Résumé Institution de la tarification à l’activité (T2A) en 2003, création des pôles en 2005, loi « hôpital, patients, santé, territoires » (HPST) en 2009, l’hôpital est soumis, depuis quelques années, à des vagues successives de réforme. La place des médecins en son sein fait l’objet de débats nourris et contradictoires. Acteur de santé publique, expert du soin, co-gestionnaire, promoteur de l’activité hospitalière… Les questions sont nombreuses. Deux personnalités du monde hospitalier ont apporté leurs réponses et proposent des voies d’évolution pour un système hospitalier engagé dans une transformation en profondeur de son organisation comme de ses modes de fonctionnement.

Aims/hypothesis: Intra-abdominal fat (IAF) and inflammatory markers are correlated with cardio-vascular risk. We compared the impact of bed-time insulin versus pioglitazone treatment on these parameters in type 2 diabetic (T2D) patients.Methods: Twenty-eight T2D patients poorly controlled with metformin and sulfonylurea were randomized to receive add-on therapy with pioglitazone or bed-time NPH insulin. IAF and subcutaneous fat (SCF) content, systemic low-grade inflammation level and expression of inflammation related genes in SCF, were measured before and after 24 weeks of treatment.Results: Insulin and pioglitazone resulted in a significant decrease in HbAlc (-1.6% and -1.2%, respectively) and a significant increase in total body fat mass (1 +/- 2.3 and 3.3 +/- 2.7 kg, respectively). There was no change in IAF content after both treatments whereas significant increase in SCF content was only seen after pioglitazone treatment (p < 0.05 versus insulin). hsCRP level decreased after pioglitazone and ferritin level decreased after insulin treatment. No change in mRNA expression of inflammation related genes was found after either treatment.Conclusion/interpretation: This suggests that a 24-week treatment with pioglitazone or bedtime insulin has a similar impact on intra-abdominal fat mass and systemic low-grade inflammation. (C) 2009 Elsevier Ireland Ltd. All rights reserved.

BACKGROUND & AIMS:Patients with diabetes are at risk for nonalcoholic fatty liver disease leading to advanced fibrosis, cirrhosis, and liver cancer. We examined the efficacy of a screening strategy with a noninvasive fibrosis biomarker (FibroTest) in patients with diabetes.METHODS:We prospectively studied 1131 consecutive patients without a history of liver disease seen for diabetes. The biomarker data were obtained, and patients with presumed advanced fibrosis were reinvestigated by a hepatologist using elastography and, if necessary, ultrasonography, endoscopy, or liver biopsy.RESULTS:The biomarker predicted advanced fibrosis in 63 of 1131 (5.6%) patients. A total of 45 patients was reinvestigated, and advanced fibrosis was confirmed in 32 patients, a 2.8% (32/1131) prevalence of confirmed advanced fibrosis, 5 cases of cirrhosis, and 4 cases of hepatocellular carcinoma. In the population with type 2 diabetes who were 45 years or older, the prevalence of confirmed advanced fibrosis was 4.3% (30/696), and hepatocellular carcinoma was 5.7 of 1000 (4/696).CONCLUSIONS:The fibrosis biomarker might be used for the detection of advanced fibrosis in patients with type 2 diabetes.

BACKGROUND & AIMS:Nonalcoholic steatohepatitis (NASH) is a liver disease that complicates insulin-resistant states. This trial tested the efficacy and safety of rosiglitazone, an insulin-sensitizing agent, in patients with NASH.METHODS:Sixty-three patients with histologically proven NASH were randomly assigned to receive rosiglitazone (4 mg/day for the first month and 8 mg/day thereafter; n = 32) or placebo (n = 31) for 1 year. Liver biopsy was performed at the end of treatment. End points were improvement in the histologic score of steatosis, normalization of serum transaminase levels, and improvement in necroinflammation and fibrosis.RESULTS:More patients treated with rosiglitazone than receiving placebo had improved steatosis (47% vs 16%; P = .014) and normalized transaminase levels (38% vs 7%; P = .005), although only half of patients responded. There was no improvement in other histologic lesions, including fibrosis, and a composite score of activity, the nonalcoholic fatty liver disease activity score. Improvement of steatosis correlated with reduction of transaminase levels (r = 0.36; P < .005), improvement in insulin sensitivity (r = 0.34; P = .008), and increase in adiponectin levels (r = -0.54; P < .01) but not with weight variations. Independent predictors of response were rosiglitazone treatment, the absence of diabetes, and massive steatosis. Weight gain was the main adverse effect (mean gain of 1.5 kg in the rosiglitazone group vs -1 kg in the placebo group; P < .01), and painful swollen legs was the main reason for dose reduction/discontinuation. Serum hemoglobin level was slightly but significantly reduced. There was no hepatic toxicity.CONCLUSIONS:In patients with NASH, rosiglitazone improves steatosis and transaminase levels despite weight gain, an effect related to an improvement in insulin sensitivity. However, there is no improvement in other parameters of liver injury.

Résumé La maladie chronique, en raison même de son incurabilité, bouleverse le rapport au temps. L’homme sait bien que la mort l’attend au bout du chemin, mais il se comporte quotidiennement comme si la vie n’avait pas de fin. Parce que le terme n’est pas fixé. Parce que la mort reste abstraite pour qui n’a pas subi l’épreuve du deuil. Paradoxalement, en brisant l’utopie inconsciente de l’immortalité, la maladie chronique tend à changer si ce n’est le sens, du moins la tonalité de la vie. L’existence ne devient pas forcément tragique, mais en tout cas moins insouciante, plus réfléchie et ce faisant dans une certaine mesure plus humaine.

that of the general population.The combination of 2 BM has a PPV of around 70% for severe liver fibrosis in both populations which suggests possibility of a screening in the general population or consulting patients at risk.

OBJECTIVE:To determine the link between glycemic control and the strategies adopted by patients in coping with diabetes-related stress. MATERIAL AND METHODS:In a cross-sectional study of 122 type 1 diabetic patients, glycemic control was evaluated on the basis of the last mean annual HbA(1c) level, and a comparison was made of two groups of patients, i.e., those with "good control" (HbA(1c)<7.5%) and "poor control" (HbA(1c) > 8.5%). Sociodemographic were collected for all patients by the referring physician. The nature of the diabetes-related stress and the coping strategies adopted by patients were determined by analyzing validated self-assessment questionnaires. RESULTS:Comparison showed that there was no significant difference between the two groups in terms of the patients' age, level of education, age at onset, duration of the diabetes, or the nature of diabetes-related stress factors. In contrast, the difference between the groups was significant in that patients in the "well controlled" group carried out more home blood glucose tests (p<0.02), had fewer complications (p<0.003), and made greater use of so-called "task oriented" strategies (p=0.023), regardless of the existence of any complications. CONCLUSIONS:Even though the nature of the diabetes-related stress appears to be the same for the two groups, type 1 diabetic patients with good glycemic control manage their condition differently (more frequent home blood glucose tests) and use coping strategies that place greater emphasis on problem solving.