François-Ludovic Sauvage

Françoise Stanke-Labesque

Marie-Claude Gagnieu

Jean-François Jourdil

Gérard Babany

Pierre Marquet
email: pierre.marquet@unilim.fr

Prof Pierre Marquet

Feasibility of ribavirin therapeutic drug monitoring in hepatitis C

Keywords: Ribavirin monitoring Hepatitis C, ribavirin, HPLC, LC-MS/MS Hepatitis C, ribavirin, HPLC, LC-MS/MS, proficiency testing, therapeutic drug monioring UV, ultraviolet, LC, liquid chromatography, HPLC, high-performance liquid chromatography, GTP, guanosine triphosphate, TDM, Therapeutic Drug Monitoring

Background: Ribavirin, a nucleoside analogue, is administered in combination with interferon to patients with chronic hepatitis C. To evaluate the feasibility of ribavirin therapeutic drug monitoring, we investigated the influence of blood collection and preanalytical conditions on ribavirin concentrations and compared the results obtained from inter-laboratory blind tests by three laboratories using different analytical techniques.

Material and Methods: On three occasions, blank serum samples spiked with ribavirin and pooled serum samples from patients on ribavirin were sent to the three laboratories. Two analytical techniques were based on LC-MS/MS and one on HPLC-UV, with protein precipitation or solid-phase extraction, all validated according to international guidelines.

Results: Inter-batch and intra-batch mean relative errors ranged from -7.4 to +10.3 % and from -10.3 to +7.4%, respectively. Relative standard deviations were <13.5% and <10.6%, respectively. Linearity, assessed blindly, between 125 and 4550 ng/mL was excellent (r >0.991) for all three methods. The two LC-MS/MS techniques were slightly less precise and accurate than HPLC-UV, perhaps because the internal standard used was not a ribavirin isotope.

Conclusion: Accurate and precise LC-MS/MS and HPLC-UV methods developed in three different laboratories provided excellent and consistent results to blind tests for ribavirin determination in spiked serum samples and pools of serum samples from patients with chronic HCV.

Introduction

The combination of peginterferon and ribavirin [1,[START_REF] Fried | Peginterferon alfa-2a plus ribavirin for chronic hepatitis C virus infection[END_REF] is the standard approved treatment of patients with chronic hepatitis C virus (HCV). Half of the patients with this combined therapy relapse or remain virological non responders. The main predictive factors of a poor sustained virological response (SVR) are an HCV genotype other than 2 or 3, a high baseline viral load and a dose of ribavirin <10.6 mg/kg of body weight (BW) [1]. Indeed, two clinical trials [1,[START_REF] Fried | Peginterferon alfa-2a plus ribavirin for chronic hepatitis C virus infection[END_REF] suggested that ribavirin dose adjustment for BW may be beneficial, while two other studies in patients with chronic HCV receiving combination therapy [START_REF] Jen | Population pharmacokinetic and pharmacodynamic analysis of ribavirin in patients with chronic hepatitis C[END_REF][START_REF] Larrat | Ribavirin quantification in combination treatment of chronic hepatitis C[END_REF] found no correlation between ribavirin dose adjusted for BW and a single ribavirin serum concentration time point at week 4 (W4) or at steady state (W12), i.e. there was a poor dose-concentration relationship. A better concentration-effect than dose-effect relationship was reported by several groups [START_REF] Larrat | Ribavirin quantification in combination treatment of chronic hepatitis C[END_REF][START_REF] Loustaud-Ratti | Ribavirin exposure after the first dose is predictive of sustained virological response in chronic hepatitis C[END_REF][START_REF] Jen | Ribavirin dosing in chronic hepatitis C: application of population pharmacokinetic-pharmacodynamic models[END_REF]. In a recent cohort study [START_REF] Loustaud-Ratti | Ribavirin exposure after the first dose is predictive of sustained virological response in chronic hepatitis C[END_REF], patients' global exposure to ribavirin was widely distributed, despite dose-adjustment for BW.

Ribavirin has a large distribution volume, a long half-life and large inter-individual pharmacokinetic variability [START_REF] Glue | The clinical pharmacology of ribavirin[END_REF]. Following a single oral dose, the plasma concentration of ribavirin exhibits a three-phase profile: rapid absorption, with a mean time to the maximum concentration (tmax) of about 1.5 h; rapid distribution (half life of approximately 3.7 h); and a long terminal elimination, the last measurable concentration time point being at approximately 100 h post-dose [START_REF] Glue | The clinical pharmacology of ribavirin[END_REF][START_REF] Dixit | The metabolism, pharmacokinetics and mechanisms of antiviral activity of ribavirin against hepatitis C virus[END_REF]. Recently, it has been suggested that the gastro-intestinal tract is the major site of ribavirin first-pass elimination [START_REF] Dixit | The metabolism, pharmacokinetics and mechanisms of antiviral activity of ribavirin against hepatitis C virus[END_REF]. High fat meals can increase ribavirin bioavailability by 46% relative to the fasting state [START_REF] Khakoo | Ribavirin and interferon alfa-2b in chronic hepatitis C: assessment of possible pharmacokinetic and pharmacodynamic interactions[END_REF], suggesting low oral bioavailability. Metabolism accounts for most of ribavirin elimination, but the exact mechanisms and sites involved are unknown. Glue et al [START_REF] Glue | The single dose pharmacokinetics of ribavirin in subjects with chronic liver disease[END_REF] showed that hepatic dysfunction had no substantial influence on the apparent clearance of ribavirin, which would mainly be affected by BW, gender, age and serum creatinine, although these four covariates only explained 27 to 40% of its inter-individual variability [START_REF] Jen | Population pharmacokinetic and pharmacodynamic analysis of ribavirin in patients with chronic hepatitis C[END_REF][START_REF] Bruchfeld | Dosage of ribavirin in patients with hepatitis C should be based on renal function: a population pharmacokinetic analysis[END_REF].

The first attempts at ribavirin pharmacokinetic (PK)-pharmacodynamic (PD) studies were based on single point sampling strategies. Jen et al reported that low ribavirin serum concentrations (with no precision on timing) at "steady state" (W4) were associated with a low SVR rate, but were less influential than the genotype or viral load [START_REF] Jen | Ribavirin dosing in chronic hepatitis C: application of population pharmacokinetic-pharmacodynamic models[END_REF]. Larrat et al also found an association between SVR and a single serum concentration taken 2-4 h after the morning dose of ribavirin at W12 (n=24; p=0.03) and W24 [START_REF] Larrat | Ribavirin quantification in combination treatment of chronic hepatitis C[END_REF]. Taking into account ribavirin concentration-time profiles, a recent study in 24 patients with genotype 1 HCV showed that after the first ribavirin dose (D0), patients with SVR had a significantly higher AUC 0-12h (p=0.03) and AUC 0-4h (p=0.03) than non-responders, with an AUC 0-4h threshold of 1755 µg.h/L. Also, ribavirin may cause anemia in a dose-dependent manner. Therefore, monitoring ribavirin plasma concentrations could be useful for tailoring individual dosing of ribavirin.

Several analytical methods have been developed for the determination of ribavirin in biological fluids (for review see [START_REF] Bosch | Ribavirin: analytical determinations since the origin until today[END_REF]) including radioimmunoassays, capillary electrophoresis, or liquid chromatography coupled with UV [START_REF] Loregian | Measurement of ribavirin and evaluation of its stability in human plasma by high-performance liquid chromatography with UV detection[END_REF][START_REF] Morello | Measurement of ribavirin plasma concentrations by high-performance liquid chromatography using a novel solid-phase extraction method in patients treated for chronic hepatitis C[END_REF] or tandem mass-spectrometric detection [START_REF] Lin | Specific, sensitive and accurate liquid chromatographic-tandem mass spectrometric method for the measurement of ribavirin in rat and monkey plasma[END_REF][START_REF] Shou | Development and validation of a liquid chromatography/tandem mass spectrometry (LC/MS/MS) method for the determination of ribavirin in human plasma and serum[END_REF]. The reported sample preparation procedures were either based on protein precipitation with various solvents [START_REF] Bosch | Ribavirin: analytical determinations since the origin until today[END_REF] or on solid-phase extraction [4-5, 13, 14]. However, these techniques were not compared head-to-head and, in the absence of an inter-laboratory blind test, their applicability to routine therapeutic drug monitoring (TDM) of ribavirin is unknown.

