Journal articles on the topic 'Rapports 10-K'

Au cours des dernières décennies, il y a de plus en plus des études universitaires sur l'importance du biochar. Ce dernier constitue un moyen efficace pour la valorisation des déchets agricoles et forestiers. Cette étude qui s’inscrit dans le même contexte a pour objectif principal de déterminer les effets combinés du fumier de chèvre (FC, 5 t ha-1) et de son biochar (BC 10 t ha-1) sur l'efficacité d'utilisation des engrais chimiques (EC) sous différents ratios (100%, 50% et 0%), avec la variété d’oignon Metan 88. Pour ce faire, des essais ont été conduits en plein champ, dans le Centre de Recherche Horticole (CRH Ayas) de l’Université d'Ankara. En effet, le dispositif expérimental est un bloc complet randomisé comportant douze (12) traitements en quatre (4) répétitions, soit quarante-huit (48) parcelles. Les différentes mesures et analyses effectuées ont permis la détermination des paramètres tels que ; le poids frais et sec, le rendement total, la chlorophylle relative, l’acide ascorbique, ainsi que les concentrations des N, P, K, Ca, Mg, Fe, Zn, Cu et Mn. Les résultats obtenus ont montré que le rendement total de l'oignon a augmenté de manière significative avec l'application du biochar, du fumier ainsi que leur combinaison. Tous les traitements d'engrais organiques et inorganiques ont considérablement augmenté les concentrations en N, P et K respectivement 38,8, 2,81 et 42,2 g Kg-1 par rapport aux témoins 33,8, 2,32 et 35,6 g Kg-1. Les concentrations en Ca et Mg respectivement 7,31 et 6,69 g kg-1 ont été augmentées avec l'engrais organique par rapport aux témoins 6,43 et 5,10 g kg-1. Le Biochar et le fumier ont donné la concentration la plus élevée de chlorophylle relative avec 297 et 294 respectivement. En conclusion , la combinaison du BC+FC a permis d’obtenir une croissance optimale de l’oignon. In recent decades, numerous academic studies were carried out in order to determine the importance of biochar. The latter constitutes an effective means for valuing the agricultural and forestry waste. The main objective of the present study was to determine the combined effects of goat manure (GM, 5 t ha-1) and its biochar (BC 10 t ha-1) on use efficiency of chemical fertilizers (CF) in different ratios (100%, 50% and 0%), in the Metan 88 variety of onion. The , trials were carried out in the open field at the Horticultural Research Center at Ankara University. The experimental device is a complete randomized block comprising twelve (12) treatments in four (4) repetitions, forty-eight (48) plots. The various measurements and analyses carried out allowed the determination of parameters such as fresh and dry weight, total yield, relative chlorophyll, ascorbic acid, the concentrations of N, P, K, Ca, Mg, Fe, Zn, Cu and Mn, as well . The obtained results showed that the total yield of onion increased significantly with biochar, manure as well as their combination. All organic and inorganic fertilizer treatments significantly increased N, P and K concentrations 38.8, 2.81 and 42.2 g Kg-1 respectively compared to controls 33.8, 2.32 and 35, 6g Kg-1. As for the concentrations of Ca and Mg 7.31 and 6.69 g kg-1 they were increased with the organic fertilizer compared to the controls 6.43 and 5.10 g kg-1 respectively.. Biochar and manure gave the highest concentration of relative chlorophyll with 297 and 294 respectively. Inconclusion , the combination of BC + CF resulted in optimal onion growth.

We developed and administered two questionnaires to assess the interview experience of both interviewers and applicants during postgraduate medical selection interviews. Using a 5 point likert scale, the questionnaires assessed three areas (1) ability to show/assess communication, interpersonal and problem solving skills; (2) ability to know the other side well and (3) level of comfort with the interview. Interviewers and applicants were asked to provide a global rating for the interview. The questionnaires were administered to both candidates and applicants from 6 departments in 18 in-person and 12 video interviews. 30 applicant and 87 interviewer survey forms were collected and analyzed. T-tests were used to compare the means of the two groups and significance levels were analyzed. Both interviewers and applicants had a higher average global satisfaction for video interviews compared to in person interviews. No difference was indicated in the ability of interviewers to assess the applicants’ skills between the two types of interviews. For both interviewers and applicants, video interviews, compared to in person interview, had a lower average score for connecting personally & establishing rapport and for satisfaction with administrative arrangements. Video interviewed applicants had a 50% probability of getting accepted in a program compared to 22% of in person interviewed candidates. We conclude that video interviews appear to be a valuable alternative to in-person interviews, with some sacrifice in personal connection and rapport. Video interviews result in significant time and cost savings for international applicants and have potential implications for the CaRMS process as well. Sackett KM, Campbell-Heider N, Blyth JB. The evolution and evaluation of videoconferencing technology for graduate nursing education. Comput Inform Nurs. 2004 (Mar-Apr); 22(2):101-6. Shepherd L, Goldstein D, Whitford H, Thewes B, Brummell V, Hicks M. The utility of videoconferencing to provide innovative delivery of psychological treatment for rural cancer patients: results of a pilot study. J Pain Symptom Manage 2006 (Nov); 32(5):453-61. Arena J, Dennis N, Devineni T, Maclean R, Meador K. A pilot study of feasibility and efficacy of telemedicine-delivered psychophysiological treatment for vascular headache. Telemed J E Health 2004 (Winter); 10(4):449-54.

Purpose The purpose of this paper is to identify essential psychological-informed executive coaching approaches that enhance the organisational learning and development process and outcomes through integrating existing research evidence. Since coaching has been widely used in leadership development related areas and previous studies confirmed that this generates positive effects on individual-level learning in the organisational setting. The identified frameworks and influential factors outlined in this paper can serve as explicit guidelines for the organisation and management team when setting selection and evaluation benchmarks for employing executive coaches. Design/methodology/approach An integrated review approach was applied to narratively synthesise 234 (k=234) identified peer-review articles between 1995 and 2018. This review followed a rigorous protocol that the authors consulted ten (n=10) experts in the field. Both qualitative and quantitative psychological-focused research evidence was included in this study. Findings First, certain psychological approaches, such as cognitive behavioural, solution-focused, GROW and strength-based approaches, were highlighted in current research evidence. Second, the essential factors and skills, for instance, building trust, transparency and rapport, and facilitating learning were identified. Third, the main organisational learning and development outcome evaluation methods were outlined in this review, such as the self-efficacy scale, organisational commitment, workplace psychological well-being, 360-degree feedback and the Multifactor Leadership Questionnaire. Research limitations/implications It is always challenging to integrate research evidence on coaching because of the diversity of theoretical disciplines upon which coaching interventions draw. Therefore, it is difficult to generate a meta-analytic review which can generate statistical results. This review also reveals room for improvement in the quality of existing coaching evidence in accordance with the criteria for evidence-based management or practice (Briner et al., 2009), such as research methodology and evaluation design. Moreover, there is a lack of evidence on this reflective process which helps professional coaches to ensure the quality of their practice and organisational support. Practical implications This review offers a new perspective on the role psychology plays in the organisational learning and development practices. The identified coaching approaches, influential interpersonal skills and outcome evaluation methods can serve as practical guidelines when applying external coaching to facilitate a better organisational learning and development process and outcome. Originality/value This is the first literature review to focus on contemporary psychological-informed coaching evidence (between 1995 and 2018) in the workplace setting. Despite the rapid growth in demand for professional coaching practitioners (International Coach Federation, 2016), there is a lack of research-informed evidence to overcome the challenges faced by organisations when employing external coaches, such as what selection criteria or evaluation benchmarks to use. This review takes a practical perspective to identify essential body of knowledge and behavioural indicators required for an executive coach to facilitate an effective learning and development outcome.

Un des objectifs de cette recherche est d'examiner les différences entre les resultats obtenus par les tests de dosage des matières organiques biodégradables (MOB). L'autre objectif est de déterminer comment les résultats peuvent correspondre à la valeur vraie de la MOB. L'étude a été menée en employant un mode le mathématique qui tient compte des principes cinétiques et stoechiométriques. Le tableau 1 présente les exemples des équations de bilan de masse qui entrent dans le modèle. Celui-ci permet de suivre la croissance de la biomasse, la dégradation du substrat (MOB), le carbone organique dissous (COD), ainsi que la production et la dégradation des produits microbiens solubles (PMS). Les PMS, qui possèdent des poids moléculaires allant de moyens à élevés, sont produits durant le métabolisme normal des cellules (RITIMANN et al., 1987). Les PMS peuvent être divisés en deux groupes de produits associés: les PAU qui sont le résultat direct de l'utilisation du substrat et les PAB qui sont produits proportionnellement à la biomasse (PAB). Certaines hypothèses sont à la base des équations du bilan massique. La biomasse n'est constituée que d'hétérotrophes. La MOB est modélisée en tenant compte de substrats facilement et difficilement dégradables. Chaque substrat se distingue par sa valeur K inscrite au tableau 3. La densité de biomasse en début de test est de 1 mgA (2400 UFC/ml), sauf quand la densité est modifiée dans le modèle. Pour les besoins de la modélisation, les valeurs de MOB, de CODB et de biomasse ont eté converties en demande chimique en oxygène (DCO). Les facteurs de conversion utilisés sont: 1,42 mg de MOB exprimée en DCO/mg de MOB exprimee en solides volatils dissous, 4,16 x 10-7 mg DCO/cellule et 2,67 mg acétate exprimé en DCO/mg de C-acétate. Un ensemble de courbes typiques pour le modèle est présenté aux figures 1 et 2. La figure 1 montre les résultats obtenus pour un substrat facilement dégradable tandis que la figure 2 présente ceux obtenus pour un substrat difficilement dégradable. Dans les deux cas, la biomasse s'accroît graduellement pour atteindre un maximum, puis rediminue. Les vitesses et intensités de réaction dépendent toutefois beaucoup des cinétiques de dégradation de la MOB. Les deux figures traduisent l'accumulation continue des PMS, qui représentent des proportions respectives de 43% et 30% de la MOB d'origine pour les substrats facilement et difficilement dégradables. L'accumulation des PMS est importante, car la courbe de décroissance du COD est le résultat net de la MOB consommée moins les PMS accumulés. Ceci implique que le changement dans le niveau de COD, qui représente le paramètre de contrôle pour les tests CODB, n'égale pas la MOB vraie. Le CODB mesuré ne représenterait plutôt que 50 à 60 % de la MOB d'origine. La figure 3 montre la relation qui existe entre le CODB et la MOB pour les deux types de substrats. Le CODB n'est pas égal à la MOB, ce qui est démontré par l'écart observé par rapport à la droite d'équivalence de pente 1. Cette différence est due à deux phénomènes: I'accumulation des PMS dépend de la MOB, tandis que l'écart entre les deux types de substrat est le résultat des courbes s'approchant de Smin sur l'axe de la MOB, lorsque le CODB tend vers zéro. Ce résultat est significatif, car des études ont démontré que la MOB dans les eaux brutes contient surtout des substrats difficilement dégradables (LECHEVALLIER et al., 1991). Ainsi, faire l'hypothèse que le CODB soit égal à la MOB pour les substrats difficilement assimilables se traduirait par une importante sous-estimation de la MOB dans l'échantillon. La figure 4 montre la relation observée entre la biomasse maximum, employée avec les tests COA (carbone organique assimilable), et la vraie MOB pour les deux substrats. Cette figure présente aussi l'étalon de calibration proposé par van ter Kooij et al (1982), qui convertit le nombre de cellules en C-acétate (4,1 x 10 6 cellules par mg C-acétate). Ni le substrat facilement utilisable ni le substrat difficilement utilisable, ne s'approche de la courbe de calibration. Ces écarts sont causés par la variation du premier ordre en ordre zéro de l'équation de Monod et aussi parce que les courbes approchent le Smin où la croissance des cellules est presque nulle. Lorsque la MOB dans l'échantillon est principalement constituée d'un substrat difficilement dégradable, I'usage d'un étalon d'acétate produit une forte sous-estimation de la MOB vraie. La figure 5 montre la relation directe entre le CODB et le COA pour les deux types de substrats. L'augmentation du rapport CODB/COA avec la diminution de la MOB s'explique par le fait que la biomasse tend vers une croissance zéro lorsque la MOB s'approche de Smin. Cette figure démontre clairement qu'il existe une différence fondamentale entre les mesures des tests CODB et COA, lorsque la MOB tend vers Smin. Toutefois, le rapport CODB/COA est presque unitaire dans le cas du substrat facilement dégradable, quand la MOB se situe à l'intérieur des limites de détection pour le dosage du CODB (environ 100 mg/l à la figure 5). Ainsi, il est possible d'obtenir le même résultat avec les deux types de tests. Le modèle permet aussi d'examiner l'effet des concentrations en biomasse initiale pour une [MOB] fixée. Pour un substrat facilement dégradable, qui est entièrement consommé en présence d'un faible inoculum, la modélisation montre que le CODB et la biomasse maximum ne sont pas affectés. Cependant, le résultat diffère pour un substrat difficilement dégradable qui n'est pas entièrement consommé avec un inoculum de faible densité. Tel que présenté à la figure 6, le CODB et la biomasse maximum augmentent fortement avec la densité de l'inoculum. Cet effet est dû à la faible croissance de la biomasse qui survient en présence d'un inoculum de faible densité; la biomasse maximum et le COD minimum sont atteints après 30 jours. Avec un inoculum important, la biodégradation survient plus rapidement et le CODB maximum est atteint avant 30 jours.

