Thèses sur le sujet « Heath, Edward »

Longtemps considéré comme un traître aux principes du Parti conservateur pour l’abandon de ses promesses politiques et son opposition à Margaret Thatcher, aujourd'hui plus personne ne remet en doute les convictions conservatrices d'Edward Heath et son attachement sincère et profond au parti. Pourtant des questions demeurent autour de son identité politique : Heath est-il davantage un héritier de Macmillan ou un précurseur du thatchérisme ? Il n'est pas toujours aisé de répondre tant sa politique fut marquée par des navigations constantes entre conservatisme progressiste et conservatisme radical. Heath se présenta aux membres de son parti et à l'électorat britannique comme l'homme de la rupture qui allait instaurer une nouvelle culture politique fondée sur le désengagement de l'Etat, la responsabilité de l'individu, la compétitivité économique et industrielle. Ce programme de modernisation connu sous le nom de « Révolution Tranquille » bousculait les piliers du consensus d'après-guerre et promettait de faire entrer le Royaume-Uni dans une nouvelle ère de prospérité et de dynamisme. Une fois confronté à la réalité du pouvoir, Heath perdit de son radicalisme et s'inscrit dans les traces de Macmillan en menant une politique interventionniste fondée sur les mêmes modèles que ses prédécesseurs de l'après-guerre. Cette thèse étudie les rapports complexes que Heath entretint avec la tradition conservatrice et les tensions entre héritage et modernité, entre changement et continuité qui caractérisent sa politique afin de définir si Heath fut davantage un héritier ou un modernisateur de la tradition conservatrice
For a long time Edward Heath suffered from a bad reputation inside the Conservative party and was seen as a traitor because of his U-turns when he was Prime Minister and his opposition to Margaret Thatcher in the 1980s. Today no one would dispute Heath's convictions and his sincere and profound attachment to the Conservative party. Yet questions remain about his political identity: Did Heath follow in the footsteps of Harold Macmillan or did he pave the way for Thatcherism? The question is still pending and causes much debate as Heath's policies were marked by constant navigations between a progressive Conservatism and a radical Conservatism. At the beginning of his career, Heath presented himself to the rest of the party and to the electorate as the radical Tory bent on implementing a new political culture based on the disengagement of the State, the responsibility of the individual and the competitiveness of the British economy. This programme of modernisation known as the “Quiet Revolution” marked a clear break from the post-war consensus and was designed to start a new era of prosperity and dynamism for the United Kingdom. Once in power however Heath lost his radicalism and pursued a moderate policy very much similar to his predecessors. This thesis examines Heath's intricate relations to the Conservative tradition and the tensions between heritage and modernity, between change and continuity that characterise his policies in order to determine whether Edward Heath was more an heir or a moderniser of the Conservative tradition

A la fin des années soixante, les idées néo-libérales ont suffisamment progressé dans le parti conservateur, pour que le gouvernement, formé en juin 1970 par Edward Heath, affirme vouloir mener une politique de désengagement de l'état de la vie économique. Priorité est également donnée à la lutte contre l'inflation. Près de dix ans plus tard, les conservateurs élus en mai 1979 se fixent les mêmes objectifs. Est-ce à dire que la politique industrielle va disparaitre de la politique économique sous le gouvernement d’Edward Heath et sous ceux de Margaret Thatcher? Non si on conçoit, par politique industrielle, un ensemble de mesures prises par les gouvernements pour influencer souvent indirectement les décisions des entreprises, notamment en matière d'investissement, et qui devrait contribuer à terme, à la réalisation des grands objectifs de la politique économique, tels que la diminution de l'inflation, la réduction du chômage. Dans ces conditions, l'état se donne pour tâche de définir un cadre économique stable au moyen des instruments macroéconomiques traditionnels (politique monétaire et politique budgétaire) et de prendre des mesures du côté de l'offre, pour améliorer la flexibilité des marches et augmenter la concurrence ce qui contribuera à un ajustement plus positif de l'économie. Toutefois, lorsque des problèmes sérieux apparaissent, le gouvernement est souvent contraint d'intervenir pour favoriser l'adaptation structurelle ou prendre en charge les effets néfastes, notamment en termes d'emplois, de cette adaptation
