Psychological effect of exercise in women with breast cancer receiving adjuvant therapy: what is the optimal dose needed?

BACKGROUND: Several meta-analyses have examined the role of exercise interventions in improving psychological outcomes in cancer survivors but most did not focus on adjuvant therapy period and did not investigate the optimal dose of exercise needed. The present meta-analysis examines the impact of exercise interventions delivered at this particular period on fatigue, anxiety, depression, and quality of life (QoL) as well as dose-response relationships between volume of prescribed exercise and these psychological outcomes. MATERIALS AND METHODS: Randomized, controlled trials that proposed an exercise intervention to patients with breast cancer undergoing chemotherapy and/or radiotherapy were systematically identified and coded. Psychological outcomes effect sizes were calculated and analyzed for trends using linear and quadratic regressions. RESULTS: Pooled effects of the 17 included studies revealed improvement for all outcomes, significant for fatigue, depression, and QoL with pooled estimates ranging from 0.2 to 0.5 favoring intervention. Significant inverse associations of the volume of prescribed exercise with fatigue and QoL were observed. CONCLUSIONS: Exercise intervention improved fatigue, depression, and QoL in patients with breast cancer receiving adjuvant therapy. Prescription of relatively low doses of exercise (<12 MET h/week) consisting in ∼90-120 min of weekly moderate physical exercise seems more efficacious in improving fatigue and QoL than higher doses.

Accuracy of computed tomographic colonography in a nationwide multicentre trial, and its relation to radiologist expertise.

OBJECTIVE: Reports on the accuracy of computed tomographic colonography (CTC) mainly involve series from expert institutions. The aims of this study were to assess CTC accuracy in a nationwide population and to relate it to radiologist performance in their initial training. DESIGN: Nationwide multicentre trial. SETTING: Twenty-eight radiologists, working in 26 mostly academic clinical units, were involved in the study after having attended a formal specialised 2-day training session on CTC. They worked through a training set of 52 cases with automatic feedback after an attempt at each case. PATIENTS: The study enrolled 845 patients with average and high risk of colorectal cancer, 737 of whom had both complete CTC and videocolonoscopy data, which constituted the dataset. INTERVENTIONS: Patients underwent same-day CTC followed by videocolonoscopy with segmental unblinding of CTC results. MAIN OUTCOME MEASURES: Sensitivity, specificity and positive and negative predictive values for detection of polyps ≥ 6 mm in per-patient and per-lesion analyses of CTC without computer-aided detection. RESULTS: Sensitivity, specificity and positive and negative predictive values for patients with polyps ≥ 6 mm were 69% (95% CI 61% to 77%), 91% (95% CI 89% to 94%), 67% (95% CI 59% to 74%) and 92% (95% CI 90% to 94%), respectively. Univariate analysis showed that the detection rate for polyps ≥ 6 mm was linked to neither radiologist case volume nor number of polyps, but was related to sensitivity achieved in the training set. Pooled sensitivity was 72% (95% CI 63% to 80%) versus 51% (95% CI 40% to 60%) for radiologists achieving above and below median sensitivity in the training set (61%), respectively. Multivariate analysis showed that sensitivity for polyps ≥ 6 mm in the training set was the only remaining significant predictive factor for subsequent performance. CONCLUSIONS: Radiologist sensitivity CTC for detection of polyps ≥ 6 mm in training was the sole independent predictor for subsequent sensitivity in detection of such polyps.

[Impact of care pathway on the delay for initiation of antituberculosis treatment in Conakry, Guinea]. / Influence des parcours de soins sur le début du traitement antituberculeux à Conakry (Guinée).

Complex care pathways can result in detrimental treatment delay particularly in tuberculosis patients. The purpose of this retrospective study was to assess the care pathways followed by tuberculosis patients prior to diagnosis and to assess impact on the delay for initiation of treatment in Conakry, Guinea. A total of 112 patients were interviewed at the time of first admission for pulmonary tuberculosis with positive bacilloscopy. Based on interview data, pathways were classified as conventional (use of health care facilities only) and mixed (use of health care facilities, self-medication, and traditional medicine). The correlation between patient characteristics and type of pathway was assessed by univariate and multivariate analysis and the two groups, i.e., conventional vs. mixed, were compared with regard to delay for initiation of treatment. The care pathway was classified as mixed in two out of three patients. Multivariate analysis showed that this type of pathway was only correlated with schooling (p=0.02). The mean delay for treatment was similar, i.e., 13.4 and 12.8 weeks for conventional and mixed pathways respectively (p<0.68). The percentage of pathways including three consultations at health care facilities was significantly higher in the conventional than mixed group (72% vs. 30%, p<0.001). The main reasons given for delayed use of health care facilities were poor knowledge of tuberculosis symptoms (26%) and high cost of care (12%). The findings of this study indicate that tuberculosis patients follow a variety of care pathways that can lead to delayed treatment. An information campaign is needed to increase awareness among the population and care providers.

