Podcasts about ICI

Charterhouse Warren. Un site archéologique, situé près de Bristol, au sud-ouest de l'Angleterre. Tout commence par une découverte macabre faite dans les années 1970 : au fond d'une fosse naturelle, les archéologues mettent au jour un amas de restes humains. Rien d'étonnant, pense-t-on d'abord : le site est un ancien puits d'extraction de plomb, utilisé plus tard comme sépulture collective.Mais les analyses plus récentes ont révélé une toute autre histoire. Il y a environ 4000 ans, à l'âge du bronze, une communauté entière aurait été massacrée, puis partiellement dévorée. Le site se transforme alors en un véritable mystère pour les scientifiques.Que sait-on ? Les restes appartiennent à au moins 40 individus — hommes, femmes, enfants. Mais ce n'est pas un tombeau organisé. Les ossements sont jetés pêle-mêle, démembrés, avec de nombreuses traces de violence extrême. Les crânes sont fracturés, les os longs portent des marques de coupures nettes, comme si l'on avait retiré chair et moelle. Certaines fractures indiquent que les victimes étaient encore en vie au moment des coups.Plus troublant encore : des traces de découpe et de cuisson ont été détectées sur plusieurs os. Ces indices accréditent la thèse d'un cannibalisme rituel ou de survie. Mais pourquoi ? Guerre tribale ? Vengeance ? Famine extrême ? Le contexte exact échappe encore aux chercheurs.Le mystère de Charterhouse Warren réside aussi dans l'absence de parallèles connus. En Europe de l'âge du bronze, les sépultures sont en général ordonnées, respectueuses. Ici, on est face à une scène de violence collective, isolée, sans précédent clair. Était-ce une attaque venue de l'extérieur ? Un massacre interne ? Une exécution de prisonniers ? Le site défie les interprétations.Ce qui ajoute encore au trouble, c'est que le site n'était pas une nécropole : c'est un ancien gouffre de mine, qui a servi d'abattoir et de décharge humaine. Pourquoi ce choix ? Était-ce pour effacer les traces ? Pour symboliser un rejet ? Pour isoler les morts du monde des vivants ?En résumé, Charterhouse Warren est un mystère parce qu'il brise les codes connus de la préhistoire britannique. Ce n'est pas un simple site funéraire, mais la scène d'un crime de masse vieux de 4000 ans — un massacre suivi d'actes de cannibalisme dont les motivations nous échappent encore. Un vrai cold case pour les archéologues… et pour l'imaginaire. Hébergé par Acast. Visitez acast.com/privacy pour plus d'informations.

Les parents, les enseignants et même... soi-même : tout le monde est très fort pour envoyer de la pression autour des résultats scolaires. Bien travailler c'est important à condition de surveiller le niveau de stress !Ma Vie d'ado, c'est le podcast du magazine Okapi. Ici, des collégiens parlent d'eux-mêmes, de leurs amis, de leurs familles et de leurs profs. Ils évoquent leur vie intime, au collège, en famille, seuls ou entre potes. Amour, amitié, délires... ils partagent aussi leurs colères, leurs coups de coeur, leurs angoisses et... leurs espoirs.  Ma Vie d'ado, c'est intime, c'est joyeux, c'est drôle, c'est triste, c'est mouvementé… C'est bouleversant comme une vie d'ado !Ma Vie d'ado, un podcast du magazine Okapi, à retrouver tous les quinze jours, dès le 1 er septembre, en même temps que le magazine !Crédits.Ce podcast est préparé et animé par le magazine Okapi (Bayard Jeunesse)  Un épisode réalisé avec la participation des classes des collèges George Pompidou à Champtoceaux (49), Camille Claudel, François Villon et Jean-Baptiste Clément, à Paris (75), Jules Verne à Vittel (88) et les collégiens Conseillers/Délégués départementaux du Gard à Nîmes (30) , René Cassin à Grand-Pontouvre (16), Gilles Gahinet à Arradon (56), Voix : Julie Pialot. Conception, réalisation, mixage : Emmanuel Viau. Montage : Yann Bonicatto. Musique  : Fixxions. Animation éditoriale : J-Y Dana / E. Viau./H.Devannes .  Production :  E.Viau. Un podcast de Bayard Jeunesse 2025- Droits réservésLe premier podcast des collégiens !https://www.okapi.fr/Hébergé par Ausha. Visitez ausha.co/politique-de-confidentialite pour plus d'informations.

Et si la solution à la crise climatique se trouvait… sous nos pieds ? Une étude scientifique majeure, menée par l'Université d'État du Kansas, remet l'agriculture au cœur du combat climatique – mais pas n'importe laquelle. Ici, pas de chimie de synthèse ni d'approche industrielle : c'est l'agriculture régénératrice, nourrie d'amendements organiques, qui montre sa force.Après 22 ans d'observation sur des parcelles de maïs cultivées sans labour et enrichies uniquement de compost et autres matières organiques, les résultats sont sans appel : ces sols stockent beaucoup plus de carbone que ceux nourris aux engrais chimiques. Et ce stockage est durable. Grâce à une technologie de pointe – la lumière synchrotron –, les chercheurs ont pu observer à l'échelle moléculaire comment le carbone organique s'enchevêtre avec les minéraux du sol pour former des liaisons stables, enfermées dans des micropores. Autrement dit, ce carbone ne bouge plus, ne s'évapore pas, il reste piégé pour longtemps.Les avantages ? Ils dépassent la seule question climatique. Ces terres riches en matière organique retiennent mieux l'eau, abritent une biodiversité souterraine florissante, et voient leur structure s'améliorer, saison après saison. Un vrai cercle vertueux, à l'opposé des sols appauvris par les traitements chimiques. « Les amendements organiques nourrissent le sol, pas seulement la plante », résume sobrement le Dr Ganga Hettiarachchi, responsable de l'étude. Derrière cette phrase, une idée simple mais puissante : changer de paradigme. L'agriculture ne doit plus être une source d'émissions, mais un puits de carbone actif.Pour comprendre ce phénomène, les chercheurs ont collaboré avec les plus grandes infrastructures de microscopie à rayons X, au Canada et aux États-Unis. Leurs observations confirment que le carbone organique s'intègre intimement à la matrice minérale du sol, formant des complexes extrêmement résistants à la dégradation. Ce mécanisme ouvre la voie à une agriculture qui capte le CO₂ au lieu de l'émettre. Cette recherche publiée dans le Soil Science Society of America Journal ne reste pas théorique. Elle appelle à une transformation des pratiques agricoles : moins d'intrants chimiques, plus de rotations de cultures, une meilleure gestion des résidus, et une valorisation du compost. Bref, redonner vie au sol pour restaurer la planète. Dans cette bataille, le fumier et le compost ne sont plus des reliques d'un autre temps. Ils deviennent les outils modernes d'une agriculture plus durable, plus autonome, et surtout, plus résiliente. Hébergé par Acast. Visitez acast.com/privacy pour plus d'informations.

