[Professional profiles and representations of staff members in Burundi health centers: Socio-professional groups with compartmentalizes knowledge]. / Profils et représentations professionnelles des agents en centre de santé au Burundi : des groupes socio-professionnels aux savoirs cloisonnés.

BACKGROUND: The professional identities, profiles and representations of Burundian health workers remain insufficiently explored. Our twofold objective is to identify the different socio-professional profiles of first-line caregivers and to explore their respective representations of health workers and work. METHODS: The first study describes the overall population of the 1047 staff members employed in 2014-2015 in 62 health centers. The second is a cross-sectional survey conducted in April 2014. Using IRAMUTEQ© software, we conducted textology analysis of the structure and contents of 911 respondents' representations via 3 free associations with regard to 6 questions on the "good worker" and the "what renders one capable of doing good work". RESULTS: At the normative level, among all categories of staff, a relational role is a foundation of professional identity, while technical or administrative functions remain marginal. At the positional level, responses differed according to initial qualification level but not as a function of their role with patients or their professional experience. Three socio-professional categories emerged. The most qualified category (one-quarter of the population) consists primarily of male caregivers, with a high turnover rate (4 years) associated with prospects for further training and career development. These persons present the most professionalized representations of the worker and work. The second quarter has an average level of qualification and turnover (10 years), and is mainly composed of female caregivers with limited professional perspectives. This group's representations are less technical and more patient-centered. Finally, the remaining half consists of relatively low-skilled staff members in charge of technical and logistical support, who are likely to spend their entire career in the same center (>20 years). Largely disregarded by the health care system and its funders, they have few opportunities for training or advancement and despite their long experience, maintain profane representations of workers and work. CONCLUSION: Our results shed light on the predicament of unskilled staff members whose expectations are rarely taken into consideration, even though they represent a significant proportion of the workforce, perform tasks essential to quality of care, and serve as bearers of the memory of their hospital center. These results also highlight the compartmentalization of practices and knowledge between categories of workers and underscore the failure of continuous training strategies targeting the unskilled.

Epidemiology of multiple sclerosis.

Multiple sclerosis (MS) is the most frequently seen demyelinating disease, with a prevalence that varies considerably, from high levels in North America and Europe (>100/100,000 inhabitants) to low rates in Eastern Asia and sub-Saharan Africa (2/100,000 population). Knowledge of the geographical distribution of the disease and its survival data, and a better understanding of the natural history of the disease, have improved our understanding of the respective roles of endogenous and exogenous causes of MS. Concerning mortality, in a large French cohort of 27,603 patients, there was no difference between MS patients and controls in the first 20 years of the disease, although life expectancy was reduced by 6-7 years in MS patients. In 2004, the prevalence of MS in France was 94.7/100,000 population, according to data from the French National Health Insurance Agency for Salaried Workers (Caisse nationale d'assurance maladie des travailleurs Salariés [CNAM-TS]), which insures 87% of the French population. This prevalence was higher in the North and East of France. In several countries, including France, the gender ratio for MS incidence (women/men) went from 2/1 to 3/1 from the 1950s to the 2000s, but only for the relapsing-remitting form. As for risk factors of MS, the most pertinent environmental factors are infection with Epstein-Barr virus (EBV), especially if it arises after childhood and is symptomatic. The role of smoking in MS risk has been confirmed, but is modest. In contrast, vaccines, stress, traumatic events and allergies have not been identified as risk factors, while the involvement of vitamin D has yet to be confirmed. From a genetic point of view, the association between HLA-DRB1*15:01 and a high risk of MS has been known for decades. More recently, immunogenetic markers have been identified (IL2RA, IL7RA) and, in particular thanks to studies of genome-wide associations, more than 100 genetic variants have been reported. Most of these are involved in the immune response and often associated with other autoimmune diseases. Studies of the natural history of MS suggest it is a two-phase disease: in the first phase, inflammation is focal with flares; and in the second phase, disability progresses independently of focal inflammation. This has clear implications for therapy. Age may also be a key factor in the phenotype of the disease. In conclusion, France is a high-risk country for MS, but it only slightly reduces life expectancy. MS is a multifactorial disease and the implications of immunogenetics are major. Preventative approaches might be derived from knowledge of the risk factors and natural history of the disease (smoking, vitamin D).

[Not Available]. / Utilisation de la radiothérapie intra-opératoire dans le traitement conservateur d'un cas de cancer du sein invasif chez un home.