Pharmacokinetics of metaflumizone in the plasma and hair of cats following topical application.

Controlled laboratory studies have shown that a novel spot-on formulation containing 20% (w/v) metaflumizone (ProMeris for Cats, Fort Dodge Animal Health, Overland Park, KS) is effective for the treatment and control of fleas on cats. Two studies were conducted to determine the distribution of metaflumizone in the plasma and hair of cats following treatment at the minimum recommended dose of 40mg/kg. Six purpose-bred cats, three males and three females, were used in each study. Plasma or hair samples were collected from each cat just prior to dosing and periodically through 56 days after treatment. Samples were analyzed by HPLC methods validated for the determination of metaflumizone. Metaflumizone concentrations in plasma were below the method limit of quantification (<50ng/ml) in all samples but one, and were frequently not detectable (<1.1ng/ml). Plasma collected 3 days post-treatment from one cat had a metaflumizone concentration of 57.8ng/ml. The frequency of measurable levels of metaflumizone in the plasma was too low to allow the calculation of pharmacokinetic parameters. Analysis of hair samples indicated that metaflumizone was widely distributed in the hair coat of the cat within 1 day after administration, reaching maximum concentrations within 1 or 2 days post-treatment. Low but quantifiable levels were still present at the end of the 56-day study. Data from the present studies indicate that the ectoparasitic activity is due to exposure of the parasites to metaflumizone on the surface of the host (skin and hair), not to exposure via the circulatory system of the host.

Pharmacokinetics of metaflumizone and amitraz in the plasma and hair of dogs following topical application.

Controlled laboratory studies have shown that a metaflumizone plus amitraz combination (ProMeris/ProMeris Duo for Dogs, Fort Dodge Animal Health, Overland Park, KS) applied topically is effective for the treatment and control of fleas and ticks on dogs. Two studies were conducted to determine the distribution of both metaflumizone and amitraz in the plasma and hair of dogs following treatment at the minimum recommended dose of approximately 20mg/kg of each active ingredient. Six purpose-bred, adult Beagle dogs were used in each study. Plasma or hair samples were collected from each dog just prior to dosing and periodically through 56 days after treatment. Samples were analyzed by HPLC methods validated for the simultaneous determination of metaflumizone and amitraz. Amitraz was detectable (>3.2ng/ml) but not quantifiable (<50ng/ml) in only two plasma samples, collected 1 and 2 days post-treatment from different dogs. Metaflumizone concentrations in plasma were generally detectable (>1.0ng/ml) but not quantifiable (<50ng/ml). Measurable levels were found in one dog 7 days post-treatment, increasing to a maximum of four dogs at 42 days after dosing, with a metaflumizone range of 59-138ng/ml. Analysis of hair samples indicated that both metaflumizone and amitraz were widely distributed at basically similar levels in the hair within 1-day after administration, reaching maximum concentrations between 2 and 7 days post-treatment. Low but quantifiable levels of both compounds were still present on hair at the end of the 56-day study. These studies indicate that the ectoparasitic activity is due to exposure of the parasites to metaflumizone and amitraz on the surface of the host (hair and/or skin), not to exposure via the circulatory system of the host.

[A qualitative study for identifying determinants of the quality of stroke patient referral]. / Etude qualitative pour l'identification des facteurs influençant la qualité de l'orientation et du transfert de patients atteints d'accident vasculaire cérébral.