At the end of the sixties following the progress of liberal ideas, the conservative government led by Edward Heath decided to disengage the state from industry. Fighting inflation was a prior aim. Ten years later the conservative government that was returned to power in May 1979 had the same objectives. One could wonder whether industrial policy was to disappear from the field of economic policy ? The answer is no if industrial policy means a set of measures taken by governments to influence indirectly the decisions of firms as regard investment in order to bring about in the long term the main objectives of economic policy such as a reduction of inflation and unemployment. In such a context the state has to define a stable economic framework thanks to traditional macro-economic instruments (monetary policy and budgetary policy) and on the supply side to take measures to make markets more flexible and increase competition. This will lead to a more flexible adjustment of the economy

Le cadre chronologique va de l’affaire Soames via le sommet européen de la Haye de 1969, en passant par la réouverture officielle des négociations à l’adhésion et la CEE le 30 juin 1970, à l’adhésion définitive des candidats le 1er janvier 1973. Notre travail s’appuie sur des sources d’archives allemandes, britanniques, françaises et communautaires. La 1e partie traite de la route du triangle Paris-Bonn-Londres vers l’élargissement dans les années 1960. La RFA remplit une fonction de médiateur entre les 2 protagonistes hostiles, la France et la Grande-Bretagne. La 2e partie se focalise sur la diplomatie britannique et des négociations qui se jouent sur plusieurs registres. L’absence de secret à Bruxelles dévalorise par moment le multilatéral et facilite des stratégies de négociations bi- ou trilatérales, qui nécessitent parfois des cartes cachées. Dans la 3e partie, il est question de la préparation minimale des négociations par Bonn et par Paris. Ensuite, entre 1970 et 1972, le couple franco-allemand semble bien en crise, malgré des stratégies de négociation parfois peu claires. La 4e partie essaie d’expliquer la réussite des négociations grâce à l’entente franco-britannique, en particulier le sommet Pompidou-Heath de mai 1971. Une stratégie du secret et de la centralisation des contacts bilatéraux, en contournant le Ministère des affaires étrangères français, s’impose. Mais cette entente est relative, car la renégociation des accords d’adhésion britannique se prépare déjà au sein du gouvernement Heath. Pour conclure, le triangle participe certainement à la réussite des pourparlers, mais celle-ci n’était pas acquise d’avance
The chronological frame goes from the Soames affair in 1969, via the European summit of The Hague of 1969, and via the official reopening of the EEC enlargement negotiations on June 30th, 1970, to the definitive accession of Great-Britain to the common market on January 1st, 1973. Our work leans on sources of German, British, French and European Community archives. The 1st part tackles the road of the triangle Paris-Bonn-London towards the widening of the EEC, already starting in the 1960s. The FRG filled a function of mediating between 2 hostile protagonists, France and Great Britain. The 2nd part focuses on the British diplomacy during the negotiations. The lack of secret in Brussels may depreciate the multilateral and facilitate strategies of bi-or trilateral negotiations, which requires hidden cards. In the 3rd part, it is question of the minimal preparation of the negotiations by Bonn and Paris. Then, between 1970 and 1972, the French-German couple seems in a huge crisis, even if their strategies of negotiation are not extremely clear. The 4th part tries to explain the success of the negotiations thanks to the French-British entente, in particular during the Pompidou-Heath summit of May 1971. A strategy of secret diplomacy and of centralization of the bilateral contacts, by by-passing the French Foreign office, seems imperative. But this French-British entente is relative, because the renegotiation of the British membership treaties already gets ready within the Heath government. To conclude, the triangle certainly participates in the success of the negotiations. Nevertheless, its success was not acquired beforehand.

Thesis (MPH)--University of Limpopo, 2011.