durée : 00:07:21 - Le journal de 8h, ici Gascogne

durée : 00:06:55 - Le journal de 7h, ici Gascogne

durée : 00:07:02 - Le journal de 6h, ici Gascogne

durée : 00:04:46 - Le journal de 7h, ICI Touraine

durée : 00:05:09 - Le journal de 8h, ICI Touraine

durée : 00:04:28 - Le journal de 12h, ici Poitou

D'origine bordelaise, Anne Labroille monte à Paris travailler. Insatiable curieuse, au détour d'un Erasmus en Angleterre, elle commence la pratique du projet urbain dans la prestigieuse agence de Jean-Michel Wilmotte où elle exerce près de quinze ans. Ici, certains demeurent toute leur carrière pour continuer de travailler sur les projets exceptionnels de cette agence. D'autres, non sans efforts, s'émancipent pour affirmer leurs propres pratiques. C'est ce que fait Anne laquelle, aujourd'hui, ancre son statut de femme et fait vibrer cette fibre au féminin au coeur de son travail : des projets dans l'espace public qui se fabriquent avec la participation des habitants. Dans ce numéro de Com d'Archi, son échange avec Anne-Charlotte qu'elle connait déjà est intéressant car elle est féministe, Anne-Charlotte non et pourtant, entre elles deux, le dialogue s'installe, s'impose... Montage audio comdarchipodcastConseil audio NyreImage teaser © Anne Labroille____Si le podcast COM D'ARCHI vous plaît n'hésitez pas :. à vous abonner pour ne pas rater les prochains épisodes,. à nous laisser des étoiles et un commentaire, :-),. à nous suivre sur Instagram @comdarchipodcast pour retrouver de belles images, toujours choisies avec soin, de manière à enrichir votre regard sur le sujet.Bonne semaine à tous ! Hébergé par Acast. Visitez acast.com/privacy pour plus d'informations.

durée : 00:06:27 - Le journal de 8h, ici Gascogne

durée : 00:04:55 - le journal de 8h, ICI Touraine

durée : 00:04:54 - le journal de 7h, ICI Touraine

Direction Blois, en bord du fleuve, où se dresse Fleur de Loire, le sublime restaurant de Christophe Hay. Ici le temps se suspend et ce n'est pas une formule, car à peine la porte franchi les lieux et l'équipe qui lui donne vie nous invite à laisser derrière nous l'agitation qui nous a animé jusqu'ici.Cette sérénité qui règne ici elle trouve sûrement ces racines dans le tempérament du chef. Une personnalité à part, qui a tracé son profil dans l'ombre d'un monument de l'histoire de la gastronomie française: Paul Bocuse.C'est lui qui a donné à Christophe Hay ses premières responsabilités, et pas des moindres... Alors nous allons voyager de la vallée de la Loire aux États-Unis, où l'empreinte d'un Paul Bocuse intime va marquer Christophe Hay pour toujours.La suite de l'histoire il l'écrira sur ses terres, au retour de cet exode hors du commun et n'aura de cesse de faire parler sa terre et bâtir une cuisine nourrie de ses propres racines. Elever un troupeau de wagyu, cultiver son jardin pour faire de l'assiette le reflet de sa région, ce n'est que la partie émergée de l'iceberg.Plongez dans l'univers d'un "terroiriste" engagé, au regard aussi radical qu'il est empreint d'humanité.Distribué par Audiomeans. Visitez audiomeans.fr/politique-de-confidentialite pour plus d'informations.

durée : 00:04:24 - Le journal de 12h, ici Poitou

durée : 00:05:05 - Le journal de 8h, ICI Touraine

durée : 00:04:29 - Le journal de 7h, ICI Touraine

durée : 00:06:46 - Le journal de 8h, ici Gascogne

durée : 00:04:14 - Le journal de 12h, ici Poitou

Éric Bélanger, Steve Bégin et André Roy discutent de la Finale de la Coupe Stanley. Ils discutent aussi avec Alexandre Carrier au sujet de notre nouveau partenariat avec La Living Sisu. Les billets sont disponible ici : https://livingsisu.com/fr/collections/lshl-ticketsAbonne-toi à notre infolettre pour avoir l'infos avant tout le monde. Alignements en primeur, annonces exclusives, contenu bonus et bien plus encore! ICI : https://forms.gle/MVoFUu3tc9CStKev6--Pour collaborations ou toutes questions : info@lapochebleue.comReste connecté avec nous sur les réseaux sociaux : Facebook: https://www.facebook.com/lapochebleueblancrouge Instagram: https://www.instagram.com/pochebleueblancrouge Youtube : https://www.youtube.com/@LaPocheBleue Nos podcasts sont disponibles sur toutes les plateformes : https://linktr.ee/lapochebleuePour tes nouvelles sportives: https://lapochebleue.com Hébergé par Acast. Visitez acast.com/privacy pour plus d'informations.

