any interaction between explicit knowledge and performance although a lack of statistical power is not to be excluded. Advantageous decision-making therefore seems to be associated with two distinct, namely implicit and explicit, systems.

Compromises between speed and accuracy are seemingly inevitable in decision-making when accuracy depends on time-consuming information gathering. In collective decision-making, such compromises are especially likely because information is shared to determine corporate policy. This political process will also take time. Speed–accuracy trade-offs occur among house-hunting rock ants, Temnothorax albipennis . A key aspect of their decision-making is quorum sensing in a potential new nest. Finding a sufficient number of nest-mates, i.e. a quorum threshold (QT), in a potential nest site indicates that many ants find it suitable. Quorum sensing collates information. However, the QT is also used as a switch, from recruitment of nest-mates to their new home by slow tandem running, to recruitment by carrying, which is three times faster. Although tandem running is slow, it effectively enables one successful ant to lead and teach another the route between the nests. Tandem running creates positive feedback; more and more ants are shown the way, as tandem followers become, in turn, tandem leaders. The resulting corps of trained ants can then quickly carry their nest-mates; but carried ants do not learn the route. Therefore, the QT seems to set both the amount of information gathered and the speed of the emigration. Low QTs might cause more errors and a slower emigration—the worst possible outcome. This possible paradox of quick decisions leading to slow implementation might be resolved if the ants could deploy another positive-feedback recruitment process when they have used a low QT. Reverse tandem runs occur after carrying has begun and lead ants back from the new nest to the old one. Here we show experimentally that reverse tandem runs can bring lost scouts into an active role in emigrations and can help to maintain high-speed emigrations. Thus, in rock ants, although quick decision-making and rapid implementation of choices are initially in opposition, a third recruitment method can restore rapid implementation after a snap decision. This work reveals a principle of widespread importance: the dynamics of collective decision-making (i.e. the politics) and the dynamics of policy implementation are sometimes intertwined, and only by analysing the mechanisms of both can we understand certain forms of adaptive organization.

International audience

PURPOSE OF REVIEW: In the absence of a specific treatment for dementia, the effective management of cognitive symptoms is a clinical priority. RECENT FINDINGS: Although some differences have been observed in the profile of cognitive complaints observed in subtypes of dementia, there is increasing recognition of common, interacting neurobiological causes suggesting the need to seek a common treatment applicable to all causes of cognitive deterioration. There also exists increasing interest in intervening at the level of minor cognitive dysfunction by reducing risk factors for subclinical states. SUMMARY: Pharmacological treatment of cognitive disorder is beneficial but has only temporary benefit for a subgroup of patients. Pharmacogenetics may have an important future role to play in deciding which patients may best benefit from the treatment. Low side effect therapies such as cognitive therapy and acupuncture show some benefits but their utility in combination with pharmacotherapies remains to be demonstrated. Prevention of milder forms of cognitive disorder by controlling risk factors such as hypertension and diabetes may reduce rates of more severe cognitive degeneration. Persons with cognitive dysfunction are commonly excluded from making decisions about the implementation of cognition-enhancing treatments although they wish to do so.

The human visual system is remarkably good at categorizing objects even in challenging visual conditions. Here we specifically assessed the robustness of the visual system in the face of large contrast variations in a high-level categorization task using natural images. Human subjects performed a go/no-go animal/nonanimal categorization task with briefly flashed grey level images. Performance was analysed for a large range of contrast conditions randomly presented to the subjects and varying from normal to 3% of initial contrast. Accuracy was very robust and subjects were performing well above chance level (approximately 70% correct) with only 10-12% of initial contrast. Accuracy decreased with contrast reduction but reached chance level only in the most extreme condition (3% of initial contrast). Conversely, the maximal increase in mean reaction time was approximately 60 ms (at 8% of initial contrast); it then remained stable with further contrast reductions. Associated ERPs recorded on correct target and distractor trials showed a clear differential effect whose amplitude and peak latency were correlated respectively with task accuracy and mean reaction times. These data show the strong robustness of the visual system in object categorization at very low contrast. They suggest that magnocellular information could play a role in ventral stream visual functions such as object recognition. Performance may rely on early object representations which lack the details provided subsequently by the parvocellular system but contain enough information to reach decision in the categorization task.