Résumé VIOLENCE ET VOL QUALIFIE : ETUDE DE CAS Cette etude est une recherche empirique de nature sociologique sur un type de criminalite : le vol qualifie ou vol avec violence. Le vol qualifie est un delit ou l'usage de la violence physique ou une intimidation a cet effet est deploye par le criminel afin de prendre illegalement l'argent ou un objet qui appartient a la victime. Plus de 350 000 vols qualifies ont lieu chaque annee en Amerique du Nord. Toutefois, jusqu'a tout dernierement aucune recherche phenomenologique n'avait ete entreprise sur le vol qualifie. La recherche qui est presentee dans cette monographie essaie donc de decrire les elements criminologiques qui sont associes au vol qualifie. La situation du vol qualifie dans une grande ville nord-americaine, c'est-a-dire la ville de Philadelphie, U.S.A., est presentee. Il s'agit de l'analyse de 1 722 evenements de vols qualifies (un echantillon de 10 pour cent) survenus a Philadelphie de 1960 a 1966. Cette recherche a essaye de saisir les tendances et les modeles (patterns) du vol qualifie dans le temps et dans l'espace. Le modele statistique utilise etait celui de l'indice de gravite de Sellin et Wolfgang (1964). Le modele theorique utilise etait celui de Wolfgang et Ferracuti (1967). Voici quelques conclusions pertinentes : a) L'indice de gravite de Sellin et Wolfgang donne une vision plus juste des tendances et des profils du vol qualifie par rapport aux statistiques policieres ordinaires, b) Cet indice de gravite a revele, par exemple, que les vols qualifies commis par des jeunes sont aussi graves que ceux perpetres par les adultes, c) Le vol qualifie execute au sein de bandes organisees augmente chaque annee. d) Plus de la moitie des vols qualifies ne comportent aucune violence physique effective, e) Plus de 85 pour cent des vols qualifies sont commis a l'egard de victimes completement inconnues des agresseurs, f) Les chances pour un voleur de ne pas etre pris par la police sont tres bonnes, g) Le vol qualifie est surtout commis par les jeunes qui sont issus de milieux defavorises. .h) Le vol qualifie est surtout lie aux commerces et aux maisons d'affaires plutot qu'a des particuliers, i) La distance qui separe les lieux de residence de l'agresseur, de la victime, et l'endroit ou se produit le vol est semblable aux distances constatees dans l'etude des migrations, des diffusions de messages et des choix maritaux. ;') L'alcool est rarement present autant chez l'agresseur que chez la victime, sauf pour environ 12 pour cent des cas. k) La victime contribue quelquefois a sa propre victimisation, soit environ 11 pour cent des cas. /) La theorie d'une sous-culture du vol plutot que celle d'une sous-culture de violence peut expliquer le comportement du voleur, m) II n'y a pas de discrimination raciale au niveau des sentences, n) Tout compte fait, le vol qualifie a plutot les caracteristiques des crimes contre la propriete que des crimes contre la personne.

Dix années après la publication du rapport de la FAO « Livestock’s long shadow », qui fait toujours référence dans les débats sur les impacts de l’élevage et la part des produits animaux dans notre alimentation, quels sont les nouveaux résultats de recherche qui affinent ce panorama mondial ? Pour répondre à cette question, les ministères français en charge de l’Environnement et de l’Agriculture ainsi que l’ADEME ont sollicité l’INRA pour synthétiser les connaissances scientifiques disponibles sur les rôles, impacts et services issus des élevages en Europe. L’exercice, qui a pris la forme d’une Expertise scientifique collective (ESCo), s’est donc intéressé aux différentes fonctions et conséquences de la production et de la consommation de produits animaux sur l’environnement et le climat, l’utilisation des ressources, les marchés, le travail et l’emploi, et les enjeux sociaux et culturels. L’expertise s’est centrée sur les services et impacts des principaux animaux d’élevage « terrestres », bovins laitiers ou allaitants, petits ruminants, porcs et volailles, et de leurs filières à l’échelle européenne. Le terme « services » renvoie à la fourniture d’un avantage marchand ou non marchand issu des activités d’élevage et/ou de l’usage de produits d’origine animale, soit une acceptation plus large que celle des services écosystémiques fournis par les agroécosystèmes. Nous utilisons l’expression « services et impacts » car les deux termes sont spontanément complémentaires, les services étant en général connotés de manière positive tandis que les impacts le sont négativement. Associer ces deux termes conduit à considérer les différents effets de l’élevage conjointement, et à souligner les complémentarités et antagonismes qui résultent des interactions entre les processus écologiques, biotechniques et économiques mis en jeu. La notion de « bouquets de services » constitue aujourd’hui un front de science dynamique dont nous avons cherché à extraire ce qui est spécifique à l’élevage. L’analyse a mis l’accent sur la variabilité des bouquets de services fournis par l’élevage selon les territoires. Une expertise scientifique consiste en un état des lieux critique des connaissances disponibles à partir d’une analyse exhaustive de la littérature scientifique. L’objectif est de dégager les acquis sur lesquels peut s’appuyer la décision publique, et de pointer les controverses, incertitudes ou lacunes du savoir scientifique. Placée sous la responsabilité scientifique de Bertrand Dumont, zootechnicien et écologue (INRA), et de Pierre Dupraz, économiste (INRA) celle-ci a réuni, pendant deux ans, vingt-six experts1 issus de différentes disciplines et institutions, et travaillant dans différents contextes afin que la diversité des résultats et des arguments scientifiques soit prise en compte. Le collectif d’experts a bénéficié de l’encadrement méthodologique de la Délégation à l’expertise, à la prospective et aux études (Depe) qui a assuré la coordination du projet, l’appui documentaire (avec la contribution des départements Phase et SAE2) et l’analyse cartographique. Le travail a abouti à la rédaction d’un rapport principal de plus de mille pages présenté publiquement en novembre 2016, d’une synthèse de 126 pages et d’un résumé en français et en anglais de huit pages. Le tout est disponible sur le site de l’INRA : http://institut.inra.fr/Missions/Eclairer-les-decisions/Expertises/Toutes-les-actualites/Roles-impacts-et-services-issus-des-elevages-europeens. Ce numéro spécial s’appuie principalement sur les éléments développés dans les chapitres 2, 6 et 7 du rapport. Le regard critique des relecteurs et le travail de réécriture des auteurs y apportent une réelle plus-value. Le premier article, coordonné par Michel Duru, présente le cadre conceptuel que nous avons proposé à partir de la littérature sur les systèmes socio-écologiques, afin de représenter de manière structurée la diversité des services et impacts rendus par les systèmes d’élevage (et de polyculture-élevage) dans les territoires. Le deuxième article coordonné par Jonathan Hercule et Vincent Chatellier établit une typologie des territoires d’élevage européens qui repose sur deux critères simples et disponibles dans les bases de données : la part des prairies permanentes dans la Surface Agricole Utile (SAU) et la densité animale par hectare de SAU. En croisant ces deux variables, nous distinguons six types de territoires que nous avons cartographiés à l’échelle européenne. Dans les cinq articles qui suivent, nous décrivons les bouquets de services rendus par l’élevage dans les territoires où il est bien représenté, le sixième type correspondant aux zones de grandes cultures. Nous analysons la variabilité qui existe autour du bouquet de services propre à chaque type, et la dynamique d’évolution de l’élevage selon les territoires. Nous traitons ainsi des territoires à haute densité animale qui concentrent 29% du cheptel européen sur seulement 10% du territoire (Dourmad et al), des territoires herbagers à haute (Delaby et al), moyenne (Vollet et al) ou faible densité animale (Lemauviel-Lavenant et Sabatier), et des territoires de polyculture-élevage (Ryschawy et al). Les deux articles qui suivent s’attachent à des configurations qui ne sont pas représentées sur la carte européenne, mais sont potentiellement présentes dans chaque catégorie de notre typologie. Nous analysons comment certaines filières s’adaptent à des attentes sociétales accrues en matière d’alimentation (produits de qualité, circuits courts) et de qualité de la vie. Marc Benoit et Bertrand Méda abordent cette question à partir d’une analyse croisée des systèmes ovins en Agriculture Biologique et poulets Label Rouge, Claire Delfosse et al en synthétisant la littérature encore fragmentaire sur l’élevage urbain et périurbain. L’article conclusif, coordonné par Bertrand Dumont, porte au débat les enseignements tirés des cartographies de services, et des modélisations et scénarios prospectifs globaux. Il propose différentes pistes pour mieux valoriser la diversité des services fournis par l’élevage. Les différents articles de ce numéro illustrent ainsi le large panorama des services et impacts de l’élevage européen. Nous espérons qu’ils donnent à voir non seulement le rôle de l’élevage vis-à-vis de la production de denrées alimentaires, de l’emploi, des dynamiques territoriales et de la construction des paysages, mais aussi comment l’élevage pourrait mieux répondre aux attentes légitimes de nos concitoyens en matière de préservation de l’environnement, de bien-être animal et de traçabilité des circuits alimentaires. Notre ambition est d’aider à sortir d’un débat qui ne considère trop souvent qu’une partie de ces effets. L’intérêt pédagogique de la grange et de la typologie des territoires d’élevage européens a déjà été largement souligné. Gageons qu’il confère à ce numéro spécial un intérêt particulier pour l’enseignement agronomique et le développement agricole. Bertrand Dumont (Inra Phase), Pierre Dupraz (Inra SAE2), Julie Ryschawy (Inra SAD, INPT) et Catherine Donnars (Inra Depe) -------1 Composition du collectif d’experts : B Dumont et P Dupraz (coord.), J. Aubin (INRA), M. Benoit (INRA), Z. Bouamra-Mechemache (INRA), V. Chatellier (INRA), L. Delaby (INRA), C. Delfosse (Univ. Lyon II), J.-Y. Dourmad (INRA), M. Duru (INRA), M. Friant-Perrot (CNRS, Univ. Nantes), C. Gaigné (INRA), J.-L. Guichet (Univ. Beauvais), P. Havlik (IIASA, Autriche), N. Hostiou (INRA), O. Huguenin-Elie (Agroscope, Suisse), K. Klumpp (INRA), A. Langlais (CNRS, Univ. Rennes), S. Lemauviel-Lavenant (Univ. Caen), O. Lepiller (CNRS, Univ. Toulouse), B. Méda (INRA), J. Ryschawy (INRA, INPT), R. Sabatier (INRA), I. Veissier (INRA), E. Verrier (Agroparistech), D. Vollet (Irstea).

