This article argues that the emergence of nosocomial infections as a public health issue is the result of specific socio-cultural processes. An analysis of the French periodical Revue d'Hygiene et de Medecine Sociale over the period 1953-1988 and of the discourse of national actors in the fight against hospital-acquired infections demonstrates that the recognition of nosocomial infections as a public health issue occurred almost independently of objective criteria related to frequency or severity. It is suggested that professional and societal factors provide a better explanation of the emergence of nosocomial infections as a public health issue. Nosocomial infections essentially rescued 'Hygiene', a discipline threatened by the reorganization of the university-hospital system following the 1958 reform. Having entered hospitals, hygienists have had to compete with microbiologists also involved in a subject that has attracted an increasing number of actors from a range of fields. Beyond the development of a public health issue, a battlefield of symbolic fights is thus emerging.

Résumé Cet article se propose d’aborder l’émergence de l’infection nosocomiale en tant que problème de santé publique comme le résultat d’un processus socio-historique spécifique. En étudiant la Revue d’hygiène et de médecine sociale de 1953 à 1988, ainsi que le discours d’acteurs nationaux de la lutte contre les infections nosocomiales, on peut montrer que ces infections deviennent, en France, un problème de santé publique reconnu quasi indépendamment de critères objectifs de fréquence ou de gravité et que les enjeux professionnels et sociaux y jouent un rôle déterminant. Les infections nosocomiales sauvent ainsi la place de l’hygiène, en tant que discipline, qui semblait condamnée par la nouvelle organisation hospitalo-universitaire mise en place suite à la loi de 1958. Une fois à l’hôpital, les hygiénistes entrent en concurrence avec certains microbiologistes qui investissent également cet objet, lequel se trouve finalement de plus en plus convoité par de multiples acteurs. Au delà de la construction d’un problème de santé publique, se constitue ainsi un véritable champ de luttes symboliques.

An intervention to prevent chronic back pain and muscular-skeletal disorder (MSD) was implemented in the second half of 2003 at an automobile factory targeting employees from the cable construction division who were redeployed internally to a another division of the plant. This action-research consisted of exploring the benefits of establishing specialized gym classes for back exercises and re-education at the workplace to help prevent chronic lower back pain. Employees who had previously reported lower back pain that was either slightly disabling to none incapacitating and those who were in-line to be redeployed to another division were all offered the opportunity to undertake a medical exam and physical therapy check-up and to respond to a self-administered questionnaire in order to assess the functional state of of each employee, his perception of pain, and the manifestation and impact of this in daily life. Employees were oriented to appropriate gym and physical therapy classes for re-educating and improving back strength under the supervision of a physical therapist. As a follow-up to this, in between sessions, the workers were invited to redo the assessment tests in order to assess and appraise the value of the effects of the exercises. The action-research carried out in the workplace shows a positive contribution of the gym classes specialized for back exercises and re-education training to the improvement of the status of those persons suffering from lower back pain. In addition, placing employees in new professional positions following their completion of these gym and physicals therapy sessions proves to be essential for validating the acquisition of knowledge gained and the commitment to adjusting to the job position.

Résumé Durant le second semestre 2003, une action de prévention des lombalgies chroniques et des troubles musculo-squelettiques (TMS) a été menée chez un constructeur automobile en direction des salariés d’un atelier de câblerie qui devaient être reclassés en interne. Cette recherche-action consistait à explorer l’intérêt de la mise en place, en milieu de travail d’ateliers de gymnastique du dos et de réentraînement à l’effort pour la prévention des lombalgies chroniques. Il était proposé aux personnes ayant un antécédent de lombalgie peu ou pas invalidant et des salariés de la câblerie en voie de reclassement de se soumettre à un bilan médical et kinésithérapique et de répondre à un questionnaire auto-administré afin d’apprécier l’état fonctionnel de chaque salarié, sa perception de la douleur et le retentissement de celle-ci dans la vie quotidienne. Les personnes étaient ensuite orientées vers des ateliers de gymnastique du dos et de réentraînement à l’effort encadrés par une kinésithérapeute. À distance des ateliers, elles étaient invitées à refaire les tests afin que puissent être appréciés les effets des séances. La recherche-action menée dans l’entreprise montre une contribution positive des ateliers de gymnastique du dos et de réentraînement à l’effort chez des personnes ayant souffert de lombalgie. Par ailleurs, la mise en situation professionnelle d’une personne suivant les ateliers de gymnastique du dos et de réentraînement à l’effort s’avère essentielle à la validation de l’appropriation des connaissances acquises et à la détermination d’aménagements du poste.