durée : 00:07:17 - Le journal de 6h, ici Gascogne

durée : 00:08:14 - Le journal de 7h, ici Gascogne

durée : 00:07:33 - Le journal de 8h, ici Gascogne

durée : 00:05:40 - Le journal de 18h, ici Gascogne

durée : 00:07:06 - Le journal de 18h, ICI Touraine

durée : 00:05:07 - Le journal de 8h, ICI Touraine

durée : 00:05:02 - Le journal de 7h, ICI Touraine

durée : 00:04:11 - Le journal de 12h, ici Poitou

durée : 00:05:22 - Le journal de 7h, ICI Touraine

durée : 00:05:13 - Le journal de 8h, ICI Touraine

durée : 00:05:03 - Le journal de 18h, ici Gascogne

durée : 00:07:17 - Le journal de 8h, ici Gascogne

durée : 00:07:18 - Le journal de 7h, ici Gascogne

durée : 00:07:53 - Le journal de 6h, ici Gascogne

durée : 00:05:44 - Le journal de 18h, ICI Touraine

My Story  Talk 20  Ministry at Basingstoke 1968-78  Part 5 Welcome to Talk 20 in our series where I'm reflecting on God's goodness to me throughout my life. Last time I was telling you how God was clearly blessing my trips abroad, to Switzeralnd, France, Belgium and the USA, and, thanks entirely to the gift that God had given me, my teaching was in increasingly great demand both at home and overseas. But how did all this fit in with my responsibilities as the pastor of the church in Basingstoke? The Lord showed me that the answer lay in two things – writing and team ministry.   Writing ministry Today, of course, it's relatively easy to communicate with people all over the world by a variety of options available through the internet. But before the internet, apart from radio and television, speaking on which was not readily available, Christian literature was the main means of communicating with potentially thousands of people. What you write can travel further than you can.   One example of this was Andy Anstey, a Canadian who became a student at Mattersey during the early years of my principalship. He told me that he had been baptised in the Spirit in a university library in Canada as a result of reading my book, The Dynamic Difference. I have never been to Canada, but one of my books had found its way there.   It had started as a booklet I wrote for the Students' Pentecostal Fellowship in 1971, Be Filled with the Spirit. Jim Hall had used it on my first trip to Illinois and persuaded me to expand it, as a result of which Receive Power was published in 1974 in time for my second trip to the States. It was finally published in 1978 by Gospel Publishing House, Springfield MO, under the title, The Dynamic Difference.   I was also writing articles for magazines like Redemption Tidings and Youth Aflame, the AoG youth magazine. At Basingstoke I had given a series of Bible studies on the Fundamental Truths of Assemblies of God, and I asked Vernon Ralphs, the editor of Youth Aflame, if he would like me to write a series of articles on the subject. Those articles were eventually published by Peniel Press as a book under the title, Know the Truth, in 1976, and with the cooperation of the publisher, I was able to give a free copy to every AoG minister at the General Conference that year.   And something similar happened with another series of articles I wrote for Youth Aflame. At Colchester I had duplicated a series of short talks for young people who had just given their lives to Jesus and these were eventually published as a book in 1977 under the title How to Live for Jesus. Both these books are still being used, over fifty years later, by a number of churches today, though Know the Truth is now published under the title You'd Better Believe It. It has been translated into several languages including German, French, Italian, Finnish, Spanish, Urdu, and Nepalese.   Another publication that is still being used widely around the world is the distance learning course I wrote on the Major Prophets for the International Correspondence Institute in Brussels under the title Themes from the Prophets. I have already mentioned that this was a subject I was lecturing on in Kenley Bible College and I already had many pages of lecture notes that I had produced and duplicated for the students.   So when Dr George Flattery, the brother of Warren and founder and director of ICI, asked me if I would be willing to write the course, I was happy to do so. This involved several visits to Brussels, each of which lasted for two weeks, where I could get on with writing the course undistracted. It was also a great opportunity to meet other Pentecostal educators from around the world, including the renowned New Testament scholar, Professor Gordon Fee who was writing the course on 1 Corinthians and became a good friend.   So I will always be grateful for the opportunity I was given to be a part of ICI, but especially for the induction teaching they offered to all their course writers, which included the requirement to read The Art of Readable Writing by Rudolf Flesch the basic message of which, as I remember it, was to write as you speak, rather than writing in the academic style you were required to use at school or university.   Other things Flesch recommended were, wherever possible, to use short words rather than long ones, personal names rather than pronouns, the active voice rather than the passive, and short sentences rather than long ones – which prompts me to close this sentence before it gets any longer!   So, to summarise, I had realised that by using literature a person's ministry could be extended far beyond their time and ability to travel. But that in itself did not solve the problem of reconciling what I perceived to be my obligations to the church where I was pastor with the travelling ministry the Lord was clearly opening up for me.   And, as I was praying about this, he answered my question by whispering into my heart the word Antioch. Of course, I knew that Antioch was the place where the disciples were first called Christians (Acts 11:26), but at first I couldn't see how it was relevant to my problem, so I decided to turn to Acts to see if I could find the answer. And I did. The answer was the development of team ministry.   Developing Team Ministry The church at Antioch was started by believers who had been scattered as a result of the persecution of the church that took place after the stoning of Stephen. Some of them went to Antioch spreading the word to both Jews and gentiles and a great number of people believed and turned to the Lord. When the apostles at Jerusalem heard about this they sent Barnabas to take care of the work, and even more people became Christians. Realising that he needed help, he went to Tarsus to find Paul and brought him to Antioch. For a whole year they met with the church and taught great numbers of people.   From this it is clear that they were both, to say the least, key people in the church. And yet in Acts 13 we are told that the Holy Spirit sent them away from the church for a time in order to pioneer churches in other countries. The reason they were able to do this and, on their return, find that the church was still strong, was because they were not the only leaders in the church. Acts 13:1 talks of three others at Antioch who were prophets and teachers.   As I read about this it became obvious to me that this was the Lord's answer to my question. If I was to continue travelling we would need other leaders in the church. So I started on a detailed study of what the New Testament has to say about the leadership of the local church, and I discovered that churches were led by a team of elders, overseers, or pastors, and as I investigated the passages where these are mentioned I saw very clearly that these were all interchangeable terms. In the New Testament the elders were the pastors. They were the ones who were the shepherds of the flock and had the responsibility of watching over, or overseeing it.   I have gone into this in detail in my book, Body Builders, and so there is no need to repeat it here. All I need to say is that I came to the conclusion that the traditional system of having just one person as the church leader really has no biblical basis and that team leadership must be the way forward.   I have already mentioned how the pastor in East Saint Louis had come to the same conclusion and it soon became apparent that this was something the Lord was saying to many different leaders around the world. I preached on this in the Home Missions Conference at Weymouth in 1973 and was pleasantly surprised that I was not the only one to hold this view.   But where were these new leaders for our church in Basingstoke to come from? The answer was simple. We already had them, but they had never been recognised. There were two men, David Moncaster and Keith Davidson, who, I felt, both met the biblical qualifications mentioned in 1 Timothy 3 and Titus 1. But before I asked the church to appoint them, I spent several weeks teaching about the principles of church leadership. If we are going to persuade people to break away from long held traditions it is vital that we show them very clearly that what we are proposing is in line with scripture.   I have already mentioned that Bill Mitchell had already been recognised as an elder in the church before I came. But after my teaching on the biblical qualifications of elders he graciously came to me and said that in the light of what I had taught he thought he was probably a deacon rather than an elder and offered to resign. I told him that I thought he was probably right, but that, as his resignation might be misunderstood by some of the members, I would prefer him to remain as an elder, nominally at least, as long as we both understood that this was not really his role. And to this he readily agreed.   So for the final few years of my time in Basingstoke the church was led by a team which we referred to as the pastoral oversight, Willaim Kay being added to the team a little later. The church continued to grow under this system of leadership, and when the Lord moved me on to Mattersey the church was in safe hands.   The call to the Bible College I have already mentioned that in 1970 I started as a visiting lecturer at Kenley Bible College. On one of my visits in January 1972 I learned that John Phillips, who was a full time residential tutor at Kenley would be leaving, and as I was travelling home that evening, I was wondering who might be chosen to replace him. It would surely be someone who was already teaching at the college and I was thinking through the names in the college prospectus when I came to my own name. But I quickly dismissed the thought as I was sure that I would be considered too young for such a responsible position. And anyway, God had called me to build a big church in Basingstoke, hadn't he?   But no sooner had I thought this than I felt a check in my spirit and said, But of course, Lord, I'll do whatever you want me to do. But if you ever do want me to leave Basingstoke I will need very clear guidance on the matter.   You may remember the struggle I had when we first moved to Basingstoke and how for some months I wondered if we had done the right thing. I didn't want a repetition of that. But now, having prayed that prayer, I tried to put the matter out of my mind. This turned out to be harder than expected and that very night, some time between 1:00 and 2:00, on Tuesday 25th January, I woke up with a burning conviction that I was going to live at the Bible College. I tried to shake it off, but it would not go away, so I went downstairs to pray. What I said to the Lord went something like this: Lord, you know I need my sleep, so if this is of you, and you want me to go to the college, would you please tell me quickly?   And he did! As I opened my King James Bible, it fell open at 2 Chronicles 34:22. I could hardly believe my eyes. It contained the words dwelt… at the college. With the exception of the parallel verse in 2 Kings 22:14, this is the only reference to the word college in the whole Bible. This had to be more than coincidence.   I had asked the Lord to tell me quickly, and he did. But, rather like Moses in Exodus 3 and 4, I found myself making excuses like, I've only been in Basingstoke for four years, and, They wouldn't choose me. I'm too young. I don't have enough experience etc. But just as God had an answer for every objection Moses made, he had an answer for mine too. For each objection I made he led me directly to a Bible passage that answered it.   As a result I was entirely convinced that I was going to live at the College. I didn't know when but thought that it might be in September after John Phillips had left. In fact it was five or six years later! I have discovered that one of the hardest things in understanding the will of God is his timing. I have also discovered that God seems to give us the clearest guidance when he knows that there is trouble ahead! It's only the certainty that we are in his will that will sustain us through trials and difficulties and tests to our faith.   And there were to be plenty of those before we got to Mattersey! But that's something for our next talk.  