INTRODUCTION: The human immune deficiency virus (HIV) leads to the acquired immune deficiency syndrome (AIDS). AIDS was first identified in the 1980’s and since then has spread globally causing one of the most dreaded pandemics of modern time. The issue of stigma is very important in the battle against HIV/AIDS as it affects attendance at health centres for obtaining ARV and regular medical check-ups, adherence of patients to ARV treatment. The fear of stigma further helps to fuel a culture of secrecy, silence, ignorance, blame, shame and fear of victimization. AIM: The aim of this study was to determine if there was any external stigmatization of HIV positive patients by health care workers (HCWs) at King Edward VIII Hospital. OBJECTIVES: To determine if the knowledge of HCWs regarding HIV/AIDS and its transmission affect the way they supply a service towards HIV positive patients at King Edward VIII Hospital and to determine the comfort level and the attitude of the HCWs in rendering care to a HIV positive patient. METHODOLOGY: This was a cross sectional survey where data was collected using an anonymous selfadministered structured questionnaire with closed ended questions on personal and professional characteristics, disease knowledge, and discriminatory practices such as attitudes and comfort levels towards people living with HIV/AIDS (PLWHA). A total of three hundred and thirty four HCWs from different units at the King Edward VIII hospital participated in this study. FINDINGS Overall the HCWs have an above average knowledge about HIV/AIDS and its transmission with only 1.8% scoring below average in the knowledge questions regarding HIV and its transmission, although some knowledge gaps were identified regarding occupational exposure risks. Evidently from the results is that HCW with higher levels of education are more knowledgeable on issues relating to HIV/AIDS. The implication is that a HCW with a better education is better equipped with the cognitive knowledge to deal with HIV/AIDS, highlighting iv the importance of education related to external stigmatization. Even though HCWs were knowledgeable about HIV/AIDS most still felt uncomfortable in performing some occupational duties on PLWHA like assisting a woman in labour and performing invasive surgical operations. Most of the HCWs showed a positive attitude towards PLWHA believing that they are not to be blamed for their condition but that individuals in the community who are perceived to be promiscuous men or women are the ones responsible for the spread of HIV/AIDS. Procedures like patients being tested without their consent and patients required to do a HIV/AIDS test before surgery that could be perceived as stigmatization have been observed in King Edward VII hospital. Patient confidentiality is also compromised in that gossiping by HCWs about the HIV/AIDS results of patients has been noted. Fortunately a significant number of HCWs are willing to report their colleagues to a higher authority if any form of stigmatization or discrimination towards PLWHA is seen at King Edward VIII Hospital. CONCLUSION Although the knowledge, attitude and comfort of the HCWs at King Edward VIII Hospital was above average continuing medical education and continuing professional development should be mandatory in the management of HIV/AIDS so that HCWs can have the needed knowledge to keep up with the changing world of HIV/AIDS medicine and also about universal precautions to take so as to reduce occupational exposures. Psychological support to the HCW is needed in dealing with PLWHA so that patients can be provided with quality and compassionate care irrespective of their HIV/AIDS status as this will eventually help in the reduction of stigma.

Dans le cadre de cette thèse, on s'intéresse à la dynamique de quelques fluides complexes. D'une part on étudie la dynamique des cristaux liquides nématiques, en utilisant les modèles proposés par Ericksen et Leslie, Beris et Edwards, Qian et Sheng. D'autre part, on analyse un fluide complexe dont la dynamique dépend de la température et qui est modélisée par le système de Boussinesq. Les cristaux liquides sont des matériaux avec une phase de la matière intermédiaire entre les liquides et les solides qui sont des phases plus connues. Dans cette thèse, on s'intéresse à l'étude du problème de Cauchy associé à chaque système modélisant leurs hydrodynamiques. Tout d'abord on obtient des résultats d'existence et d'unicité de solutions faibles ou classiques, solutions qui sont globales en temps. Ensuite, on analyse la propagation de la régularité des données initiales pour ces solutions. Le cadre fonctionnel adopté pour les données initiales est celui des espaces de Besov homogènes, généralisant des classes d'espaces mieux connues : les espaces de Soboloev homogènes et les espaces de Hölder. Le système Ericksen-Leslie est considéré dans la version simplifiée proposée par F. Lin et C. Liu, version qui préserve les principales difficultés du système initial. On étudie ce problème en dimension supérieure ou égale à deux. On considère le système dans le cas inhomogène, c'est-à dire avec une densité variable. De plus, on s'intéresse au cas d'une densité de faible régularité qui est autorisée à présenter des discontinuités. Donc, le résultat que l'on démontre peut être mis en relation avec la dynamique des mélanges de nématiques non miscibles. On démontre l'existence globale en temps de solutions faibles de régularité invariante par changement d'échelle, en supposant une condition de petitesse sur les données initiales dans des espaces de Besov critiques. On démontre aussi l'unicité de ces solutions si de plus on suppose une condition supplémentaire de régularité pour les données initiales. Le système Beris-Edwards est analysé dans le cas bidimensionnel. On obtient l'existence et l'unicité de solutions faibles globales en temps, lorsque les données initiales sont dans des espaces de Sobolev spécifiques (sans condition de petitesse). Le niveau de régularité de ces espaces fonctionnels est adapté pour bien définir les solutions faibles. L'unicité est une question délicate et demande une estimation doublement