From public to occupational health: towards an inverse push-pull paradigm in nanotechnologies innovation

Nanotechnologies are an important set of new technologies no longer at a very early stage in their development. The financial support for R&D in this domain is greater than a few Giga Euros/year for innovation and considerably lower (less than 1-2%) for risk management. At the factory level, As Low As Reasonably Achievable (ALARA) methods have to be used in order to protect workers against possible exposure. New "short-term" toxicological studies show that nano-particles are seldom exempt of effects in humans... Thus, for the general population, more and more anxious about the future, nanotechnologies are the object of numerous debates. Ultimately, the population is asking governmental bodies to take the required preventive measures. Social pressure is now initiated by the public towards innovative industries, which have to prove, before the marketing stage, the absence of any risk for the users and demonstrate a safety driven governance.

A tool to evaluate rapidly the quality of clinical trials on topical acne treatment

Practicing dermatologists rarely evaluate therapeutic trials. This study was designed to build a simple evaluation tool, use it to evaluate the quality of published trials and thereby consider their applicability. Reports on 146 therapeutic trials, published from 1969 to 2004, were selected. A 50-item list was used for an initial assessment. After comparison with existing grids, a shortened nine-item list was established and used for this analysis. The results were analyzed item by item (logistic regression) and globally (principal component analysis). An index was then established and validated using Cronbach's coefficient alpha. The overall quality of trials was poor: 9% to 73% positive response range. This rate increased after 1990 for six items. Two factors explained almost 60% of the total variance: factor 1 summing six items concerning the formal content of the articles and factor 2 its underlying basis. Using the sum of these six variables, Cronbach's coefficient alpha reached 0.716; their mean sum improved from 1969 to 1970-2001-2005. The significantly improved quality of trials, based on the mean sum over time, supports well-founded basis of this tool. Regarding the application of evidence-based medicine in clinical practice, this tool is user friendly and should facilitate the updating of our knowledge.

[Linking: relationships between health professionals in the informal health networks]

BACKGROUND

During the last years, the french health system has been developing formal health networks. So, it was necessary to study informal health networks as <<social actors>> networks. More precisely, we studied the nature of relationships between various stakeholders around general practionners wich are commonly considering as the <<pivot>> stakeholder of the health system private sector.

METHODS

Fieldwork (ethnography based on direct observations and interviews) was conducted between October 2002 and april 2004, in the South-East of France. Ten monographs of general practioner's offices were achieved in a rural area; then, we achieved fieldwork of the informal health networks identified.

RESULTS

There is a cultural frame wich is common to all private professionals. This frame includes a triple ideal (teamwork built up the hospital model, independance, and an relational approach with patients). This frame does not square with the real practices. In fact, regulation mechanisms preserve the balance of relashionships between professionnal groups, by restricting/promoting exchanges and complex alliance strategies. These mecanisms include: (1) a few professionnal's rule as disponibility (to the patients and to the professionnals), as communication about patient, as patient's reference, as obligation to communicate between professionals; (2) some constraints such as territory superposition and competition with other professional groups; (3) some needs for: rileiving (of emotions and worries connected to work), sharing (decisions, responsabilities), of delegation (medical treatment, practices), protection against social and legal risk through the creation of trust relationships. These trust relationships are based on several logics (affinity, solidarity, similarity). The study shows the major place of the patient who is often the main organizer of his network, and even though he makes an important structuring work between medical staff, and an information transfer (on his diagnosis, on his treatment, and << on >> professionals). The patient's role of <<coordination>> is underestimated.

CONCLUSION

The results show that in studied informal networks, professionnals do not have a transversal view of the patient's care management. This is due to the lack of knowledge of each health agent about the work of others, to the symbolic compartmentalization between professional groups, and because the difficulties encountered (i.e. burden work).

The awareness and use of outcome measures by South African physiotherapists

Physiotherapists as well as otherhealth care providers a reunder pressure to provide evidence for the effectiveness of their interventions. Therefore it has become necessary to employ standardized androbust outcome measures in clinical practice. The objective of this study was to determine the awareness of and use of outcome measures (OM’s)amongst physiotherapists in South Africa. A survey was conducted in2004 using a self-developed electronic questionnaire consisting of 18questions, both open- and closed-ended. A population-based sample consisting of 1102 members on the email address list of the South Africa Society of Physiotherapy (SASP) was used. Data analysis consisted ofboth descriptive statistics and qualitative analysis for the open-endedquestions. The response rate was 15.2% (n=168). Ninety one percent of respondents reported to have heard of OM’s while 84% reported using OM’s regularly. Impairment related measures were predominantly in use. The two main themes that emerged from therespondents’comments related to reasons forusing OM’s were “effective clinical practice”(82%) and “evidence-basedpractice” (15%). Time constraints and lack of sufficient knowledge in the use of OM’s, were cited as obstacles tousing OM’s. These findings have implications forthe South African physiotherapy community in terms of education,continuous professional development (CPD) and future research in the usage frequency of OM’s.