The aim of the present study was to evaluate the feasibility of ribavirin TDM by comparing the results obtained at repeated inter-laboratory blind tests by three laboratories employing different HPLC methods, never compared or harmonized before (two with MS/MS and one with UV detection).

Materials and methods

a. Description of the analytical methods

The organic solvents, reagents, all of analytical grade, and the pure compounds were supplied by different retailers (Sigma Aldrich, Saint-Quentin Fallavier, France; Merck, Darmstadt, Germany; Prolabo, Fontenay-sous-Bois, France; Carlo Erba, Val-de-Reuil, France). The analytical methods applied by the three participating laboratories are described in Table 1.

Briefly, serum or plasma samples were extracted using either solid-phase extraction with 100 mg, 1 mL Bond-Elut Phenyl Boronic Acid cartridges (Varian, Harbor City, CA, USA), or a simple protein precipitation procedure. The LC-MS/MS methods were carried out with a 2000 The three methods were validated in-house in terms of linearity, inter-and intra-assay precision and accuracy, and extraction recovery. Linearity was evaluated using least-square quadratic regression of ribavirin-to-internal standard (IS) peak-area ratios versus theoretical concentrations for the laboratories using MS/MS detection, and linear regression for HPLC-UV. Accuracy was expressed as the bias relative to the theoretical concentrations, and precision as the percent root mean square error (RMSE%) of back-calculated concentrations.

Intra-assay precision and accuracy were assessed at different concentration levels by extraction and analysis on the same day of replicates of fortified serum samples.

Extraction recoveries were determined at several concentration levels, by spiking a series of ribavirin-free serum samples with the appropriate amounts of ribavirin and the internal standard (IS), and another series with the IS alone. After extraction and evaporation, the dry extracts were reconstituted with the chromatographic mobile phase for samples of the first series, and with the mobile phase spiked with the nominal amount of ribavirin for samples of the second series.

For the LC-MS/MS methods, ion suppression was investigated by injecting 10 different blank human serum samples into the LC system while a solution of ribavirin was continuously infused in parallel in the ionization source through a PEEK tee.

b. Inter-laboratory blind tests

The inter-laboratory survey carried out at the university hospitals of Grenoble, Limoges and Lyon, France (referenced here as Laboratories 1, 2 and 3 in a different order), involved blank serum samples spiked with ribavirin at known concentrations (blinded to the three laboratories) and pools of patients' serum. Blood from patients treated with ribavirin was repeatedly collected into tubes without an anticoagulant at day 1, week 12, week 12 + 1 day and week 24 of ribavirin treatment, as part of a pharmacokinetic study [START_REF] Loustaud-Ratti | Ribavirin exposure after the first dose is predictive of sustained virological response in chronic hepatitis C[END_REF]. All patients gave their written informed consent for this study, which was approved by the regional ethics committee and authorized by the French Drug Agency (AFSSAPS).

After 15 minutes of centrifugation of blood samples at 1733 g and 4°C, serum was aliquoted and stored at -80°C in brown 1.5 mL polypropylene tubes until analysis. For this study, pools

Results

The main method validation results obtained by each laboratory in-house are reported in Table 1. Intra-and inter-assay accuracy and precision were all <15.0% over the calibration ranges used. The lower band of these ranges (which was not the actual LOQ for at least one of the LC-MS/MS methods) was between 10 ng/mL and 100 ng/mL, depending on the intended use, whether TDM at steady-state, or pharmacokinetic studies after a single, or the first dose.

Examples of chromatograms obtained in each laboratory are presented in Figure 1. The results of the ion suppression study performed by laboratories 1 and 2, using MS/MS detection, are shown in Figure 2. For method 1, a slight decrease of the signal close to 14 min led to an increase in the chromatographic run time up to 18 min (though the retention time of ribavirin and IS were around 4 min) to eliminate all contaminations. For method 2, the signal remained stable during ribavirin and internal standard elution (between 1.5 and 2.1 min), then slightly decreased around 4 min but returned to initial conditions before the 6 th minute.

As part of the inter-laboratory survey, the intra-assay precision and accuracy were assessed blindly at three concentrations (775, 1750 and 3150 ng/mL), showing mean relative errors between -10.3 and +7.4% and RSD% always <10.6% (Figure 3). Similarly, inter-assay precision and accuracy were evaluated using three other blank serum samples spiked at 375, 2150 and 3750 ng/mL, repeatedly sent with shipments 1, 2 and 3. The mean relative error ranged between -7.4 and +10.3% and the RSD% was <13.5% (Figure 4). The linearity of the three analytical methods was assessed from the results reported for the blank serum samples spiked at 10 different concentrations between 125 and 4550 ng/mL (Figure 5). The calculated coefficients of correlation were all >0.991, with the best correlation being obtained by the laboratory using HPLC-UV (lab 2). The mean relative error (MRE) of back-calculated concentrations varied between -10.0 and +16.0% with the highest MRE for the lowest spiked concentrations, and the inter-laboratory RSD ranged from 0.3 to 14.6%.

The applicability of the three methods was also investigated through the analysis of pools of samples collected from patients with hepatitis C at day 0, week 12 and week 24 after the beginning of the treatment with ribavirin. Each pool corresponded to a given sampling time, between 0.5 hour and 10 hours post-dose, resulting in a large range of concentrations. Among the 40 pools analyzed, in only three instances was inter-laboratory RSD >30%, due to outlier results reported by any one of the laboratories with regards to the two others. For all the other patients' pools, the reported concentrations varied from 157 to 3572 ng/mL, the interlaboratory RSD% was 8.7% on average and always < 17.0% (Figure 6).

Discussion

This study shows that HPLC-UV or LC-MS/MS methods developed in three different laboratories and employing different types of sample extraction procedures gave excellent and equivalent results for ribavirin determination in blinded tests. The data were from both spiked and patients' serum samples, suggesting that routine ribavirin monitoring is technically feasible, despite the absence of commercial assays.

The three analytical techniques presented were set up for different clinical trials, with the aim of measuring either ribavirin morning trough concentrations at steady-state (labs 2 and 3) or ribavirin pharmacokinetic profiles after the first and repeated doses (lab 1), which explains the differences in terms of LOQ and linearity range, in particular between the two LC-MS/MS techniques. All three fulfilled the international requirements for analytical method validation.