logarithmique pour une norme sur la différence entre deux solutions dans un espace de Banach convenable. Le lemme d'Osgood permet alors de conclure à l'unicité de la solution. On obtient également un résultat de propagation de régularité d'indice positif. Afin de prendre en compte l'inertie des molécules, on considère aussi le modèle proposé par Qian et Sheng, et on étudie le cas de la dimension supérieure ou égale à deux. Ce système montre une caractéristique structurale spécifique, plus précisément la présence d'un terme inertiel, ce qui génère des difficultés significatives. On démontre l'existence d'une fonctionnelle de Lyapunov et l'existence et l'unicité de solutions classiques globales en temps, en considérant des données initiales petites. Enfin, on analyse le système de Boussinesq et on montre l'existence et l'unicité de solutions globales en temps. On considère la viscosité en fonction de la température en supposant simplement que la température initiale soit bornée, tandis que la vitesse initiale est dans des espaces de Besov avec indice de régularité critique. Les données initiales ont une composante verticale grande et satisfont à une condition de petitesse spécifique sur les composantes horizontales: elles doivent être exponentiellement petites par rapport à la composante verticale
The present thesis is devoted to the dynamics of specific complex fluids. On the one hand we studythe dynamics of the so-called nematic liquid crystals, through the models proposed by Ericksen and Leslie, Beris and Edwards, Qian and Sheng.On the other hand we analyze the dynamics of a temperature-dependent complex fluid, whose dynamics is governed by the Boussinesq system.Nematic liquid crystals are materials exhibiting a state of matter between an ordinary fluid and a solid. In this thesis we are interested in studying the Cauchy problem associated to eachsystem modelling their hydrodynamics. At first, we establish some well-posedness results, such asexistence and uniqueness of global-in-time weak or classical solutions. Moreover we also analyzesome dynamical behaviours of these solutions, such as propagations of both higher and lowerregularities.The general framework for the initial data is that of Besov spaces, which extend the most widelyknown classes of Sobolev and Hölder spaces.The Ericksen-Leslie system is studied in a simplified form proposed by F. Lin and C. Liu,which retains the main difficulties of the original one. We consider both a two-dimensional and athree-dimensional space-domain. We assume the density to be no constant, i.e. the inhomogeneouscase, moreover we allow it to present discontinuities along an interface so that we can describe amixture of liquid crystal materials with different densities. We prove the existence of global-in-timeweak solutions under smallness conditions on the initial data in critical homogeneous Besov spaces.These solutions are invariant under the scaling behaviour of the system. We also show that theuniqueness holds under a tiny extra-regularity for the initial data.The Beris-Edwards system is analyzed in a two-dimensional space-domain. We achieve existenceand uniqueness of global-in-time weak solutions when the initial data belongs to specific Sobolevspaces (without any smallness condition). The regularity of these functional spaces is suitable inorder to well define a weak solution. We achieve the uniqueness result through a specific analysis,controlling the norm of the difference between to weak solutions and performing a delicate doublelogarithmicestimate. Then, the uniqueness holds thanks to the Osgood lemma. We also achieve aresult about regularity propagation.The Qian-Sheng model is analyzed in a space-domain with dimension greater or equal than two.In this case, we emphasize some important characteristics of the system, especially the presence ofan inertial term, which generates significant difficulties. We perform the existence of a Lyapunovfunctional and the existence and uniqueness of classical solutions under a smallness condition forthe initial data.Finally we deal with the well-posedness of the Boussinesq system. We prove the existence ofglobal-in-time weak solutions when the space-domain has a dimension greater or equal than two.We deal with the case of a viscosity dependent on the temperature. The initial temperature is justsupposed to be bounded, while the initial velocity belongs to some critical Besov Space. The initialdata have a large vertical component while the horizontal components fulfil a specific smallnessconditions: they are exponentially smaller than the vertical component

Imagine a world where someone’s personal information is constantly compromised, where federal government entities AKA Big Brother always knows what anyone is Googling, who an individual is texting, and their emoticons on Twitter. Government entities have been doing this for years; they never cared if they were breaking the law or their moral compass of human dignity. Every day the Federal government blatantly siphons data with programs from the original ECHELON to the new series like PRISM and Xkeyscore so they can keep their tabs on issues that are none of their business; namely, the personal lives of millions. Our allies are taking note; some are learning our bad habits, from Government Communications Headquarters’ (GCHQ) mass shadowing sharing plan to America’s Russian inspiration, SORM. Some countries are following the United States’ poster child pose of a Brave New World like order of global events. Others like Germany are showing their resolve in their disdain for the rise of tyranny. Soon, these new found surveillance troubles will test the resolve of the American Constitution and its nation’s strong love and tradition of liberty. Courts are currently at work to resolve how current concepts of liberty and privacy apply to the current conditions facing the privacy of society. It remains to be determined how liberty will be affected as well; liberty for the United States of America, for the European Union, the Russian Federation and for the people of the World in regards to the extent of privacy in today’s blurred privacy expectations.