Résumé La tuberculose pulmonaire à microscopie positive non traitée, constitue un réservoir pour la transmission de la maladie. La présente étude, avait pour objectifs de déterminer le délai, les différents recours et les facteurs liés au retard de diagnostic de la tuberculose pulmonaire à Conakry Guinée. À travers une étude transversale, 113 patients consécutifs présentant une tuberculose pulmonaire à microscopie positive ont été interviewés par questionnaire. Le délai total médian du début des symptômes au diagnostic de la tuberculose était de 11 semaines. Ce délai était supérieur à 4 semaines chez 90 patients (80 %). Le délai médian lié au service conventionnel de soin (6 semaines) était le double du délai lié au patient (3 semaines). 54 % des patients ont eu recours en premier lieu à des soins non conventionnels. Pour raccourcir ce délai, il faut renforcer les compétences des soignants à détecter la tuberculose et sensibiliser la population.

Histological, clinical and radiological features, and molecular genetic analysis are among the factors that have been considered in defining the prognosis of oligodendrogliomas (OD), but they have yielded conflicting results.

OBJECT:Demonstration of the loss of chromosomes 1p and 19q in the presence of a brain neoplasm marks the emergence of genotype as a prognostic indicator. The authors report gene expression data for oligodendroglioma and correlate genotype with response to therapy. Gene expression subgroups may represent distinct types of disease.METHODS:Eighty-seven cases of supratentorial oligodendroglioma were selected from 145 cases treated in a single center between January 1990 and December 2001. Fluorescence in situ hybridization was used to determine the status of chromosomes 1p and 19q. Parameters evaluated included clinical data and radiological and histological features. Univariate and multivariate analyses were performed and a probability value less than 0.05 was considered significant. The patients included 48 women and 39 men. The overall mean age at presentation was 45 years for women and 36 years for men (p = 0.006). The univariate analysis identified the following as favorable prognostic factors: younger patient age (p = 10(-5)), female sex (p = 0.0025), seizure as a presenting symptom (p = 10(-5)), normal clinical examination (p = 10(-5)), absence of lesion enhancement on neuroimaging studies (p = 0.0231), lack of histological necrosis (p = 0.0003), absence of mitoses (p = 0.0014), 1p and 19q deletions (p = 0.0001), absence of recurrence (p = 0.0021), and adjuvant radiotherapy and/or chemotherapy (p = 10(-5)). The multivariate analysis identified patient age (p = 10(-5)) and chromosomal anomalies (p = 0.002) as independently linked to survival. Three molecular subtypes emerged: oligodendroglioma with 1p and 19q deletions, oligodendroglioma demonstrating polysomia and a lack of meaningful response to radiotherapy or chemotherapy, and oligodendroglioma with no 1p-9q deletion in which partial response was seen.CONCLUSIONS:According to our data, oligodendrogliomas could be divided into three molecular subtypes. Although chemotherapy seems efficient for managing this tumor, additional studies should be conducted to compare the efficacy of radiotherapy and chemotherapy.

Relative differences in environment, behaviour, social composition as well as access to health care tend to suggest that levels of health may vary between urban and rural areas. The aim of this study was to identify rural-urban variations in mortality risks in the region of Brittany for the period from 1988 to 1992. The definition of urban and rural areas used adhered to that of the zoning of urban areas established by the INSEE (the National Statistical Office). The amalgamation of all causes of standardised mortality ratios (SMR) show only a moderately increased risk in the rural areas compared with the overall regional level (+4% in men, +5-7% in women). The analysis of cause specific SMRs display higher rural mortality for cardiovascular diseases and external causes of death, road traffic accidents in particular (+24% in men). Among all specific causes investigated, only lung cancer mortality risk appears to be higher in urban areas.

Recent changes in the organisation of the French health system include 1996's ordinances, and more recently (4th Law march 2002). The general tendency of all these reforms is the management of the health system at the regional level in France. In This paper we try to find how health data management systems could be concerned by this changes. In the first part we will explain why the health data management systems are implicated in theses changes. After that we specify the kind of information needed for strategic management of health at the regional level in Brittany. Then we discuss what information is available from all health data management systems at the regional level as far as decision making in health is concerned.