The previously published sample preparation procedures were either based on protein precipitation with various solvents [START_REF] Bosch | Ribavirin: analytical determinations since the origin until today[END_REF] or solid-phase extraction with cartridges containing phenyl boronic acids with a high affinity for compounds containing diol moieties, due to reversible boronate formation [START_REF] Larrat | Ribavirin quantification in combination treatment of chronic hepatitis C[END_REF][START_REF] Loustaud-Ratti | Ribavirin exposure after the first dose is predictive of sustained virological response in chronic hepatitis C[END_REF][START_REF] Bruchfeld | Dosage of ribavirin in patients with hepatitis C should be based on renal function: a population pharmacokinetic analysis[END_REF][START_REF] Bosch | Ribavirin: analytical determinations since the origin until today[END_REF][START_REF] Loregian | Measurement of ribavirin and evaluation of its stability in human plasma by high-performance liquid chromatography with UV detection[END_REF][START_REF] Morello | Measurement of ribavirin plasma concentrations by high-performance liquid chromatography using a novel solid-phase extraction method in patients treated for chronic hepatitis C[END_REF]. Recently, Morello et al. [START_REF] Morello | Measurement of ribavirin plasma concentrations by high-performance liquid chromatography using a novel solid-phase extraction method in patients treated for chronic hepatitis C[END_REF] have used another type of extraction cartridge (Microsep 3K Omega) and liquid chromatography with UV detection, yielding similar results. As recently reviewed [START_REF] Bosch | Ribavirin: analytical determinations since the origin until today[END_REF], other LC-MS/MS methods for ribavirin determination have been published [START_REF] Lin | Specific, sensitive and accurate liquid chromatographic-tandem mass spectrometric method for the measurement of ribavirin in rat and monkey plasma[END_REF][START_REF] Shou | Development and validation of a liquid chromatography/tandem mass spectrometry (LC/MS/MS) method for the determination of ribavirin in human plasma and serum[END_REF][START_REF] Lin | Pharmacokinetics and metabolism of [(14)C]ribavirin in rats and cynomolgus monkeys[END_REF], some of which yielded shorter turnaround times. However, the absence of the ion suppression phenomenon, frequently observed when protein precipitation procedures are employed, was not documented in these papers.

Different analytical approaches have been employed here to minimize this phenomenon, i.e., in method 2, dilution of the sample before precipitation and in method 1 solid-phase extraction, which is theoretically cleaner and tends to prevent or minimize ion suppression.

However, according to the results presented in figure 2, this phenomenon could not be totally avoided, though no ion suppression was visible at the retention times of ribavirin and the internal standards. The use of an isotope-labelled analog of ribavirin as internal standard could help to compensate for any residual ion suppression and, above all, improve precision.

UV detection was the most frequently employed technology for ribavirin, owing to the accessible analytical ranges involved [START_REF] Larrat | Ribavirin quantification in combination treatment of chronic hepatitis C[END_REF][START_REF] Bruchfeld | Dosage of ribavirin in patients with hepatitis C should be based on renal function: a population pharmacokinetic analysis[END_REF][START_REF] Loregian | Measurement of ribavirin and evaluation of its stability in human plasma by high-performance liquid chromatography with UV detection[END_REF][START_REF] Morello | Measurement of ribavirin plasma concentrations by high-performance liquid chromatography using a novel solid-phase extraction method in patients treated for chronic hepatitis C[END_REF][START_REF] Paroni | High-performance liquid chromatographic determination of ribavirin in serum and urine and of its urinary metabolite 1,2,4-triazole-3-carboxamide[END_REF][START_REF] Granich | High-performance liquid chromatography (HPLC) assay for ribavirin and comparison of the HPLC assay with radioimmunoassay[END_REF][START_REF] Svensson | Determination of ribavirin in serum using highly selective solid-phase extraction and high-performance liquid chromatography[END_REF][START_REF] Inoue | Liquid chromatography assay for routine monitoring of cellular ribavirin levels in blood[END_REF], but the sample volumes required were generally higher and the extraction procedure longer than those for most of the LC-MS/MS methods.

The results obtained from the inter-laboratory blind tests in the present study were excellent for all three methods, and even better in terms of precision and linearity for the HPLC-UV technique, although the in-house method validation results were almost equivalent (Table 1).

LC-MS/MS is used increasingly for TDM [START_REF] Saint-Marcoux | Current role of LC-MS in therapeutic drug monitoring[END_REF] in clinical laboratories. However, its variability can be somewhat higher than that of "classical" HPLC in the absence of isotopelabelled internal standards, and LC-MS/MS techniques need to be thoroughly validated, including the investigation of ion suppression or potential interferences, before they can be applied in a clinical setting [START_REF] Sauvage | Pitfalls and prevention strategies for liquid chromatography-tandem mass spectrometry in the selected reaction-monitoring mode for drug analysis[END_REF]. Otherwise, quantification or even identification errors can occur, and the advantages of mass-spectrometry can be lost.

The recently reported relationship between early exposure to ribavirin (plasma AUC 0-4h ) and clinical outcome in hepatitis C patients, [START_REF] Loustaud-Ratti | Ribavirin exposure after the first dose is predictive of sustained virological response in chronic hepatitis C[END_REF] together with the results of the present study, suggest that HPLC-UV or LC-MS/MS techniques can be used for the routine TDM of ribavirin as well as to conduct prospective multicentre clinical trials to validate the clinical benefit of such monitoring. The setting up of a larger and regular inter-laboratory proficiency testing scheme, involving more laboratories, using different detection modes, would be of the utmost interest in both these aims.

  , Foster City, CA, USA), equipped with a TurboIon-Spray TM and a Turbo V TM ionization source, respectively. HPLC-UV employed a UV 6000LP detector (Thermo Fisher Scientific, Les Ulis, France) operated at 214 and 240 nm.

of serum were prepared by mixing 4

 4 aliquots from 4 different patients sampled at the same time post-dose and treatment period. After vortex-mixing, these pools were aliquoted into brown 1.5 mL polypropylene tubes.Outdated drug-free serum from healthy-volunteers provided by the Etablissement Français du Sang was aliquoted and spiked with working solutions of ribavirin in water at different concentrations between 125 and 4550 ng/mL. All the samples were kept at -80°C until their shipment to the laboratories in dry ice. Shipment 1 included 22 randomly distributed blank serum samples spiked at 10 different concentrations of ribavirin (125, 375, 775, 1400, 1750, 2150, 2650, 3150, 3750 and 4550 ng/mL), including 5 replicates of the samples at 775, 1750 and 3150 ng/mL for estimating the intra-assay precision and accuracy. Shipment 2 was made of aliquots of the 3 spiked blank serum samples at 375, 2150 and 3750 ng/mL already distributed in shipment 1, and 20 samples from patients' serum pools. Shipment 3 contained aliquots of the same 3 spiked serum samples at 375, 2150 and 3750 ng/mL (for inter-assay accuracy and precision estimation), and 20 aliquots of patients' serum pools.

Figure 1 :

 1 Figure 1: Typical chromatograms of extracted patients' samples analysed with method 1 (A), method 2 (B) and method 3 (C).

Figure 2 :

 2 Figure 2: Investigation of the ion suppression phenomenon by means of a continuous infusion of ribavirin at 1 µg/mL and parallel injection of extracts of blank samples applying method 1 (A) and method 2 (B).

Figure 3 :

 3 Figure 3: Intra-series precision and accuracy: relative bias obtained by the three laboratories at 775 ng/mL (A), 1750 ng/mL (B) and 3150 ng/mL (C).

Figure 4 :

 4 Figure 4: Inter-series precision and accuracy: relative bias obtained by the three laboratories at 375, 2150 and 3750 ng/mL.

Figure 5 :

 5 Figure 5: Blind linearity evaluation of the three methods.

Figure 6 :

 6 Figure 6: Analysis of pools of patients' samples: relative differences of ribavirin concentrations found by each laboratory with respect to the mean measured values.

Table 1 :

 1 Description of the three analytical methods developed for the analysis of ribavirin Addition of 500 µL of an ammonium acetate solution at pH 9 and 30 µL of a 100 mg/L solution of 3-methyl cytidine methosulfate (IS) in water.• Equilibration of the PBA cartridge with methanol-formic acid (97:3 by volume) and 0.25 M ammonium acetate at pH 9.• Elution with 3 mL of methanolformic acid (97:3 by volume).