RÉSUMÉLe principal objectif de cet article est d’encourager une approche plus large, supraconfessionnelle, du mariage et de la famille à l’époque moderne. La conjugalité a été “désacralisée” par les réformateurs protestants du 16e siècle. Martin Luther, parmi d’autres, a refusé le statut de sacrement au mariage, tout en valorisant celui-ci comme une arme contre le péché. En réaction, le concile de Trente a réaffirmé avec force que le mariage est bien un des sept sacrements chrétiens. Mais, promouvant la supériorité du célibat, l’Église catholique n’a jamais beaucoup insisté sur les vertus de la vie et de la piété familiales avant le 19e siècle. En parallèle, les historiens décèlent des signes de “sacralisation” de la famille protestante à partir du 16e siècle. Leurs conclusions doivent être relativisées à la lumière de recherches plus récentes et plus critiques, centrées sur les rapports et les représentations de genre. Elles peuvent néanmoins inspirer une étude élargie et comparative, inexistante dans l’historiographie traditionnelle, des réalités et des perceptions de la famille chrétienne au-delà des frontières confessionnelles.MOTS-CLÉ: Époque Moderne, mariage, famille, protestantisme, Concile de TrenteABSTRACTThe main purpose of this paper is to encourage a broader supra-confessional approach to the history of marriage and the family in the Early Modern era. Wedlock was “desacralized” by the Protestant reformers of the 16th century. Martin Luther, among others, denied the sacramental status of marriage but valued it as a weapon against sin. In reaction, the Council of Trent reinforced marriage as one of the seven sacraments. But the Catholic Church, which promoted the superiority of celibacy, did little to defend the virtues of family life and piety before the 19th century. In parallel, historians have identified signs of a “sacralization” of the Protestant family since the 16th century. These findings must be relativized in the light of newer and more critical studies on gender relations and representations. But they can still inspire a broader comparative study, non-existent in traditional confessional historiography, of the realities and perceptions of the Christian family beyond denominational borders.KEY WORDS: Early Modern Christianity, marriage, family, Protestantism, Council of Trent BIBLIOGRAPHIEAdair, R., Courtship, Illegitimacy and Marriage in Early Modern England, Manchester, Manchester University Press, 1996.Beaulande-Barraud, V., “Sexualité, mariage et procréation. Discours et pratiques dans l’Église médiévale (XIIIe-XVe siècles)”, dans Vanderpelen-Diagre, C., & Sägesser, C., (coords.), La Sainte Famille. Sexualité, filiation et parentalité dans l’Église catholique, Problèmes d’Histoire des Religions, 24, Bruxelles, Éditions de l’Université de Bruxelles, 2017, pp. 19-29.Bels, P., Le mariage des protestants français jusqu’en 1685. Fondements doctrinaux et pratique juridique, Paris, Librairie générale de droit et de jurisprudence, 1968.Benedict, P., Christ’s Churches Purely Reformed. A Social History of Calvinism, New Haven/London, Yale University Press, 2002.Bernos, M., “Le concile de Trente et la sexualité. La doctrine et sa postérité”, dansBernos, M., (coord.), Sexualité et religions, Paris, Cerf, 1988, pp. 217-239.Bernos, M., Femmes et gens d’Église dans la France classique (XVIIe-XVIIIe siècle), Paris, Éditions du Cerf, Histoire religieuse de la France, 2003.Bernos, M., “L’Église et l’amour humain à l’époque moderne”, dans Bernos, M., Les sacrements dans la France des XVIIe et XVIIIe siècles. Pastorale et vécu des fidèles, Aix-en-Provence, Publications de l’Université de Provence, 2007, pp. 245-264.Bologne, J.-C., Histoire du mariage en Occident, Paris, Lattès/Hachette Littératures, 1995.Burghartz, S., Zeiten der Reinheit – Orte der Unzucht. 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This presentation focuses on a transdisciplinary approach to innovative and collaborative learning practices driven by technology. It highlights two salient elements associated with industry practices and processes in relation to learning and educational contexts: empowerment of individuals and communities of practice through technology, and a broader consideration of industrial approaches to the concept of learning and teaching enhanced within a digital environment. More precisely, this presentation will feature some of the key theoretical frameworks used in three different settings of learning and teaching in France with regards to the life-long learning approach thanks to Social and Emotional Learning (SEL) (WEF, 2016). It will also discuss the positive effect of the Internet and its affordances (Southerton & Taylor, 2020) on reducing the differences between theoretical and applied knowledge via professional-focused communities (Danvers, 2003). Thus, it will briefly explain that spatial and cognitive learning proximities (Lave & Wenger 1991; Fruchter, 2001) can be reduced by virtue of technology (Anders, 2016; Antonczak, 2019; Glazewski & Hmelo-Silver, 2019) and that ‘computer-supported collaborative learning’ methods can facilitate social and shared problem-solving (Sawyer, 2005; Levallet & Chan, 2018; Presicce et al., 2020) without the ‘restriction of time and place’ (Cheng et al., 2019, 489). Additionally, it will point out some aspects of problem-solving through ‘emancipatory learning and social action’ (Merriam, 2001, 9) through the use of ‘actual’ content and ‘actionable feedback’ (Woods & Hennessy, 2019) enhanced by digital tools and tactics. Next, it will focus on three case studies by concisely presenting key specifics for each of the courses, including the various digital tools used and followed by some quick interim reflections. Then it will summarise the challenges and the barriers encountered across the different practices such as virtual delivery, the size of the students' groups and some connectivity considerations. It will be followed by the principal advantages and opportunities, like the professionalisation dimension through interactive and authentic learning enhanced by affordances. And it will conclude with some managerial recommendations as experiential and practical methods (knowledge codification) thanks to industry-based teaching supported by digital technologies. The presentation will close with the overall conclusion in relation to digital technology and some of the key 21st-century career skills. In general, the findings will be of interest to academics, practitioners and policymakers. The added value of this transdisciplinary investigation is that it improves research on collaborative innovation and collective knowledge by creating a bridge between the fields of Education and Business. 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The purpose of this article is to analyze the so-called human capital theory and to clarify the concept of public good, as well as the frequency of the expression "public" in the Declarations adopted at the Regional Conferences of Higher Education in Latin America and the Caribbean in 2008 and 2018. For this, in methodological terms, this article analyzes documents from certain International Organizations (UNESCO, World Bank and OECD) and seeks theoretical support in Reinhart Koselleck's History of Concepts and other authors such as Roger Dale, Susan Robertson, Bob Jessop, Stephen Gill, Paul Samuelson , Karl Polanyi and Pierre Bourdieu.ResumoO presente artigo tem o objetivo de analisar a chamada teoria do capital humano e precisar o conceito de bem público, bem como a frequência da expressão “público” nas Declarações aprovadas nas Conferências Regionais de Educação Superior na América Latina e Caribe, em 2008 e 2018. Para isto, em termos metodológicos, o presente artigo analisa documentos de determinadas Organizações Internacionais (UNESCO, Banco Mundial e OCDE) e busca apoio na História dos Conceitos de Reinhart Koselleck e em autores como Roger Dale, Bob Jessop, Stephen Gill, Paul Samuelson, Karl Polanyi, Pierre Bourdieu.Keywords: Public good, Human capital theory, Commodification, Education, CRES 2008 and CRES 2018.Palavras-chave: Bem público, Teoria do capital humano, Mercadorização, Educação, CRES 2008 e CRES 2018.ReferencesALVES, Giovanni. O que é o precariado? Blog da Boitempo. Extraído de <https://blogdaboitempo.com.br/2013/07/22/o-que-e-o-precariado/>, 22 Jul 2013, acesso em 28 fev 2019.ARENDT, Hannah. A crise na educação. In: Entre o passado e o futuro. Tradução: Mauro W. Barbosa de Almeida. 3ª reimpressão da 5ª ed. de 2000. São Paulo: Perspectiva, 2005.AUDITORIA CIDADÃ DA DÍVIDA. Dividômetro: quanto pagamos (juros e amortizações) – dívida pública federal. Auditoria Cidadã da Dívída. 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Las excavaciones arqueológicas realizadas en Monte Molião permitieron la recogida de un importante conjunto de artefactos de hueso pulido, de la Edad del Hierro y de época Romana, que supone un total de 80 piezas. Están distribuidas por distintas categorías funcionales, relacionadas con el adorno personal, con la actividad textil, con el juego y con la escritura. Otros integran la categoría de complementos de muebles. El conjunto es revelador de la presencia, en el sur de Portugal, de individuos con costumbres y usanzas que siguen patrones estéticos y sociales del Mediterráneo romanizado.Palabras clave: Algarve romano, mundus muliebris, textiles, ludi, stiliTopónimo: PortugalPeriodo: Edad del Hierro, época romana ABSTRACTThe archaeological digs undertaken in in Monte Molião led to the discovery of 80 bone artefacts, dating from Iron Age and Roman times. They are divided into several functional categories, connected with personal adornment, textile activity, games, and writing. 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On présente dans cet article, les résultats d’une étude portant sur l’estimation du coût de l’électricité produite par différents types d’aérogénérateurs installés dans les régions de Sétif et Tiaret, deux sites localisés dans les Hauts Plateaux du Nord de l’Algérie. Cette étude est basée sur des données vent de l’Office National de la Météorologie (ONM) mesurées au niveau des stations de Sétif et Tiaret. Les données considérées portent sur dix années de mesures. Le traitement statistique des données a été effectué avec le logiciel WAsP. Il ressort que la vitesse moyenne annuelle du vent est de 3.46 m/s à Sétif et 5.07 m/s à Tiaret et ce, à 10 m de hauteur par rapport au sol. Nous avons ensuite déterminé les paramètres statistiques de Weibull (facteur de forme, k et facteur d’échelle, c) à 10 mètres, puis à différentes hauteurs (30, 50 et 70 m). Ces derniers ont été obtenus par extrapolation en utilisant une loi de puissance basée sur les paramètres de Weibull. Ensuite, toujours à l’aide du logiciel WAsP, trois modèles d’aérogénérateurs disponibles dans le commerce ont été retenus à savoir, Bonus 300 kW/33, Bonus 1.0 MW/54 et Vestas 2.0 MW/V80 et nous avons évalué leurs performances avec le calcul du facteur de capacité et de l’énergie annuelle produite par chaque type d’aérogénérateur, pour les deux régions. Un calcul économique a été ensuite effectué en utilisant la méthode PVC (Présent Value Cost). Il en résulte que le plus faible coût de production d’électricité éolienne est obtenu avec le modèle Vestas 2 MW/V80 avec un prix de revient du kilowattheure (kWh) de l’ordre de 0.0644 $/kWh à Sétif et de 0.0342 $/kWh à Tiaret.

L’administration et le ciblage contrôlés de médicaments représentent un défi passionnant pour améliorer l’efficacité thérapeutique et/ou prophylactique des molécules biologiquement actives tout en réduisant leurs effets secondaires. Ainsi, différents systèmes tels que les supports macromoléculaires solubles, les liposomes et les particules polymériques ont été intensivement décrits et testés cliniquement. Pour cette étude, le taxol@ (TX, paclitaxel) a été choisi comme médicament hôte modèle pour comparer son encapsulation dans des nanoparticules à base de poly- alkylcynamoacrylates (PACA) et de poly-alkylmethylidenemalonate (PAMM en particulier le PMM 2.1.2). Une trajectoire de dynamique moléculaire pour chaque espèce a été générée à 300 K et étendue sur 1000 ps par pas de 1 fs. Les conformères échantillonnés toutes les 10 ps ont ensuite été minimisés en énergie en utilisant d'abord la méthode MM2 d'Allinger et la méthode Newton-Raphson bloc-diagonal jusqu'à ce que le gradient obtenu soit inférieur à 0,01 kcal/mol. Nous avons aussi utilisé les méthodes AMI et PM3, COSMO ainsi que les calculs théoriques et enfin les méthodes semi-empiriques SCF-MO AMI et PM3, telles qu'elles sont mises en œuvre dans l'ensemble CS MOPAC trouvé dans CS Chem3DPro 7.0.0. Nous avons adopté une approche tout à fait différente par rapport à celle précédemment combinant la dynamique moléculaire et la mécanique semi-quantique (AMI, PM3 et PM3 COSMO). Les oligomères de PAMM ont tendance à adopter une forme en U, contrairement à ceux de PACA qui adoptent préférentiellement des conformations hélicoïdales avec une disposition radiale des chaînes latérales. Ce résultat a été confirmé par plusieurs publications qui rapportent que, pendant la polymérisation anionique du monomère MM 2.1.2, un processus important de cyclotrimérisation a lieu, produisant un mélange de 4 diastéréo-isomères racémiques de cyclohexanone, c'est-à-dire 2S,4R,6R et 2S,4S,6S, et leurs contreparties énantiomériques. Ces études donnent un aperçu de l'architecture et de la dynamique des nanoparticules. L'approche in silico utilisée ici permet de prédire que le Taxol serait piégé plus efficacement dans le PAAM que dans le PACA, ce qui est en accord avec les résultats expérimentaux.