durée : 00:04:09 - Le journal de 12h, ici Poitou

Direction Blois, en bord du fleuve, où se dresse Fleur de Loire, le sublime restaurant de Christophe Hay. Ici le temps se suspend et ce n'est pas une formule, car à peine la porte franchi les lieux et l'équipe qui lui donne vie nous invite à laisser derrière nous l'agitation qui nous a animé jusqu'ici.Cette sérénité qui règne ici elle trouve sûrement ces racines dans le tempérament du chef. Une personnalité à part, qui a tracé son profil dans l'ombre d'un monument de l'histoire de la gastronomie française: Paul Bocuse.C'est lui qui a donné à Christophe Hay ses premières responsabilités, et pas des moindres... Alors nous allons voyager de la vallée de la Loire aux États-Unis, où l'empreinte d'un Paul Bocuse intime va marquer Christophe Hay pour toujours.La suite de l'histoire il l'écrira sur ses terres, au retour de cet exode hors du commun et n'aura de cesse de faire parler sa terre et bâtir une cuisine nourrie de ses propres racines. Elever un troupeau de wagyu, cultiver son jardin pour faire de l'assiette le reflet de sa région, ce n'est que la partie émergée de l'iceberg.Plongez dans l'univers d'un "terroiriste" engagé, au regard aussi radical qu'il est empreint d'humanité.Distribué par Audiomeans. Visitez audiomeans.fr/politique-de-confidentialite pour plus d'informations.

On accueille Tom-Éliot Girard à La vie sociale cette semaine! Dans cet épisode touchant, on plonge dans une discussion lumineuse et nécessaire sur l'identité queer, la découverte de soi et le courage d'exister en grand, même (et surtout) quand la société voudrait qu'on se fasse plus petit.e. On parle de nos rêves, d'affirmation et des difficultés d'être toujours soi dans un monde rempli de comparaisons, de vivre sa vérité, pas celle des autres. Le comédien et chanteur nous ouvre son coeur avec des paroles douces et vraies. Un épisode qui donne envie de s'aimer plus fort et d'oser plus.   @icitoutv Premier Trio, la série jeunesse la plus populaire sur Radio-Canada, est dispo sur ICI.TOU.TV EXTRA! Cliquez juste ici pour l'écouter : https://bit.ly/premiertrio-vie-sociale @piknicmtl La saison Piknic est lancée et se déroule du 17 mai au 12 octobre avec 19 événements réguliers et plus d'une vingtaine d'OfF Piknic. Parmi les artistes attendus : Ki/Ki, Chippy Nonstop, John Digweed, Mochakk, Black Coffee (sold out), Polo & Pan, Carl Cox et bien d'autres. Les passes de saison sont encore disponibles, tout comme la programmation complète et les billets sur piknicelectronik.com. @vizzyhardseltzerca Vizzy Pops Crémeux est une innovation rafraîchissante dans le monde des boissons alcoolisées, combinant les saveurs nostalgiques des friandises glacées classiques avec la modernité d'une boisson pétillante alcoolisée. Cette gamme unique propose trois saveurs gourmandes: Pop Crémeux à la Fraise, Pop Crémeux à l'Orange & Pop Crémeux à la Framboise. Et n'oublie pas : il faut avoir l'âge légal! La vie sociale sur les réseaux sociaux : Instagram et TikTok @baladolaviesociale Retrouvez Tom-Éliot Girard sur les réseaux sociaux : @tom.eliot   Retrouvez Cam et Karl sur les réseaux sociaux : Instagram @cam_ds / TikTok @ds.camille Instagram et TikTok @karl_hardy

