[Toulouse, an "urban figure of public health". Dealing with public local struggles against health social differences]. / Toulouse, une "figure urbaine de la santé publique". À propos de l'action publique municipale de lutte contre les inégalités sociales de santé.

When drawing up the portrait of "urban figures of public health", in 1998, Didier Fassin considered Toulouse to be one of the worthy "local experiments". Fifteen years after his precursory work, the recently developed local public policy against health social differences gives an opportunity to question ourselves about the effectiveness of such a quality then associated to the city. A cognitive analysis of the elaboration of the Toulousian health public policy meaning enables to notice that the process of health legitimization on a local scale takes the following forms. On the one hand, renaming health as a legitimate object of public policies sets it up as a common wealth. On the other hand, local public policy puts the emphasis on health education and tries to increase the standing of social appraisal coming from associative experiments and abilities of the inhabitants themselves. Finally, it calls for citizens' mobilization and solidarity in order to promote a "health democracy" able to struggle efficiently against health social differences.

Treatment of male urethral strictures - possible reasons for the use of repeated dilatation or internal urethrotomy rather than urethroplasty.

OBJECTIVE: To investigate the possible reasons for repeated urethral dilatation or optical internal urethrotomy rather than urethroplasty in the treatment of male urethral strictures. PATIENTS AND METHODS: Men referred to the stricture clinic of our institution during the period April 2007 - March 2008 were reviewed and the operative urological procedures performed in the same period were analysed. Statistical analysis was performed using Student's t-test and Fisher's exact test (p<0.05 statistically significant). RESULTS: The mean age of the 125 men was 49.9 years (range 12.8 - 93.4 years). Previous stricture treatment had been given 1 - 2, 3 - 4 and 5 - 6 times in 52%, 32% and 12% of patients, respectively (4% had not undergone treatment). In these groups, previous treatment was dilatation in 70%, 76% and 72%, urethrotomy in 26%, 15% and 28%, and urethroplasty in 4%, 9% and 0, respectively. The group with 5 - 6 compared with 1 - 2 previous treatments was significantly older (mean age 60.2 v. 46.6 years) and had a significantly greater proportion with underlying co-morbidities (80% v. 52%). The group that had undergone urethroplasty compared with 5 - 6 repeated dilatations or urethrotomies was significantly younger (mean age 48.2 v. 60.2 years) with a lower prevalence of co-morbidities (47% v. 80%). During the study period urethroplasty was performed in 16 (2%) of 821 inpatients, whereas 55 men were seen who had undergone ≥3 previous procedures, indicating that urethroplasty was performed in less than one-third of cases in which it would have been the optimal treatment. Owing to limited theatre time, procedures indicated for malignancy, urolithiasis, renal failure and congenital anomalies were performed more often than urethroplasty. CONCLUSIONS: Factors that possibly influenced the decision to perform repeated urethrotomy or dilatation instead of urethroplasty were limited theatre time, increased patient age and the presence of underlying co-morbidities.

Carcinoma of the head of the pancreas. Morbidity and mortality of surgical procedures.

This retrospective study analyses the peri-operative morbidity and mortality of 165 patients presenting with carcinoma of the head of the pancreas over a 5-year period. Patients clinically fit for surgery (84%) were subdivided into three main groups, namely: group I (6%) underwent pancreaticoduodenal resection; group II (42%) had locoregionally advanced disease; and group III (36%) with metastatic disease. The latter group was subdivided into groups IIIa (22%) without ascites and IIIb (14%) with ascites. In the palliative groups (II and III), 61% underwent operative biliary drainage procedures, 33% a combined biliary drainage and a duodenal bypass procedure and 5% a duodenal bypass only. Obstructive jaundice recurred in 3% of cases after operative biliary drainage. Only 7% of patients required a duodenal bypass during follow-up. The mortality rates after surgery were 22% following pancreaticoduodenectomy (group I), 1.5% for the palliative procedures in group II, but 17% in group IIIa patients with metastatic disease without ascites and 83% when ascites was present (group IIIb). This study demonstrates that patients with ascites, although clinically fit for surgery, had a prohibitively high operative mortality rate and represented a subgroup of patients better treated by non-operative methods. Surgical drainage of the biliary system in all other cases had acceptably low morbidity and mortality rates. A prophylactic duodenal bypass is not mandatory.

[Partial ileal bypass for familial hypercholesterolemia]. / Gedeeltelike ileale omleiding vir familiële hipercholesterolemie.