	Volume sample	Method 1 200 µL	Method 2 5 µL	Method 3 500 µL
	Extraction procedure	• Addition of 700 µL of an ammonium acetate solution at pH 8.5 and 50 µL of a 10 mg/L solution of 6-methylaminopurine 9-ribofuranoside (IS) in water. • Solid-phase extraction on a PBA cartridge equilibrated with methanol-formic acid (97:3 by volume) and 0.25M ammonium acetate. • Elution with 3 mL of methanol-formic acid (97:3 by volume).	Addition of 200 µL of a 1 µg/L solution of 3-methyl cytidine methosulfate (IS) in acetonitrile-water-perchloric acid (97:2:1 by volume). • Vortex-mixing of the mixture for 30 seconds and centrifugation at 20,000 g for 10 minutes. .
	Column Mobile phase	Atlantis HILIC Silica, 5 µm (150 × 2.1 mm) (Waters) Aqueous ammonium formate and acetonitrile	Luna HILIC, 3 µm (100 × 2.0 mm) (Phenomenex) Aqueous ammonium acetate and acetonitrile	Uptisphere HDO-QS, 3 µm (150 × 4.6mm) (Interchim) Aqueous orthophosphoric acid and acetonitrile

• Dilution with 15 µL of water. • •

Acknowledgments

This study was funded by Roche Pharma, France. We gratefully thank Ingrid Barthelemy, Jean-Louis Dupuy, Karine Delaune, Franck Giraudie, Karine Scalabrino, Cécile Girard and Chantal Nahum for their excellent technical assistance.


Sylvie Fainzang
email: sylvie.fainzang@orange.fr

New forms of sociality on the Internet Users, advocates, and opponents of self-medication

Individuals are turning more and more often to the Internet when self-medicating, notably to discussion forums to gather information concerning a certain illness or medicine, collect the opinions of others, and exchange experiences in order to make their decisions and therapeutic choices. This sharing of experiences is creating new forms of sociality. There is, however, another use of the Internet that involves taking a stance on self-medication and on direct access to medicines, and, specifically in France, on the state's new policy on medicinal access. In this virtual public sphere, pharmacists, drug users, and other interested parties exchange points of view concerning the risks, knowledge, and competence of individuals with regard to self-medication, which they justify with therapeutic, economic and political reasons. Here I examine two types of cybernetic socialities, information seeking/sharing and opinion voicing, in order to define what distinguishes them and what unites them, and find that these new forms of sociality can be divided into practical and theoretical forms, where the common issue is the enactment of autonomy.

Introduction

Anyone examining new forms of sociality in the health domain today is expected to refer to the concept of 'biosociality' first proposed by [START_REF] Rabinow | Artificiality and Enlightenment: From Sociobiology to Biosociality[END_REF], which aims to account for the grouping of people based on their common genomic characteristics. However, forms of health-related socialities exist that are not built on biological phenomena.

Indeed, though healthcare is generally associated with visiting a doctor and establishing a doctor-patient relationship, we are seeing an increase in people choosing to self-medicate in France today. People decide for themselves whether they are ill, and when and how to treat themselves. In order to make these decisions and choices, they refer to various sources in order to inform their actions: close friends and family, pharmacists, the media, and more and more frequently, the Internet, with its specialized websites or discussion forums. On these sites, diverse exchanges take place when participants share their experiences. Just as the search for therapeutic information engenders socialities, cybernetic relationships in return influence the way in which individuals treat their health problems.

A second use of the Internet consists of taking a standadvocating for or against the practice of self-medication and the issue of over-the-counter medicines which have been made available through policy changes in the last few years. Self-medication and over-thecounter sales have thus become a subject of public debate in this new space of the Internet, where people exchange opinions on the risks, knowledge, and competence of individuals. Here, professional, political, and citizen voices express their opinions and opposing viewpoints are offered by various actors: public authorities, the pharmaceutical industry, doctors, pharmacists, and self-medicating individuals. In so doing, each adds their own subjectivity to bolster the interest groups they embody, and each acts for various therapeutic, economic, or political reasons.

The socialities that emerge through using the Internet in the context of self-medication generally take two forms:

1) Seeking: Participating in discussion forums in order to learn how to treat illness, or to exchange advice on medicinal use. 2) Advocating or opposing: Contributing to an Internet-based discussion, launched for example by a consumer magazine or health website, in order to give an opinion on the practice of self-medication and direct access to medicines.

What distinguishes and what unites these two forms? What are the diverse new socialities involved, and what are the common issues at stake in these new forms of sociality? My analysis shows that these two types of exchange, and the resulting new forms of sociality, are divided into practical and theoretical parts, where the main issue is the enactment of autonomy.

To inform and be informed

Since patient use of medical websites, forums, and discussion lists has today come to symbolize the democratization of knowledge, more and more social scientists have taken an interest in the subject [START_REF] Hardey | Doctor in the House: The Internet as a Source of Lay Health Knowledge and the Challenge to Expertise[END_REF][START_REF] Akrich | Problématiser la question des usages[END_REF]. [START_REF] Thoer | Quelques réflexions sur des pratiques d'utilisation des médicaments hors cadre médical[END_REF] emphasize, following [START_REF] Giddens | Modernity and Self-Identity[END_REF], that the availability of health-related information on the Internet allows laypeople to reappropriate knowledge; as a tool, this helps to free patients from biomedical domination because it enables the empowerment of individuals regarding their health. This echoes [START_REF] Hardey | Doctor in the House: The Internet as a Source of Lay Health Knowledge and the Challenge to Expertise[END_REF] who notes that the Internet is the site of a new struggle over expertise in health, transforming the relationship between health professionals and their clients, which is a worrying transformation for health professionals in that they risk losing their role as the exclusive holders of expert knowledge.

Clearly, the information found on the Internet does not only come from professional sites. Information distributed by specialists on sites for the general public, whether approved by health institutions or not, is collected together with information based on the experiences of others who contribute to discussion forums. The two are sometimes mixed in accounts given by patients. From this point of view, 'searching the Internet' combines expert knowledge and lay opinions (to use the terminology favoured by sociologists), in order to compare differing points of view, in other words, to mobilize academic or professional knowledge as well as knowledge from personal experience. The phrase 'consulting the Internet' thus covers heterogeneous practices, since visiting a public forum and looking at a professional site are different social practices.

Consulting the Internet to answer health questions has led to serious concerns among those who believe that the proliferation of non-validated information constitutes a danger for individuals. While some are troubled by the lack of controls over Internet content, Akrich and Meadel (2009) note that laypeople possess a high degree of expertise. Some people become true experts on their illness and invest considerable energy reading and commenting on the Internet for the benefit of others. In this respect, studies have shown that patients using the Internet are more informed than doctors think, since they are assisted by more experienced patients [START_REF] Wyatt | L'extension des territoires du patient: Internet et santé au quotidien[END_REF], and that they are capable of making reasonable assertions on medical matters [START_REF] Nettleton | The Mundane Realities of the Everyday Lay Use of the Internet for Health and their Consequences for Media Convergence[END_REF].

The building of cybernetic relationships in the health domain is, for the most part, the result of a desire to collect personal accounts concerning the efficacy of a medicine and its associated risks. In the context of self-medication, people make medicinal choices not only based on their own experience or the experiences of family and friends, but on those of anonymous Internet users. Although self-medication implies personal choice, individuals are never alone, nor are they totally independentthey are subject to a thousand influences, from those around them as well as the larger society. The aim is to benefit from the experience of other people on the Internet, despite their anonymity, concerning the efficacy of a medicine, the level of satisfaction, or a medicine's potential side effects. People turn to discussion forums in particular when they are confronted with a symptom they do not recognize, in order to identify its etiology and its seriousness. For example, Mme F. experienced a very uncomfortable sensation when eating and drinkinga bitter taste filled her mouth as soon as she consumed anything. The feeling was so troublesome that she began to think it was pathological. She considered taking antihistamines to control what she thought was an allergy, and went on an Internet discussion forum where she learned from various accounts that this disagreeable sensation could be caused by the consumption of a variety of pine nut from Chinaa type of pine nut that she had indeed eaten the day beforeand that the symptom generally disappeared of its own accord after around a week. This information saved her from resorting to medical treatment.