B.S.
Bachelors
Health and Public Affairs
Legal Studies

Defence date: 19 September 2007
Examining board: Prof. Pascaline Winand, E(UI) ; Doctor Piers Ludlow, (London School of Economics and Politics) ; Prof. Arfon Rees, (EUI) ; Prof. Beatrice Heuser, (Universität der Bundeswehr München/University of Reading)
PDF of thesis uploaded from the Library digital archive of EUI PhD theses
This is a study of the consequences for the Anglo-American special relationship of Heath’s attempt to place Britain at the centre of the EC. British accession to the EC is widely regarded as the chief accomplishment of the Heath Government, although the positive influence of membership are issues which are still debated. In contrast, contemporary Anglo-American relations, during the stewardship of Prime Minister Edward Heath and President Richard Nixon, are described as either inconsequential or as bewildering. The conventional interpretation of the Nixon-Heath years is that Heath pursued a European objective for Britain and that he was indifferent with regard to the special relationship.

The purpose of health service research is to produce knowledge that will contribute to the improvement in the delivery of health care and it is in this spirit that this study of the quality of paediatric care at King Edward VIII Hospital was undertaken. The main method utilized was an evaluation of aspects of the process of care of selected conditions, as measured against a predefined set of standards. This was accomplished by a retrospective review of patient records. Assessments were also made of the utilization of the Department's services, manpower and equipment. The surveys conducted involved the Outpatient's Department, the General and the Neonatal Wards of the Paediatric Department of the King Edward VIII Hospital, Durban. The Hospital Administration's routine and computerized data were also analyzed. Among the findings was that the routinely collected data is inadequate,providing only limited information for management purposes. The assertion that the utilization of the Department is high was confirmed, as was the claim that some resources are inadequate to cope with increasing demand. Many factors contribute to this, including high bed occupancy, high patient to doctor ratios, and several factors outside of direct hospital control (primary care services). The general clinical care of patients is high, but particular aspects were found to be in need of attention; for example, the metabolic and fluid management of the ill young patient and medical records in general. Immediate and long-term recommendations pertaining to the Paediatric Department and the Administration are presented.

Psychiatric morbidity in the postpartum period has been a subject of research for years that has been plagued by much controversy. Most of the studies have come from Western countries. Studies that were done in Africa have concentrated on psychotic disorders in in-patients. A pilot study done by Cheetham et al (1981) at King Edward VIII Hospital found a high incidence of 'transient situational disturbances', which required further investigation. AIMS AND OBJECTIVES: 1. To document the spectrum of psychiatric morbidity in an out-patient population of postpartum Zulu women; 2. To define predictive factors which would identify women 'at risk'; 3. To assess the feasibility of 'Western' screening instruments; 4. To investigate whether 'postpartum blues' occurs in Zulu women. RESEARCH DESIGN A prospective, descriptive study was undertaken. Sample Selection: 177 postpartum Zulu women attending the ' Well-Baby' Clinic at King Edward VIII Hospital were randomly selected for inclusion in the study. Methodology: Three questionnaires: The General Health Questionnaire- 30, Pitt's Questionnaire of Anxiety and Depression and The Kennerley Blues Questionnaire were administered to the subjects. A Structured Clinical Interview DSM-III (SCID) was conducted in those women with symptoms. FINDINGS: 1. The majority of the sample were between the ages of 20 and 30 years, unmarried, with a Senior Primary education and a baby of 20 weeks. 2. 45.76% of the sample had a psychiatric diagnosis, with 18.07% having major depression. Other disorders included: adjustment disorders, schizophrenia and dysthymia. 3. Significant variables using Chi-square analysis were: inadequate antenatal care, a negative response from the partner and the absence of cultural rituals. No association was found with demographic and obstetric variables. 4. T-test analysis showed a correlation between the questionnaires and the SCID. 5. 37.3% had experienced 'postpartum blues'. CONCLUSIONS: 1. The spectrum of psychiatric morbidity is affective in nature and similar to other studies. 2. 'Postpartum blues' does occur in Zulu women. 3. Antenatal screening with 'Western' instruments could reduce psychiatric morbidity. 4. The nomenclature of puerperal disorders is inadequate and needs review. 5. More prospective, community-based research is needed, especially in rural Zulu women.
Thesis (M.Med.)-University of Natal, Durban, 1992.