Prise en charge de l'acné chez l'adolescent

Acne is an androgen-dependant inflammatory folliculitis with non-inflammatory lesions (open and closed comedos) and inflammatory papules, pustules and sometimes nodules. Topical retinoïds, benzoyl peroxyde, antibiotics with anti-inflammatory properties, antiandrogens in female acne (antiandrogens and antiandrogenic oral contraceptives), and isotretinoin are the major drugs used in the management of the affection. Acne has to be treated according to the type of acne, severity, age and sex. Acne may also be the major sign of ovarian (PCOS) or adrenal hyperandrogenism in either female teenagers or both sexes, respectively.

Corrélation clinique et psychologique dans l’acné : utilisation des grilles ECLA et CADI

BACKGROUND

The psychological consequences of acne are frequently unrelated to the severity of the actual lesions. Thus, a number of scales have been designed and validated to allow quantitation of the severity of acne, such as the ECLA scale (Echelle de Cotation des Lésions d'Acné or Acne Lesion Score Scale) while others are designed to evaluate quality of life, such as the CADI (Cardiff Acne Disability Index) questionnaire recently validated in the French language. The purpose of this study was to use both of these scales in individual applications in order to determine whether or not any correlation exists between the two specific tools and to determine the two groups of patients affected by acne.

METHODS

One hundred and twenty-eight acne patients (21+/-6.8 years) seen by seven dermatologists were included in this study. The severity of their acne was evaluated using the ECLA scale; the seven participating dermatologists were trained in the use of this scoring system. In addition, patients completed the CADI quality-of-life questionnaire after their consultation. Each factor on the ECLA was compared with each item in the CADI questionnaire by means of analysis of variance.

RESULTS

There was no correlation between overall scores on the ECLA and CADI scales (r(2)=0.0242). However, a positive correlation was observed between overall CADI score and factors F1 and F3 in the ECLA scale (p=0.0085 and p=0.0373 respectively). In contrast, the global score on the ECLA scale was significantly correlated with item 5 of the CADI questionnaire, namely patients' perception of their acne (p=0.0035).

CONCLUSION

Acne, even in mild forms, has a detrimental psychological effect on patients. The ECLA score coupled with the CADI assessment system appear to be two useful and complementary scores for use in complete acne patient management.

Des usagers sceptiques face aux médicaments génériques: une approche anthropologique

BACKGROUND

Since the enactment of the 2002 legislative measures favoring the prescription of generic drugs, various quantitative studies have shown that approval by prescribers and users has risen in France. Nevertheless, scepticism remains as well as distrust towards these drugs focusing on their effectiveness compared with brand-name drugs, on potential dangers, and on the interruption they cause in prescription and consumption habits. Using a comprehensive approach, this article analyzes the social and cultural logic behind the negative image of generic drugs.

METHODS

The materials issued from an ethnographic study on the prescription of drugs for high blood pressure. Sixty-eight interviews were undertaken between April 2002 and October 2004 with people (39 women and 29 men, between the age of 40 and 95, 52 over the age of 60) treated for over a year for high blood pressure in rural areas in the Southeast of France. Thirteen people provided unsolicited opinions about generic drugs.

RESULTS

Analysis of the information collected shows that users have various representations of generic drugs, including the idea of counterfeited and foreign drugs. These representations interfere with the adjustment process and the development of consumer loyalty. They are part of a set of social representations about drugs which form and express the user's reality. In these representations, the drug is an ambivalent object, carrier of both biological effectiveness and toxicity; it is also the metonymical extension of the prescriber, bestowing upon the prescription a symbolic value.

CONCLUSION

By placing the generic drug in its network of symbolic and social meaning, this study highlights the coherence of the scepticism towards generic drugs by consumers (and prescribers) with a system of common opinion in which drugs are everyday things, personalized and compatible with users, symbolic exchange carriers in the physician-patient relationship, and in which confidence in the drug is also that given to the health care system in general.