The extent of reduction in cholesterol levels, the maintenance of low levels in the long-term, the morbidity and mortality as well as the acceptance of side-effects of the partial ileal bypass (PIB) is reviewed. The mean reduction in cholesterol levels following PIB was 35.2% in males and 35.8% in female patients. The reduction is significant and it is maintained over a 10-year period. The morbidity and mortality is low and side-effects are well tolerated. Our results indicate that the PIB may play an important role in the cholesterol-lowering armamentarium.

Characterization of immune complexes containing cytomegalovirus-specific IgM antibodies following a kidney graft.

In order to demonstrate the viral specificity of IgM-containing immune complexes (IgM-CIC) detected by a C1q assay in renal allograft recipients developing a CMV infection, a technique is described allowing: 1) the dissociation of IgM-CIC by action of an acid buffer, and 2) the characterization of the viral specificity of IgM antibodies released by this treatment. This step was performed by ELISA and Western Blot. When technique was applied to the follow-up of a renal allograft recipient developing a recurrent CMV infection within 2 months post-graft, it was found that the IgM-CIC detected on the day of the graft were not CMV-specific, whereas the IgM-CIC detected during the second month after transplantation contained CMV-specific IgM antibodies. These CMV-specific IgM-CIC were detected as early as the urinary viral excretion. It was shown by Western Blot analysis that these IgM antibodies reacted with a 45-47 kDa viral polypeptide which is a viral target for specific humoral response at the early phase of CMV infection.

Blocking-ELISA for detection of specific antibodies to the glycoproteins of the human immunodeficiency virus type 1 (HIV-1).

A blocking ELISA was developed to confirm the specificity of screening tests for anti-HIV-1 antibodies. A murine monoclonal antibody (McAb) raised against recombinant gp160 was used in combination with a commercial technique (ELA-VIA-1). After determining the optimal experimental conditions, the assay was applied to 92 samples presenting different reactivities by Western blot (WB) analysis. All the sera containing antibodies to gp160/gp120 (53) were positive in our assay. The six patients who sero converted showed a low positivity by ELAVIA-1 (optical density near the cutoff value) reacted by blocking-ELAVIA-1 with an McAb binding inhibition greater than 85%. By contrast, negative samples (29) and specimens that exhibited reactivity only against gag-proteins (10) were not detected (McAb binding inhibition smaller than 15%). This sensitive and specific blocking-ELAVIA-1 represents a convenient alternative to WB as a confirmatory test. The technique is time-saving and inexpensive and can easily be integrated with a screening test for diagnostic or epidemiologic studies on HIV-1 infection.

A new C1q solid-phase assay for the detection of IgM immune complexes: application to the follow-up of kidney graft recipients with recurrent cytomegalovirus infection.

A C1q solid-phase enzyme assay for detecting circulating immune complexes (CIC) containing immunoglobulins M was developed. IgM immune complexes (IgM-CIC) bind to purified C1q-coated microplates. The amount of bound IgM-CIC is determined by adding anti-mu-alkaline phosphatase conjugate. This assay proved IgM-CIC specific; it does not detect IgG-CIC nor free anti-CMV IgM. Furthermore Rheumatoid Factor (RF) does not interfere with this test. Then, 119 renal allograft recipients were followed-up for the presence of seric IgM-CIC. Among them, 86 patients developed a recurrent Cytomegalovirus (CMV) infection and 33 did not. In the non-infected population, IgM-CIC were detected in only 15.2% of the patients. In contrast, patients with recurrent CMV infection showed a significantly higher frequency of detectable IgM-CIC (62.8%) (p less than 0.01). These IgM-CIC were detected: (a) during the first two or three weeks after graft; (b) in the course of the second month post graft. This second peak of IgM-CIC was never observed in subjects non-infected with CMV. IgM-CIC occurred before or at the same time as the detectable anti-CMV IgM and virus excretion in urines. Presence of IgM-CIC was not influenced by graft rejection episodes. Such a marker might help in discriminating immune response to viral infection from immune graft rejection.

Pattern of anti-cytomegalovirus IgM antibodies determined by immunoblotting. A study of kidney graft recipients developing a primary or recurrent CMV infection.