durée : 00:05:14 - Le journal de 7h, ICI Touraine

durée : 00:04:58 - Le journal de 8h, ICI Touraine

durée : 00:07:00 - Le journal de 6h, ici Gascogne

durée : 00:07:14 - Le journal de 8h, ici Gascogne

durée : 00:05:27 - Le journal de 18h, ici Gascogne

durée : 00:05:52 - Le journal de 18h, ICI Touraine

durée : 00:07:21 - Le journal de 7h, ici Gascogne

Listen to ASCO's Journal of Clinical Oncology Art of Oncology article, "A Whipple of Choice” by Dr. Carl Forsberg, who is an Assistant Professor of Strategy and History at Air Force War College. The article is followed by an interview with Forsberg and host Dr. Mikkael Sekeres. Dr Forsberg shares his experience with an uncommon cancer treated by a new therapy for which no directly relevant data were available. Transcript Narrator: A Whipple of Choice, by C. W. Forsberg, PDH I sat across from a hepatobiliary surgeon on a gray October afternoon. “To be frank,” he told me, “we don't know what to recommend in your case. So we default to being conservative. That means a Whipple surgery, even though there are no data showing it will improve your outcome.” The assessment surprised me, diverging from my expectation that doctors provide clear recommendations. Yet the surgeon's willingness to structure our conversation around the ambiguity of the case was immensely clarifying. With a few words he cut through the frustrations that had characterized previous discussions with other physicians. I grasped that with an uncommon cancer treated by a novel therapy with no directly relevant data, I faced a radical choice. My situation that afternoon was worlds away from where I was 5 months earlier, when I was diagnosed with presumed pancreatic cancer at the age of 35. An early scan was suspicious for peritoneal metastasis. The implications seemed obvious. I prepared myself for the inevitable, facing my fate stoically except in those moments when I lingered next to my young son and daughter as they drifted to sleep. Contemplating my death when they were still so vulnerable, I wept. Then the specter of death retreated. Further tests revealed no metastasis. New doctors believed the tumor was duodenal and not pancreatic. More importantly, the tumor tested as deficient mismatch repair (dMMR), predictable in a Lynch syndrome carrier like me. In the 7 years since I was treated for an earlier colon cancer, immune checkpoint inhibitor (ICI) immunotherapy had revolutionized treatment of dMMR and high microsatellite instability tumors. One oncologist walked me through a series of recent studies that showed extraordinary responses to ICI therapy in locally advanced colon and rectal tumors with these biomarkers.1-4 He expressed optimism that my cancer could have a similar response. I embarked on a 24-week course of nivolumab and ipilimumab. After 6 weeks of therapy, a computed tomography (CT) scan showed a significant reduction in tumor size. My health rebounded as the tumor receded. This miraculous escape, however, was bound by the specter of a Whipple surgery, vaguely promised 6 months into my treatment. At the internationally renowned center where I was diagnosed and began treatment with astonishing efficiency, neither oncologists nor surgeons entertained the possibility of a surgery-sparing approach. “In a young, healthy patient like you we would absolutely recommend a Whipple,” my first oncologist told me. A second oncologist repeated that assessment. When asked if immunotherapy could provide a definitive cure, he replied that “if the tumor disappeared we could have that conversation.” My charismatic surgeon exuded confidence that I would sail through the procedure: “You are in excellent health and fitness—it will be a delicious surgery for me.” Momentum carried me forward in the belief that surgery was out of my hands. Four months into treatment, I was jolted into the realization that a Whipple was a choice. I transferred my infusions to a cancer center nearer my home, where I saw a third oncologist, who was nearly my age. On a sunny afternoon, 2 months into our relationship, he suggested I think about a watch-and-wait approach that continued ICI therapy with the aim of avoiding surgery. “Is that an option?” I asked, taken aback. “This is a life-changing surgery,” he responded. “You should consider it.” He arranged a meeting for me with his colleague, the hepatobiliary surgeon who clarified that “there are no data showing that surgery will improve your outcome.” How should patients and physicians make decisions in the absence of data? My previous experience with cancer offered little help. When I was diagnosed with colon cancer at the age of 28, doctors made clear recommendations based on clear evidence. I marched through surgery and never second-guessed my choices. A watch-and-wait approach made sense to me based on theory and extrapolation. Could duodenal tumors treated by ICIs behave that differently from colorectal cancers, for which data existed to make a watch-and-wait approach appear reasonable? The hepatobiliary surgeon at the regional cancer center told me, “I could make a theoretical argument either way and leave you walking out of here convinced. But we simply don't know.” His comment reflects modern medicine's strict empiricism, but it foreclosed further discussion of the scientific questions involved and pushed the decision into the realm of personal values. Facing this dilemma, my family situation drove me toward surgery despite my intuition that immunotherapy could provide a definitive cure. The night before I scheduled my Whipple procedure, I wrote in my journal that “in the face of radical uncertainty one must resort to basic values—and my priority is to survive for my children. A maimed, weakened father is without doubt better than no father at all.” To be sure, these last lines were written with some bravado. Only after the surgery did I viscerally grasp that the Whipple was a permanent maiming of the GI system. My doubts lingered after I scheduled surgery, and I had a final conversation with the young oncologist at the cancer center near my home. We discussed a watch-and-wait approach. A small mass remained on CT scans, but that was common even when tumors achieved a pathological complete response.5 Another positron emission tomography scan could provide more information but could not rule out the persistence of lingering cancer cells. I expressed my low risk tolerance given my personal circumstances. We sat across from one another, two fathers with young children. My oncologist was expecting his second child in a week. He was silent for moments before responding “I would recommend surgery in your situation.” Perhaps I was projecting, but I felt the two of us were in the same situation: both wanting a watch-and-wait approach, both intuitively believing in it, but both held back by a sense of parental responsibility. My post-surgery pathology revealed a pathological complete response. CT scans and circulating tumor DNA tests in the past year have shown no evidence of disease. This is an exceptional outcome. Yet in the year since my Whipple, I have been sickened by my lack of gratitude for my good fortune, driven by a difficult recovery and a sense that my surgery had been superfluous. Following surgery, I faced complications of which I had been warned, such as a pancreatic fistula, delayed gastric emptying, and pancreatic enzyme insufficiency. There were still more problems that I did not anticipate, including, among others, stenoses of arteries and veins due to intraabdominal hematomas, persistent anemia, and the loss of 25% of my body weight. Collectively, they added up to an enduringly dysfunctional GI system and a lingering frailty. I was particularly embittered to have chosen surgery to mitigate the risk that my children would lose their father, only to find that surgery prevented me from being the robust father I once was. Of course, had I deferred surgery and seen the tumor grow inoperable or metastasize between scans, my remorse would have been incalculably deeper. But should medical decisions be based on contemplation of the most catastrophic consequences, whatever their likelihood? With hindsight, it became difficult not to re-examine the assumptions behind my decision. Too often, my dialogue with my doctors was impeded by the assumption that surgery was the obvious recommendation because I was young and healthy. The assumption that younger oncology patients necessarily warrant more radical treatment deserves reassessment. While younger patients have more years of life to lose from cancer, they also have more years to deal with the enduring medical, personal, and professional consequences of a life-changing surgery. It was not my youth that led me to choose surgery but my family situation: 10 years earlier, my youth likely would have led me to a watch-and-wait approach. The rising incidence of cancer among patients in their 20s and 30s highlights the need for a nuanced approach to this demographic.  