Male breast cancer is a rare disease, accounting for less than 1% of all breast cancer cases. It is often diagnosed late, at a more advanced stage than its female counterpart. Therefore, it is more commonly treated with mastectomy. In early stages, a conservative treatment associating lumpectomy, sentinel lymph node (SLN) biopsy and whole-breast external beam radiotherapy (EBRT) is possible and has been described. Recently, intra-operative radiation therapy (IORT) has been assessed as an alternative to EBRT in selected female breast cancer cases. Its use has never been described in male patients. In this article, we present the case of a 56 years old man treated with lumpectomy with the excision of the nipple-areola complex, SLN biopsy, and IORT with electron beams (IOERT), for early breast cancer disease. This case demonstrates that the IORT technique is feasible on men with early breast cancer (pT1N0).

A prospective observational post-marketing study of natalizumab-treated multiple sclerosis patients: clinical, radiological and biological features and adverse events. The BIONAT cohort.

BACKGROUND AND PURPOSE: BIONAT is a French multicentric phase IV study of natalizumab (NTZ)-treated relapsing-remitting multiple sclerosis (MS) patients. The purpose of this study was to collect clinical, radiological and biological data on 1204 patients starting NTZ, and to evaluate the clinical/radiological response to NTZ after 2 years of treatment. METHODS: Patients starting NTZ at 18 French MS centres since June 2007 were included. Good response to NTZ was defined by the absence of clinical and radiological activity. Data analysed in this first report on the BIONAT study focus on patients who started NTZ at least 2 years ago (n = 793; BIONAT2Y ). RESULTS: NTZ was discontinued in 17.78% of BIONAT2Y. The proportion of patients without combined disease activity was 45.59% during the first two successive years of treatment. Systematic dosage of anti-NTZantibodies (Abs) detected only two supplementary patients with anti-NTZ Abs compared with strict application of recommendations. A significant decrease of IgG,M concentrations at 2 years of treatment was found. CONCLUSIONS: The efficacy of NTZ therapy on relapsing-remitting MS in a real life setting is confirmed in the BIONAT cohort. The next step will be the identification of biomarkers predicting response to NTZ therapy and adverse events.

[Cost of multiple sclerosis in France]. / Coûts de la sclérose en plaques en France.

Multiple sclerosis (MS) is one of the 30 chronic conditions specifically listed by the French healthcare system as a long-term disease (affections de longue durée [ALD]) for which the main health insurance fund (Caisse nationale d'assurance maladie des travailleurs salariés [CNAMTS]) provides full (100%) coverage of healthcare costs. The CNAMTS insures 87% of the French population (52,359,912 of the 60,028,292 inhabitants). The objectives of this study were to evaluate the direct and indirect medical costs of MS among the entire population insured by the CNAMTS in France in 2004. The CNAMTS provided us with access to the ALD database of patients with MS that contains different MS-related expenditures made in 2004. We calculated the overall direct and indirect cost of MS and the cost per patient and per item of expenditure. In 2004, 49,413 patients were registered on the ALD list for MS. Direct cost for MS patients was 469,719,967 €. The direct cost per patient and per year was 9,506 € with variations between regions (French administrative divisions) ranging from 10,800 € in northeastern France (Champagne-Ardenne) to 8,217 € in western France (Pays de la Loire). The different items of expenditure were treatments (44.5%), hospitalization (27.9%), nursing care (5.8%), physiotherapy (5.7%), transport (4%), biology (1.1%), and other (1.5%). During the course of the disease, the overall cost of MS increased slowly during the first 15 years (from 8,000 to 11,000 €), but dramatically the last year of life (23,410 €). The costs of immunomodulator treatments were higher during the first six years after registration on the ALD list. Conversely, physiotherapy costs increased linearly with time during the course of MS. Indirect costs were an estimated 116 million euros in 2004. A disability pension (8,918 € per patient) was perceived by 9,430 patients (19.1%) and a daily allowance (3,317 € per patient) by 9,894 patients (20%). In France, MS has an important economic impact, comparable to human immunodeficiency virus infection.

National estimate of multiple sclerosis incidence in France (2001-2007).