Although forums are primarily consulted in order to gain information on specific medicines and illnesses, a secondary benefit of this strategy is that socialities are established through placing trust in the knowledge and experience of others. In web forums, individuals discuss precautions to be taken, conditions to adhere to in order to guarantee a medicine is innocuous, and the risks of interactions between medicines. One person thus queried: 'Is it possible to take Doliprane at the same time as Zelitrex? I have herpes on my lip which is very painful and a splitting migraine. I am desperate, please reply'. People may prefer searching for opinions on forums over asking a pharmacist, out of embarrassment (a pharmacy does not lend itself to intimate talk about the body), for convenience (the advice arrives quicker), or simply to gain several points of view. Likewise, opinions gathered in one's social environment (family, friends, colleagues) can complement or compete with opinions gathered on the Internet.

Visiting these forums does not necessarily mean active participation. Visitors may simply be hoping to find out about a problem or a medicine from a discussion in which they do not actively participate or express an opinion, although they may identify with those who are actively participating. Even if there is no exchange of points of view to speak of, a sociality is nevertheless established. This situation is comparable to a group of people in which some listen without speakingthe speakers know they will be heard (or, in the case of the Internet, read) by the others. In other cases, exchanges are established, sometimes in an occasional manner, sometimes repeatedly, when participants express themselves several times and turn their exchanges with others into real conversations that double up as an exchange of services.

The use of forums thus establishes new forms of sociality since the criteria at the base of ordinary socialities are modified because of the anonymity of participants. Someone can contribute to a discussion by revealing a private problem affecting their body (for example, hemorrhoids, erectile dysfunction, or female hirsutism), whereas in ordinary socialities, embarrassment and the rules of social acceptability would stop them from doing so. Because participation in these forums is characterized by anonymity, exchanges can unfold between people of different ages concerning gynaecological, urological, and sexual problems; while within the context of ordinary relationships in social life, an elderly person would not generally reveal information concerning his or her body to a young person. This form of sociality is oblivious to gender, age, and to a certain extent, social background. The social and sociodemographic variables that organize and constrain ordinary forms of sociality on a subject as intimate as the body and its malfunctions are abandoned in this anonymous context. This liberates discussions that would normally be withheld, even sometimes, as we have seen, from pharmacists or doctors.

Forms of sociality created by searching for information on an illness and treatment, or the desire to transmit knowledge and experience, are both the constituents and the secondary consequences of these exchanges. It is remarkable that such exchanges are peppered with polite phrases identical to those governing forms of sociality observable in everyday life, such as 'please', 'you're welcome', and 'thank you'. For example, one might pose a question on a forum like this: 'Hello everyone, here is my problem: Do you think that this medicine could cause such side effects? Thank you everyone for your help! Have a good day!' or, 'Hi all, I'd like to thank you all for being able to discuss this delicate subject so openly'. Expressions of empathy such as 'Bon courage' or 'Good luck' are common, as are phrases aiming to comfort someone showing distress when writing about their illness: 'You're not alone', or 'Hang in there'. Anger can be expressed as well, as seen in the response by a person who was reminded that 'tobacco is harmful to the arteries', who replied: 'What a stupid comment!' He came back to the site a month and a half later to write: 'Yes, I got a bit carried away, but the person replying to me was convinced I had an old person's illness, atherosclerosis, but I am only 26!' A forum visitor can also attract disapproval from the people to whom he/she reveals his problem. In one instance, someone replied, 'What do you expect us to say? You tell us how stupid you were and [...] you want some encouragement perhaps? Pffff ... Words can't express... Only humans could be so stupid!'

Participants can also judge themselves, having revealed their carelessness:

I don't know if you remember, I have already had to deal with this type of problem: 'a double dose this evening'. Well, I made the same stupid mistake this evening. Really bloody stupid! Last time I had this problem, I remember feeling strangely tired, shaking hands and body.... a really bad thing I did there!! So yes, I wanted to ask you what you think the consequences could be. Does this sort of problem never happen to you? Good night all.

The obvious distress led to an encouraging reply posted the next day: 'How are you feeling this morning? I hope your night wasn't too disturbed'.

Finally, there are also humorous exchanges and interactions demonstrating the shared amusement of both participants. Some punctuate their posts with 'lol', or use emoticons expressing laughter, winks, etc. This form of sociality thus shares with ordinary socialities the expression of emotion (politeness, sympathy, antipathy, complicity, mockery, anger, encouragement), peppered with words of humour, jokes, and sometimes teasing, disapproval, even blame, just like relationships forum participants might have with their family, friends, and colleagues.

Taking a stance

The tendency for individuals to develop social connections based on the subject of selfmedication can also be found in the context of the public debate on self-medication and the issue of direct access to medicines to which it is connected today. On 30 June 2008, the French Ministry of Health issued a decree authorizing a certain number of medicines to be sold over the counter in France. This has given rise to lively debates concerning access to medicine without a medical prescription, and direct access to medicines sold over the counter in pharmacies. The debate becomes even more heated when the question of over-the-counter drugs is thrown together with the issue of distribution, including the efforts of supermarkets to challenge the current monopoly of pharmacies on these goods.

I will not examine here the stances and arguments of all the groups of actors involved (public authorities, the pharmaceutical industry, doctors, pharmacists, and self-medicating individuals), as they are expressed in the public sphere. This was the focus of another study whose objective was to understand these actors' cognitive, symbolic, and ideological motivations in order to define their governing values and their underlying logic [START_REF] Fainzang | L'automédication ou les mirages de l'autonomie[END_REF]. I will limit my discussion to the points of view expressed in online discussions hosted by the magazine 60 millions de consommateurs concerning open access to medicines, in which both pharmacists and laypeople participated. Competence and risk are two of the major issues discussed in these exchanges on self-medication and over-the-counter access.

Opinions expressed by pharmacists cover three aspects of the controversy. They include a mix of opinions hostile either to the concept of self-medication or to the practice of selling medicine over the counter or in supermarkets. Opinions hostile to the concept of selfmedication are most often justified by evoking the danger it presents: 'It is in the USA that there are the most cases of hospitalization because of self-medication. No medicine is harmless! They are all dangerous!' one pharmacist declares. Others accept the idea of self-medication but do not agree that medicines should be available over the counter, even for cases deemed 'benign'. One pharmacist wrote: 'It is unacceptable that harmful molecules are for sale over the counter', and she uses the example of the fact that 'taking aspirin when pregnant can be very serious for the foetus'. Another commenter agrees, remarking that 'a sore throat and a headache can be the first signs of scarlet fever', and that in order to 'avoid complications, the correct treatment' must be taken 'as soon as the symptoms arise, symptoms that require serious questioning'.

While some pharmacists approve of self-medication, they nevertheless stress loudly and clearly the importance of their role in providing advice, which potentially implies keeping the medicine behind the counter. Their hostility to over-the-counter drugs is sometimes linked to the risks posed by their consumption. One of them, writing under the name of the group Pharmaciens en colère, emphasizes that medicine is not an everyday consumer good: 'If medicine is sold over the counter so that we can consume it at a lower price, French people will consume even more when they are already consuming too much'.