The interpretation of laboratory test results requires reference or cutoff values. An improved diagnosis with accurate, reliable laboratory reference ranges saves valuable healthcare resources essential for effective clinical evaluation and monitoring. This benefit provides improved cost containment by eliminating unnecessary testing, treatment changes, and use of other healthcare resources during the episode of care. Based on the above fact, this study was designed to establish reference ranges for hematological parameters in apparently healthy voluntary non-remunerated blood donors. The study was a hospital based cross-sectional experimental study conducted between February and October 2020. Blood samples were taken from 356 healthy adults (18 to 60 years) 211 (59.3%) males and 145 (40.7%) females and routine hematology analysis performed. Patients were assessed as healthy on the basis of a medical history and medical examinations. Venous blood from the antecubital fossa was collected in 2-3mL of K- ethylenediamine tetra acetic acid (EDTA) for complete blood counts. A total of nineteen hematological parameters were tested in this study and showed significant differences (p<0.001) among males and females with the former showing higher CBC values, except WBC, GRAN# and platelet. More than 10% of the female population presented results that were out of that of the accompanying manual of the hematology analyzer used in the study. The reference range for LYM % for the female was above the upper limit of the manufacturers’ manual reference and for GRAN% in the males was below the lower limit of the accompanying manual of the hematology analyzer. Several differences were also observed when compared to previously established values from Yaounde (Cameroon), most notably in platelets. Our findings for CBC parameters, are in general agreement with previously published data from more limited trials undertaken in other African countries. In spite of the uncontrolled factors influencing hematological values, this study permitted to establish new hematological reference values for use in the North West region of Cameroon. In the absence of previously detailed and more comprehensive investigated hematological reference values for the region we offered to use these results for clinical management of patients from this region and interpretations of laboratory data. L'interprétation des résultats des tests de laboratoire nécessite des valeurs de référence ou de coupure. Un diagnostic amélioré avec des plages de référence de laboratoire précises et fiables permet d'économiser de précieuses ressources de santé essentielles pour une évaluation et un suivi cliniques efficaces. Cet avantage permet une meilleure maîtrise des coûts en éliminant les tests inutiles, les changements de traitement et l'utilisation d'autres ressources de soins de santé pendant l'épisode de soins. Sur la base de ce qui précède, cette étude a été conçue pour établir des plages de référence pour les paramètres hématologiques chez des donneurs de sang volontaires non rémunérés apparemment en bonne santé. L'étude était une étude expérimentale transversale en milieu hospitalier menée entre février et octobre 2020. Des échantillons de sang ont été prélevés sur 356 adultes en bonne santé (18 à 60 ans) 211 (59,3%) hommes et 145 (40,7%) femmes et une analyse hématologique de routine a été réalisée. Les patients ont été jugés sains sur la base des antécédents médicaux et des examens médicaux. Le sang veineux de la fosse antécubitale a été collecté dans 2-3 ml d'acide K-éthylènediamine tétra acétique (EDTA) pour une numération globulaire complète. Un total de dix-neuf paramètres hématologiques ont été testés dans cette étude et ont montré des différences significatives (p <0,001) entre les hommes et les femmes, le premier montrant des valeurs de FSC plus élevées, sauf globules blancs, GRAN # et plaquettes. Plus de 10% de la population féminine a présenté des résultats différents de ceux du manuel d'accompagnement de l'analyseur d'hématologie utilisé dans l'étude. La plage de référence pour LYM% pour la femelle était au-dessus de la limite supérieure de la référence manuelle du fabricant et pour GRAN% chez les mâles était inférieure à la limite inférieure du manuel d'accompagnement de l'analyseur d'hématologie. Plusieurs différences ont également été observées par rapport aux valeurs précédemment établies à Yaoundé (Cameroun), notamment dans les plaquettes. Nos résultats pour les paramètres du FSC, sont en accord général avec les données publiées antérieurement à partir d'essais plus limités entrepris dans d'autres pays africains. Malgré les facteurs incontrôlés influençant les valeurs hématologiques, cette étude a permis d'établir de nouvelles valeurs hématologiques de référence à utiliser dans la région du Nord-Ouest du Cameroun. En l'absence de valeurs de référence hématologiques étudiées précédemment détaillées et plus complètes pour la région, nous avons proposé d'utiliser ces résultats pour la prise en charge clinique des patients de cette région et l'interprétation des données de laboratoire. <p> </p><p><strong> Article visualizations:</strong></p><p><img src="/-counters-/edu_01/0775/a.php" alt="Hit counter" /></p>

<strong><span style="font-family: TimesNewRomanPS-BoldMT;"><span style="font-family: TimesNewRomanPS-BoldMT;"><p align="left"> </p></span></span><span style="font-size: x-small; font-family: TimesNewRomanPS-BoldMT;"><span style="font-size: x-small; font-family: TimesNewRomanPS-BoldMT;">SAMMENDRAG</span></span></strong><span style="font-size: x-small; font-family: TimesNewRomanPSMT;"><span style="font-size: x-small; font-family: TimesNewRomanPSMT;"><p align="left">I 1998-99 er den første landsrepresentative kostholdsundersøkelsen blant spedbarn og småbarn gjennomført i Norge</p><p align="left">for å beskrive kostholdet blant barn opp til 2 års alder og relatere kostvanene til de kostanbefalingene som gis.</p><p align="left">Inntaket av både næringsstoffer og fremmedstoffer skal beregnes. Undersøkelsen inngår i Statens råd for ernæring</p><p align="left">og fysisk aktivitet (SEF) sitt system for kartlegging av kostholdet i den norske befolkningen, og er et samarbeid</p><p align="left">mellom SEF, Statens næringsmiddeltilsyn, Institutt for ernæringsforskning ved Universitetet i Oslo og Statistisk</p><p align="left">sentralbyrå. Hovedmålet er å øke kunnskapen om kostholdet til spedbarn og småbarn i Norge, for å få et bedre</p><p align="left">grunnlag for å fremme et godt kosthold og forebygge kostholdsrelaterte helseproblemer i denne aldersgruppen.</p><p align="left">Semikvantitative matvarefrekvensskjema ble vurdert å være den beste metoden å benytte. Det ble utviklet 3 forskjellige</p><p align="left">selvadministrerte matvarefrekvensskjema (optisk lesbare) for å kartlegge kostholdet blant 6, 12 og 24 måneder</p><p align="left">gamle barn. Bilder av matporsjoner ble inkludert som hjelp til å bestemme mengder. Frekvensskjemaene ble sendt</p><p align="left">pr. post til mødrene av et landsrepresentativt utvalg av 3000 6 måneder gamle barn. De samme barna ble fulgt opp</p><p align="left">ved 12 måneders alder ved at barnas mødre da mottok et nytt frekvensskjema (Spedkost). Videre ble et frekvensskjema</p><p align="left">sendt mødrene til et landsrepresentativt utvalg av 3000 24 måneder gamle barn (Småbarnskost). Data for</p><p align="left">barnas vekt og lengde ble samlet inn i samarbeid med landets helsestasjoner. Det er gjennomført en pilotundersøkelse</p><p align="left">for å prøve ut frekvensskjemaene og undersøkelsesopplegg. Videre blir frekvensskjemaene validert mot veid</p><p align="left">registrering over 7 dager. Datainnsamlingen ble avsluttet i juli 1999, og rapporter fra undersøkelsen er ventet i år</p><p align="left">2000. Hensikten med artikkelen er å beskrive metoden og begrunne valg av metode for Spedkost og Småbarnskost.</p><span style="font-size: x-small; font-family: TimesNewRomanPSMT;"><span style="font-size: x-small; font-family: TimesNewRomanPSMT;"><p align="left">Lande B, Frost Andersen L, Bærug A, Trygg K, Lund-Larsen K, Bjørneboe G-EAa.</p></span></span></span><span style="font-size: x-small; font-family: TimesNewRomanPSMT;"><p align="left"> </p></span></span><p align="left"><strong><span style="font-size: x-small; font-family: TimesNewRomanPS-BoldMT;"><span style="font-size: x-small; font-family: TimesNewRomanPS-BoldMT;">Development of a method</span><strong><span style="font-size: x-small; font-family: TimesNewRomanPS-BoldMT;"><p align="left"> </p><p align="left"> </p><p align="left"><span style="font-size: x-small; font-family: TimesNewRomanPSMT;"></span><strong><span style="font-size: x-small; font-family: TimesNewRomanPS-BoldMT;"><span style="font-size: x-small; font-family: TimesNewRomanPS-BoldMT;">ENGLISH SUMMARY</span></span></strong><span style="font-size: x-small; font-family: TimesNewRomanPSMT;"><span style="font-size: x-small; font-family: TimesNewRomanPSMT;"><p align="left">In 1998-99 the first Norwegian national dietary survey among infants and children was conducted in order to describe</p><p align="left">the dietary habits among children up to the age of 2 years, and to relate these habits to the dietary recommendations.</p><p align="left">Intakes of both nutrients and non-nutrients will be estimated. The survey is part of the national food</p><p align="left">surveillance system in Norway, and is a collaboration between the National Council on Nutrition and Physical</p><p align="left">Activity, the Norwegian Food Control Authorities, the Institute for Nutrition Research (University of Oslo) and</p><p align="left">Statistics Norway. The main objective is to increase the knowledge about dietary habits among Norwegian infants</p><p align="left">and young children in order to promote a healthy diet and prevent diet-related health problems in this age group. A</p><p align="left">self-administered semi-quantitative food frequency questionnaire was considered the best method. Three questionnaires</p><p align="left">were developed to assess dietary intake among 6, 12 and 24 months old children. Pictures were included</p><p align="left">to help with decisions of portion sizes. The semi-quantitative food frequency questionnaire (FFQ) was distributed to</p><p align="left">the mothers of a national representative sample of 3000 6 months old infants. This cohort of infants was followed up</p><p align="left">at 12 months of age, when their mothers received a new FFQ (Spedkost). Furthermore, a FFQ was distributed to the</p><p align="left">mothers of a national representative sample of 3000 24 months old children (Småbarnskost). Data on weight and</p><p align="left">length were collected in cooperation with the child health centres. A pilot study was conducted in cooperation with</p><p align="left">the child health centres to test the questionnaires and study design. Furthermore, the questionnaires are validated</p><p align="left">against 7 days weighed record of food intake. The data collection was closed in July 1999, and reports of the survey</p><p align="left">are expected in 2000. The purpose of this article is to describe the method and discuss the choice of method for the</p><p>national dietary survey among infants and young children – Spedkost/Småbarnskost.</p></span></span></p></span></strong></span></strong><em><span style="font-size: x-small; font-family: TimesNewRomanPS-ItalicMT;"><span style="font-size: x-small; font-family: TimesNewRomanPS-ItalicMT;">Nor J Epidemiol </span></span></em><span style="font-size: x-small; font-family: TimesNewRomanPSMT;"><span style="font-size: x-small; font-family: TimesNewRomanPSMT;">2000; </span></span><strong><span style="font-size: x-small; font-family: TimesNewRomanPS-BoldMT;"><span style="font-size: x-small; font-family: TimesNewRomanPS-BoldMT;">10 </span></span></strong><span style="font-size: x-small; font-family: TimesNewRomanPSMT;"><span style="font-size: x-small; font-family: TimesNewRomanPSMT;">(1): 43-50.</span></span></p><p align="left">for use in a national representative dietary survey among Norwegian infants and children –</p><strong><span style="font-size: x-small; font-family: TimesNewRomanPS-BoldMT;"><span style="font-size: x-small; font-family: TimesNewRomanPS-BoldMT;"><p align="left">Spedkost/Småbarnskost.</p></span></span></strong>