Objectives. We sought to evaluate socioeconomic disparities in serum screening for Down syndrome and assess whether such disparities are more likely to reflect limits in access or information or, rather, informed decisionmaking. Methods. A nationally representative sample of 12 869 French women completed interviews after giving birth. Results. We found substantial disparities in the likelihood of (1) women not being offered screening, (2) screening not being offered as a result of late prenatal care, and (3) women not knowing whether or not they had undergone screening. Except in the case of nationality, there was essentially no evidence of differences in refusal of testing. Conclusions. Rather than representing informed decisionmaking, socioeconomic disparities in screening for Down syndrome are mostly due to limits in access or to information.

International audience; In the present report, we examine electrodermal activity (skin conductance responses, SCRs) in monkeys trained to perform target-selection (TS) tests. In each test, the animal was presented in successive trials with the same two unequally rewarded targets on a touch screen. The probabilistic contingencies of the rewards associated with each target rendered the selection of the best difficult. Our findings revealed SCRs time-locked to the arm movements toward the rewarded targets, occurring after the target touches. Parameters of the SCRs were stable when the uncertainty of the choices and of the outcomes varied. The results support the hypothesis that the physiological processes indexed by the SCRs are the correlate of anticipatory appetitive behavior. In contrast, there is no evidence that the SCRs reflect cognitive processes associated with the detection of the best target.

International audience; Studies using semantic priming paradigms to measure the integrity of the features underlying concepts in semantic dementia (SD) reported differential impairment, in that functional features appeared to be more robust to brain damage than other features, such as perceptual ones. However, these prior studies were single case reports and the inclusion of too many heterogeneous features under the "functional features" heading casts doubts on their apparent preservation. To verify the robustness of functional features compared with perceptual ones, we carried out a group study where we deliberately restricted the exploration of semantic features to two clearly defined types of attribute: visuoperceptual ("visual") versus contextual-functional ("contextual"). We administered an implicit lexical-decision priming task to 8 SD patients and 31 healthy matched controls, at baseline. Four of the patients underwent a follow-up assessment at one year. For controls, we found a significant priming effect in the visual condition, but not in the contextual one, whereas the SD group exhibited the reverse pattern of performances. The follow-up data provided evidence of the robustness of the dissociation between priming performances in the two attribute conditions. The fact that a particular priming effect was observed in the SD patients but not in controls could be regarded as a sign of semantic disequilibrium. Since perceptual features have been shown to be a core determinant of similarity-based/taxonomic relationships, whereas complementary-based/thematic processing relies mainly on contextual relationships, we interpreted our findings in terms of the differential recruitment of one of the two systems of semantic relationships (taxonomic vs. thematic). Moreover, these two distinct and parallel systems have previously been reported to coexist - and compete - in healthy adults. We thus argue that controls automatically drew on similarity-based/taxonomic relationships, leading to a significant priming effect for visual features but not for contextual ones. By contrast, their impaired perceptual features forced the SD patients to resort to the system of thematic relationships.

International audience; The existence of an ethics consultation unit in nephrology (UCEN) gives to the nephrologist the collegiality required to meet the difficulties of therapeutic choice on a legislative level, particularly in indications of stop dialysis. The discussion conducted, outside the emergency, is guided by a tool for reflexion that details successive steps necessary to the identification of elements required for decision-making. Thanks to complementary skills provided by the participants and training acquired, the UCEN can approach other ethic issues encountered during practice such as contrindication for a kidney transplantation or maintenance of conservative treatment, or performing invasive procedures on patients refusing transfusion. Propositions are not always relevant due to opposition or ambivalence of some patients, their relatives, an external or disagreements between teams or a mismatch between the technical and the patient's condition. These non-conformities decrypted always have an explanation, sometimes they are understood and accepted by the teams, and sometimes they became source of regrets when they extend life in very poor conditions. The UCEN, if it does not solve every single point, remains a place and a time of sharing that face difficult situations, help the nephrologist positioning himself on maintaining treatments that were first to avoid and prevent the realization of unreasonable acts and accept their limits.

Item does not contain fulltext Decision-making plays a pivotal role in daily life as impairments in processes underlying decision-making often lead to an inability to make profitable long-term decisions. As a case in point, pathological gamblers continue gambling despite the fact that this disrupts their personal, professional or financial life. The prevalence of pathological gambling will likely increase in the coming years due to expanding possibilities of on-line gambling through the Internet and increasing liberal attitudes towards gambling. It therefore represents a growing concern for society. Both human and animal studies rapidly advance our knowledge on brain-behaviour processes relevant for understanding normal and pathological gambling behaviour. Here, we review in humans and animals three features of pathological gambling which hitherto have received relatively little attention: (1) sex differences in (the development of) pathological gambling, (2) adolescence as a (putative) sensitive period for (developing) pathological gambling and (3) avenues for improving ecological validity of research tools. Based on these issues we also discuss how research in humans and animals may be brought in line to maximize translational research opportunities.