There are several underlying rationales behind the points of view expressed by the pharmacists. Some are supporting corporations or professions, some are defending consumers and denouncing the greed of supermarkets and the pharmaceutical industry, and others are speaking up for public health. These different rationales are sometimes combined together based on the risks involved in self-medicationrisks inherent in what is judged to be the incompetence of patients: 'users do not know how to recognize symptoms and cannot know if they are benign or not'; 'most French people do not know the difference between aspirin and paracetamol'. The fact that people lack medical information leads some to judge the situation to be irreparable: 'The state is acting irresponsibly. We know very well that people will not read the contraindications and an accident can happen very quickly'. This point of view sometimes takes the form of lamenting that people are incapable of self-medicating correctly in spite of the information available to them: 'It is an illusion to think that people will selfmedicate responsibly; how can we be sure that patients take the correct dose, at the right time, if no one is guiding them?' Laypeople responded to these differing opinions. While the majority are in favour of self-medication, opinions are more reserved when it comes to over-the-counter access, for either therapeutic or economic reasons. In strictly economic terms, the decree also provokes disparate reactions. Some object to reduced prices, fearing this may spur people to consume more, while others like the fact that the decree forces pharmacists to make prices on the medicines transparent. Others meanwhile predict the opposite: that the price of over-thecounter medicines will actually rise.

But the crux of the debate is above all the capacity of a patient to decide whether to acquire medicine and undergo treatment without the intervention of healthcare professionals. Some warmly welcome this increased access, while still hoping to see pharmacists continuing to provide advice and fearing that supermarkets will take over the sector: 'Is it not a bit risky to buy these substances at the same time as eggs and chocolate? Supervision performed by pharmacists during sales is not just a myth, it prevents numerous medicinal accidents', one participant declares. Others agree. One worries about the consequences of selling medicine over the counter precisely because it opens the way for supermarkets to sell these products, which implies that medicine will become trivialized: 'Pills are not sweets as represented by Leclerc in its advert showing a necklace similar to the candy necklaces we used to eat as children!' But this argument is challenged by someone who points out that pharmacists sell sweets too; still others see the fact that medicines could become available in supermarkets as a positive development. Responding to pharmacists who advocate their role as advisors, some counter that such an advisory role is simply fantasy: 'Pharmacists do not intervene to warn patients when they buy medicines that are not compatible with each other'. Another consumer confirms this: 'When we go to the pharmacy, no one asks us anything more than in the supermarket; we are served, and that's it; pharmacists have become simple shopkeepers; they are there to sell and make money, that is all!' Finally, the availability of over-the-counter drugs, in both pharmacies and supermarkets, is warmly welcomed by certain consumers who appreciate being able to choose for themselves and resented being infantilized regarding access to these medicines, as shown by these statements: 'We are capable of taking care of our little problems!' and 'Yes, we are not kids; we know what we are doing!' On the grounds that they possess sufficient competence, they affirm their desire to take their health into their own hands and their ability to be autonomous. Another disagrees: 'Recently I almost put the life of my unborn baby in danger by taking aspirin: my pharmacist stopped me, luckily, since he said it could have been fatal for my baby', showing her appreciation for pharmacist competence. The claim that individuals possess sufficient competence is confirmed by some and challenged by others.

These exchanges serve as a sounding board for individuals' to discuss their experiences and daily practices, and in so doing they develop a sociality as an actor in the domain of self-medication. The points of view expressed fulfil various functions: they aim either to reinforce cohesion or to develop a conflicting or critical relationship between groups of social actors. While pharmacists defend a corporatist position, laypeople sometimes express criticism of pharmacists' practices that they might not dare state openly in person.

Here again, the exchange of points of view is liberated by anonymity, but through a different mechanism: it is not the moral dimension of ordinary sociality that disappears here, but the social and political dimensions that would normally make face-to-face criticism of the practices of health care professionals difficult. Overall, these cybernetic exchanges crystallize the social relationships between drug users and pharmacists on the questions of consumer competence and autonomy.

Synthesis

Several authors have taken an interest in new forms of sociality created through links established via the Internet, or what Casilli (2010) calls 'digital links', such as those facilitated by social networks. While Casilli (2010, p. 57) speaks in terms of 'virtual sociability', I prefer not to retain the term 'virtual' because it implies that this sociability only exists as a potential. In the field of cybernetics, 'virtual' refers to a simulation of reality, but here we are dealing with its actual achievement. The so-called virtual world, as a space for communication created by the global interconnection of computers within which its users navigate, is, from an anthropological point of view, a very real world, as are the practices that take place there and the relationships that are formed there.

According to Casilli (2010, p. 57), the Internet brings new forms of interaction: 'face to face meetings are no longer the exclusive means of interaction'. He emphasizes that we now have multiple means to communicate without having to go anywhere (through mobile telephone, e-mail, Internet forums, etc.), and it is no longer necessary to physically meet other people (p. 122). However, Casilli shows that the body has not disappeared, far from it: the body is very much there, at the exact centre of our daily life, as the questions raised by web users over how to stay in good health reveal. The body is omnipresent and remains at the centre of individual preoccupations.

Other authors have concentrated on forms of sociality created by chronic conditions of ill health (for example [START_REF] Whyte | Health Identities and Subjectivities: The Ethnographic Challenge[END_REF], whether they take place on the Internet or [START_REF] Rabinow | Artificiality and Enlightenment: From Sociobiology to Biosociality[END_REF]Rabinow ( [1996]]) coined the term 'biosociality' to account for the manner in which biological nature, as revealed and monitored by science, constitutes the foundation of social life. He thus proposed the notion of biosocialities in the context of his work on the human genome to account for groupings of people based on their common genomic particularities.

To illustrate what he means by biosociality, he takes the example of the existence of neurofibromatosis groups, 'whose members meet to share their experiences, lobby for their disease, educate their children, redo their home environment and so on' (Rabinow, 2005, p. 102). As [START_REF] Whyte | Chronicity and Control: Framing Noncommunicable Diseases in Africa[END_REF] remarks, biosociality has henceforth become one of the central questions examined in social science research on chronic illness. These works outline new forms of sociality found in patient support and advocacy groups, or seen in social transformations as a result of innovations in the genomic domain [START_REF] Gibbon | Biosocialities, Genetics and the Social Sciences: Making Biologies and Identities[END_REF]. [START_REF] Ducournau | Génétique en ligne: déterritorialisation des régulations de santé publique et formes de développement commercial[END_REF] document biosocialities that revolve around sharing information about one's own genetics, which they dub 'Facebook genomics'. These interactions included exchanges among people who buy genetic tests on the Internet that provide information on their predispositions to certain diseases, and who begin online exchanges because of the genetic proximity suggested by their results.

Although the exchanges of questions and advice taking place on discussion forums described here are based on a pathological condition or a particular symptom and fall within the scope of new forms of sociality in the health domain, we cannot identify these exchanges as 'biosocialities', as [START_REF] Beaudevin | Old Diseases and Contemporary Crisis: Inherited Blood Disorders in Oman[END_REF] stresses that these are defined as associations of people affected by the same disease. Nor can we talk here about 'biological citizenship' [START_REF] Rose | Biological Citizenship[END_REF]. On the one hand, the biosociality argument implies that social relationships are formed on the basis of a biological phenomenon or of biological characteristics. In our case, people are not necessarily experiencing a biological transformation of their body nor do they share the same illness. On the other hand, exchanges can take place regarding a bodily reality without the person necessarily experiencing it at the time of writing or experiencing it themselves, since the discussions also refer to experiences of family and friends. Furthermore, sociality developed around a shared preoccupation at a certain moment in daily life does not necessarily imply a health 'condition', as experiencing an occasional symptom cannot be considered as identical to living with a chronic illness. Finally, sociality is based on sharing a common concern for a body experience that might be but is not necessarily pathological, or a body experience that is not recognized as pathological by medical professionals [START_REF] Fainzang | The Other Side of Medicalization: Self-Medicalization and Self-Medication[END_REF].