We describe a case of vancomycin-induced linear IgA bullous dermatosis (LABD) with unusual features in a 75-year old woman who received intravenous vancomycin for methicillin-resistant Staphylococcus Aureus infection. Our patient demonstrated an unusual lesional distribution with initial facial involvement and a longer latent period than usual, which to our knowledge has not yet been reported in the literature. A skin punch biopsy including direct immunofluorescence study (IMF) confirmed the diagnosis of LABD. The patient’s cutaneous eruptions resolved over the next 14 days with stoppage of medication and supportive care without the need for systemic steroids. Physicians should be aware of this rare type of autoantibody mediated drug reaction in patients put on vancomycin. Early diagnosis using a skin punch biopsy with direct IMF study would avoid unnecessary laboratory investigations and initiate prompt management.RésuméNous décrivons ici un cas de dermatose bulleuse à IgA linéaire (DIgAL) d’origine médicamenteuse et aux caractéristiques inhabituelles, chez une femme âgée de 75 ans ayant reçu de la vancomycine par voie intraveineuse pour traiter une infection causée par un Staphylococcus Aureus résistant à la méthicilline. La patiente présentait une distribution inhabituelle des lésions avec une atteinte initiale à la face et une période de latence plus longue que la normale. À notre connaissance, cela n’a jamais été rapporté dans la littérature. Une biopsie à l’emporte-pièce de la peau, doublée d’un test d’immunofluorescence directe, a confirmé le diagnostic de DIgAL. Les lésions cutanées de la patiente se sont résorbées dans les quatorze jours suivant l’arrêt du médicament, avec des soins de soutien et sans recours à des stéroïdes systémiques. Il est important que les médecins soient informés de ce type rare de réaction médicamenteuse à médiation d’autoanticorps chez les patients sous vancomycine. Un diagnostic précoce par biopsie à l’emporte-pièce et test d’immunofluorescence directe permet d’éviter des examens de laboratoire superflus et de débuter une prise en charge rapide.Case SynopsisA 75-year-old woman presented to the emergency department with an altered level of consciousness and sepsis requiring intubation. She had been treated with Keflex for a wound infection post L5-S1 lumbar discectomy and fusion surgery, but now presented with an epidural abscess and ventriculitis confirmed to be due to methicillin-resistant Staphylococcus Aureus bacteremia. The patient was taking naproxen, baclofen, levothyroxine, fenofibrate, omeprazole, sotalol, hydrochlorothiazide, ativan, zopiclone, and acetaminophen. The patient was started on vancomycin just prior to duraplasty with incision and drainage. 27 days later, she developed a morbilliform maculopapular cutaneous eruption, which started on her face before progressing diffusely to the trunk and limbs (Figure 1A). The lesions were pruritic and urticarial with blanchable, erythematous, well-demarcated plaques containing some fine scale (Figure 1B). Blistering began ten days after presentation of the eruption resulting in erosion (Figure 1C and Figure 1D). There was no mucous membrane involvement or fever present.A BCD Figure 1. (A) Initial presentation of malar erythema on face. (B) Eruption involving extremities with a maculopapular (morbilliform) appearance. (C&D) Blistering began ten days after initial presentation of eruption. Investigations were unremarkable except for an elevated eosinophil level of 2.6 × 109/L and mild leukocytosis of 11.2 × 109/L. Peak serum vancomycin was found to be within therapeutic range at 21.2 μmol/L. A drug rash with eosinophilia and systemic symptoms (DRESS) syndrome was originally suspected; however, the patient had no fever nor any systemic symptoms making this diagnosis unlikely. A punch biopsy of skin lesion was performed for definitive diagnosis. Vancomycin was discontinued and changed to linezolid and the patient received intravenous fluids and topical steroids (betamethasone valerate 0.05% with 0.25% camphor and 0.25% menthol to affected areas of the body and valerate 2% to lesions on the face) to treat the eruption. The patient’s cutaneous eruptions resolved over the next 14 days with additional supportive care, which included pain control, fluid and electrolyte management and nutritional support without the need for systemic steroids.Histologic examination of the diagnostic skin punch biopsy showed a subepidermal blister with abundant inflammatory infiltrate in the dermis composed of numerous neutrophils, a few eosinophils and lymphocytes. The blister contained fibrin, neutrophils and eosinophils (Figure 2A and Figure 2B). Punch biopsy of peri-lesional skin for direct immunofluorescence (DIF) study showed IgA deposition in a linear fashion along the basement membrane zone (Figure 2C) confirming the diagnosis of LABD.ABC Figure 2. (A) Hematoxylin and eosin (H & E) stain of punch biopsy skin back shows a subepidermal blister (star) (B) Higher magnification showing abundant neutrophils (arrow, H&E stain). (C) Direct immunofluorescence (IMF) test on the perilesional skin shows linear IgA deposition along the basement membrane zone (arrow). DiscussionLinear immunoglobulin A (IgA) bullous dermatosis (LABD) is an acquired autoimmune subepidermal blistering disease of the skin and/or mucous membranes, which is defined by the histopathological finding of subepidermal vesicles with predominantly neutrophilic infiltration and linear IgA deposits in the basement membrane zone. This disease can occur in idiopathic and drug-induced forms. While the idiopathic form is more often seen in children and has been associated with specific HLA haplotypes, drug-induced LABD occurs predominantly in adulthood. 1,2 Drug-induced LABD has been reported with many drugs, including amiodarone, ampicillin, captopril, cefamandole, cyclosporine, diclofenac, glibenclamide, INF-gamma, IL-2, lithium, penicillin G, phenytoin, piroxicam, somatostatin, trimethoprim, vigabatrin, NSAIDs and acetaminophen.3,4 However, it has been most consistently associated with intravenous administration of vancomycin, which is responsible for approximately half the cases in the literature,5 and does not appear to be dose dependent.3 Although our patient was taking other medications that can precipitate LABD (NSAIDs and acetaminophen), the onset and time course of the disease strongly suggest that vancomycin is the causative agent.Vancomycin is known to produce a diverse variety of adverse drug reactions including the red man syndrome, which is an infusion-related reaction peculiar to vancomycin. Non- bullous maculopapular rash is the most frequent type of skin eruption, a hypersensitivity reaction. Systemic involvement causing DRESS syndrome has been rarely reported. Severe drug reactions such as leukocytoclastic vasculitis, extensive fixed drug eruptions (which are localized), Stevens-Johnson syndrome, toxic epidermal necrolysis and LABD are very rare.Vancomycin-induced LABD is a subepidermal blistering eruption, which is classically characterized by the appearance of many pruritic tense bullae on a base of annular erythema. However, the presentation can clinically mimic a variety of other vesiculobullous diseases, including patterns resembling dermatitis herpetiformis, bullous pemphigoid, erythema multiforme, and even more severe disorders like Stevens-Johnson syndrome and toxic epidermal necrolysis which makes the diagnosis difficult. 6 The histologic differential diagnoses for subepidermal blistering disease include bullous pemphigoid and dermatitis herpetiformis. Although there is histologic overlap between these conditions, predominance of neutrophils in the infiltrate and the classic IMF pattern of linear deposition of IgA along the basement membrane zone confirmed the diagnosis of LABD in our patient.Our patient presented with some unique clinical features worth mentioning. Firstly, cases of vancomycin-induced LABD in the literature are varied, but lesions have been reported to appear within 1–3 weeks of vancomycin administration.1,3,7 This is in contrast to the latency period of this case, where our patient’s lesions erupted almost one month after vancomycin administration. Additionally, cases in literature have most commonly reported cutaneous involvement affecting the limbs and trunk with sparing usually of the face and neck.1,8,9 However, our patient presented with a malar type eruption on the face at the initial presentation before spreading to the extremities. The variability in the presentation (latency period, lesional morphology, distribution) is important for clinicians to recognize so vancomycin-induced LABD is kept in the differential diagnosis and confirmatory skin biopsies are performed without delay. The variability of vancomycin-induced LABD may reflect the pathophysiology of the disease, which has still not been fully elucidated. Like other drug-induced immune conditions, it is possible the vancomycin cross-reacts with a component of the epidermal basement membrane, exposes sequestered antigens or alters the confirmation of epitopes resulting in the formation of autoantibodies.10 While the target antigens in idiopathic LABD have been extensively investigated, there are few reports of the causative target antigens in the drug-induced form.2 Reported basement membrane zone (BMZ) antigens include a 97 KDa protein (which may be identical to the extracellular portion of BPAg2), a 230 KDa protein (similar to BPAg1), BP180, LAD285, unidentified 210 KDa, 130 KDa and 83 KDa antigens.2,4,5,7,11 Most recently, IgA antibodies to the 145- and 165-kDa a3 subunits of laminin-332 have been reported in a case of vancomycin-induced LABD.12 The fact IgA autoantibodies have been reported to react with numerous BMZ antigens may explain why the disease presentation is so heterogeneous. Other laboratory investigations also underscore the variable and unpredictable manifestations of this drug-induced cutaneous disease because in addition to linear IgA deposition along the BMZ, patients may also have deposition of C3, IgG and circulating IgG and IgA autoantibodies (none of which were seen in our patient). 8,9A careful drug history is extremely important as immunohistopathological and clinical features are identical between drug-induced and idiopathic forms, yet prognosis and treatment are quite different.1 The prognosis of drug-induced LABD is usually favourable as patients experience remission with drug withdrawal, while spontaneous remission in the idiopathic form is 10–50%.7 Idiopathic LABD usually requires dapsone and if needed topical or oral steroid treatment, but its course may be protracted.13In conclusion, we report a case of vancomycin-induced LABD, which presented with a few unique clinical features that to the authors’ best knowledge have not been previously reported in the literature. Specifically, our patient’s morbilliform eruption started almost one month after the initiation of vancomycin and began on the face before spreading to the extremities. Prompt histological evaluation with IMF study allows precise diagnosis of this condition. This case report highlights the importance of keeping LABD in the differential diagnosis of vancomycin-induced blistering drug reactions which would prompt clinicians to perform a diagnostic skin biopsy, make a rapid diagnosis, initiate appropriate treatment and avoid unnecessary delay and investigations.DisclosureThe authors have no conflicts of interest.Ethics approval is not required for this type of research at our institution.References1. Fortuna G, Salas-Alanis JC, Guidetti E, et al. A critical reappraisal of the current data on drug-induced linear immunoglobulin A bullous dermatosis: A real and separate nosological entity? JAAD 2012;66:988–94.2. Palmer RA, Ogg G, Allen J, et al. Vancomycin-induced linear IgA disease with autoantibodies to BP180 and LAD 285. Br J Dermatol 2001;145:816–20.3. Neughebauer BI, Negron G, Pelton S, et al. Bullous skin disease: an unusual allergic reaction to vancomycin. Am J Med Sci 2002;323:273–8.4. Chanal J, Ingen-Housz-Oro S, Ortonne N, et al. Linear IgA bullous dermatosis: comparison between the drug-induced and spontaneous forms. Br J Dermatol 2013;169:1041–8.5. Eisendle K, Bonatti H, Sepp N, et al. Vancomycin-induced linear IgA bullous dermatosis in an immunosuppressed transplant recipient. JEADV 2007;21:996–97.6. Delavalle RP, Burch JM, Tayal S, et al. Vancomycin-associated linear IgA bullous dermatosis mimicking toxic epidermal necrolysis. JAAD 2003;48:S56–7.7. Waldman MA, Black DR, Callen JP. Vancomycin-induced linear IgA bullous disease presenting as toxic epidermal necrolysis. Clin Exp Dermatol 2004;29:633–6.8. Armstrong AW, Fazeli A, Yeh SW, et al. Vancomycin-induced linear IgA disease manifesting as bullous erythema multiforme. J Cutan Pathol 2004;31:393–97.9. Nousari HC, Kimyai-Asadi A, Caeiro JP, et al. Clinical, demographic and immunohistologic features of vancomycin-induced linear IgA bullous disease of the skin. Medicine (Baltimore) 1999;78:1–8.10. Selvaraj PK, Khasawneh FA. Linear IgA bullous dermatosis: a rare side effect of vancomycin. Ann Saudi Med 2013;33(4):397–99.11. Paul C, Wolkenstein P, Prost C, et al. Drug-induced linear IgA disease: target antigens are heterogeneous. BJD 1997;136(3):406–11.12. Zenke Y, Nakano T, Eto H, et al. A case of vancomycin-associated linnear IgA bullous dermatosis and IgA antibodies to the α3 subunit of laminin-332. BJD 2013;170(4):965–69.13. Jones DH, Todd M, Craig TJ. Early diagnosis is key in vancomycin-induced linear IgA bullous dermatosis and Stevens-Johnson syndrome. JAOA 2004;104:157–63.