[Nicorandil-associated anal ulceration]

BACKGROUND

Nicorandil is a potassium-channel activator used in the treatment of angina pectoris. The first cases of anal ulcerations induced by nicorandil were published in 2002.

CASE REPORT

A 71-year-old man presented with a 2-year history of anal ulcerations occurring within a few months of initiation of treatment with Nicorandil. Histological tests on a biopsy sample showed granulation tissue with non-specific chronic inflammation. Nicorandil was stopped and this resulted in complete healing of the ulcers after three months.

DISCUSSION

Nicorandil can induce chronic and extensive anal ulcerations. The pathogenesis is unknown. Patients are usually treated with high doses of nicorandil. Dermatologists should be aware of this rare side-effect which heals after withdrawal of the drug.

Hypertrichose lanugineuse acquise et adénocarcinome gastrique

INTRODUCTION

Acquired hypertrichosis lanuginosa is a form of obligatorily paraneoplastic disease characterised by the recurrence of lanuga hair during adulthood. We report a case in which this hypertrichosis allowed diagnosis of gastric cancer.

OBSERVATION

A 51 year-old woman was seen for hypertrichosis present for 3 months. Clinical examination led to diagnosis of acquired hypertrichosis lanuginosa, which subsequently resulted in the discovery of gastric adenocarcinoma. Surgical excision of the tumour resulted in the disappearance of hypertrichosis with no recurrence during the ensuing 13 months.

DISCUSSION

Acquired hypertrichosis lanuginosa is rare, with only 50 or so cases reported in the literature since the condition was first described in 1865 by Turner. These cases confirm the obligatorily paraneoplastic nature of this particular dermatosis. Our finding is original since it is the first recorded case of association with gastric adenocarcinoma. It is also unique in terms of the strictly parallel development of acquired hypertrichosis lanuginosa and the tumour, with complete disappearance of the hypertrichosis in the weeks following surgical removal of the tumour, and in terms of prolonged survival (complete remission 17 months after the onset of symptoms). The mechanism responsible for acquired hypertrichosis lanuginosa is unknown. Two hypotheses have nevertheless been suggested: acquired hypertrichosis lanuginosa could be associated with secretion by the tumour of an as yet unidentified serum factor, or with a nutritional deficiency that may accompany this form of cancer.

Syndrome d’hypersensibilité médicamenteuse associé à une primo-infection HHV6

INTRODUCTION

Drug hypersensitivity syndrome is a severe life-threatening drug reaction. An association between this syndrome and HHV6 reactivation has been hypothesized.

CASE-REPORT

A 45 year-old women was treated with sulfasalazine for polyarthralgia. One month after beginning the treatment, she developed a drug hypersensitivity syndrome with severe acute hepatic failure. HHV6 serology and serum PCR revealed a primary HHV6 infection.

DISCUSSION

We report the second case of drug hypersensitivity syndrome associated with a primary HHV6 infection. An immunological disorder may explain such an association by increasing viral replication. Detection and titration of anti-HHV6 antibodies in each case of drug hypersensitivity syndrome should help to confirm this association and possibly modify treatment strategy.

Private practitioners`use of exercise therapy in lower back pain

Introduction: Lower back pain (LBP) is a common problem treated by physiotherapists.  Recent research confirms the need for a more dynamic approach, to the management of this condition and includes progressive activity and exercise.  The current use of exercise therapy for people with LBP and the implementation of evidence based practice in this field in South Africa, is unknown.  As 80% of physiotherapists in South Africa offer services in private sector, the purpose of the study was to determine the use of this modality by physiotherapists.  The specific aims were to determine how many physiotherapists utilise exercise therapy, how much therapy time is spent on it and how the modality is applied.  This information can determine whether there is a need for continuing professional development in this area.Method: A stratified random sample of 489 South African physiotherapists was selected to take part in a survey by means of a questionnaire.  Data was analysed descriptively and relationships between categories were analysed using Chi-square tests (p<5).Results: A response rate of 85% was reached.  All but one physiotherapist used exercise therapy however, only 16% of the physiotherapists spent more than half of the course of treatment on exercise therapy.  Most respondents (96%) specified dosages, 95% progressed exercises, but only 46% alwaysre-assess exercises at follow-up visits.  Homeexercises are often prescribed, but group exercises are seldom used.Conclusion: South African physiotherapists in private practice use exercise therapy as a treatment modality for  people with LBP.  Inconsistencies concerning the implementation and time spent on exercises, suggests the need for continual professional development in this area