Proponents of Canadian health reform in the 1990s argued for regional structures, which enables budget silos to be broken down and integrated budgets to be formed. Although regionalization has been justified on the basis of its potential to increase home care resources, political science draws upon the scope of conflict theory, which instead suggests marginalized actors, such as home care, may be at risk of being cannibalized in order to safeguard the interests of more powerful actors, such as hospitals. Prince Edward Island, Nova Scotia, and New Brunswick, constitute a natural policy experiment. Each has made different decisions about the regionalization model implemented to restructure health care delivery. The policy question underpinning this research is: What are the implications of the different regional models chosen on the allocation of resources to home care? Provincial governments are at liberty to fund home care within the limits of their fiscal capacity and there are no federal terms and conditions which must be complied with. This policy analysis used a case comparison research design with mixed methods to collect quantitative and qualitative data. Two financial outcomes were measured: 1) per capita provincial government home care expenditures and 2) the home care share of provincial government health expenditures. Hospital data was used as a comparator. Qualitative data collected from face-to-face, semi-structured interviews with regional elite key informants supplemented the expenditure data. The findings align with the scope of conflict theory. The trade-off between central control and local autonomy has implications for these findings: 1) home care in Prince Edward Island increased it share from 1.6% to 2.2% of provincial government health spending; 2) maintaining central control over home care in Nova Scotia resulted in an increase in its share from 1.4% to 5.4%, and 3) in New Brunswick, home care share grew from 4.1% to 7.6%. Inertia and entrenchment of spending patterns was strong. Health regions did not appear to undertake resource reallocation to any great extent in either Prince Edward Island or New Brunswick. Resource reallocation did occur in Nova Scotia where the hospital share of government spending went down and was reallocated to home care and nursing homes. But, Nova Scotia is the only province of the three in which home care was not regionalized. Regional interests in maintaining existing levels of in-patient hospital beds was clearly a source of tension between the overarching policy goals formulated for health reform by the provincial governments and the local health regions.

According to several studies, there have been improvements in adolescent sexual behaviour; declining adolescent pregnancies, fewer adolescents having more than one sexual partner, and an increasing numbers of adolescents using contraceptives. Notwithstanding these improvements, there are concerns regarding adolescents’ sexual health including adolescents’ limited knowledge of sexual health issues, high rates of sexually transmitted infections and the need to eliminate barriers to adolescent sexual health services. The purpose of this study was to explore adolescents’ perceptions of the facilitators and barriers to the promotion of healthy sexuality of adolescents living in PEI. A qualitative descriptive design guided by CST and a socio-ecological framework was used to explore participants’ perceptions. Six female high school students, 16-18 years of age, participated in a face-to-face semi-structured interview followed by a second face-to-face follow up interview. Seven themes emerged from the data that was analyzed through thematic analysis: The Illusion of Accessible Resources; Risky Behaviours; Peer Pressure Alive and Well in High School; Cyberbullying; Parental Influence on Adolescent Decision Making; Inefficient and Underutilized School Health Resources; and Inefficient and Underutilized Community Health Resources. While it is evident that some promotion of healthy sexuality of adolescents is occurring in PEI, more investigation and development is needed to better support adolescents with comprehensive school services including guidance and education. The results of this study can be used to guide this future development.

Introduction. Previous studies have established that infants born to mothers with advanced HIV disease and co-infections are smaller, premature and have rapidly progressive HIV disease and an early death. King Edward VIIIth Hospital, in Durban, admits many sick mothers and manages a large proportion of low birth weight and ill newborns. On discharge and follow-up, the mortality and morbidity of these infants are known to be high and are related to the prematurity. How much is related to being HIV exposed is still uncertain. Aim. To determine the perinatal transmission rate of HIV-1 and mortality at 12 months in HIV exposed infants that were admitted to and discharged from the Neonatal Unit, in Durban, South Africa. Methods. In this observational study, data from the outpatient charts of HIV exposed infants that required specialised neonatal care and subsequent follow up, between the period November 2007 and December 2009, were collected. Perinatal transmission rates and mortality of these infants were compared with maternal and infant risk factors. Results. Data on 463 HIV exposed, predominantly low birth weight infants are presented. The median maternal CD4 count was 309cells/mm3 with 16.8% of mothers commenced on HAART. Maternal co-infection with TB was found in 19.2% of the cohort. Early HIV transmission occurred in 11.5% of infants and was influenced by the type of ARV exposure (None, 20%; single dose NVP, 14.3%; dual therapy, 10.6%; maternal HAART, 8.5%). The dual therapy regimen for 7 days was more protective than that for 28 days (p=0.045). HIV infection was associated with higher risk of neonatal sepsis (RR 1.6; 95% CI, 1.1-2.3; p=0.015). The mortality for the cohort at 12 months was 10%. Maternal HAART was associated with a lower mortality: 2.95% vs.10.2% (RR 3.0; 95% CI, 0.4-20.5). There was a higher mortality rate in those that were low birth weight (RR 4.2; 95% CI, 1.02-18.8; p=0.037); those that were HIV infected (RR 4.8; 95% CI, 1.9-11.6; p=0.002) and those that were breastfeeding compared to formula feeding (RR 2.7; 95% CI, 1.1-6.8; p=0.038). Discussion. Rates of HIV transmission within the PMTCT programme were similar to that reported by the Department of Health. Early maternal ARVs for PMTCT prophylaxis, prevents HIV transmission. The coverage of maternal HAART was sub-optimal. Breastfeeding was associated with a higher HIV transmission rate and was most likely associated with non-exclusive breastfeeding during neonatal admission. Recommendations. Maternal HAART or ARV prophylaxis should be commenced early in the pregnancy for the best benefits. Meticulous attention should be paid to the feeding practices of high risk HIV exposed infants admitted for specialised neonatal care.