Morning report (MR) is a valued educational experience in internal medicine training programs. Many senior residents and faculty have not received formal training in how to effectively facilitate MR. Faculty at the University of Toronto were surveyed to provide insights into what they felt were key elements for the successful facilitation of MR. These insights fell within 5 major categories: planning and preparation, the case, running the show, wrapping up and closing the loop.Résumé Le rapport du matin (RM) est un outil pédagogique précieux dans les programmes de formation en médecine interne. Nombre de résidents séniors et de membres du corps enseignant n’ont toutefois jamais reçu de formation officielle sur la façon de faciliter l’élaboration du RM. Nous avons sondé les membres du corps enseignant de l’université de Toronto pour avoir un aperçu de ce qu’ils percevaient comme étant des éléments-clés susceptibles d’améliorer grandement l’élaboration du RM. Les réponses reçues se répartissent en cinq principales catégories: la planification et la préparation du RM, les caractéristiques du cas évalué, l’importance et la façon de prendre en main le processus, le résumé des informations et l’art de « boucler la boucle». Morning report (MR) has long been an integral and valued part of Internal Medicine training programs in North America.1,2 Some residents recognize MR as the most important educational activity during their training.3 Medical students, residents and faculty typically attend MR. Although the structure and function of MR can vary across institutions, it usually involves a case-based discussion facilitated by a faculty member, chief medical resident (CMR), or other senior resident. The facilitator discusses pertinent aspects of one or more clinical cases to teach medical knowledge, clinical reasoning and other important aspects of physician competencies, such as communication and collaboration skills. 4 Residents have expressed a preference for an interactive teaching session led by an individual with extensive medical knowledge and excellent clinical acumen.5Despite trainees’ perceptions about the core educational function of MR and their preference for skilled facilitators, most residents and many faculty have never received any formal training on how to conduct an effective MR. This, coupled with a lack of resources in the literature, may contribute to feelings of trepidation about assuming the role of facilitator.6 Based on this need, we were invited by the organizing group of residents at the 2015 Canadian CMR Conference, held in Toronto, Canada, to lead a seminar to introduce CMRs to the principles of effective MR facilitation. The conference was attended by over 70 current and future CMRs. In preparation for this seminar, we reviewed available literature and found that practical guidelines on how to facilitate a successful MR were generally lacking. To help us to provide guidance and to capture broad opinions and experiences, we recruited a sample of 24 faculty at the University of Toronto, including many award-winning teachers whose experience in leading MR ranges from 3 to over 30 years. We asked them to provide insights into what they felt were key elements of facilitating a successful MR. While not a systematic collection of data, their insights taken together represent a broad experience base. Given the relative lack of evidence-based literature describing how to facilitate MR, we decided to disseminate a refined summary of the shared wisdom we uncovered in hopes that it would benefit other CMRs and junior faculty as they take on this challenging role.The insights provided fall within 5 main themes (Table 1) which are discussed below, followed by a brief discussion about future directions for MR:1) Planning and preparation2) The case3) Running the show4) Wrapping up5) Closing the LoopTable 1. Experience-Based Tips to Running an Effective Morning ReportPLANNING AND PREPARATION:1) Ensure audiovisual aids are present and working before starting. 2) Start and end on time. 3) Encourage all faculty to attend and participate. 4) Know the audience (including names).THE CASE:5) The case can be undifferentiated or one for which the diagnosis and even response to treatment is known. 6) There are pros and cons to the facilitator knowing details of the case in advance. 7) If details of the case are not known to the facilitator, determine with the person presenting if the discussion should be focused on diagnosis, management or other pertinent issues. 8) Cases need not be limited to inpatients and can include ambulatory cases and case simulations.RUNNING THE SHOW:9) Establish a respectful learning climate. 10) Personal anecdotes and reflections on past cases can engage the audience. 11) Ensure time is spent discuss learning issues valuable to all present. 12) Facilitate and engage in discussion rather than deliver a lecture. 13) Use a mix of pattern recognition (heuristics) and analytical reasoning strategies. 14) Start with a question that has an obvious answer if dealing with a quiet audience. 15) Promote volunteerism for answers as much as possible, but direct a question to a specific person if no one volunteers. 16) Begin by engaging the most junior learners and advance to involve senior learners. 17) Encourage resource stewardship and evidence-based medicine. 18) Acknowledge areas of uncertainty and don’t be afraid to say “I don’t know”. 19) Teaching “scripts” or the use of a systematic approach to developing a differential diagnosis can be used when discussing less familiar topics. 20) Highlight the variability in clinical approach amongst "the experts" in the room.WRAPPING-UP:21) Ensure there is time to summarize “take home points”. 22) Provide learners with the opportunity to summarize what they have learned.CLOSING THE LOOP23) Reinforcement of learning can include a distribution of a relevant paper or providing a summary of learning points via email or blog. 24) Maintain a case log to ensure a balanced curriculum. 25) Provide feedback to the case presenter and facilitator.Planning and Preparation It is important for the organizer and facilitator (these may or may not be the same person) to be diligent when preparing for MR. The person in charge of organizing MR should ensure that all necessary audiovisual equipment is in working order, which may be as simple as ensuring there is a whiteboard and working marker. To optimize housestaff attendance, the sessions and facilitators should be scheduled in a regular and predictable way. The lure of a light breakfast should not be underestimated and may add to the social aspect of this event. Sessions should begin and finish on time (or even slightly early). Ideally, deferring pages for all but critical clinical issues should occur. Having faculty regularly attend MR as audience participants, and not just as facilitators, improves the attendance of learners who see through role-modelling the importance of continuing medical education and lifelong learning. Faculty presence also raises the level of discussion around grey areas of diagnosis and management, providing trainees with a spectrum of opinions and approaches to clinical medicine, specifically role-modelling how faculty approach clinical uncertainty. The organizer must also ensure that someone, usually a trainee, is responsible for bringing the details of one or more clinical cases to be discussed.The facilitator should ensure they know the names and year of training of the housestaff in attendance. It is helpful if the organizer can provide a list (ideally with pictures) of those who will be in attendance for the facilitator to reference. Over time, this helps to develop a sense of community within the group. It also allows the facilitator to engage all participants and with the goals of first posing level-specific questions to the more junior learners and ending with the most senior learners.The Case The selected clinical case can be either a new patient seen in consultation in the past 24 hours or a patient that has been in hospital for some time and for whom results of investigations and response to treatment are known. Ideally, the majority of the cases selected should not involve particularly rare medical issues and should mirror the clinical case mix of patients being cared for by the trainees. Trainees will benefit more from discussions about common clinical problems rather. However, to highlight issues of diagnostic reasoning, it can be beneficial to occasionally discussing uncommon case including typical presentations of rare diseases or unusual presentations of common problems.The faculty surveyed expressed differing opinions when asked if they thought the details of the case should be known to the facilitator in advance. Knowing the details of the case in advance can ensure the facilitator is comfortable with the content area and allows them to focus on aspects of the case that they think will have the highest learning impact for trainees. However, when the case is not known to the facilitator, the audience will be more likely to garner insight into the clinical reasoning process of the facilitator. The opportunity to learn about the cognitive process that an “expert” uses when generating a differential diagnosis and formulating plans for investigation and management is potentially much more valuable than the discussion of content that could be read in a textbook or electronically. When the details of a case are not known, the discussion is more spontaneous and the lines of discussion are more reflective of the thoughts of the trainees, rather than the facilitator. The discussion can be guided by the case itself and the trainees’ questions and answers. A mixed approach to case discussion will provide the variety that the participants value.Although traditionally MR has focused on the diagnosis or management of one or more clinical cases from the inpatient service, its format is flexible enough to provide opportunity for discussion or for other important aspects of patient care. MR can also address ambulatory cases,7 include the presence of a real patient for the purposes of highlighting history-taking and clinical findings and also incorporate discussion of simulated cases, such as code blue scenarios. The discussion can also be enriched by the health professionals from other disciplines including, pharmacists, physical therapists, occupational therapists, nurses, and social workers. The case can also be selected to allow the discussion to be focused on other specific elements of management, such as resource utilization and “choosing wisely,”8 quality and safety, bioethics, and evidence-based medicine.9Running the Show In developing their skills in facilitation, many of the faculty surveyed discussed that they continuously build on the facilitation skills that they have learned over time, the basic principles of which are described elsewhere.10,11 Through feedback and reflection, they adapt to a style that reflects how they believe the MR should be conducted.The facilitator must establish a respectful climate at MR that is conducive to learning. He or she must ensure that the session is collegial and enforce that the goal of the session is learning, rather than showmanship. The environment should encourage interaction and permit people to ask questions. Trainees should feel comfortable enough to answer questions and test hypotheses, even if answers are incorrect. However, the facilitator must ensure that the correct information is conveyed to the group and that incorrect answers are explored as key teaching points. Humour can put people at ease. Self-deprecating humour can be non-threatening and freely employed if it is within the facilitator’s comfort zone. However, humour should never come at the expense of a trainee. Personal anecdotes and reflections on past cases can engage the audience, relax the atmosphere and vividly impart key facts and clinical wisdom.It is important for the facilitator to be respectful of time. Trainees often report that too much time is spent on reviewing the history and physical examination and on the development of an exhaustive differential diagnosis while less time is spent on investigation and management issues, which senior trainees find most valuable. There need not be a fixed formula related to how much time to spend on specific components of the case. A skilled facilitator will expand and abbreviate aspects of the case discussion based on the specific case presented. Some cases represent excellent opportunities to review evidence-based physical examination, some may highlight issues of resource stewardship related to investigation and some are particularly well-suited to discussion of evidence-based management.The facilitator should facilitate a clinical discussion, rather than deliver a didactic talk. He or she should coach the audience to identify key historical facts or findings on physical examination to allow everyone to fully participate in the case formulation and clinical reasoning that will follow. Demonstrating a mix of pattern recognition and heuristics (e.g., “Quick – what do you think the diagnosis is?”) and analytical reasoning strategies will help trainees learn to employ and recognize the strengths and limitations of each.In the face of a quiet audience, questions that have obvious answers should be posed first. The facilitator should promote volunteerism as much as possible; however, addressing specific members of the audience prevents silence and can help ensure everyone is engaged in the discussion. Sensitivity to the level of trainee is important. A facilitator should avoid potential embarrassment of a trainee by allowing a more junior learner to come up with the answer to a question that the more senior trainee could not answer. In other words, there should be an inviolate sequence wherein, for any given topic, the facilitator starts with trainees at an appropriate level for the questions and moves upward sequentially by level of training. This allows participants to relax and set their focus on learning, rather than avoiding eye contact and fearing embarrassment.A skilled facilitator should not allow any one person to dominate the discussion and should also refrain from asking multiple questions to the same participant. However, it can be valuable to challenge a respondent or the group to elaborate on their answers, as this can uncover gaps in knowledge and understanding and provide additional opportunities for learning.It is important to ensure that the discussion is of interest to trainees at all levels. If faculty are present, their opinions should be sought throughout the case. It is helpful to highlight the variability in approach amongst “the experts” in the room. Judicious use and justification of investigations should be encouraged to promote learning about resource stewardship and evidence-based medicine principles should be incorporated, when relevant.Many facilitators are anxious about how to handle situations where they don’t know the answer to a particular clinical problem. In these cases, a demonstration of the clinical reasoning process and a focus on an approach to clinical problems can be helpful. Some of the most useful discussions centre on how to deal with uncertainty and on how to find answers to clinical questions in real-time using available resources. The facilitator should not hesitate to say “I don’t know,” as this demonstrates that nobody has infinite knowledge and role-models the necessity of recognizing one’s limitations. Teaching scripts relating to specific topics or the use of an etiologic or body systems-based approach to developing a differential diagnosis are helpful teaching approaches6.Wrapping Up Sufficient time should be dedicated to recapitulation and repetition of one to 3 key take home messages. This serves to reinforce the important points that were discussed and to ensure that participants walk away with key messages to facilitate learning. Having a few members of the audience identify what they have learned is often beneficial as the facilitator may not identify the same issues as the trainees.Closing the Loop Further reinforcement can occur if a summary of the take home points, or a relevant paper, is circulated by email or posted to a blog.12 This must be done in a manner that protects patient confidentiality. Updates on previously presented diagnostic dilemmas will enhance learning. Finally, the organizer of MR can keep a log of cases that have been presented to avoid excessive repetition of topics and ensure a balanced curriculum.A process for the person presenting the case to be provided with feedback about their presentation skills by the facilitator or peers should be implemented. It is also important for the facilitator to receive feedback about their teaching and the session overall. Feedback will help faculty refine their facilitation skills, especially if coupled with faculty development initiatives to improve teaching skills.13 It may also be important for novice clinician teachers who need to build a teaching portfolio as part of their academic review and promotion process. 