Purpose Medical practices in oncology are expected to be multidisciplinary, yet few articles studied how this may be concretely applied. In the present study, we evaluated the organization of two multidisciplinary committees, one for breast cancer and one for sarcoma, in a French Comprehensive Cancer Centre. Methods Both tumours were specifically chosen so as to emphasise substantial differences in relation with incidence, histological subtypes, management strategy, and scientific evidence. Between 2003 and 2004, 404 decision processes were observed, 210 for sarcoma (26 meetings) and 194 for breast cancer (10 meetings). The number of physicians who took part in the discussions and their medical specialties were systematically noted as well as the number of contradictory discussions, medical specialties represented in these contradictory discussions and the topics of contradiction. The last measured data was whether the final committee's decision was in conformity with the referent preferences or not. All these measures were related to the referent's medical speciality and working place, to the stage of the disease and to the disease management stage. Results Committees’ specificities concerned their organization, referent's medical specialties, the number of participants in discussions and their medical specialties. Discussions in the sarcoma committee tended to be more multidisciplinary, involving more specialties. Initial strategy proposal for one patient was modified during the discussions for 86 patients out of 210 (41%) and for 62 out of 194 (32%) respectively for sarcoma and breast cancer. However, there was no significant difference in the rate of contradictory discussions between breast cancer and sarcoma committees (32% versus 41% respectively; P = 0.08). The rates of contradictory discussions were similar for localized cancers, local relapse and metastasis disease (37%, 41% and 34% respectively; P = 0.86). Conclusions The present study reports more than 30% of changes concerning strategy for patient with cancer due to multidisciplinary discussions. This indicates that, providing tumour committees are adapted to the pathologies’ characteristics, they can promote a collective and multidisciplinary approach to oncology.

International audience; CONTEXT: The setting of multidisciplinary meeting (MDM) by the French Cancer Plan has introduced new decisional elements in the patient-physician relationship in oncology. METHODS: To assess the potential impact of MDM on this relationship, a study was conducted at the Tours Hospital: 145 questionnaires were collected from patients whose files have been discussed in MDM, 40 questionnaires were collected from physicians attending these meetings and an analysis of 324 files was performed. RESULTS: Patients recognize the decisional process of MDM as reassuring for 80% of them. However, a majority (73%) expressed that the most important for them is the relationship with the referring physician, almost all (96%) having a total or great confidence in him. The results emphasize that trust appears to be related to the quality of communication, open dialogue and the competence of the doctor in particular in the choice of treatment. A review of files shows that in 91% of cases, the opinion of the RCP is applied and that, in 69% of cases, the referring doctor delivers the information to the patient after MDM. From the physicians' perspective, 33/40 report that the MDM do not alter their relationship with the patient. We note that 35/40 express that the consultation after MDM facilitates the presentation of the decision and 37/40 that the decision is always or often applied in accordance with the opinion of the MDM. CONCLUSION: MDM appears in most cases in this study not to modify the patient-physician relationship. Due to the patient confidence into the referring physician, the role of this one is essential in integrating the decisional multidisciplinary opinion of MDM and it is important to ensure from his/her disengagement in the decisional process.

International audience; PURPOSE: Since the 2005 French law on end of life and patients' rights, it is unclear whether practices have evolved. We investigated whether an intensive communication strategy based on this law would influence practices in terms of withholding and withdrawing treatment (WWT), and outcome of patients hospitalised in intensive care (ICU). METHODS: This was a single-centre, two-period study performed before and after the 2005 law. Between these periods, an intensive strategy for communication was developed and implemented, comprising regular meetings and modalities for WWT. We examined medical records of all patients who died in the ICU or in hospital during both periods. RESULTS: In total, out of 2,478 patients admitted in period 1, 678 (27%) died in the ICU and 823/2,940 (28%) in period 2. In period 1, among patients who died in the ICU, 45% died subsequent to a decision to WWT versus 85% in period 2 (p < 0.01). Among these, median time delay between ICU admission and initiation of decision-making process was significantly different (6-7 days in period 1 vs. 3-5 days in period 2, p < 0.05). Similarly, median time from admission to actual WWT decision was significantly shorter in period 2 (11-13 days in period 1 vs. 4-6 days in period 2, p < 0.05). Finally, median time from admission to death in the ICU subsequent to a decision to WWT was 13-15 days in period 1 versus 7-8 days in period 2, p < 0.05. Reasons for WWT were not significantly different between periods. CONCLUSION: Intensive communication brings about quicker end-of-life decision-making in the ICU. The new law has the advantage of providing a legal framework.