Calculations on surgery versus a watch-and-wait approach in cases like mine, where there are no data showing that surgery improves outcomes, also require doctors and patients to account holistically for the severity of the surgery involved. Multiple surgeons discussed the immediate postsurgical risks and complications of a pancreaticoduodenectomy, but not the long-term challenges involved. When asked to compare the difficulty of my prior subtotal colectomy with that of a pancreatoduodenectomy, the surgeon who performed my procedure suggested they might be similar. The surgeon at the regional cancer center stated that the Whipple would be far more difficult. I mentally split the difference. The later assessment was right, and mine was not a particularly bad recovery compared with others I know. Having been through both procedures, I would repeat the subtotal colectomy for a theoretical oncologic benefit but would accept some calculated risk to avoid a Whipple. Most Whipple survivors do not have the privilege of asking whether their surgery was necessary. Many celebrate every anniversary of the procedure as one more year that they are alive against the odds. That I can question the need for my surgery speaks to the revolutionary transformation which immunotherapy has brought about for a small subset of patients with cancer. The long-term medical and personal consequences of surgery highlight the urgent stakes of fully understanding and harnessing the life-affirming potential of this technology. In the meantime, while the field accumulates more data, potentially thousands of patients and their physicians will face difficult decisions on surgery verses a watch and- wait approach in cases of GI tumors with particular biomarkers showing exceptional responses to ICI therapy.7,8 Under these circumstances, I hope that all patients can have effective and transparent conversations with their physicians that allow informed choices accounting for their risk tolerance, calculations of proportionality, and priorities.  Dr. Mikkael Sekeres: Hello, and welcome to JCO's Cancer Stories: The Art of Oncology, which features essays and personal reflections from authors exploring their experience in the oncology field. I'm your host, Dr. Mikkael Sekeres. I'm Professor of Medicine and Chief of the Division of Hematology at the Sylvester Comprehensive Cancer Center at University of Miami. Today, we are so happy to be joined by Dr. Carl Forsberg, Assistant Professor of Strategy and History at the Air Force War College. In this episode, we will be discussing his Art of Oncology article, "A Whipple of Choice." At the time of this recording, our guest has no disclosures. Carl, it is such a thrill to welcome you to our podcast, and thank you for joining us. Dr. Carl Forsberg: Well, thank you, Mikkael, for having me. I'm looking forward to our conversation. Dr. Mikkael Sekeres: So am I. I wanted to start, Carl, with just a little bit of background about you. It's not often we have a historian from the Air Force College who's on this podcast. Can you tell us about yourself, where you're from, and walk us through your career? Dr. Carl Forsberg: Sure. I was born and raised in Minnesota in a suburb of Minneapolis-St. Paul and then went to undergraduate on the East Coast. I actually started my career working on the contemporary war in Afghanistan, first as an analyst at a DC think tank and then spent a year in Kabul, Afghanistan, on the staff of the four-star NATO US headquarters, where I worked on the vexing problems of Afghanistan's dysfunctional government and corruption. Needless to say, we didn't solve that problem. Dr. Mikkael Sekeres: Wow. Dr. Carl Forsberg: I returned from Afghanistan somewhat disillusioned with working in policy, so I moved into academia, did a PhD in history at the University of Texas at Austin, followed by postdoctoral fellowships at Harvard and Yale, and then started my current position here at the Air Force War College. The War Colleges are, I think, somewhat unusual, unique institutions. Essentially, we offer a 1-year master's degree in strategic studies for lieutenant colonels and colonels in the various US military services. Which is to say my students are generally in their 40s. They've had about 20 years of military experience. They're moving from the operational managerial levels of command to positions where they'll be making strategic decisions or be strategic advisors. So we teach military history, strategy, international relations, national security policy to facilitate that transition to a different level of thinking. It really is a wonderful, interesting, stimulating environment to be in and to teach in. So I've enjoyed this position here at the War College quite a lot. Dr. Mikkael Sekeres: Well, I have to tell you, as someone who's been steeped in academic medicine, it sounds absolutely fascinating and something that I wouldn't even know where to start approaching. We have postdoctoral fellowships, of course, in science as well. What do you do during a postdoctoral fellowship in history and strategy? Dr. Carl Forsberg: It's often, especially as a historian, it's an opportunity to take your dissertation and expand it into a book manuscript. So you have a lot of flexibility, which is great. And, of course, a collegial environment with others working in similar fields. There are probably some similarities to a postdoc in medicine in terms of having working groups and conferences and discussing works in progress. So it was a great experience for me. My second postdoc occurred during the pandemic, so it turned out to be an online postdoc, a somewhat disappointing experience, but nevertheless I got a lot out of the connections and relationships I formed during those two different fellowships. Dr. Mikkael Sekeres: Well, there are some people who used the pandemic as an excuse to really just plow into their writing and get immersed in it. I certainly wrote one book during the pandemic because I thought, “Why not? I'm home. It's something where I can use my brain and expand my knowledge base.” So I imagine it must have been somewhat similar for you as you're thinking about expanding your thesis and going down different research avenues. Dr. Carl Forsberg: I think I was less productive than I might have hoped. Part of it was we had a 2-year-old child at home, so my wife and I trying to, you know, both work remotely with a child without having childcare really for much of that year given the childcare options fell through. And it was perhaps less productive than I would have aspired for it to be. Dr. Mikkael Sekeres: It's terrifically challenging having young