Résumé Les systèmes de soins anglais et français ont fait l’objet ces dernières années d’importantes réformes, dans un contexte de crise, motivées entre autres en France par le taux de croissance des dépenses de santé et en Angleterre par des dysfonctionnements dont les listes d’attente. Après une description des carac-téristiques actuelles du National Health Service (NHS), certains points de convergence et de divergence de politique respectives des deux pays seront évoqués : convergences des choix de priorités, la déconcentration des décisions, la négociation entre acteurs locaux, le développement du concept de qualité, les divergences de formulation des objectifs et d’implication des usagers. Cette approche permettra de mieux comprendre l’élaboration de ces politiques et leurs évolutions.

Background: Crohn s disease (CD) is characterized by bacterial invasion of the mucosa and the development of fistulae.Both phenomena point towards a disturbed immune reaction and reduced granulocyte function.This hypothesis is supported by results of antibiotic therapy in CD and case reports on healing of fistulae after treatment with G-CSF (N Engl J Med 340:239;1999).The Aim of this study was therefore to compare granulocyte function in CD patients with healthy controls.Methods: Phagocytic function of granulocytes was tested by assessing the uptake of opsonized E.coli using flow cytometry and the Phagotest kit (Orpegen Pharma, Germany) in 16 patients with Crohn's disease (7 fistulizing, 9 non fistulizing, age range 19-51 years) and 10 healthy volunteers (age 20-42).Additionally, secretion of pro-and contra-inflammatory cytokines was determined after whole blood LPS stimulation (50 pg/ml, Milenia Ex vivo stimulation kit, DPC Biermann, Germany) for 4 h (TNF-a) and 24 hours (ILlO), respectively.Results: Granulocytic phagocytosis was not impaired in CD as compared to healthy controls (77.0% vs. 82.2%E. coli positive cells; 849.1 vs. 967.6mean fluorescence intensity [mJ.i.]).The subgroup analysis of patients with versus without fistulae also showed no difference (69.8% vs. 82.1% E.coli positive cells; 760.4 vs. 911.2m.f.i.).CD patients had higher LPS-induced TNF-a secretion than controls (550.1 vs. 286.8pg/ml, not significant).Again no significant difference between fistulizing vs. non fistulizing patients was found (716.2 vs. 431.4pg/ml).Furthermore, CD patients showed significantly lower IL-lO secretion after LPS stimulation than controls (63.4 vs. 150.5 pg/ml, p=0.023).However, no significant difference between patients with fistulizing and non-fistulizing CD was seen (34.5 vs. 85.9 pg/ml).In conclusion, our data do not support the hypothesis that a defect in granulocyte phagocytic function is involved in the pathogenesis of CD or the development of fistulae.Effects of antibiotic or GCSF therapy must be explained by a different mechanism.

Background: Crohn s disease (CD) is characterized by bacterial invasion of the mucosa and the development of fistulae.Both phenomena point towards a disturbed immune reaction and reduced granulocyte function.This hypothesis is supported by results of antibiotic therapy in CD and case reports on healing of fistulae after treatment with G-CSF (N Engl J Med 340:239;1999).The Aim of this study was therefore to compare granulocyte function in CD patients with healthy controls.Methods: Phagocytic function of granulocytes was tested by assessing the uptake of opsonized E.coli using flow cytometry and the Phagotest kit (Orpegen Pharma, Germany) in 16 patients with Crohn's disease (7 fistulizing, 9 non fistulizing, age range 19-51 years) and 10 healthy volunteers (age 20-42).Additionally, secretion of pro-and contra-inflammatory cytokines was determined after whole blood LPS stimulation (50 pg/ml, Milenia Ex vivo stimulation kit, DPC Biermann, Germany) for 4 h (TNF-a) and 24 hours (ILlO), respectively.Results: Granulocytic phagocytosis was not impaired in CD as compared to healthy controls (77.0% vs. 82.2%E. coli positive cells; 849.1 vs. 967.6mean fluorescence intensity [mJ.i.]).The subgroup analysis of patients with versus without fistulae also showed no difference (69.8% vs. 82.1% E.coli positive cells; 760.4 vs. 911.2m.f.i.).CD patients had higher LPS-induced TNF-a secretion than controls (550.1 vs. 286.8pg/ml, not significant).Again no significant difference between fistulizing vs. non fistulizing patients was found (716.2 vs. 431.4pg/ml).Furthermore, CD patients showed significantly lower IL-lO secretion after LPS stimulation than controls (63.4 vs. 150.5 pg/ml, p=0.023).However, no significant difference between patients with fistulizing and non-fistulizing CD was seen (34.5 vs. 85.9 pg/ml).In conclusion, our data do not support the hypothesis that a defect in granulocyte phagocytic function is involved in the pathogenesis of CD or the development of fistulae.Effects of antibiotic or GCSF therapy must be explained by a different mechanism.