International audience; Memory consolidation benefits from sleep. In addition to strengthening some memory traces, another crucial, albeit overlooked, function of memory is to erase irrelevant information. Directed forgetting is an experimental approach consisting in presenting "to be remembered" and "to be forgotten" information that allows selectively decreasing or increasing the strength of individual memory traces according to the instruction provided at learning. This paradigm was used in combination with functional MRI to determine, in humans, what specifically triggers at encoding sleep-dependent compared with time-dependent consolidation. Our data indicate that relevant items that subjects strived to memorize are consolidated during sleep to a greater extent than items that participants did not intend to learn. This process appears to depend on a differential activation of the hippocampus at encoding, which acts as a signal for the offline reprocessing of relevant memories during postlearning sleep episodes.

International audience; Memory consolidation benefits from sleep. In addition to strengthening some memory traces, another crucial, albeit overlooked, function of memory is to erase irrelevant information. Directed forgetting is an experimental approach consisting in presenting "to be remembered" and "to be forgotten" information that allows selectively decreasing or increasing the strength of individual memory traces according to the instruction provided at learning. This paradigm was used in combination with functional MRI to determine, in humans, what specifically triggers at encoding sleep-dependent compared with time-dependent consolidation. Our data indicate that relevant items that subjects strived to memorize are consolidated during sleep to a greater extent than items that participants did not intend to learn. This process appears to depend on a differential activation of the hippocampus at encoding, which acts as a signal for the offline reprocessing of relevant memories during postlearning sleep episodes.

Background Great variability in breast cancer (BC) treatment practices according to patient, tumour or organisation of care characteristics has been reported but the relation between these factors is not well known. In two French regions, we measured compliance with Clinical Practice Guidelines for non-metastatic BC care management and identified factors associated with non-compliance at clinical and organisational levels. Methods Eligible patients had invasive unilateral BC without distant metastases and at least two contacts with one of the two regional healthcare systems (2003-2004) in the first year after diagnosis. Medical data were collected from patient medical records in all public and private hospitals (99 hospitals). The care process was defined by 20 criteria: clinical decisions for treatment and therapeutic procedures. Each criterion was classified according to level of compliance ("Compliant", "Justifiable" and "Not Compliant") and factors of non-compliance were identified (mixed effect logistic regression). Results 926 women were included. Non-compliance with clinical decisions for treatment was associated with older patient age (OR 2.1; 95%CI: 1.3-3.6) and region (OR 3.0; 95%CI: 1.2-7.4). Non-compliance with clinical decisions for radiotherapy was associated with lymph node involvement or the presence of peritumoural vascular invasion (OR 1.5; 95%CI: 1.01-2.3) and non-compliance with overall treatment (clinical decisions for treatment + therapeutic procedures) was associated with the presence of positive lymph nodes (OR 2.0; 95%CI: 1.2-3.3), grade III versus grade I (OR 2.9; 95%CI: 1.4-6.2), and one region of care versus another (OR 3.5; 95%CI: 1.7-7.1). Finally, heterogeneity of compliance in overall treatment sequence was identified between local cancer units (p < 0.05). Conclusion This study provides interesting insights into factors of non-compliance in non-metastatic BC management and could lead to quality care improvements.

International audience; Memory consolidation benefits from sleep. In addition to strengthening some memory traces, another crucial, albeit overlooked, function of memory is to erase irrelevant information. Directed forgetting is an experimental approach consisting in presenting "to be remembered" and "to be forgotten" information that allows selectively decreasing or increasing the strength of individual memory traces according to the instruction provided at learning. This paradigm was used in combination with functional MRI to determine, in humans, what specifically triggers at encoding sleep-dependent compared with time-dependent consolidation. Our data indicate that relevant items that subjects strived to memorize are consolidated during sleep to a greater extent than items that participants did not intend to learn. This process appears to depend on a differential activation of the hippocampus at encoding, which acts as a signal for the offline reprocessing of relevant memories during postlearning sleep episodes.