children at home during the pandemic and also trying to work remotely with them at home. I'm curious, you are a writer, it's part of your career, and I'm curious about your writing process. What triggers you to write a story like you did, and how does it differ from some of your academic writing? Dr. Carl Forsberg: Yeah. Well, as you say, there is a real difference between writing history as an academic and writing this particular piece. For me, for writing history, my day job, if you will, it's a somewhat slow, painstaking process. There's a considerable amount of reading and archival work that go into history. I'm certainly very tied to my sources and documents. So, you know, trying to get that precision, making sure you've captured a huge range of archival resources. The real narrative of events is a slow process. I also have a bad habit of writing twice as much as I have room for. So my process entailed a lot of extensive revisions and rewriting, both to kind of shorten, to make sure there is a compelling narrative, and get rid of the chaff. But also, I think that process of revision for me is where I often draw some of the bigger, more interesting conclusions in my work once I've kind of laid out that basis of the actual history. Certainly, writing this article, this medical humanities article, was a very different experience for me. I've never written something about myself for publication. And, of course, it was really driven by my own experiences of going through this cancer journey and recovering from Whipple surgery as well. The article was born during my recovery, about 4 months after my Whipple procedure. It was a difficult time. Obviously kind of in a bad place physically and, in my case, somewhat mentally, including the effects of bad anemia, which developed after the surgery. I found it wasn't really conducive to writing history, so I set that aside for a while. But I also found myself just fixating on this question of had I chosen a superfluous Whipple surgery. I think to some extent, humans can endure almost any suffering with a sense of purpose, but when there's a perceived pointlessness to the suffering, it makes it much harder. So for me, writing this article really was an exercise, almost a therapeutic one, in thinking through the decisions that led me to my surgery, addressing my own fixation on this question of had I made a mistake in choosing to have surgery and working through that process in a systematic way was very helpful for me. But it also, I think, gave me- I undertook this with some sense of perhaps my experience could be worthwhile and helpful for others who would find themselves in a situation like mine. So I did write it with an eye towards what would I like to have read? What would I like to have had as perspective from another patient as I grappled with the decision that I talk about in the article of getting a Whipple surgery. Dr. Mikkael Sekeres: So I wonder if I could back up a little bit. You talk about the difficulty of undergoing a Whipple procedure and of recovery afterwards, a process that took months. And this may come across as a really naive question, but as, you know, as an oncologist, my specialty is leukemia, so I'm not referring people for major surgeries, but I am referring them for major chemotherapy and sometimes to undergo a bone marrow transplant. Can you educate us what makes it so hard? Why was it so hard getting a Whipple procedure, and what was hard about the recovery? Dr. Carl Forsberg: Yeah, it was a long process. Initially, it was a 14-day stay in the hospital. I had a leaking pancreas, which my understanding is more common actually with young, healthy patients just because the pancreas is softer and more tender. So just, you know, vast amount of pancreatic fluid collecting in the abdominal cavity, which is never a pleasant experience. I had a surgical drain for 50-something days, spent 2 weeks in the hospital. Simply eating is a huge challenge after Whipple surgery. I had delayed gastric emptying for a while afterwards. You can only eat very small meals. Even small meals would give me considerable stomach pain. I ended up losing 40 lb of weight in 6 weeks after my surgery. Interestingly enough, I think I went into the surgery in about the best shape I had been in in the last decade. My surgeon told me one of the best predictors for outcomes is actual muscle mass and told me to work out for 2 hours every day leading up to my surgery, which was great because I could tell my wife, "Sorry, I'm going to be late for dinner tonight. I might die on the operating table." You can't really argue with that justification. So I went in in spectacular shape and then in 6 weeks kind of lost all of that muscle mass and all of the the strength I had built up, which just something discouraging about that. But just simply getting back to eating was an extraordinarily difficult process, kind of the process of trial and error, what worked with my system, what I could eat without getting bad stomach pains afterwards. I had an incident of C. diff, a C. diff infection just 5 weeks after the surgery, which was obviously challenging. Dr. Mikkael Sekeres: Yeah. Was it more the pain from the procedure, the time spent in the hospital, or psychologically was it harder? Dr. Carl Forsberg: In the beginning, it was certainly the physical elements of it, the difficulty eating, the weakness that comes with losing that much weight so quickly. I ended up also developing anemia starting about two or 3 months in, which I think also kind of has certain mental effects. My hemoglobin got down to eight, and we caught it somewhat belatedly. But I think after about three or 4 months, some of the challenges became more psychological. So I started to physically recover, questions about going forward, how much am I going to actually recover normal metabolism, normal gastrointestinal processes, a question of, you know, what impact would this have long-term. And then, as I mentioned as well, some of the psychological questions of, especially once I discovered I had a complete pathological response to the immunotherapy, what was the point to having this surgery? Dr. Mikkael Sekeres: And the way you explore this and revisit it in the essay is absolutely fascinating. I wanted to start at the- towards the earlier part of your essay, you write, "The surgeon's willingness to structure our conversation around the ambiguity of the case was immensely clarifying." It's fascinating. The ambiguity was clarifying to you. And the fact that you appreciated the fact that the surgeon was open to talking about this ambiguity. When do you think it's the right thing to acknowledge ambiguity in medicine, and when should we be more definitive? When do you just want someone to tell you, “Do this or do that?” Dr. Carl Forsberg: That's a great question, which I've thought about some. I think some of it is, I really appreciated the one- a couple of the oncologists who brought up the ambiguity, did it not at the beginning of the process but a few months in. You know, the first few months, you're so as a patient kind of wrapped up in trying to figure out what's going on. You want answers. And my initial instinct was, you know, I wanted surgery as fast as possible because you want to get the tumor out, obviously. And so I think bringing up the ambiguity at a certain point in the process was really helpful. I imagine that some of this has to do with the patient. I'm sure for oncologists and physicians, it's got to be a real challenge assessing what your patient wants, how much they want a clear answer versus how much they want ambiguity. I've never obviously been in the position of being a physician. As a professor, you get the interesting- you start to realize some students want you to give them answers and some students