Thesis (M.Med.)-University of KwaZulu-Natal, Durban, 2012.

Contexte: L'implantation valvulaire aortique par cathéter (TAVI) est une procédure relativement jeune dont l'objectif est de traiter les patients atteints de sténose aortique sévère pour qui la chirurgie cardiaque conventionnelle est considérée à haut risque ou contre-indiquée. Cette procédure a subi, au fil du temps, des améliorations sur le plan technologique (succession de différentes générations de prothèses valvulaires) ainsi que sur le plan technique (simplification des différentes étapes de la procédure). Objectif: L'objectif de ce travail est de décrire l'impact clinique d'une avancée technologique, soit le passage de la deuxième vers la troisième génération de la prothèse Edwards, et d'une avancée technique, soit l'implantation de la prothèse sans pré-dilatation de la valve native. Méthodes: Nous présentons d'abord, par le biais d'une revue et méta-analyse, les résultats cliniques du TAVI au début de son utilisation à plus grande échelle, en 2012. Ensuite, une étude monocentrique rétrospective dans un centre à haut volume décrit les résultats du passage de la deuxième vers la troisième génération de la valve Edwards chez 507 patients. Enfin, une étude rétrospective avec appariement a testé différentes stratégies de pré-dilatation durant la procédure: une pré-dilatation systématique, une pré-dilatation sélective chez des patients présentant des caractéristiques cliniques précises, et l'absence de pré-dilatation. Résultats: Dans l'article présentant les résultats cliniques au début de l'expérience TAVI, le taux de mortalité à 30 jours variait entre 5 et 18%. Le taux de décès à 1 an était estimé à 23% (méta-analyse, random effects model). Le taux d'AVC à 30 jours était entre 0 et 6.7% et le taux de complication vasculaire majeure entre 2 et 16%. L'étude sur le passage de la SAPIEN XT vers la SAPIEN 3 a montré une diminution non significative de la mortalité à 30 jours (de 8.7 à 3.5%; p=0.21) et des AVC à 30 jours (de 2.8 à 1.4%; p=0.6), ainsi qu'une diminution significative des complications vasculaires majeures à 30 jours (de 9.9 à 2.8%; p<0.0001). Cependant, il y a eu une augmentation significative du taux de pacemaker (de 9.8 à 17.3%; p=0.03). L'étude sur la pré-dilatation versus le direct TAVI a montré une absence d'effet adverse du direct TAVI en termes de décès ou complications vasculaires à 30 jours. Nous avons trouvé une tendance à la réduction des AVC avec le direct TAVI (3 vs. 1%; p=0.11), en particulier chez les patients avec une valve aortique peu ou modérément calcifiée. Cependant, chez les patients avec calcification extensive de la valve, le risque de malposition de la prothèse était numériquement plus élevé. Au cours des 3 études présentées, la mortalité à 1 an a peu évolué (entre 20 et 25%). Conclusions: Les événements adverses à court terme ont diminué après le changement de génération de valve Edwards. Le direct TAVI permet de simplifier la procédure sans augmenter les taux d'effets adverses. Cependant, les deux avancées présentent des limites qui incitent à la prudence.