The information sharing examined above is perhaps closer to the notion of 'therapeutic citizenship' as defined by [START_REF] Nguyen | Antiretroviral Globalism, Biopolitics, and Therapeutic Citizenship[END_REF], in which expert clients are incorporated into health care activities, with the difference that these exchanges do not involve active healing but centre instead on giving advice on healthcreating what might be called 'health citizenship'. This term is more appropriate to account for what is happening in these new forms of sociality, since the exchanges are pursued in order to encourage or dissuade recourse to a treatment or a specific medicine, but neither 'seekers' nor 'advocates' are in fact incorporated into the healing activity. It is only the self-medicating person who participates in the health care activity, thus exercising their therapeutic citizenship. From the synthesis of therapeutic citizenship (asking for advice in order to self-administer treatment) and health citizenship (exchanging advice about health) comes 'health sociality'. In the situation where people take a stance on self-medication, it involves asserting a citizen's point of view regarding an offer of services and a therapeutic strategy, without playing a therapeutic role. The aim is thus to assert a posture, for or against self-medication, linked to a philosophical, or even political, position on the question of autonomy and user competence. This position participates in health citizenship since the key issue is to define the conditions in which it is judged reasonable or not to treat oneself alone, and to express an opinion on the validity or not of self-medication and access to over-the-counter medicines.

These diverse forms of sociality are based either on the experience of a symptom, an ailment, or a medicineas a useror on a personal doctrine concerning the recourse to selfmedicationas an advocate or opponent. In the first configuration, they are the result of a therapeutic quest; in the second, they are the result of a quest for social recognition and the assertion of competence within the domain. In both cases, social exchanges are created on the basis of the legal, social, and physiological possibility of managing one's own body. These exchanges aim either to improve the efficacy of one's practice or to give it legitimacy; they all stem from a desire to make one's voice heard or to interact with the bodies of others. In conclusion, the forms of sociality developing among users, advocates, and opponents of selfmedication in the cybernetic space, form a diptych, practical and theoretical, on the issue of autonomy: autonomy in principle versus autonomy in action.


Sophie Herment-Dujardin

Daniel Hirst
email: daniel.hirst@lpl.univ-aix.fr

Emphasis in English : a Perceptual Study based on Modified Synthethic Speech

A number of utterances were extracted from a set of recordings of spontaneous speech after listeners had judged that they contained one or more emphatic words. Synthetic versions of the utterances were created, neutralising the variability of segmental duration, pitch movement, pauses and semantic content (by a process of delexicalisation). These synthetic stimuli were then rated by native speakers allowing a comparative evaluation of the contribution of the different parameters to the perception of emphasis.

Introduction

A number of experiments have been carried out on emphasis and its acoustic parameters. Fundamental frequency and duration are generally considered as its essential correlates. Cooper et al. [START_REF] Cooper | Acoustical aspects of contrastive stress in question-answer contexts[END_REF] and Eady et al. [START_REF] Eady | Acoustical characteristics of sentential focus : narrow vs. broad and single vs. dual focus environments[END_REF] showed that both F0 and duration increase on emphatic words but they also underline the importance of the word's position in the utterance, and of adjacent words. Tannen [START_REF] Tannen | Conversational Style[END_REF] studied what she calls 'high-involvement style' and found that the relevant parameters for this were pitch, amplitude, voice quality and pause. Selting [START_REF] Selting | Emphatic speech style -with special focus on the prosodic signalling of heightened emotive involvement in conversation[END_REF] demonstrated that prosody is the main constitutive cue of 'emphatic speech-style', along with 'lexical devices, such as intensifying lexical items, and syntactic devices' (p404). Winkler [START_REF] Winkler | Interrelations between Fundamental Frequency and Other Acoustic Parameters of Emphatic Segments[END_REF] insisted on the pragmatic dimension of emphasis : "'emphatic' is the category for all sequences which seem to be nonneutral, non-normal, non-standard or nonfactual/detached". Finally, Hirst & Di Cristo [6], in their survey of the intonation systems of twenty languages wrote: "in the majority of languages described in this volume, focalisation and/or emphasis is said to be best manifested by an extra pitch prominence, giving rise to larger F0 movements often accompanied by extra intensity and duration" (p32).

The experiment described here aims at testing the importance of four parameters : F0, duration, pause and semantics. For this purpose, modified synthethic speech was used and a perceptual experiment carried out.

We first give the background for the experiment, then we describe the modifications and the experiment. Finally the results are discussed.

Background for the experiment

The experiment described here is part of a larger study on the acoustic and prosodic correlates of emphasis in English [7]. This study was based on spontaneous speech : the database includes a political TV debate, an informal conversation, and a radio program with two women talking about an emotional subject. The starting point of the study is a perceptual experiment in which naïve native English speakers listened to selected segments of the database and were asked to mark emphatic passages. A deliberately vague definition of emphasis was given as what is "being made prominent in some way" and is "not neutral", "with a special involvement on the part of the speaker".

The results of the first experiment made it possible to determine a degree of emphasis for each word, based on the percentage of listeners marking each word as emphatic. A prior experiment had shown that this measure was highly correlated with estimates of degree of emphasis by subjects.

Sentences were then chosen containing at least one very emphatic word and a second perceptual study was carried out, based on manipulated synthethic speech, in order to measure the importance of the four parameters mentionned above.

Manipulations

Five sets of synthetic stimuli were thus created: -stimuli as close as possible to the original sentences; used as reference sentences.

-stimuli in which the pitch variation was neutralised; -stimuli in which phoneme lengthenings were neutralised; -stimuli in which pauses were deleted or inserted; -delexicalised stimuli.

In order to synthethize these segments, MBROLA [8] was used, which requires phonemic transcription using SAMPA [9], segmental durations in milliseconds and fundamental frequency values in Hertz (each phoneme can be accompanied by pairs of values representing time and frequency, with time expressed as percent duration of the phoneme). Figure 1 shows an example of a MBROLA pho file:

Source-sentences

Twelve segments (sentences or intonation units) containing at least one very emphatic word wwere selected :

-some contained pauses, so that it was possible to remove them ; -some contained words in which phonemes were longer than expected or usual ;

-some segments presented large pitch movements and others were very flat as far as the fundamental frequency was concerned ; -some segments were chosen for their semantics: either because one word was unusual (kerfuffle for example) or highly marked semantically (violence for example). These sentences were synthethised with the original durations and F0 values (measured with PRAAT [10] on the original segments, cf. figure 1). When the speaker was female, the F0 values were divided by 1.3 to make the values compatible with the diphones which were recorded by a male voice. These twelve synthetic stimuli, as close as possible to the original versions, constituted the reference segments. This was necessary because the synthetic version, although of very high quality, was not perfect. The distance between the degree of emphasis of the original segments and the manipulated synthethic segments might have been too great and the results distorted.

Duration

The same segments were resynthethized, but the variability in duration was neutralised by setting the value for each phoneme to an average value for that phoneme (using data from [11]). This average value replaced the original value in all the sentences.

Fundamental frequency

As mentioned above, it is possible to have no F0 value for a phoneme: MBROLA makes a linear interpolation every 10 milliseconds between two consecutive values of F0.

In order to neutralise pitch variation, just two F0 values were fixed for each segment: 135 Hz on the first phoneme and 90 Hz on the last phoneme of the segment corresponding to average low values for male speakers. Completely monotonic pitch was not used since this created an articifical 'metallic' sound to the synthetic utterances.

The original durations were kept.

Pauses

Most of the source-sentences contained pauses. These were removed, but the original durations and F0 values were kept. In a few segments, pauses were added (varying between 300 and 400 ms according to the context).