really want to discuss the ambiguities and the challenges of a case. And so I'm, I imagine it might be similar as a physician, kind of trying to read the patient. I guess in my case, the fact was that it was an extraordinarily ambiguous decision in which there wasn't data. So I think there is an element, if the data gives no clear answers, that I suppose there's sort of an ethical necessity of bringing that up with the patient. Though I know that some patients will be more receptive than others to delving into that ambiguity. Dr. Mikkael Sekeres: Well, you know, it's an opportunity for us to think holistically about our patients, and you as a patient to think holistically about your health and your family and how you make decisions. I believe that when we're in a gray zone in medicine where the data really don't help guide one decision versus the next, you then lean back towards other values that you have to help make that decision. You write beautifully about this. You say, "In the face of radical uncertainty, one must resort to basic values, and my priority is to survive for my children. A maimed, weakened father is without doubt better than no father at all." That's an incredibly deep sentiment. So, how do you think these types of decisions about treatment for cancer change over the course of our lives? You talk a lot about how you were a young father in this essay, and it was clear that that was, at least at some point, driving your decision. Dr. Carl Forsberg: Yeah, I certainly have spent a lot of time thinking about how I would have made this decision differently 10 years earlier. As I mentioned the article, it was interesting because most of my physicians, honestly, when they were discussing why surgery made sense pointed to my age. I don't think it was really my age. Actually, when I was 23, I went off to Afghanistan, took enormous risks. And to some extent, I think as a young single person in your 20s, you actually have generally a much higher risk tolerance. And I think in that same spirit, at a different, earlier, younger stage in my life, I would have probably actually been much more willing to accept that risk, which is kind of a point I try to make, is not necessarily your age that is really the deciding factor. And I think once again, if I were 70 or 60 and my children, you know, were off living their own lives, I think that also would have allowed me to take, um, greater risk and probably led me to go for a watch-and-wait approach instead. So there was a sense at which not the age, but the particular responsibilities one has in life, for me at least, figured very heavily into my medical calculus. Dr. Mikkael Sekeres: It's so interesting how you define a greater risk as watch and wait, whereas a surgeon or a medical oncologist who's making recommendations for you might have defined the greater risk to undergo major surgery. Dr. Carl Forsberg: And I thought about that some too, like why is it that I framed the watch and wait as a greater risk? Because there is a coherent case that actually the greater risk comes from surgery. I think when you're facing a life and death decision and the consequence, when you have cancer, of course, your mind goes immediately to the possibility of death, and that consequence seems so existential that I think it made watch and wait perhaps seem like the riskier course. But that might itself have been an assumption that needed more analysis. Dr. Mikkael Sekeres: Do you think that your doctor revealing that he also had young children at home helped you with this decision? Dr. Carl Forsberg: I think in some ways for a doctor it's important to kind of understand where your patient is in their own life. As a patient, it was interesting and always helpful for me to understand where my physicians were in their life, what was shaping their thinking about these questions. So I don't know if it in any way changed my decision-making, but it definitely was important for developing a relationship of trust as well with physicians that we could have that mutual exchange. I would consider one of my primary oncologists, almost something of a friend at this point. But I think it really was important to have that kind of two-way back and forth in understanding both where I was and where my physician was. Dr. Mikkael Sekeres: I like how you frame that in the sense of trust and hearing somebody who could make similar considerations to you given where he was in his family. One final question I wanted to ask you. You really elegantly at the end of this essay talk about revisiting the decision. I wonder, is it fair to revisit these types of decisions with hindsight, or do we lose sight of what loomed as being most important to us when we were making the decisions in real time? Dr. Carl Forsberg: That's a great question, one that is also, I think, inherent to my teaching. I teach military history for lieutenant colonels and colonels who very well may be required, God willing not, but may be required to make these sort of difficult decisions in the case of war. And we study with hindsight. But one thing I try to do as a professor is put them in the position of generals, presidents, who did not have the benefit of hindsight, trying to see the limits of their knowledge, use primary source documents, the actual memos, the records of meetings that were made as they grappled with uncertainty and the inherent fog of war. Because it is, of course, easy to judge these things in hindsight. So definitely, I kept reminding myself of that, that it's easy to second guess with hindsight. And so I think for me, part of this article was trying to go through, seeing where I was at the time, understanding that the decision I made, it made sense and with what I knew, it was probably the right decision, even if we can also with hindsight say, "Well, we've learned more, we have more data." A lot of historical leaders, it's easy to criticize them for decisions, but when you go put yourself in their position, see what the alternatives were, you start to realize these were really hard decisions, and I would have probably made the same disastrous mistake as they would have, you know. Let's just say the Vietnam War, we have our students work through with the original documents decisions of the Joint Chiefs in 1965. They very frequently come to the exact same conclusions as American policymakers made in 1965. It is a real risk making judgments purely on the basis of hindsight, and I think it is important to go back and really try to be authentic to what you knew at the time you made a decision. Dr. Mikkael Sekeres: What a great perspective on this from a historian. Carl Forsberg, I'd like to thank you, and all of us are grateful that you were willing to share your story with us in The Art of Oncology. Dr. Carl Forsberg: Well, thank you, and it's yeah, it's been a, it's a, I think in some ways a very interesting and fitting place to kind of end my cancer journey with the publication of this article, and it's definitely done a lot to help me work through this entire process of going through cancer. So, thank you. Dr. Mikkael Sekeres: Until next time, thank you for listening to JCO's Cancer Stories: The Art of Oncology. Don't forget to give us a rating or review, and be sure to subscribe so you never miss an episode. You can find all of ASCO's shows at asco.org/podcasts. Until next time, thank you so much. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.   Show notes:Like, share and subscribe so you never miss an episode and leave a rating or review.  Guest Bio: Dr. Carl Forsberg is a Assistant Professor of Strategy and History at the Air Force War College.

durée : 00:07:20 - Le journal de 6h, ici Gascogne

durée : 00:06:52 - Le journal de 7h, ici Gascogne

durée : 00:05:16 - Le journal de 18h, ici Gascogne