BACKGROUND: Referral of patients from acute to rehabilitation care is a key stage in the overall quality of stroke care. The aim is to choose the most appropriate care pathway taking into account patient needs and preferences, as well as constraints such as bed availability. The objective of the project was to identify factors contributing to the quality of transfer decisions. METHODS: Semi-directive interviews were conducted among health care professionals, patients and their relatives. From this work, a preliminary list of factors contributing to the quality of the referral decision was issued. In order to identify their pertinence and feasibility, these factors were re-phrased into criteria, and introduced into a Delphi questionnaire which was circulated twice among a panel of 39 health care professionals. RESULTS: At the end of the Delphi survey there was consensus about: the importance of the mutual knowledge between acute and rehabilitation teams, the possibility to call on rehabilitation competencies in order to define rehabilitation objectives while the patient is hospitalised in acute care, the attention given to patient preferences, and reliability of information exchange between teams. A consensus was reached for one of the six criteria regarding feasibility, specifically the awareness of admission procedures in rehabilitation wards. CONCLUSION: Establishing a list of selected criteria is a first step in the development of an evaluation tools which could be used within a network of health care structures involved in the care of stroke patients.

[Clinical guidelines: what are the viewpoints of physicians and housestaff working in hospital medical departments?]. / Recommandations de pratique clinique: le point de vue des médecins et des internes des services hospitaliers de médecine adulte.

BACKGROUND: Factors facilitating use of clinical guidelines by physicians working in French public hospitals are unknown. We wanted to ascertain the desires of physicians and housestaff working in medical departments. METHODS: A cross-sectional survey using a self-administered questionnaire with closed-ended questions and free comment was conducted in the two academic regional hospitals and the 20 district hospitals of Brittany. The following items were noted: individual and professional characteristics, use of and opinion about clinical guidelines, perceived usefulness of specific attributes of guidelines or implementation efforts. The results are shown separately for physicians and housestaff. The statistical significance of associations between physician characteristics and their opinions was tested by using the chi-square test. RESULTS: 390 out of 783 responded (50%). Nine housestaff and eight physicians out of ten responders found more positive than negative points to guidelines (decision making tool, standardization of practices, versus rigidity, lack of freedom in practice). One out of three reported using them regularly. Guidelines focusing on general medicine, covering both diagnosis and treatment, developed at the national level with local adaptation, synthetic and pocket-sized guide-book given directly to the housestaff by the department's physicians, were more likely to be used. One physician out of two would use more guidelines from specialty organizations, or would use them as a self-training tool in practices evaluation. CONCLUSION: Implementation of guidelines in hospital medical departments should take into account the housestaff demands as well as the need for the physicians' implication.

Differential pulse voltammetry in brain tissue. II. Detection of 5-hydroxyindoleacetic acid in the rat striatum.

Differential pulse voltammetry with electrochemically treated carbon fiber electrodes was used to study, in anesthetized rats, the alterations of the striatal electrochemical signal appearing at +300 mV (peak 3), following pharmacological manipulation of the animals. Decreases in peak 3 were obtained after injections of NSD 1015, Ro 4-4602 and Clorgyline. This, in conjunction with biochemical measurements, suggested that 5-hydroxyindoleacetic acid (5-HIAA) is, to a considerable extent, responsible for this electrochemical signal. Increases in peak 3 obtained after reserpine, L-tryptophan and D,L-5-HTP, as well as biochemical data reinforced this hypothesis, as did the detection of peak 3 in cerebrospinal fluid and its increase after probenecid injection. The occurrence of a feed-back mechanism is discussed following injection of D,L-5-HTP.

Differential pulse voltammetry in brain tissue. I. Detection of 5-hydroxyindoles in the rat striatum.

In vitro, differential pulse voltammetry combined with electrochemically treated carbon fiber electrodes enabled detection, in different solution of 5-hydroxyindole compounds, of an oxidation peak 3 at +300 mV. In vivo, a striatal peak 3 was also recorded at this potential. Electrolytic or 5,7-dihydroxytryptamine lesions interrupting the medial forebrain bundle (MFB) were followed by a decrease of 65% and 64% in peak height, but not elimination of the peak. Biochemical determinations were significantly correlated to the peak 3 measurements. The existence of peak 3 as well as hydroxyindole compounds in blood suggested a blood contamination under the experimental conditions employed. This possibility is confirmed both by the complete disappearance of striatal peak 3 in animals with the MFB lesioned and surgically prepared a week before recordings, and by biochemical measurements in parachlorophenylalanine-treated or perfused (phosphate-buffered saline solution) animals.

Efficacy of moxidectin 2% equine gel against natural nematode infections in ponies.