The chronic colitis developed by HLA-B27 transgenic rats is associated with altered in vivo mucin synthesis

HLA-B27 transgenic rats spontaneously developing a chronic inflammation mainly involving the colon are recognized as a powerful animal model for IBD. We investigated the mucin production in 6-month-old HLA-B27 rats by measuring in vivo fractional synthesis rate (FSR) and expression of mucins. In the inflamed colon of HLA-B27 rats, the mucin FSR was stimulated by 75% compared to F-344 controls, while MUC2,3 mRNA expression was unchanged. A local depletion in mucus-containing goblet cells was observed, suggesting a rapid mucin production/release and/or a real global decrease in goblet cell number. In the noninflamed jejunum of HLA-B27 rats, the mucin FSR was reduced by 35% compared to controls, while MUC2,3 mRNA expression was unchanged. Different alterations in mucin metabolism and expression are observed between HLA-B27 rats and a model of chemically induced chronic colitis (DSS-treated rats), suggesting that mucin alterations may be dependent on the animal model and colitis underlying mechanism.

Vulvar cicatricial pemphigoid of childhood

We report a 9-year-old girl with a vulvar autoimmune bullous dermatosis. A diagnosis of localized bullous pemphigoid or cicatricial pemphigoid was made on the basis of immunohistologic data. Since the lesions were unresponsive to topical corticosteroids but healed completely on dapsone at a dosage of 1.5 mg/kg/day, we favor the diagnosis of vulvar cicatricial pemphigoid. Only two such cases have been reported thus far. The diagnostic criteria and therapeutic modalities are discussed.

Mucin production and composition is altered in dextran sulfate sodium-induced colitis in rats

We evaluated the small and large intestinal mucin production in a rat model of human ulcerative colitis by measuring the in vivo fractional synthesis rate (FSR) and the expression of mucins. A chronic colitis was induced by oral administration of 5% dextran sulfate sodium (DSS) for 9 days followed by 2% DSS for 18 days. DSS-treated rats showed increased colonic MUC2,3 mRNA levels compared pair-fed controls. The mucin FSR was unaffected while mucin-containing goblet cells were depleted in the vicinity of lesions. In the small intestine, no inflammatory lesions were observed but ileal MUC2 mRNA levels and mucin FSR were decreased by 46% and 21%, respectively. Finally, DSS-treated rats showed a marked decrease in mucin's threonine + serine content all along the gut, which may lead to a reduction of potential O-glycosylation sites. Our data indicate that the chronic colitis may impair the mucus layer protective function all along the gut.

[Acquired zinc deficiency in a breast-fed premature infant]

Symptomatic zinc deficiency can occur in exclusively breast-fed infants. We report a case in a preterm infant.

CASE REPORT

A 3-months-old exclusively breast-fed premature infant presented with peri-orificial and acral eczematoid lesions. Laboratory investigations revealed lowered zinc levels in the infant's serum and in her mother's milk. A rapid healing occurred after oral zinc supplementation.

DISCUSSION

Zinc deficiency in breast-fed infants is a rare disease caused by a low level of zinc in mother's milk. The clinical features resemble those of acrodermatitis enteropathica. Oral zinc supplementation is required until weaning.

Physiotherapy students’ perceptions of an innovative approach to clinical practice orientation

The transition from the classroom to clinical practice is stressful for many students. In the current situation in South Africawith the shortages of clinicians’ posts in hospitals, this transition is evenmore difficult given the reduced time that clinicians have for supervisingundergraduate students. The University of Stellenbosch initiated structured peer-led introduction to clinical education (SPLICE), duringwhich senior physiotherapy students orientate second year students toclinical practice.The aim of this study was to investigate the perceptions of all of thesecond, third and fourth year students who took part in these SPLICEsessions. This information was captured using a questionnaire with open and closed questions. The response of all of the students was extremely positive. Common to all cohorts of students was the opinion of themotivational benefits of the sessions as well as the opinion that their confidence increased. Students in the variousyears of study differed in the ways in which they felt more confident. Closely linked were those comments referring to a sense of increased preparedness for clinical practice and a positive learning environment. A positive change inattitude towards clinical practice was also noted in many second year students.Further research is needed into the effect that SPLICE might have had on the second year students when they enterclinical practice as third year students. The role and opinions of patients during these sessions, and indeed during anyclinical education sessions, including clinical examinations, needs further investigation.