14 If it is clear the faculty utilize the feedback, it serves to role-model self-reflection and promote a culture of frequent formative feedback.The Future of MR MR has a long tradition and can be an evolving teaching format capable of meeting current educational needs. For example, with the implementation of competency-based medical education (CBME) into residency training programs, the competencies being developed for Internal Medicine trainees can provide a framework to organize aspects of learning experiences, including MR. 15 Issues of advocacy and stewardship may be highlighted as explicit learning points of cases, as MR allows for discussion of authentic core clinical tasks and problems, avoiding the reduction of competencies to endless lists taught without the necessary context needed for deeper learning.16 There are also challenges to implementing and sustaining a successful MR in today's current training climate. Issues such as duty-hour restrictions, increased volume and acuity of patients, and pressure to discharge patients early in the day17–19 have prompted some to modify the traditional MR. An “afternoon report” allows for attention to clinical duties early in the day and preserves teaching for later in the day. MR should continue to evolve to meet current education and healthcare delivery needs, and these innovations should be described in the literature and studied.Although these tips have been generated from shared experiences at a single centre, we believe they will be useful to facilitators in many other settings, as they represent the experiences of many facilitators with many cumulative years of experience. This article is intended to stimulate others to reflect upon and discuss what they have found to be the key elements to facilitating a successful MR.Acknowledgements We would like to thank our colleagues who contributed tips and whose teaching has influenced the careers of countless trainees: Dr. Ahmed Bayoumi, Dr. Isaac Bogoch, Dr. Mark Cheung, Dr. Allan Detsky, Dr. Irfan Dhalla, Dr. Vera Dounaevskaia, Dr. Trevor Jamieson, Dr. Lauren Lapointe Shaw, Dr. Jerome A. Leis, Dr. Don Livingstone, Dr. Julia Lowe, Dr. Ophyr Mourad, Dr. Valerie Palda, Dr. Joel Ray, Dr. Donald Redelmeier, Dr. Steve Shadowitz, Dr. Rob Sargeant.References1. Parrino TA, Villanueva AG. The principles and practice of MR. JAMA 1986;256(6):730–33.2. Amin Z, Guajardo J, Wisniewski W, Bordage G, Tekian A, Niederman LG. MR: focus and methods over the past three decades. Acad Med 2000;75(10):S1–S5.3. Gross CP, Donnelly GB, Reisman AB, Sepkowitz KA, Callahan MA. Resident expectations of MR: a multi-institutional study. Arch Int Med 1999;159(16):1910–14.4. McNeill M, Ali SK, Banks DE, Mansi IA. MR: can an established medical education tradition be validated? J Grad Med Educ 2013;5(3):374–84.5. Ways M, Kroenke K, Umali J, Buchwald D. MR: A survey of resident attitudes. Arch Int Med 1995;155(13):1433–37.6. Sacher AG, Detsky AS. Taking the stress out of MR: an analytic approach to the differential diagnosis. J Gen Intern Med 2009;24(6):747–51.7. Wenderoth S, Pelzman F, Demopoulos B. Ambulatory MR. J Grad Med Educ 2002;17(3):207–209.8. Kane GC, Holumzer C, Sorokin R. Utilization management MR: Purpose, planning and early experience in a university hospital residency program. Sem Med Pract 2001;4(1):27–36.9. Banks DE, Runhua Shi M. Decreased hospital length of stay associated with presentation of cases at MR with librarian support. J Med Libr Assoc 2007;95(4):381–87.10. Azer SA. Challenges facing PBL tutors: 12 tips for successful group facilitation. Med Teach 2005;27(8):676–81.11. Skeff KM. Enhancing teaching effectiveness and vitality in the ambulatory setting. J Gen Intern Med 1988;3(1):S26–S33.12. Bogoch II, Frost DW, Bridge S, Lee TC, Gold WL, Pansiko DM, Cavalcanti R. MR blog: a web-based tool to enhance case-based learning. Teach Learn Med 2012;24(3):238–41.13. Boerboom TB, Stalmeijer RE, Dolmans DH, Jaarsma DA. How feedback can foster professional growth of teachers in the clinical workplace: A review of the literature. Stud Educ Eval 2015;46:47–52.14. Fleming VM, Schindler N, Martin GJ, DaRosa DA. Separate and equitable promotion tracks for clinician-educators. JAMA 2005;294(9):1101–1104.15. Frank JR, Snell LS, Ten Cate O, Holmboe ES, Carraccio C, Swing SR, Harris, KA. Competency-based medical education: theory to practice. Med Teach, 2010;32(8):638–45.16. Hawkins RE, Welcher CM, Holmboe ES, Kirk LM, Norcini JJ, Simons KB, Skochelak SE. Implementation of competency‐based medical education: are we addressing the concerns and challenges? Med Educ. 2015;49(11):1086–1102.17. Arora VM, Georgitis E, Siddique J, Vekhter B, Woodruff JN, Humphrey HJ, Meltzer DO. Association of workload of on-call medical interns with on-call sleep duration, shift duration, and participation in educational activities. JAMA 2008;300(10):1146–53.18. Horwitz LI, Krumholz HM, Huot SJ, Green ML. Internal medicine residents' clinical and didactic experiences after work hour regulation: a survey of chief residents. J Gen Int Med 2006;21(9):961–65.19. 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Introduction Our home is the most intimate space we inhabit. It is the centre of daily existence – where our most significant relationships are nurtured – where we can impart a sense of self in both physical and psychological ways. To lose this place is overwhelming, the physical implications far-reaching and the psychological impact momentous. And yet, there is little research on what happens when home is lost as a consequence of relationship breakdown. This paper provides an insight into how the meaning of home changes for those going through separation and divorce. Focusing on heterosexual couples, my research reveals that intense feelings of grief and loss are expressed as individuals in a relationship dispute reflect on different aspects of home which are destroyed as a consequence of their partnership collapse. Attitudes to the physical dwelling often reflect the changing nature of the relationship as it descends into crisis. There is a symbolic element as well, which is mirrored in the ways that the physical space is used to negotiate power imbalances, re-establish another life, maintain continuity for children, and as a bargaining tool to redress intense anger and frustration. A sense of empowerment eventually develops as the loss of the relationship is accepted and life adjustments made. Home: A Place of Profound Symbolic and Physical Meaning Home is the familiar, taken-for-granted world where most of us are nurtured, comforted and loved. Home is where we can dream and hope, relax and be ourselves, laugh and cry. For the majority, home is a safe and welcoming place, although positive associations are not universal as some experience home as a negative, threatening and unloving place. Home transcends the domestic physical structure, encompassing cultural, symbolic and psychological significance, as well as extending to the neighbourhood, city, region and nation. Home provides a sense of belonging in the world and is a refuge from the dangers and uncertainty of the environment at large. It is the centre of important human relationships and their accompanying domestic roles, rituals and routines. Home is where the bonds between partners, child and parent, brother and sister are reinforced, along with extended family members and close friends Home is a symbol of personal identity and worth, where the individual can exercise a degree of power and autonomy denied elsewhere. Significant life events, both sad and happy, learning experiences, and celebrations of varying type and magnitude, all occur at home. These are the bases for our memories of home and its importance to us, serving to imbue the notion with a sense of permanence and continuity over time. Home represents the interface between public and private worlds; a place where cultural and societal norms are symbolically juxtaposed with expressions of individuality. There has been a range of research from “humanistic-literary” to “empirical-behavioural” perspectives showing that home has “complex, multiple but inter-related meanings” (Porteous and Smith 61). And while this intellectual endeavour covers a wide range of disciplines and perspectives (for good overviews see Blunt and Dowling; Mallett; Chapman and Hockey) research on the loss of home is more limited. Nevertheless, there are some notable exceptions. Recent work by Robinson on youth homelessness in Sydney illustrates that the loss of home affects the way in which it is desired and valued, and how its absence impacts on self identity and the grief process. Fried’s seminal and much older study also tells of intense grieving, similar to that associated with the death of a loved one, when residents were forcibly removed from their homes – places perceived as slums by the city planners. Analogous issues of sorrow are detailed by Porteous and Smith in their discussion of situations where individuals and entire communities have lost their homes. The emphasis in this moving text is on the power and lack of understanding displayed by those in authority. Power resides in the ability to destroy the home of others; disrespect is shown to those who are forced to relocate. There is no appreciation of the profound meanings of home which individuals, communities and nations hold. Similarly, Read presents a range of situations involving major disruptions to meanings of home. The impact on individuals as they struggle to deal with losing a house or neighbourhood through fire, flood, financial ruin or demolition for redevelopment, demonstrates the centrality of notions of home and the devastation that results when it is no longer. So too do the many moving personal stories of migrants who have left one nation to settle in another (Herne et al), as well as more academic explorations of the diaspora (Rapport and Dawson) and resettlement and migrant women home-making (Thompson). Meanings of home are also disrupted, changed and lost when families and partnerships fall apart. Given the prevalence of relationship breakdown in our society, it is surprising that very little work has focussed on the changed meanings of home that follow. Cooper Marcus examined disruptions in bonding with the home for those who had to leave or were left following the end of a marriage or partnership. “The home may have been shared for many years; patterns of territory, privacy, and personalisation established; and memories of the past enshrined in objects, rooms, furniture, and plants” (222). Gram-Hanssen and Bech-Danielsen explore both the practical issues of dissolving a home, as well as the emotional responses of those involved. Anthony provides further illumination, recommending design solutions to help better manage housing for families affected by divorce. She concludes her paper by declaring that “…the housing experiences of women, men, and children of divorce deserve much further study” (15). The paucity of research on what happens to meanings of home when a relationship breaks down was a key motivation for the current work – a qualitative study involving self-reflection of the experience of relationship loss; in-depth interviews with nine people (three men and six women from English speaking middle class backgrounds) who had experienced a major partnership breakdown; and focus group sessions and one in-depth interview with nine professional mediators (six women and three men) who work with separating couples. The mediators provided an informed overview of the way in which separating partners negotiate the loss of a shared home across the range of its physical and psychological meanings. Their reflections confirmed that the identified themes in the individual stories were typical of a range of experiences, feelings and actions they had encountered with different clients. Relationship Breakdown and Meanings of Home: What the Research Revealed The Symbolism of Home The interview, focus group and reflective data all confirmed the centrality of home and its multi-dimensional meanings. Different physical and symbolic elements were uncovered, mirroring theoretical schemas in the literature. These meanings go far beyond a physical space and the objects therein. They represent different aspects of the individual’s sense of self, well-being and identity, as well as their roles and feelings of belonging in a family and the broader social and cultural setting. Home was described as a place to be one’s self; where one can relax away from the rest of the world. Participants talked about home creating a sense of belonging and familiarity. This was achieved in many ways including physical renovation of the structure, working in the garden, enjoying the dwelling space and nurturing family relationships. As Helen said, …the home and children go together… I created belonging by creating a space which was mine, which was always decorated in a very particular way which is mine, and which was my place of belonging for me and my kin… that’s my home – it’s just absolutely essential to me. Home was described as an important physical place. This incorporated the dwelling as a structure and the special things that adorn it. Objects such as the marital bed, family photos, artifacts and pets were important symbols of home as a shared place. As the mediators pointed out, in the splitting up process, these often take on huge significance as a couple try to decide who has what. The division is typically the final acknowledgement that the relationship is over. The interviewees told me that home extended beyond the dwelling into the wider neighbourhood. This encompassed networks of friendships, including relationships with local residents, business people and service providers, to the physical places frequented such as parks, shops and cafes. These neighbourhood connections were severed when the relationship broke down. The