International audience; Patients suffering from Alzheimer's disease (AD) or semantic dementia (SD) both exhibit deficits on explicit tasks of semantic memory. Semantic priming (SP) paradigms provide a very pure and precise implicit measurement of semantic memory impairment, and a previous study of AD (Giffard et al., 2002) using one such paradigm revealed that AD patients in the initial stages of semantic deterioration presented an abnormally large priming effect (hyperpriming) in a category-coordinate condition, compared with controls. This astonishing phenomenon could stem from the specific loss of distinctive attributes that make it possible to distinguish between semantically close concepts, while attributes shared by different concepts belonging to a given category remain intact. To test this hypothesis and compare the degradation of semantic memory in AD and SD, we devised an SP paradigm in which word pairs had either a category-coordinate or an attribute relationship. In accordance with our hypothesis, we distinguished between shared (duck-feathers) versus distinctive attributes (zebra-stripes) and close (tiger-lion) versus distant (elephant-crocodile) category-coordinate relationships. This paradigm, together with two explicit semantic memory tasks (picture-naming and categorization), was administered to 16 AD and 8 SD patients and 30 elderly control subjects. The AD patients, at the very beginning of semantic deterioration, only displayed impaired SP effects in the distinctive attribute condition, whereas in the SD patients, who had more severe semantic deterioration, we observed an extinction of SP effects in both attribute conditions. In SD patients, we also report hyperpriming effects in both category-coordinate conditions. Our results suggest that semantic memory impairment follows the same course in both AD and SD, affecting distinctive attributes first and then shared ones. In accordance with distributed models of semantic memory, the loss of distinctive attributes leads to a confusion between close concepts and it is this which causes the transient hyperpriming phenomenon.

International audience; Patients suffering from Alzheimer's disease (AD) or semantic dementia (SD) both exhibit deficits on explicit tasks of semantic memory. Semantic priming (SP) paradigms provide a very pure and precise implicit measurement of semantic memory impairment, and a previous study of AD (Giffard et al., 2002) using one such paradigm revealed that AD patients in the initial stages of semantic deterioration presented an abnormally large priming effect (hyperpriming) in a category-coordinate condition, compared with controls. This astonishing phenomenon could stem from the specific loss of distinctive attributes that make it possible to distinguish between semantically close concepts, while attributes shared by different concepts belonging to a given category remain intact. To test this hypothesis and compare the degradation of semantic memory in AD and SD, we devised an SP paradigm in which word pairs had either a category-coordinate or an attribute relationship. In accordance with our hypothesis, we distinguished between shared (duck-feathers) versus distinctive attributes (zebra-stripes) and close (tiger-lion) versus distant (elephant-crocodile) category-coordinate relationships. This paradigm, together with two explicit semantic memory tasks (picture-naming and categorization), was administered to 16 AD and 8 SD patients and 30 elderly control subjects. The AD patients, at the very beginning of semantic deterioration, only displayed impaired SP effects in the distinctive attribute condition, whereas in the SD patients, who had more severe semantic deterioration, we observed an extinction of SP effects in both attribute conditions. In SD patients, we also report hyperpriming effects in both category-coordinate conditions. Our results suggest that semantic memory impairment follows the same course in both AD and SD, affecting distinctive attributes first and then shared ones. In accordance with distributed models of semantic memory, the loss of distinctive attributes leads to a confusion between close concepts and it is this which causes the transient hyperpriming phenomenon.

Background A number of studies have identified advanced age as a barrier to accessing specialised oncological care. Many factors can influence the care provided for elderly patients after a diagnosis of cancer has been established or is suspected. Only one European study has analysed the decision processes leading general practitioners (GPs) to refer elderly patients with cancer to oncologists. The objectives of the current study are to describe the factors that influence these decisions and to identify the particular factors and GP characteristics that are associated with systematic referral of these patients in South-West France. Methods This is a cross-sectional study on a representative sample of GPs in Aquitaine, South-West France. Questionnaire items were selected using a Delphi consensus approach and sent by post. Two logistic regression models were constructed to investigate GPs' decisions to refer these patients. Results The response rate obtained was 30%. Half of the general practitioners reported "always" referring their elderly cancer patients to oncologists. More than 75% reported being influenced by patient-related elements (patient and/or family wishes, comorbid factors, unsuitability of invasive investigations, physical and mental autonomy), by cancer-related elements (severity of symptoms, expected side-effects) and an organisational element (whether the general practitioner was used to collaborating with oncologists). Logistic regression analysis showed that cancer site and organisational difficulties in patient management were significantly associated with the decision to refer elderly patients with early-stage cancer. For advanced stages, oncology training, patient age, organisational difficulties in patient management and stage of cancer were significantly associated with the decision to refer elderly patients. Conclusions Cancer-linked factors and organisational difficulties have been highlighted as influencing the decisions of GPs in the referral of elderly patients to a cancer team. These results highlight the need to implement continuous medical education specific for the management of elderly patients, to better apprehend the nature of these difficulties and to suggest solutions suited to local settings.