BACKGROUND: In France, the incidence of multiple sclerosis (MS) is not well known, and MS is one of the 30 long-term illnesses for which patients are covered for 100% of their health care costs. OBJECTIVE: To estimate the incidence of MS in France and its geographic variations. METHODS: We estimated the national rate for notification of MS to the main French health insurance system, and its confidence interval (CI), between November 2000 and October 2007, which covers 87% of the population. We analysed geographic variations using a Bayesian approach. RESULTS: Between November 2000 and October 2007, among a covered population of 52,449,871, some 28,682 individuals were registered as having MS. After age standardization according to the European population, the notification rate for MS was 6.8 per 100,000 (6.7-6.9), 9.8 (9.7-10.0) in women and 3.7 (3.6-3.8) in men. When the under-notification rate (11.5% and 29%) was taken into account, the notification rate per 100,000 inhabitants was estimated between 7.6 and 8.8. The notification rate was higher in north-eastern France, and lower on the Atlantic coast and in the Alps as well as on both sides of the Rhône River. CONCLUSIONS: This study, conducted on a representative French population, provides for the first time national estimates of MS incidence between November 2000 and October 2007.

[Focal subarachnoid hemorrhage and cerebral amyloid angiopathy: a non-fortuitous association]. / Hémorragie méningée focale et angiopathie amyloïde cérébrale : une association non fortuite.

INTRODUCTION: Cerebral amyloid angiopathy is a degenerative angiopathy due to amyloid deposits in the walls of the meningeal and cortical vessels. It is considered as a major cause of cerebral hemorrhage to the elderly. It was recently demonstrated that the association of focal meningeal bleedings and cerebral hemorrhage is very suggestive of cerebral amyloid angiopathy. In contrast, the links between subarachnoid hemorrhage and amyloid angiopathy are less well-known. CASES REPORTS: We report nine cases of cerebral amyloid angiopathy. The clinical presentation was variable, but all had at least one inaugural meningeal bleeding. As cortico-meningeal biopsies were not performed the Boston criteria were used to establish the diagnosis. CONCLUSION: Cerebral amyloid angiopathy is an underestimated cause of subarachnoid hemorrhage. Our observations show that this diagnosis should be evoked when focal meningeal bleeding occurs without head trauma or when focal subarachnoid hemorrhage is followed by a subcortical hematoma in an elderly subject.

[Subjective quality of life profile in patients with multiple sclerosis]. / Profil de qualité de vie subjective chez les sujets atteints de sclérose en plaques.

OBJECTIVES: This study aimed to assess subjective quality of life in patients with multiple sclerosis regarding the criteria of satisfaction and importance attached to various domains of life. METHOD: Sixty-one subjects took part in this study. The psychological evaluation consisted of a clinical interview and three questionnaires: subjective quality of life profile (PQVS), State-Trait anxiety inventory (STAI), Beck depression inventory (BDI). RESULTS: The results show a low level of general satisfaction of subjective quality of life. Fatigue and pain are the most unsatisfactory domains of life while the relationships with close relations and medical staff are perceived as the most satisfactory and important domains of life. Some differences are observed between men and women regarding the satisfaction of conjugal life and fatigue perception. The subjective quality of life seems mainly correlated to anxiety, depression and to the level of handicap. CONCLUSIONS: Our results emphasize the necessity of taking into account the subjective perception of the disease which can lead in an appropriated treatment. These results underline the place of anxious and depressive disorders associated with multiple sclerosis, which seem to have a certain impact on the subjective quality of life.

[Long-lasting and isolated Uhthoff's phenomenon after effort preceding multiple sclerosis]. / Phénomène d'Uhthoff lié à l'effort, isolé, précédant une sclérose en plaques.

INTRODUCTION: Described in 1890, Uhthoff's symptom corresponds to a transient blurred vision provoked by physical exercise or an increase of temperature. It is a frequent symptom occurring during the course of multiple sclerosis. PATIENTS AND METHOD: We report here four cases of patients presenting isolated Uhthoff phenomenon preceding multiple sclerosis by several years. RESULTS: These four patients presented transient neurological symptoms induced by intensive sporting activity for 1 to 6 years before diagnosis of multiple sclerosis. These symptoms were often visual but sometimes motor or sensorial. All symptoms appeared above a certain threshold specific to each patient, after 15 to 30minutes of intense physical exercise (bike, running or handball) and all disappeared after a few minutes to one hour rest with full recovery to baseline. DISCUSSION: Uhthoff's phenomenon is explained by a conduction block. It is due to axonal demyelization that provokes a reorganization of sodium channels induced by a decrease in a safety factor highly sensitive to temperature, or by release of soluble blocking substances (oxide nitric or cytokines). CONCLUSION: Without being specific, this symptom is strongly suggestive of this disease. Our case reports confirm the existence of "infraclinic multiple sclerosis".