In order to improve the knowledge of the humoral immune response to CMV infection, we developed an immunoblotting technique which allowed a better analysis of the changes in the pattern of anti CMV-polypeptides IgM. We examined 234 sera belonging to 27 renal allograft recipients developing a primary or recurrent CMV infection and 12 non infected recipients. Thus we found that 11 main anti CMV-polypeptides IgM antibodies were present in over 25% of the infected patients. They reacted with proteins whose molecular weights ranged from 32K to 205K. We showed that anti-p 45-47 IgM antibodies were present in 100% of CMV infected recipients and never in the non-infected population. They appeared very early in the course of the infection (5.43 weeks post-graft for primary infection and 5.00 weeks for recurrent ones) and, therefore, constitute a good marker of active infection. Two other CMV-specific IgM antibodies (anti-p 60-64 and anti-p 100) were found exclusively in the course of primary infections. Anti-p 60-64 IgM was observed at a high frequency (57.1%) and with a mean delay of 6.57 weeks post-graft. Therefore, the anti-p 60-64 IgM detection could be helpful for the diagnosis of primary infection. In almost 100% of both primary and recurrent infections, we observed anti-p 140 and anti-p 38 IgM antibodies. Only about 50% of non-infected patients had low levels of anti-p 140 and anti-p 38 IgM. The follow-up of recurrent infections showed that the anti CMV-polypeptides IgM antibodies appeared earlier than in primary infection. When we compared anti-p 45-47 IgM detection by immunoblotting and anti-CMV IgM detected by ELISA we observed that immunoblotting permitted the diagnosis 2.5 weeks earlier for primary infection, and 1 week earlier for recurrent infection, than ELISA. In addition, the detection of anti-p 45-47 IgM antibodies also occurred earlier than virus excretion.

Assessment of a secure/intensive care/forensic ward.

Recent trends in psychiatric hospitals have re-established the need for semi-secure, well-staffed acute wards. Such a ward is described and 400 consecutive admissions over a 34-month period reviewed. Using 13 beds all the acute patients requiring security and intensive treatment are managed from a total catchment area of 600,000. A wide range of referral agencies and diagnostic categories are encountered. Staff in the general psychiatric hospital where the ward is situated are satisfied with the service. A small group of chronically-disturbed patients require separate facilities.

Combined (stressed and non-stressed) antenatal fetal heart rate monitoring.

Acceleration patterns of the fetal heart rate, or a normal heart rate during spontaneous contractions, were used as a short weekly screening test to evaluate fetal well-being in 1102 high-risk pregnancies. When accelerations or contractions were absent during the initial screening, oxytocin was administered to stimulate uterine contractions. The mean duration of the antenatal monitoring was 18.5 min when the initial antenatal monitoring was normal, but 38.8 min when the initial results were uncertain. Oxytocin was administered to 38% of patients. This reduced the number of occasions where the diagnosis was uncertain from 46.6% to 12%. Patients with uncertain antenatal fetal monitoring had significantly more late decelerations during labor as well as newborns with low Apgar scores when compared to those with normal antenatal monitoring. Patients with abnormal antenatal monitoring (positive stress test) had significantly more low 5-min Apgar scores, late decelerations during labor and growth-retarded infants than the patients with normal antenatal fetal monitoring. Only 1 intrauterine death occurred within 7 days of a normal antenatal heart rate recording. No preventable fetal deaths occurred when antenatal monitoring demonstrated an acceleration pattern of the fetal heart rate.

Double-blind controlled trail of electroconvulsive therapy (E.C.T.) and simulated E.C.T. in depressive illness.

40 patients prescribed electroconvulsive therapy (E.C.T.) for treatment of a depressive illness were randomly allocated to two groups. One group had the first two E.C.T. treatments replaced by simulated E.C.T. on a double-blind basis. The results show that E.C.T. is significantly superior to simulated E.C.T. in the treatment of depressive illness.

Experiment in managing sociopathic behaviour disorders.

A ward catering for both sexes admitted patients with aggressive suicidal, or otherwise disturbed behaviour for observation and treatment until decisions could be made about their long-term needs. Patients were referred from the police, special hospitals, and the courts and some were transferred from other wards in the hospital. A third of the first 100 patients were admitted for forensic reasons. Twelve inmates were discharged to long-term accommodation for disturbed patients. The ward was intended to provide fairly short-term accommodation, though no time limits were set, and it was run as a medium secure unit. The ward was run by 16-18 nurses with support from medical teams, occupational therapists, and clinical psychologists. It has secured its status as a special unit within the hospital and will continue with the active support of the hospital staff.