International audience; Human health risk assessment can be used to support decisions for public health regulations and actions. Characterizing the hazards of inhaled toxicants generally includes extrapolation from observations on experimental animals, subjected to intermittent or subchronic exposures, to a human environmental context with exposure that is usually continuous and long-term. The extrapolation is usually based on a simple linear relationship derived from Haber's rule which assumes that, for a given chemical compound, multiplying the same concentration by the same duration of exposure will yield the same biological response. This study assessed the reliability of this assumption. The p-power in the equation C×t(p)=k was calculated for 21 chemicals, based on a comparison of LOAELs for subacute, subchronic and chronic durations. A bibliographic survey was then carried out to study the reliability of the intermittent-to-continuous exposure adjustment factors currently used in risk assessment. The results showed that the value of p, assumed to be 1 in risk assessment methodology, was not in fact equal to 1 for any of the selected chemicals. Moreover, in the case of respiratory tract irritation, the value of p varied from 0 to 0.44, as confirmed by experimental studies. These results suggest that a more in-depth and case-by-case approach is required for regulatory toxicology, based on toxicokinetics and toxicodynamic data analysis for each toxicant before applying a temporal-adjustment factor.

International audience; The incidence of acute myeloblastic leukemia increases with age. The unfavorable biology of the disease, comorbidities, and significant side effects of the intensive treatment make treatment decisions difficult. New and less toxic targeted approaches are under investigations in this setting and the main problem remains to determine which strategy for patients over 65 years of age. Some of them will be treated successfully using intensive chemotherapy, while a majority of them will fail. Older patients are heterogeneous and enrolling them in investigational therapy is justified, according to proven methods to stratify them.

International audience; INTRODUCTION: A "resting state" or "default mode network" has been highlighted in functional neuroimaging studies as a set of brain regions showing synchronized activity at rest or in task-independent cognitive state. STATE OF THE ART: A considerable and increasing number of studies have been conducted over the last few years so as to unravel the cognitive function(s) of this brain network. PERSPECTIVES: This review gives an overview of anatomical, physiological and phenomenological data regarding the default mode network. Different hypotheses have been proposed regarding the role of this network. Several studies have highlighted its involvement in autobiographical memory, prospection, self, attention, and theory of mind. The influence of the attention level and consciousness onto resting state brain network activity has also been discussed. Specific changes have been described in normal aging, Alzheimer's disease (AD) and multiple sclerosis (MS). CONCLUSIONS: These studies altogether contribute to a better definition of the default mode network, in terms of implicated brain structures, subtending mechanisms, and potential cognitive roles. For instance, similarities and relationships were found between self-related brain activity and resting-state activity in regions belonging to this network, namely posterior cingulate and prefrontal areas that may reflect introspective activity experienced, more or less consciously, when the brain is not specifically engaged in a cognitive task. As a whole, the default mode network appears as a non human-specific intrinsic functional network, active all over the life from birth until aging where it is progressively modified, and sensitive to different pathologies including AD and MS. On the other hand, many points remain to be clarified concerning this network, such as the exact part of its activity dedicated to self-related cognitive processes (introspection, imaginary mental scenario based on past autobiographical experiences) and that involved in a sentinel-like attentional process designated to react to possible environmental events. Indeed, it seems that this network is functional even in case of low level of consciousness, i.e., during light sleep. Conversely, a loss of self and environment perception as in coma, deep sleep or anesthesia might modulate its connectivity along the anteroposterior axis, i.e., frontal activity disappearance associated with a parietal reinforcement of connectivity. Since studies aiming at highlighting these points are still uncommon to date, exhaustive and objective explorations are needed to better understand all these resting state processes.