The efficacy of moxidectin 2% oral gel (Equest, Fort-Dodge) against European worm strains was studied through post-mortem worm counts and feacal egg counts (FECs) in 12 young ponies naturally infected. The animals were allocated in two groups of six ponies each: the first one was treated at 0.4 mg/kg b.w. and the second one received a placebo and served as control. All the ponies were necropsied 14 days post-treatment. The efficacy of moxidectin in reducing strongyle FECs ranged from 99.8% to 100% from 3 to 14 days after treatment. Moxidectin efficacy was 100% against Trichostrongylus axei and Triodontophorus spp., > 99.9% against Cyathostomes adults and L5, 92% against S. edentatus L5, 100% against O. equi L5, 99% against O. equi L4, and 92% against G. intestinalis. No animal treated with moxidectin was harbouring P. equorum, Habronema spp., G. pecorum nor G. nasalis, while the control group was slightly infected with these parasites. This experiment confirms the post-mortem worm count results obtained in the United States and the FECs results reported in Europe. Moxidectin showed to be safe in young ponies.

Persistent efficacy of topical moxidectin against Dictyocaulus viviparus and Ostertagia ostertagi.

The persistent activity of moxidectin topically administered at the dose rate of 0.5 mg kg-1 bodyweight was evaluated against experimental nematode infection in 30 calves randomly allocated to six groups. Five groups were treated on days -42, -35, -28, -21 and -14. The 6th group remained untreated as a control. On Day 0, the calves were infected experimentally with 1000 Dictyocaulus viviparus and 50,000 Ostertagia ostertagi larvae and killed 3 weeks later. The formulation of moxidectin showed excellent activity against both parasites for up to 5 weeks (> 99%). Six weeks after treatment the reduction in the number of D. viviparus was still high (> 90%). No adverse reactions to moxidectin were observed in any of the animals.

[Cancer of the esophagus in the department of Côte-d'Or]. / Le cancer de l'oesophage dans le département de la Côte-d'Or.

The registry of digestive tract tumors established for the department of Côte-d' Or was used to study the incidence and characteristics of oesophageal cancer in the area. The crude annual incidence rate was 15.5/100,000 for males, ans 1.1/100,000 for females. The corresponding age standardized rate (world standard) were 12.7 and 0.6. The sex ratio was 21.2. As compared to other cancer registries the Côte-d' Or is in intermediate range for males, in the low range for females. The incidence of oesophageal cancer was similar in urban and rural areas. The risk of oesophageal cancer in males was five times higher in workers than in high executives and professionals. There was no significant variation in oesophageal cancer incidence over the 8 years of the study. Rates tended to decrease slightly in both sexes. Most cancers were squamous cell carcinomas (92%). Adenocarcinomas represented 5% of the cases. The risk of an associated tumour of the upper respiratory and digestive tract was important (17.5%). Only 10.4% of the patients underwent curative surgery, while 53.4% were referred for radiotherapy alone. The overall 1-year survival rate was 18.4%, and the 5-year survival rate was 2.8%. The 5-year survival rate was 7.2% after curative surgery, and 3.2% after radiotherapy. These results underline the fact that the prognosis of oesophageal cancer in a well defined population where only one patient out of ten can benefit from curative surgery, remains poor.

[Acceptability of the Hemoccult test in general medical practice. Results of a pilot study]. / Acceptabilité du test Hémoccult en consultation de médecine générale. Résultats d'une étude pilote.

In view of preparing a controlled trial to assess the efficacy of screening for colorectal cancer by fecal occult blood testing in reducing cancer mortality, a pilot study was performed to evaluate the acceptability rate of the Hemoccult test in non selected subjects consulting in a general practice. 566 subjects aged 45 to 74 years from two small towns, Neuville-aux-Bois (Loiret) and Vicherey (Vosges) were included in the study. The screening test was proposed by GPs to 89.2% of their patients; of these, 5.6% refused the test and 9.4% did not return it. Of the tests carried out, 80.8% were performed spontaneously, and 19.2% after a recall letter. Acceptability depended neither on age or on sex. The patients' confidence in his GP was the most important acceptability factor (60%), followed by explanations the GP had provided, and ease of application. The results suggest that after receiving the correct information, a GP will succeed in prescribing the Hemoccult test to most high-risk subjects and that acceptability then proves excellent. Experience drawn from the pilot study has been very useful in conceiving the on-going controlled trial in Burgundy.

[Management by specialists of patients with digestive cancers in the Department of Côte-d'Or]. / La prise en charge par les médecins spécialistes des malades atteints de cancers digestifs dans le département de la Côte-d'Or.