Inflammatory demyelinating events following treatment with anti-tumor necrosis factor.

BACKGROUND: Tumor necrosis factor alpha (TNF-alpha) is an inflammatory cytokine involved in certain inflammatory diseases including multiple sclerosis (MS), rheumatoid arthritis (RA), and Crohn's disease. The anti-TNF-alpha treatments used for RA may be associated with inflammatory demyelinating events affecting the central nervous system and may possibly aggravate known MS. OBJECTIVE: We report here three new cases of inflammatory demyelinating events of the central nervous system following treatment with anti-TNF-alpha. RESULTS: The neurological symptoms appeared on average 5 months after initiation of the treatment. For all patients, the inflammatory process was confirmed by brain magnetic resonance imaging. The symptoms totally or partially regressed as soon as anti-TNF-alpha treatment was stopped except for one patient who developed clinically defined MS. CONCLUSIONS: Inflammatory demyelination of the central nervous system may be associated with the use of anti-TNF-alpha. Patients with rheumatoid arthritis treated with these treatments should benefit from a follow-up which includes brain MRI.

[Epidemiology of multiple sclerosis: The special situation in France]. / Epidémiologie de la sclérose en plaques : la particularité française.

In France, the risk of multiple sclerosis is considered medium to high risk. Several incidence and prevalence studies have been performed at regional and national levels. Prevalence is evaluated between 143 and 60 per 100 000 inhabitants. Prevalence of multiple sclerosis is higher in northeastern France. Incidence varies between 4.1 and 8.2 per 100 000 inhabitants depending on the region. In certain regions such as Lorraine, incidence among women seems to be on the rise.

[What has changed for stroke at the beginning of the 21st century]. / Les accidents vasculaires cérébraux : ce qui a changé au début du xxi(e) siècle.

INTRODUCTION: Striking developments in stroke epidemiology, initially based on the results of the Framingham study, have greatly improved our neuroepidemiological knowledge of the disease. STATE OF ART: The development of stroke registries has made it possible to evaluate the descriptive epidemiology of stroke and its evolution. With the increasing use of CT-scan, MRI, and either cardiac or vascular imaging, the diagnosis of stroke and its subtypes has been made easier. Over the last 20 years, a decrease in the incidence and mortality of stroke has been observed in Western countries. In contrast, in Dijon, which has the only population-based stroke registry in France, stable incidence rates have been reported. However, over the same period, age at stroke onset has risen by five years in men and eight years in women, which is probably related to both population aging and improvements in primary prevention and general health. The reported decrease in case-fatality rates suggests better acute management of stroke patients, and explains in part the increase in the prevalence of stroke. In addition, the assessment of vascular risk factors has demonstrated that high blood pressure remains the principal risk factor for both ischemic and hemorrhagic stroke, and that antihypertensive treatment is able to reduce stroke incidence. PERSPECTIVES: Epidemiology studies could make it possible to measure the impact of new therapeutic strategies applied in both primary and secondary prevention. CONCLUSION: Prevention, diagnosis, and acute treatment of stroke have considerably improved, but cerebrovascular diseases together with myocardial infarction remain the leading cause of death. Despite the absence of a rise in the incidence of stroke, its prevalence has increased. This is due to the decrease in case-fatality rates. As a consequence, there is an urgent need to organize health networks around stroke. Moreover, the rise in stroke-free life expectancy is a positive finding that reflects improvements in prevention.

Clinical parameters to predict response to interferon in relapsing multiple sclerosis.