Background: Opinions and practice regarding end-of-life decisions in neonatal medicine show considerable variations between countries. A recent change of the legal framework, together with an ongoing debate among French neonatologists, led the French Society of Neonatology to reconsider and update its previous recommendations. Objectives: To propose a set of recommendations on the ethical principles to be respected in the making and application of end-of-life decisions. Methods: A multidisciplinary working group on ethical issues in perinatal medicine composed of neonatologists, obstetricians and ethicists. Results: Withholding or withdrawing life-sustaining treatment may be acceptable, and unreasonable therapeutic obstinacy is condemned. This implies that the child’s best interests must always be the central consideration. Although the parents must be involved in the decision process so that they form an alliance with the healthcare team, and a collegial approach is of utmost importance, any crucial decision affecting the patient’s life calls for individual medical responsibility. Because every newborn is rightfully an integral member of a human family, his or her dignity must be preserved. The goal of palliative care is to preserve the quality of a life, also at its end. The intention underlying an act has to be analyzed perceptively. Euthanasia, i.e. to perform an act with the deliberate intention to cause or hasten a patient’s death, is legally and morally forbidden. Conversely, to withhold or withdraw a life-sustaining treatment can be justified when the intention is to cease opposing, in an unreasonable manner, the natural course of a disease. Conclusions: This statement provides the principles identified by French neonatologists on which to base their decisions concerning the ending of life. Arguments are set forth, discussed and compared with international statements and previously published considerations.

International audience; In the first part of this work, the outcome following very premature birth was assessed. This enabled a gray zone to be defined, with inherent major prognostic uncertainty. In France today, the gray zone corresponds to deliveries occurring at 24 and 25 weeks of postmenstrual age. The management of births occurring below and above the gray zone was described. Withholding intensive care at birth for babies born below or within the gray zone does not mean withholding care but rather providing palliative care to prevent pain and suffering during the time period preceding death. Given the high level of uncertainty, making good decisions within the gray zone is problematic. Decisions should be based on the infant's best interests. Decisions should be reached with the parents, who are entitled to receive clear and comprehensive information. Possible decisions to withhold intensive care should be made following the procedures described in the French law of April 2005. Guidelines, based on gestational age and the other prognostic elements, are proposed to the parents before birth. They are applied in an individualized fashion, in order to take into account the individual features of each case. At 25 weeks, resuscitation and/or full intensive care are usually proposed, unless unfavorable factors, such as severe growth restriction, are associated. A senior neonatologist will attend the delivery and will make decisions based on both the baby's condition at birth and the parents' wishes. At 24 weeks, in the absence of unfavorable associated factors, the parents' wishes should be followed in deciding between initiating full intensive care or palliative care. Below 24 weeks, palliative care is the only option to be offered in France at the present time.

International audience; BACKGROUND AND OBJECTIVE: Several systems for the diagnosis of melanoma from images of naevi obtained under controlled conditions have demonstrated comparable efficiency with dermatologists. However, their robustness to analyze daily routine images was sometimes questionable. The purpose of this work is to investigate to what extent the automatic melanoma diagnosis may be achieved from the analysis of uncontrolled images of pigmented skin lesions. MATERIALS AND METHODS: Images were acquired during regular practice by two dermatologists using Reflex 24 x 36 cameras combined with Heine Delta 10 dermascopes. The images were then digitalized using a scanner. In addition, five senior dermatologists were asked to give the diagnosis and therapeutic decision (exeresis) for 227 images of naevi, together with an opinion about the existence of malignancy-predictive features. Meanwhile, a learning by sample classifier for the diagnosis of melanoma was constructed, which combines image-processing with machine-learning techniques. After an automatic segmentation, geometric and colorimetric parameters were extracted from images and selected according to their efficiency in predicting malignancy features. A diagnosis was subsequently provided based on selected parameters. An extensive comparison of dermatologists' and computer results was subsequently performed. RESULTS AND CONCLUSION: The KL-PLS-based classifier shows comparable performances with respect to dermatologists (sensitivity: 95% and specificity: 60%). The algorithm provides an original insight into the clinical knowledge of pigmented skin lesions.

International audience; To describe the therapeutic practice used in 2006 by French rheumatologists and hospital staff in RA patients, and to estimate the proportion of patients currently treated with DMARDs including biologics, and to estimate the ratio of patients treated according to the SFR national recommendations. This multicentre cross-sectional study was performed in a random sample of rheumatologists selected from a comprehensive national database and stratified by setting and region. Each rheumatologist established a registry of subsequent RA patients (first step), and filled in a detailed questionnaire for the 10 first patients from the registry (second step). At the day of inclusion, RA characteristics and DMARD treatments over the past 12 months were recorded. The majority of the RA patients were women (mean age: 58 yrs). The mean DAS 28 score was 3.6, and RA was considered as clinically and radiologically severe in almost 27.0% of the cases. In the registry part, 89.9% of RA patients were currently treated with DMARDs, and 29.3% of them received a biologic DMARD alone or in combination. In 1610 patients with detailed questionnaire record, the efficacy of the current DMARD treatment was good in almost 60% of the patients. Finally, the physician's decision was to continue the ongoing treatment in 4/5 cases. In this study, RA characteristics were similar to the typical RA observed in previous studies. Biologics were major drugs in DMARD treatments with 30.1% RA patients currently treated. Modification of treatments was essentially linked to a lack of therapeutic response.