The relative frequency of consultation of the different specialists involved in the diagnosis and treatment of cancer is not well known in France. This study was completed with data collected by the Digestive Tract Cancer Registry in Côte d'Or. Among 3.192 digestive tract cancers diagnosed between 1976 and 1982, 64 p. 100 were treated by gastroenterologists or surgeons. Only 18% of the patients consulted an oncologist. The frequency of consultation of gastroenterologists in the care of digestive tract cancers was independent on the location of the cancer but varied with the place of residence, fluctuating from 69.7% for patients living in the town of Dijon, to 39.9% for patients living in a town with a regional hospital without gastroenterologist. The inverse phenomenon was observed for oncologists. They treated 63.2% of the patients with esophageal cancer and 31.2 p. 100 of patients with rectal cancer, but less than 10 p. 100 of the patients with gastric, colonic, liver, biliary tract or pancreatic cancer. The number of surgeons consulted depended essentially on the operability of the cancer. Between 1976 and 1982 consultation with gastroenterologists and surgeons by patients with digestive tract cancer increased by 4.4 p. 100 (p less than 0.05) and 2.1 p. 100 per year (p less than 0.01), respectively. The frequency of consultation of oncologists remained stable: +0.3 p. 100 per year. These results confirm the importance of a training policy oriented towards specialists who are not oncologists. They must take note of their importance in the diagnosis and the organization of the fight against digestive tract cancers.

The persistence of the efficacy of injectable or oral moxidectin against Teladorsagia, Haemonchus and Trichostrongylus species in experimentally infected sheep.

The persistence of the efficacy of moxidectin was evaluated against experimental gastrointestinal nematode infections in 55 lambs randomly allocated to 11 equal groups and infected on day 0. Moxidectin 1 per cent injectable solution was administered at a dose rate of 0.2 mg moxidectin/kg bodyweight to five of the groups on days -42, -35, -28, -21 and -14; five other groups were treated with moxidectin 0.1 per cent oral drench at the same dose rate on days -35, -28, -21, -14 and -7, and the 11th group remained untreated as a control. The lambs were infected experimentally with 8000 Teladorsagia circumcincta, 2000 Haemonchus contortus and 10,000 Trichostrongylus colubriformis infective larvae and killed three weeks later. Both formulations of moxidectin showed excellent activity against T circumcincta and H contortus with almost 100 per cent efficacy against the abomasal parasites for up to 35 days after treatment. The efficacy of moxidectin 1 per cent injectable against T colubriformis was much higher (> 99 per cent) than that of the oral drench and it was highly effective up to 21 days after treatment, and gave a moderate reduction in worm burden for up to 35 days after treatment. No adverse reactions to moxidectin were observed in any of the animals.

[Breast cancer screening and medical consumption]. / Dépistage du cancer du sein et consommation médicale.

BACKGROUND: The use of general health services by women targeted by breast cancer screening campaigns, and its variations, are poorly known. A survey has been undertaken during one of these campaigns in a britton department. This study aimed at pointing out possible differences in use of general health services: search for an overuse by women whose screening resulted positive/negative, in relation to women whose screening resulted full negative; search for an overuse by women having participated, in relation to women within the age range of the screening campaign and not having wished to participate. METHODS: Three groups of women, aged 50 to 69 years, free of breast cancer, were compared. A random sample was drawn in each group, weighing for age in group D0. Inclusion of cases was undertaken between January 1995 (beginning of the screening campaign) and June 1996. Use of health services was recorded during the six months following the first screening test, using the health insurance services data. Expenses related to inpatient care were not recorded. RESULTS: The structure of age of the three groups was comparable. The proportion of women having requested no reimbursement was identical between the groups D+ and D-. For the D+ group, the average cost was 4,246 Francs per woman. It dropped to 3,871 Francs after deduction of expenses related to additional medical examinations following the finding of a positive screening test. It was 5% higher than the average cost in the D- group (3,698 Francs). The cost varied a great deal within each group and the differences observed between the groups were not statistically significant The proportion of women of the D0 group not having requested any reimbursement was significantly lower than those of the groups D- and D+, overall, and for the majority of the categories of expenditure. CONCLUSION: The result of the screening does not induce significant variation of use of general health services, apart from the expenses induced by the invalidation of the positive result. The group of women not having participated in screening includes a stronger proportion of both low and higher health services users.

[Survival in colorectal cancers in population statistics]. / La survie des cancers colo-rectaux dans les statistiques de population.