BACKGROUND: To identify clinical parameters of response to beta-interferon (IFN-beta) in relapsing-remitting multiple sclerosis (RRMS) from an East France cohort. METHODS: Data from 2,645 patients, identified by Burgundy and Lorraine multiple sclerosis (MS) networks, were computerized by a neurologist using the European Database for MS software. Patient inclusion criteria were: clinically or laboratory-supported definite RRMS according to Poser's diagnostic criteria and treatment with IFN-beta for at least 6 months. Four criteria were chosen to predict a response to IFN-beta. The first criterion was any patient who had a lower annualized relapse rate under IFN-beta therapy than during the year preceding treatment; the second criterion was a lower relapse rate than during the 2 years preceding treatment. The third was any patient free of relapse during the first 2 years of IFN-beta therapy. The last criterion concerned the variation in the degree of disability measured by the Disability Status Scale during the first year of treatment. Multivariate logistic regression analyses were performed. RESULTS: 751 RRMS cases were included. A higher relapse rate in the year preceding IFN-beta onset, an older age at MS onset and having a polysymptomatic onset of MS were significantly associated with a response for the first criterion. With the 3 other criteria, no parameter predicting response was identified. CONCLUSION: Only the relapse rate in the year before initiation of IFN-beta treatment appears to be able to predict response to treatment but not the one of 2 years before.

[Contribution of the Dijon Stroke Registry after 20 years of data collection]. / Les apports du registre dijonnais des accidents vasculaires cérébraux en 20 ans d'activité

INTRODUCTION: The Dijon Stroke Registry is the only population-based registry in France which has collected neurological data without interruption for more than 20 years. This registry has produced reliable epidemiological data from a large non-selected population. PATIENTS AND METHODS: During the 20-year study period, 3142 ischemic strokes, 341 primary cerebral hemorrhages and 74 subarachnoid hemorrhages were recorded. Age at first stroke rose by five years in men and eight years in women. RESULTS: Comparing the descriptive epidemiology data between 1985 to 1989 and the 2000-2004 periods, the following results were noted: age- and sex-standardized incidences of first-ever stroke were stable except for lacunar stroke where the incidence increased significantly (p=0.05), and for cardioembolic stroke where incidence decreased significantly (p=0.01); 28-day case-fatality rates decreased significantly mainly for lacunar stroke (p=0.05) and for primary cerebral hemorrhage (p=0.03). The proportion of subjects with hypercholesterolemia and diabetes increased significantly (p<0.01). Analysis of cohort data issuing from the registry yielded the following findings: hyperglycemia during the acute stage of cerebral infarct was linked with poor prognosis; lower levels of E. apolipoprotein linked to HDL-cholesterol were associated with atherothrombotic infarcts; activation of coagulation factors was linked with atherothrombotic infarct; decreased N-acetyl-aspartate, a marker of the number of neurons, and increased serum lactate, a marker of anaerobic metabolism measured by proton magnetic resonance spectroscopy were noted in the cohort of cerebral infarct victims; release of platelet V-glycoprotein was noted in cerebral infarct; the incidence of cerebral infarct rose during autumn and during periods with high levels of atmospheric ozone and was higher in male smokers aged more than 40 years with hypertension. The population-based registry contributed to the assessment of medicoeconomic expenditures and professional practices. CONCLUSION: In Dijon, age- and sex-standardized stroke incidence has remained stable over the past 20 years. Increasing age at first-ever stroke, decreasing case-fatality rate, increasing use of antiplatelet treatments and a reduction in certain prestroke risk factors were noted.

[Immunofixation compared to isoelectric focusing in the detection of oligoclonal bands in cerebrospinal fluid of multiple sclerosis patients]. / Comparaison de l'immunofixation après électrophorèse sur gel d'agarose avec la focalisation isoélectrique dans la détection des bandes oligoclonales d'IgG du liquide céphalo-rachidien de patients atteints de sclérose en plaques.

INTRODUCTION: Intrathecal immunoglobulins (Ig) synthesis, reflected by oligoclonal bands (OCBs) in cerebrospinal fluid (CSF) is observed in up to 90 percent of patients with clinically definite Multiple Sclerosis (MS). The gold standard laboratory test to establish the presence of OCBs in CSF of MS patients is isoelectric focusing (IEF). However, a quicker and less expensive method has been developed: immunofixation (IF). METHODS: The aim of this study was to compare these two methods carried out 74 CSF/serum pairs of MS, 103 CSF/serum pairs of subject controls and to determine their sensitivity and specificity. RESULTS: The agreement between results from IEF and IF was excellent (Kappa = 0.84). IEF sensitivity (78 percent) was not significantly different from that of IF (74 percent) (p = 0.3). Similarly, the specificity of IEF (93 percent) was not significantly different from that of IF (95 percent) (p = 0.2). CONCLUSION: IF is a semi automated method which is easier to perform than IEF and which appears to be as efficient as IEF.