International audience; Multidisciplinary meeting (MDM) in oncology has been institutionalised in France by the Cancer Plan. This study aims to determine the place of MDM in the decision process. From November 2004 to July 2005, we observed 29 meetings at the Tours Hospital and 324 case presentations, 80 in orthopaedics, 151 in gastroenterology and 93 in chest medicine. Forty physicians attending the meetings answered a questionnaire exploring their opinions on MDM and the collegial decision. We found that MDM is mostly the place for technical discussions and that patients' wishes are rarely addressed. The different medical specialities are well represented but we observed that only physicians attend MDM. Decisions for straightforward cases are rapidly validated. For more complex clinical situations (25 to 40% of case presentations), the multidisciplinary approach allows to adapt guidelines or to choose alternative treatments. All the physicians interviewed express that MDM legitimates the medical decision. It occurs that they disagree with the RCP decision. We discuss how MDM impacts on the medical decision as well as the shift from the individual decision to the collective one, particularly in term of responsibility.

International audience; The medical reasoning model that is used for LTDs in the PICU generates conflictual situations when compared to the models that are used in other specialties. These models represent various expressions of subjectivity, as in any medical decision. Acknowledging this fact could facilitate its integration into clinical practice and should improve authentic debates that are necessary to ensure continuity of care for these children.

Objective: This study analyzes decision making during preoperative surgical planning through two cognitive indicators: conflict and cognitive control. Background: Planning is a critical stage in naturalistic decision making, and there is some evidence suggesting that this activity depends on the level of expertise and the demands of the task. The specificity of surgery resides in the necessity to cope with (potential) conflicts between the purpose of the surgical intervention and the biological laws governing the patient's body. Method: Six neurosurgeons (two board-certified neurosurgeons, two chief residents, and two residents) described the operative procedure envisaged on nine surgical cases of increasing surgical complexity. A detailed analysis of one surgical case described by one expert was performed. Moreover, we measured the number of conflicts and controls reported by each surgeon. Results: Two experts were the only ones for which the report of conflicts increased with surgical complexity (respectively, 75% and 73% of the conflict variance predicted by complexity). The two experts significantly activated a higher proportion of knowledge-based control (respectively, 43% and 38%) than did intermediates and residents. The residents significantly activated more motor skill—based controls (respectively, 40% and 44%) than did intermediates and experts. Conclusion: It seems that expert surgical decision making to cope with task demands is significantly associated with conflict monitoring. Knowledge-based control to regulate conflict is mainly produced by experts. Application: Conflicts and controls analyzed through verbal reports can be used as relevant indicators to highlight critical moments in decision making that potentially require assistance from information systems.

Objectives Little is known about how dentists implement caries management and provide restorative dental services in everyday practice. This study explored whether or not recent concepts in caries management were implemented in practice by private practitioners. The influence of patient and practitioner characteristics on the provision of restorative dental services was also investigated through multidimensional analyses. Methods A sample of French general private dental practitioners was asked to record the characteristics of 35 preventive or restorative treatments made on vital permanent teeth. The data collection form was designed to explore dentists’ attitudes towards caries management and their use of minimally invasive therapies. Results Twenty-six practitioners recorded the characteristics of 921 treatments performed on 457 patients. Results indicate that participants rarely performed non-invasive treatments. They used an inappropriate detection tool, as most of decisions to treat were based on visual inspection frequently associated with probing. Multidimensional analysis showed that dentists provided different restorative treatments depending on patient characteristics, with minimally invasive, esthetic restorations preferentially performed for healthy, young and well-insured patients. Restorative treatments and detection tools also varied markedly among practitioners. These variations in service patterns were not related to a specific patient profile in each dental practice. Conclusions Results indicate that recent concepts in caries management have not yet been adopted in everyday practice. Patient and dentist characteristics influence the provision of restorative dental services. Decision-making in caries management not only depends on pathophysiology but also seems to be influenced by many other factors.

International audience; Conflicts and controls analyzed through verbal reports can be used as relevant indicators to highlight critical moments in decision making that potentially require assistance from information systems.