Available population based survival statistics for colorectal cancers were compared. The results based on relative survival rates showed similar data in Finland, Norway, Geneva and Cote d'Or. The survival rates were lower in Great Britain and Iceland. Several factors complicate survival comparisons: age, exact localization of the tumour, definitions and distribution of tumour stages. Adjustment of these factors is necessary. If their definitions differ, no conclusion can be based upon the data. Population based survival figures provide public health authorities with a basis for monitoring cancer patient care. They are also useful for assessing the resources required for cancer treatment, follow-up and rehabilitation. They provide clinicians with survival data for reference.

[Cervical smears in general medicine. Evaluation of the regular performance of cervical smears among the patients of general practitioners in the Rhône-Alpes region]. / Les frottis cervicaux en médecine générale. Evaluation de la réalisation régulière de frottis cervicaux dans la clientèle de médecins généralistes de la région Rhône-Alpes.

Cervical smears in the area of "Rhône Alpes" are evaluated through a population examined by general practitioners. Among 10,000 examined women, aged from 15 to 69 years, 20% had never been smeared. In 8% of the remaining 8,000 cases, the smear was realized since more than 5 years. Absence or prolonged delay was more frequently met with more aged women, from unfavorable or rural area; or foreigner (from South of Europe or from North-West Africa). These results are discussed and compared with those of other studies whether inside or outside France. Certainly, they are under-estimated as regards the general population. In fact, this study considers an already mostly medicalized population together with volunteer general practitioners. However, it's always less medicalized than in most of French studies considering this subject.

[Factors affecting quality of care for elderly subjects undergoing surgery for hip fracture: review of the literature]. / Facteurs de qualité de la prise en charge des sujets âgés opérés d'une fracture de l'extrémité supérieure du fémur: revue de la littérature.

Hip fractures are one of the leading causes for admission of elderly subjects to healthcare facilities. Because of population aging, the incidence of hip fractures has increased considerably over the last years and will continue to increase in industrialized countries. Hip fracture in an elderly subject may be life threatening and has a significant functional and social impact not only because of the fracture itself, but also because of the risk of complications related to the patient's health status and the long hospital stay. The purpose of this work was to identify in the published literature professional practices, excepting the surgical procedure, associated with better early and long-term outcome in elderly patients with hip fracture. Questions raised concerning the patient's hospital stay include factors related to the preoperative phase (time to surgery, usefulness of traction), the operation itself (antibiotic prophylaxis, anesthesia technique), and the postoperative phase (prevention of venous thrombosis, malnutrition, episodes of confusion, duration of indwelling bladder catheter, correction of anemia, geriatric care during the stay in the orthopedic ward, early and intense rehabilitation, prevention of recurrence). Among these factors, several appear to be associated with better outcome, including long-term outcome--surgery as early as possible in light of the patient's general status, antibiotic prophylaxis in accordance with standard recommendations (SFAR), prevention of venous thrombosis with low-molecular-weight heparin initiated at admission and associated with elastic contention. Oral nutritional support is probably beneficial and should be proposed for all patients. Particular attention must be given to prevention of confusion in order to reduce the rate of institutionalization. The rythm of rehabilitation exercises should be at least five sessions per week. Finally, there are several methods, which are effective in preventing recurrence, taking into account osteoporosis, risk of falls. Preventive measures should be instituted for all patients undergoing surgery for hip fracture.

[Difficulties with the implementation and institutional stakes in the continuing education of private physicians]. / Difficultés de mise en place et enjeux institutionnels de la formation continue des médecins libéraux.

The Formation Medical Continue (FMC) is a continuing education programme for private practice doctors (generalists and specialists), and was established in the legislation of April 1996. In analysing the stages of the policy's introduction, an attempt was made to understand the difficulties encountered in its implementation. Using a semi-directive questionnaire, the opinions concerning the policy were collected from the different actors in the process: professionals, social welfare organisations, government agencies and health organisations. The analysis of their perceptions was complemented by an analysis of historical data and a review of the literature. The greatest difficulties with implementation related to the interactions among the stakeholders: the "game" of the medical unions, among themselves and with social security and government agencies; the under-representation of the medical profession, exacerbated by its divisions and the split between generalists and specialists; the indecision of government agencies, leaving the stakeholders waiting; the "game" of the social security funds, which act as if the principle of "mutualisation" of FMC funds can be by-passed. Conflicts of interest regarding the FMC have "crystallised" among the different stakeholders, as well as within the medical corpus. These conflicts relate in particular to the creation of the memorandum agreement and to the definition of the relationship with the pharmaceutical industry.