This paper is concerned by the possible use of the French Health Professional Network for Continuing Medical Education.. Based on our experience of development of a Virtual Medical University on the web server of the Medical School of the University of Rennes (www.med.univ-rennes1.fr) we plan to extend it to Continuing Medical Education. Most of the concepts can be used and the tools developed previously for the medical students and already available at our Medical School and University Hospital can be applied. We also plan to use problem based learning as it is now used in our Medical school for the Medical student before going to their residency or intership training. In the context of the French medical reform where Continuing Medical Education will be required for all private practitioners such training can be proposed to the physicians who are connected to the Intranet health network. The same model and system structure can be applied for any specialized field of clinical medicine including general practice and will be made available on the French Health Network .

OBJECTIVES:The aim of the study was to determine the incidence and the main clinical data of inflammatory bowel disease in Brittany.METHODS:According to EPIMAD registry's methodology, private and public gastroenterologists (n = 139) of Brittany (2836418 inhabitants) referred all patients consulting for the first time, in 1994 and 1995 with clinical symptoms compatible with inflammatory bowel disease. An interviewer practitioner completed at the gastroenterologist's consulting room a standard questionnaire for each patient. Each case was reviewed separately by four experts to assign a diagnosis of definite, probable, possible Crohn's disease, ulcerative colitis, unclassifiable chronic colitis, or acute colitis (onset of symptoms < 6 weeks).RESULTS:657 cases were recorded: 205 Crohn's disease (31%), 165 ulcerative colitis (25%) including 75 ulcerative proctitis (46%), 42 unclassifiable chronic colitis (7%), 245 acute colitis (37%). The crude mean annual incidence (per 10(5) inhabitants) based on definite and probable cases only was 2.8 for Crohn's disease and 2.9 for ulcerative colitis. The female/male ratio was 0.9 for Crohn's disease and 0.5 for ulcerative colitis. The median age at time of diagnosis was 27 for Crohn's disease and 36 for ulcerative colitis. The median time between onset of symptoms and diagnosis was equal to 3 months for Crohn's disease and ulcerative colitis.CONCLUSION:In Brittany the observed incidence of ulcerative colitis is similar to that of Crohn's disease and close to that observed in northern France. The incidence of Crohn's disease is lower. However, the real incidence of inflammatory bowel disease is currently underestimated due to the large number of acute colitis requiring a follow up and the cases of Crohn's disease classified as possible not taken into account.

Objectives. - The aim of the study was to determine the incidence and the main clinical data of inflammatory bowel disease in Brittany.Methods. - According to EPIMAD registry's methodology, private and public gastroenterologists (n=139) of Brittany (2 836 418 inhabitants)referred all patients consulting for the first time, in 1994 and 1995 with clinical symptoms compatible with inflammatory bowel disease. An interviewer practitioner completed at the gastroenterologist's consulting room a standard questionnaire for each patient. Each case was reviewed separately by four experts to assign a diagnosis of definite, probable, possible Crohn's disease, ulcerative colitis, unclassifiable chronic colitis, or acute colitis (onset of symptoms <6 weeks).Results. - 657 cases were recorded : 205 Crohn's disease (31%), 165 ulcerative colitis (25%) including 75 ulcerative proctitis (46%), 42 unclassifiable chronic colitis (7%), 245 acute colitis (37%). the crude mean annual incidence (per 10(5) inhabitants) based on definite and probable cases only was 2.8 for Crohn's disease and 2.9 for ulcerative colitis. The female/male ratio was 0.9 for Crohn's disease and 0.5 for ulcerative colitis. The median age at time of diagnosis was 27 for Crohn's disease and 36 for ulcerative colitis. The median time between onset of symptoms and diagnosis was equal to 3 months for Crohn's disease and ulcerative colitis.Conclusion. - In Brittany the observed incidence of ulcerative colitis is similar to that of Crohn's disease and close to that observed in northern France. The incidence of Crohn's disease is lower. However, the real incidence of inflammatory bowel disease is currently underestimated due to the large number of acute colitis requiring a follow up and the cases of Crohn's disease classified as possible not taken into account.