Context: Transcatheter aortic valve implantation (TAVI) is a relatively young procedure intended to treat patients with severe aortic stenosis who are at high risk for conventional surgery, or inoperable. This procedure underwent multiple technological improvements (successive generations of devices) and multiple technical improvements (simplification of various steps in the procedure). Objective: We intend to describe the clinical impact of a technological improvement (the transition from the second to the third generation of the Edwards device in a high-volume center) and that of a technical improvement (TAVI without pre-dilatation, known as direct TAVI). Methods: We first describe, through a meta-analysis, the state of TAVI at the beginning of its widespread use, in 2012. Next, we describe, through a single-center retrospective study, the clinical impact of the transition from the second to the third generation of the Edwards device in 507 patients. Finally, in a retrospective study with matching, we tested three pre-dilatation strategies: systematic pre-dilatation, selective pre-dilatation, and direct TAVI. Results: In the article describing the initial TAVI experience, the 30-day mortality rate was between 5 and 18%. One-year mortality was estimated at 23% by meta-analysis (random effects model). Stroke rate at 30 days was between 0 and 6.7% and major vascular complication rate was between 2 and 16%. The transition from SAPIEN XT to SAPIEN 3 resulted in a non-significant reduction in 30-day mortality (from 8.7 to 3.5%; p=0.21) and 30-day stroke rate (from 2.8 to 1.4%; p=0.6), and a significant reduction in major vascular complications (from 9.9 to 2.8%; p<0.0001). However, there was a significant increase in permanent pacemaker rate (from 9.8 to 17.3%; p=0.03). Next, we found no adverse effect of performing direct TAVI in terms of mortality or vascular complications at 30 days. We found a trend towards a reduction in stroke rate with direct TAVI (3 vs. 1%; p=0.11), particularly in patients with mildly or moderately calcified valves. However, in those with extensive valvular calcification, the risk of device malposition was numerically higher. In all three studies presented, there was little variation in 1-year mortality (20 to 25%). Conclusions: Short-term adverse events were reduced by the transition towards the third-generation Edwards device. Direct TAVI is feasible and safe. However, both of these improvements have limitations and should be considered carefully.

La présente thèse par articles aborde différentes facettes du dépistage prénatal de certaines aneuploïdies au premier trimestre de la grossesse. L’introduction retrace l’historique du dépistage prénatal et énonce les différents marqueurs biochimiques et échographiques associés aux aneuploïdies. La première publication démontre que le tabagisme maternel abaisse significativement les niveaux sanguins maternels de PAPP-A et de la fraction libre de la β-hCG et augmente significativement la clarté nucale, confirmant la nécessité de contrôler cette co-variable dans le calcul de risque final, du moins pour la trisomie 18. Le deuxième article identifie des seuils de clarté nucale au-delà desquels la biochimie génétique n’apporte aucune valeur additionnelle au dépistage prénatal de la trisomie 21 et de la trisomie 18. Pour les fœtus avec clarté nucale supérieure aux seuils établis, un diagnostic prénatal intrusif devrait être offert sans délai. Le troisième et dernier article porte sur la première détermination des niveaux plasmatiques maternels de la protéine FLRG (follistatin-related gene) au premier trimestre de grossesse et sur son rôle potentiel à titre de marqueur biochimique dans le dépistage prénatal de la trisomie 21. Bien que détectables, les niveaux plasmatiques maternels de FLRG ne sont pas significativement altérés en présence de fœtus avec syndrome de Down. Dans la discussion générale, les trois articles sont abordés sous un angle plus spécifique au Québec. Des données complémentaires et originales y sont présentées. Une discussion sur l’évolution future du dépistage prénatal est entamée et des axes de recherche sont proposés.
In this thesis by articles, we explore different facets of first trimester prenatal screening of aneuploidy. Introduction retraces the origin of prenatal screening and enunciates current biochemical and ultrasound markers associated with aneuploidy. In the first article, impact of maternal smoking on first-trimester prenatal screening results is assessed for Down syndrome and trisomy 18. Both maternal blood levels of PAPP-A and free β-hCG are significantly decreased by maternal smoking while fetal nuchal translucency (NT) thickness is significantly increased. Without adjustment, this results in an increase of false positives, at least for trisomy 18. Based on these results, adjustment for smoking should be mandatory in first-trimester prenatal screening. In the second article, we identify NT threshold values above which biochemical screening provides no additional benefit. In pregnancies in which NT is above the proposed upper cut-offs, invasive prenatal screening should be offered without undue delay. In the third and last article, maternal plasma levels of follistatin- related gene protein (FLRG) are determined for the first time in first trimester of pregnancy. Its potential role as a new marker for Down syndrome is assessed. Although FLRG can be successfully detected in maternal plasma, its levels are not significantly altered by the presence of Down syndrome fetuses. In the general discussion, articles are mainly addressed under a Quebec standpoint. Additional and complementary original data are presented and different clinical research avenues are proposed.