Delexicalisation

In order to test the importance of semantics, the segments were delexicalised : the original phonemes were replaced by other phonemes, while the original acoustic and prosodic criteria (F0 values, durations and pauses) are not modified. This experiment was mainly inspired by Pagel et al.

[12] and Ramus & Mehler [13], who present three different delexicalisation methods:

In the first all the phonemes were replaced by /a/ and the result is one long /a/ varying according to pitch.

In the second, vowels were replaced by /a/ and consonants by /s/.

The third transformation, called 'saltanaj' : all the vowels were replaced by /a/, constrictives by /s/, stops by /t/, liquids by /l/, nasals by /n/ and semivowels by /j/. We adopted a modified version of 'saltanaj' which we called 'jastradanz' : vowels were replaced by /a/, voiced stops by /d/, voiceless stops by /t/, nasals by /n/, voiced constrictives by /z/, voiceless constrictives by /s/, semi-vowels by /j/, and liquids/ by /r/ rather than /l/. This gave better results for consonant clusters. With saltanaj, words beginning with a stop followed by /r/ will begin with the cluster /tl/ which is impossible at the beginning of a word in English. With jastradanz, those words will begin with /tr/ or /dr/.

The delexicalised segments thus obtained were synthethized with the French version of MBROLA, in order to make it credible to the listeners that they were listening to utterances in an unknown language.

The advantage of this technique was that it was possible to present listeners with a written 'text' corresponding to the lexicalised utterances, something which is not possible with other techniques of delexicalisation.

Perceptual test

After all the manipulations, five sets of twelve stimuli were obtained, a total of sixty sentences. The same principle as for the first experiment was applied: naïve native speakers were asked to mark the emphatic passages in the stimuli they heard and a degree of emphasis was determined for each word.

First, the listeners heard the delexicalised sentences, and the other stimuli were then divided into two groups so that the test was not too long for the listeners. Each stimulus was heard twice and in random

Results and discussion

Table 1 below shows the results of the five stimuli for one segment : the numbers are the degree of emphasis, corresponding to the percentage of listeners marking the word as emphatic. The first column with numbers shows the degree of emphasis for the original nonsynthetic segment, obtained from the first experiment It is interesting to compare the degree of emphasis on the resynthethized non-modified segment (reference segments) and on the original segment because the intensity parameter cannot be directly manipulated with MBROLA. In the segment shown in table 1 above, the word 'Christmas' is much less emphatic in the reference segment than in the original one. This is probably due to intensity: the first syllable of the word has higher intensity than the other syllables of the whole segment, as can be seen from the intensity tier shown in figure 2: In most cases, the perception of emphasis is not modified when a pause is removed. This might be due to the fact that the durations of the words preceding the pauses were not modified while it is known that a word preceding a pause is always longer. When a pause is added, the difference in the perception of emphasis is not relevant either. The effect of pauses on emphasis remains a complex phenomenon which this experiment does not clarify.

Duration

This experiment clearly shows that duration alone isnot sufficient to express emphasis but it nevertheless plays an important part in the perception of emphasis when it is associated with other parameters, F0 and semantics.

The experiment also shows that the duration of the word as a whole is not always significant : the segmental durations are important. The lengthening of a single phoneme can be enough to change the perception of a word. The adjacent words are also important. Words preceding a focused word are usually shorter.

Finally, when duration is modified in an unexpected, unusual way, the word sounds emphatic.

Fundamental frequency

From non-emphatic, a word can be perceived as emphatic when only the fundamental frequency is changed. Unlike duration, F0 alone can express emphasis. This is what the results for the monotonic stimuli show. The most relevant examples are those for which the pitch movement is very large or undulating in the reference sentence: a steep fall or a sing song movement. It is also clear that the pitch range on the whole segment is an important factor. If the contour is rather flat in the reference sentence, a very small rise in F0 is sufficient to emphasise a word.

In many cases, F0 is associated with duration and in one segment clearly with a pause.

The results show that for most of the stimuli, F0 is fundamental in the perception of emphasis. There are cases, however, in which emphasis remains strongly perceived although the pitch is flat. The semantic criterion probably plays an important role here.

Semantics

Emphasis is still perceived in the delexicalised stimuli, which confirms the importance of the other parameters, more specifically F0 and duration.

As far as semantics is concerned, it is interesting to distinguish two categories: semantically marked words, and neutral words.

The first category of words are usually marked as emphatic and for a few of them, no emphasis was perceived for the corresponding delexicalised stimuli. This shows that the very meaning of the word makes it emphatic. Such words are nevertheless often highlighted by a pitch movement and/or a longer duration.

For the neutral words, the association between F0 and/or duration, and semantics is essential in the perception of emphasis.Neutral words are generally not expected to be emphasised, but if they are put into relief by a pitch movement for example, they are perceived as very emphatic if the context allows it. If the context makes emphasis impossible, they are not perceived as emphatic in the reference stimuli but are very emphatic in the delexicalised stimuli.

This experiment brings out the importance of context and of syntactic structure as well in one segment which contains what is usually called an emphatic 'do',. In this segment, 'do' is perceived as emphatic in all the stimuli except the delexicalised one and the one with the modified F0. Here again, the association of the two parameters is made clear.

Conclusion

The perceptual experiment based on modified synthetic speech carried out and described in this paper confirms the importance of three parameters : F0, duration and semantics. No correlation was found between perceived emphasis and the presence or absence of a pause.

The interpretation of the results shows that it is impossible to analyse each parameter separately. They are all embedded and associated to express emphasis.

For each set of stimuli, we added the percentages of emphasis of each word. The corresponding figure is shown below. This figure shows that for the monotonic stimuli, the degree of emphasis decreases far more than in the other stimuli. The semantic criterion comes next.These two parameters consequently seem to be the most relevant ones for the perception of emphasis.

We also note that it is impossible to extract a single parameter in relation to emphasis. In some cases, F0 is crucial, in others, the combination of F0 and the context is necessary and the two are inseparable, in others, it is duration and F0 which make the word sound emphatic, or one parameter is essential but others while secondary but nonetheless contribute to the degree of emphasis.

Our experiment confirms that emphasis is perceived thanks to a complex, subtle and particularly variable combination of several parameters.

Figure 1 :

 1 Figure 1: a sample 'pho' file for Mbrola. each line contains the SAMPA transcription of the phoneme, its duration and time and frequency of pitch assoicated with the phoneme.

Table 1 :

 1 Degrees of emphasis for P1.

Figure 1 :

 1 Figure 1: intensity tier from PRAAT for P1.3S01

Figure 2 :

 2 Figure 2 :combined percentage for each set of stimuli


Subba Reddy Oota

Frédéric Alexandre

Xavier Hinaut

Investigating Long-Term Context of Language Models on Brain Activity during Narrative Listening in fMRI

• Introduction 1 Sequence-based and pretrained language models have been found

to be successful for text-driven prediction of brain activations. 2 However, these models still lack long-term memory plausibility (i.e. how they deal with long-term dependencies and contextual information)

Can current language models deal with long-term dependencies? T ransformer language models (BERT, XML, GPT,…) • Questions 1 What kind of language models can represent long-term dependencies? 2 Could these language models also predict better brain activity while subjects are engaged in longer stories ?

• Main Contributions 1 We propose the problem of finding which type of language models are the most predictive of fMRI brain activity for listening tasks.

• Models Considered

Conclusion

• Language models with longer context (e.g. Longformer) better predict brain activity while subjects listening to stories. • Future Directions: (i) Use more plausible language models than Transformers. (ii) Make hierarchical language models.

Figure 1 :

 1 Figure 1:Sequence length is fixed to 512 words in Transformers.

1Figure 2 :

 2 Figure 2:Whole Brain

Acknowledgements

• We thank Gaël Jobard and Clara Moreau for their very helpful comments on the poster.