Die Reform des staatlichen Gesundheitsdienstes in GroBbritannien: das Ende eines Mythos Der staatliche Gesundheitsdienst GroBbritanniens wird oftmals den Systemen gegeniibergestellt, die auf dem Versicherungsprinzip basieren, wie beispielsweise der Sozialversicherung in Frankreich, wo der Erbringer von Gesundheitsdiensten und der Versicherer, der die Kosten erstattet, zwei verschiedene Einheiten darstellen. Beim britischen Gesundheitsdienst, der ausschlieBlich aus Steuermitteln finanziert wird, ist eine solche Unter- scheidung bedeutungslos. Hinsichtlich der Kostendâmpfung und der Effizienz kennt dieser Gesundheitsdienst jedoch die gleichen Problème wie die anderen Système. Vor diesem Hintergrund zielten die in den neunziger Jahren durchgefuhrten Reformen auf die Schaffung eines Quasimarktes in einem System ab, das bis dahin ûberaus zentralisiert war; dadurch sollte erneut eine gewisse Unterscheidung zwischen Kunden und Anbietern von Gesundheitsdiensten eingefuhrt und dem Allgemeinmediziner eine grôBere Rolle und Verantwortung zugewiesen werden. Lângerfristig wird dièse grôBere Verantwortlichkeit sicherlich zu einer starkeren Effizienz des Systems beitragen. Es stellt sich allerdings die Frage, ob dies nicht eine Selektion der Patienten entsprechend ihren Risiken zur Folge haben wird.

From 1 January 1982 to 31 December 1986 in five haematological centers of the west of France (Rennes, Rouen, Nantes, Tours and Angers), we have collected 503 cases of myelodysplastic syndrome (MDS). These cases were classified by FAB recommendation as followed: 85 refractory anemia with ring sideroblasts (RARS); 273 refractory anemia in which 86 were without blasts (RA), 153 were with excess of blasts (RAEB) and 34 were with excess of blasts and in transformation (RAEB-t); 111 chronic myelomonocytic leukaemia (CMML); and 34 cases with borderline features. The point date for statistical study was 31 December 1988, and the scoring method of Bournemouth was applied to compare with our findings (62% resulted in death, and 18% in leukemic transformation). It was demonstrated that haemoglobin, platelets, and bone marrow-blasts are the best factors to predict survival or leukemic transformation (LT). But peripheral neutrophils don't affect the survival time excepted when lower than 500 μl (13 months vs 19.6 months). A scoring system based on haemoglobin (Hb), platelets (Pl), and bone marrow blasts (BMB) may be represented in a three-dimensional space and is a good tool to know the own value of each parameter. This 3-D system shows that BMB and Pl are the most important factors and are correlated with survival, per cent of death, and LT (p < 0.0001). The LT is observed in 18% of the whole population. RAEB and RAEB-t progress in AML2 (14.6%) or AML4 (1.4%), and CMML progress in AML2 (8.1%) or AML4 (11.7%). We observed that monocytes are not good parameters to predict the type of leukemic transformation. Furthermore, survival of RA treated with Ara-C(ld) or not treated was similar.

Au haut risque de contaminations professionnelles liées aux soins, bien connues, s'est ajouté depuis 1981 la contamination liée au VIH et aux infections opportunistes qui l'accompagnent.Depuis juin 1987, les cas de S.I.D.A. avérés étaient au nombre de 1917 en France et 32395 aux États-Unis.Les risques encourus par les professionnels de santé ont fait l'objet de nombreuses études aux États-Unis en analysant les séropositivations. Si le risque professionnel d'infection par le virus VIH semble limité, un cas cependant de chirurgien-dentiste malade du S.I.D.A. a été décrit, pour lequel les seules raisons retrouvées sont professionnelles. Travaillant à New-York au contact d'une population à risque et sans précaution particulière, il a contracté une infection virale par un contact muqueuse-cutanée/sang et salive.Face aux risques de contamination par le virus et toutes les affections associées, des recommandations pour les soins en odonto-stomatologie s'imposent. Ces précautions regroupent cinq points capitaux :– information sur les facteurs de risque ;– protection du praticien et de ses aides ;– antisepsie et protection des mains ;– utilisation d'instruments, matériels et aiguilles à usage unique, dans la mesure du possible ;– utilisation de la stérilisation ou désinfection à haut niveau pour le matériel réutilisable.L'ensemble de ces mesures est détaillé et discuté dans cet article. A partir de mesures simples concernant la prévention du risque infectieux en cabinet dentaire, il est possible de diminuer le risque de survenue d'une infection nosocomiale, notamment virale ou opportuniste, tant pour le patient que pour le praticien. Une prévention adaptée et une discipline stricte des comportements permettent de réduire au minimum le risque infectieux dont on sait la gravité dans le cas des infections à VIH.