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.