data revealed home as a shared space where couples undertook daily tasks such as preparing meals together and doing the housework. There was pleasure in these routines which further reinforced home as a central aspect of the partnership, as Laura explained: But for the most part it [my marriage relationship] was very amicable… easy going, and it really was a whole thing of self-expression. And the house was very much about self-expression. Even cooking. We both loved to cook, we’d have lots of dinner parties… things like that. With the loss of the relationship the rhythm and comfort of everyday activities were shattered. Sharing was also linked to the financial aspects of home, with the payment of a mortgage representing a combined effort in working towards ownership of the physical dwelling. While the end of a relationship usually spelt severe financial difficulty, if not disaster, it also meant the loss of that shared commitment to build a secure financial future together extending into old age. The Deteriorating Relationship A decline in the physical qualities of the dwelling often accompanied the demise of the inter-personal relationship. As the partnership descended into crisis, the centrality of home and its importance across both physical and symbolic elements were increasingly threatened. This shift in meaning impacted on the loss experienced and the subsequent translation into conflict and grief. It [the house] was quite run down, but I think it kind of reflected our situation at the time which was fairly strained in terms of finances and lack of certainty about what was happening… tiny little damp house and no [friendship] network and no money and no stability, that’s how it felt. (Jill) Not only did home begin to symbolise a battleground, it started to take on lost dreams and hopes. For Helen, it embodied a force that was greater than the relationship she had shared with her husband. And that home became the symbol of our fight… a symbol of how closely glued we were together… And I think that’s why we had such enormous difficulty breaking up because the house actually held us together in some way … it was as though the house was a sort of a binding force of the relationship. The home as the centre of family relationships and personal identity was threatened by the deteriorating relationship. For Jill this represented ending her dream that being a wife and mother were what she needed to define her identity and purpose in life. I was very unhappy. I’d got these two babies, I’d got what I thought was quite a catch husband, who was doing very well… but yet somehow I felt very unhappy and insecure, very insecure, and I realised that the whole role I had carved out for myself wasn’t going to do it. The End of the Relationship: Disruption, Explosion, Grief and Loss While the relationship can be in crisis for many months, eventually there is a point where any hope of reconciliation disappears. For some separating couples this phase was heralded by a defining, shattering and shocking moment when it was clear that their relationship was over. Both physical and emotional violence were reported by my interviewees, including these comments from Helen. And so my parting from the home was actually very explosive. In fact it was the first time he ever hit me, and it was in the hitting of me that I left home… And while the final stage was not always dramatic or violent, there was a realisation that this was the end of the dream – the end of home. A deep sadness resulted, as evident in Greg’s story: I was there in the house by myself and I can remember the house was empty, all the furniture had been shifted out…I actually shed a few tears as I left the house because…the strongest feeling I had was that this was a house that had such a potential for me. It had such a potential for a good loving relationship and I just felt that it did represent, leaving then, represented the kind of the dashing of the hope that I had in that relationship. In some cases the end of the relationship was accompanied by feelings of guilt for shattering the home. In other cases, the home became a battleground as the partners fought over who was going to move out. …if they’re separated under the one roof and nobody’s moved out, but certainly in one person’s mind the marriage is over, and sometimes in both… there’s a big tussle about who’s going to move out and nobody wants to go… (Mediator) The loss of home could also bring with it a fear of never having another, as well as a rude awakening that the lost home was taken for granted. Cathy spoke of this terror. I became so obsessed with the notion that I’d never have a home again, and I remember thinking how could I have taken so much for granted? The end of a relationship was accompanied by a growing realisation of impending loss – the loss of familiar and well-loved surroundings. This encompassed the local neighbourhood, the dwelling space and the daily routine of married life. I can remember feeling, [and] knowing the relationship was coming to an end, and knowing that we were going to be selling the house and we were going to be splitting…, feeling quite sad walking down the street the last few times… realising I wouldn’t be doing this much longer. I was very conscious of the fact that I was… going up and down those railway station escalators for the last few times, and going down the street for the last few times, and suddenly…[I felt]… an impending sense of loss because I liked the neighbourhood… There was also a loss in the sense of not having a physical space which I kind of wanted to live in… [I] don’t like living in small units or rented rooms… I just prefer what I see as a proper house… so downsizing [my accommodation] just kind of makes the whole emotional situation worse …there was [also] a lack of domesticity, and the kind of sharing of meals and so on that does…make you feel some sort of warmth… (Greg) Transitions: Developing New Meanings of Home Once there was an acknowledgment – whether a defining moment or a gradual process – that the relationship was over, a transitional phase dawned when new meanings of home began to emerge. Of the people I interviewed, some stayed on in the once shared dwelling, and others moved out to occupy a new space. Both actions required physical and psychological adjustments which took time and energy, as well as a determination to adapt. Organising parenting arrangements, dividing possessions and tentative steps towards the establishment of another life characterised this phase. While individual stories revealed a variety of transitional approaches, there were unifying themes across the data. The transition could start by moving into a new space, which as one mediator explained, might not feel like home at all. …[one partner has] left and often left with very little, maybe just a suitcase of clothes, and so their sense of home is still the marital home or the family home, but they’re camping at a unit somewhere, or mother’s spare room or a relative’s backyard or garage or something… They’re truly homeless. For others, while setting up a new space was initially very hard and alien, with effort and time, it could take on a home-like quality, as Helen found. I did take things from the house. I took all the things I’d hidden in cupboards that were not used or second-hand… things that weren’t used everyday or on display or anything… things I’d take like if you were going camping… I wasn’t at home… it was awful…[but gradually]… I put things around… to make it homely for me and I would spend hours doing it, Just hours… paintings on the wall are important, and a stereo system and music was important. My books were important…and photographs became very important. Changes in tenure could also bring about profound feelings of loss. This was Keith’s experience: Well I’m renting now which is a bit difficult after having your own home… you feel a bit stifled in the fact that you can’t decorate it, and you can’t do things, or you can’t fix things… now I’m in a place which is drab and the colours are horrible and I don’t particularly like it and it’s awful. The experience of remaining in the home once one’s partner leaves is different to being the one to leave the formerly shared space. However, similar adaptation strategies were required as can be seen from Barbara’s experience: …so, I rearranged the lounge room and I rearranged the bedroom…I probably did that fairly promptly actually, so that I wasn’t walking back into the same mental images all the time…I’m now beginning to have that sense of wanting to put my mark on it, so I’ve started some painting and doing things… Laura talked about how she initially felt scared living on her own, despite occupying familiar surroundings, but this gradually changed as she altered the once shared physical space. Sally spoke about reclaiming the physical space on her own and through these deliberative actions, empowering herself as a single person. Those with dependent children struggled in different ways during this transition period. Individual needs to either move or reclaim the existing space were often subjugated to the requirements of their off-spring – where it might be best for them to live and with whom they should principally reside. I think the biggest issue is where the children are going to be. So whoever wants the children also wants the family home. And that’s where the pull and tug starts… it’s a big desire not to disrupt the children and to keep a smooth life for them. (Mediator) Finally, there was a sense of moving along. Meanings of home changed as the strength of the emotional attachment weakened and those involved began to see that another life was possible. The old meanings of home had to be confronted and prized apart, just as the connections between the partners were painstakingly severed, one by one. Sally likened this time consuming and arduous process to laboriously unpicking the threads of a tightly woven cloth. Empowerment: Meanings of Home to Mirror a New Life …I’ve realized too that I’m the person I am today because of that experience. (Sally) The stories of participants in this research ended with hope for the future. Perhaps this reflects my interviewees’ determination to build a new life following the loss of their relationship, most having the personal resources to work through their loss, grief and conflict. This is not however, always the case. Divorce can lead to long lasting feelings of failure, disappointment and a sense that one has “an inability to love or care…” (Ambrose 87). However, “with acceptance of the separation many come to see the break-up as having been beneficial and report feeling they have an improved quality of life” (88). This positive stance is mirrored in my mediator focus group data and other literature (for example, Cooper Marcus 222-238). Out of the painful loss of home emerges a re-evaluation of one’s priorities and a revitalized sense of self, as illustrated by Barbara’s words below. That’s come out of the separation, suddenly going, ‘Oh, hang on, I can do what I want to do, when I want to do it’. It’s quite nice really… I’ve decided [to] start pursuing a few of the things I always wanted to do, so I’m using a bit of the space [in the house] to study… I’m doing a lot of stuff that nurtures me and my interest and my space… Feelings of liberation were entwined with meanings of home as spaces were decorated afresh, and in some cases, a true home founded for the first time. [since the end of the relationship]… I actually see my space differently, I want less around me, I’ve been really clearing out things, throwing things out, clearing cupboards… kind of feung shui-ing every corner and just really keeping it clear and clean… I’ve painted the whole house. It was like it needed a fresh coat of something over it… (Laura) Empowerment embodied lessons learnt and in some cases, a more cautious redefining of home. Barbara put it this way: I’m really scared of losing what I’ve now got [my home on my own] and that sense of independence… maybe I will not go into a relationship because I don’t want to put that at risk. Finally, meanings of home took on different dimensions that reflected the new life and hope it engendered. …it’s very interesting to me to be in a house now that is a very solid, square, double brick house… [I feel] that it’s much more representative of who I am now… the solidness is very much me… I feel as though I inhabit my home more now… I have much more sense of peace around my home now than I did then in the previous house… it’s the space where I feel extremely comfortable… a space to meditate on… I’m home – I can now be myself… (Helen) I don’t know whether… [my meaning of home] is actually a physical structure any more…Now it’s come more into … surrounding myself with things that I love, like you know bits and pieces that you can take, your photographs and your pet… it’s really much more about being happy I think, and being happy in a space with somebody that you love, rather than living in a box like a prison, with somebody that you really despise (Keith) Conclusion … the physical moving out from my own home was probably the hardest thing I’ve ever had to do in my entire life. (Jane) The trauma of divorce is a crisis that occurs in many of our lives, and one which often triggers a profound dislocation in person-dwelling relations. (Cooper Marcus 222) This paper has presented insights into the ways in which multi-dimensional meanings of home change when an intimate familial relationship breaks down. The nature and degree of the impacts vary from one individual to another, as do the ways in which the identifiable stages of relationship breakdown play out in different partnership situations. Nevertheless, this research revealed a transformative journey – from the devastation of the initial loss to an eventual redefining of home across its symbolic, psychological and physical constructs. References Ambrose, Peter J. Surviving Divorce: Men beyond Marriage. Sussex: Wheatsheaf Books, 1983. Anthony, Kathryn H. “Bitter Homes and Gardens: The Meanings of Home to Families of Divorce.” Journal of Architectural and Planning Research 14.1 (1997): 1-19. 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Smith. Domicide: The Global Destruction of Home. Montreal and Kingston: McGill-Queens UP, 2001. Rapport, Nigel, and Andrew Dawson, eds. Migrants of Identity: Perceptions of Home in a World of Movement. New York: Oxford, 1998. Read, Peter. Returning to Nothing: The Meaning of Lost Places. Cambridge: Cambridge UP, 1996. Robinson, Catherine. “‘I Think Home Is More than a Building’: Young Home(less) People on the Cusp of Home, Self and Something Else.” Urban Policy and Research 20.1 (2002): 27–38. Robinson, Catherine. “Grieving Home.” Social and Cultural Geography 6.1 (2005): 47–60. Thompson, Susan. “Suburbs of Opportunity: The Power of Home for Migrant Women.” In K. Gibson and S. Watson, eds. Metropolis Now: Planning and the Urban in Contemporary Australia. Australia: Pluto Press, 1994. 33-45. Citation reference for this article MLA Style Thompson, Susan. "Home and Loss: Renegotiating Meanings of Home in the Wake of Relationship Breakdown." M/C Journal 10.4 (2007). echo date('d M. Y'); ?> <http://journal.media-culture.org.au/0708/07-thompson.php>. APA Style Thompson, S. (Aug. 2007) "Home and Loss: Renegotiating Meanings of Home in the Wake of Relationship Breakdown," M/C Journal, 10(4). Retrieved echo date('d M. Y'); ?> from <http://journal.media-culture.org.au/0708/07-thompson.php>.