[Another way to take care of diabetic patients: diabetic pathway "diabaide"]. / Une autre prise en charge des patients diabétiques: la filière de soins coordonnée "diabaide".

The diabetic pathway project is based on the objective of bettering the care of diabetic patients, through a new organisation of the care which should be more based on collaboration, on the sharing of information and on the coordination of activities. This project concern 6000 patients. The diabetic pathway is organised into three groups of intervention. The group called "first intention" (patient, physician and pharmacist), the multidisciplinary group (team of specialized professionals in diabetes care) and the group of independent professionals. The patients care is based on common procedures and guidelines. The physician remains the agent of the patient.

Variability of attitudes toward early initiation of HAART for HIV infection: a study of French prescribing physicians.

This study assessed prescribing physicians' attitudes toward early initiation of HAART, three months after the dissemination of the first French official treatment guideline. Telephone interviews have been made in a national random sample of physicians with full- or part-time practice in hospital departments delivering care for HIV-infected patients. Questionnaires included hypothetical clinical cases. Logistic regression compared characteristics of respondents according to attitudes toward HAART. Among the 483 respondents (response rate = 87.0%), agreement was high with official recommendations to systematically initiate HAART with protease inhibitors (PIs) for patients with CD4+ cell counts < or = 300/mm3, following a diagnosis of acute primary HIV infection, or for HIV sexual risk post-exposure prophylaxis. Confronted with a case of a naive asymptomatic patient with stable 450 CD4+/mm3, 34.6% would prescribe HAART with PIs in any case, and 29.8% only if the patient has plasma viral load < or = 10,000 HIV RNA copies/ml. The remaining 35.6% would not prescribe PIs and were older, had limited activity in HIV care and expressed more interest in alternative medicines. To avoid a confusing impact of variability of clinical attitudes toward uncertainties associated with antiretroviral treatments among HIV-infected patients, shared decision-making between patient and physician should be promoted for initiation of HAART.

[Therapeutic attitude to HIV infection: uncertain and variable scientific attitudes. 1998 national survey of physicians prescribing antiretroviral drugs]. / Attitudes thérapeutiques pour l'infection à VIH: incertitudes scientifiques et variabilités. Enquête nationale 1998 auprès des médecins prescripteurs d'antirétroviraux. Groupe PAMPA. Pratiques et Attitudes des Médecins Prescriteurs d'Antirétroviraux.

OBJECTIVES: Analyze the attitudes of French practitioners managing HIV infected patients towards multidrug antiretroviral therapies with protease inhibitors, open issues, and the official guidelines (Dormont report). METHODS: A telephone survey was conducted in February-March 1998 on a random sample of the nation file of hospital physicians prescribing antiretroviral drugs (response rate 87%, n = 483). RESULTS: The responding clinicians were in general agreement on defining virological efficacy at three months treatment as an undetectable viral load (86.5%). There was a general concensus on multidrug therapy with a protease inhibitor in case of primary infection (83.2%) or sexual exposure with risk of HIV transmission (83.2%). Inversely, only 43.7% abandoned PCP and toxoplasmosis prophylaxis in patients with CD4 counts above 350/mm3 taking tritherapy antiretroviral regimens. When asked to state their approach to a hypothetical case of an asymptomatic patient with a CD4 count of 450, 35.6% would not propose multidrug therapy with an antiprotease, 29.8% would only envisage such a regimen if the viral load was above 10,000 copies/ml, and finally 34.6% would prescribe a multidrug regimen with a protease inhibitor whatever the viral load. CONCLUSION: The variability observed in routine clinical practices would appear to be justified in light of the uncertainty about the long-term effects of the new antiretroviral drugs for HIV/AIDS.

HIV / AIDS and manufacturing in Abidjan.

PIP: Abidjan is the major industrial and commercial capital of West Africa. Since 1989 in Abidjan, AIDS has been the leading cause of death among adult men and the second among women. The indirect and direct costs of HIV/AIDS were identified and assessed in 1995 and 1996 in a food processing company of 275 employees, a textile company of 1150, and a packaging company of 83. The necessary data were collected with the assistance of company doctors, directors, managers, and workers. Total costs incurred are calculated on the basis of the number of employees infected by HIV and notified as such by company doctors. Analysis of the costs found that HIV/AIDS impacts in different ways upon the various plants and the share of those items incurring the highest costs varies among plants. Sickness rather than the death of employees costs all of the firms the most. The companies have responded in various creative ways.^ieng

Preeclampsia in diabetic pregnancies.

Diabetic pregnancies complicated by preeclampsia are of concern because of poor perinatal outcome. However, with improved maternal and fetal surveillance the impact of preeclampsia in diabetic pregnancies is declining. This prospective controlled study compared the incidence of preeclampsia and maternal-fetal outcome in 334 diabetic pregnancies and 16,534 nondiabetic pregnancies. The incidence of preeclampsia was 9.9% (33/334) in diabetic pregnancies compared with 4.3% (716/16,534) in nondiabetic controls. The incidence of preeclampsia rose with increasing severity of diabetes by White classification, but was still 8.9% after exclusion of diabetic patients with nephropathy or chronic hypertension. The perinatal mortality rate per 1000 births was 60 for preeclamptic diabetic patients compared with 3.3 for normotensive diabetic patients. Parity, maternal age, and blood glucose control were similar in preeclamptic diabetic patients compared with normotensive diabetic patients. We conclude that preeclampsia is twice as common in diabetic pregnancies compared with normal controls.

Physicians' acceptability of termination of pregnancy after prenatal diagnosis in southern France.

The acceptability of prenatal diagnosis for Down's syndrome has been extensively studied over the last 15 years but that of other pathologies remains largely unexplored. The main goals of this study were to approach physicians' opinions on six reasons for termination of pregnancy showing different deficiencies, i.e., Down's, Turner and Klinefelter syndromes, cystic fibrosis, spina bifida, and haemophilia, and to identify the origins of reserves. The influence of sociodemographic and professional characteristics of physicians on their opinions and attitudes during the consultation were studied. The data presented are based on information gathered in 1985 by a mailed questionnaire answered by 853 general practitioners, gynaecologists, obstetricians, and pediatricians in the Marseilles Genetic Centre's region. Stepwise logistic regression was used for the multivariate analysis. The results showed that 78 per cent of those answering favour termination of pregnancy for Down's syndrome and that only moral reticences were mentioned by the physicians opposed. Conversely, for haemophilia, only 21 per cent of the physicians considered this indication justified; those opposed were for the most part concerned that severity of illness did not justify termination of pregnancy. Overall, 33 per cent of physicians would voice their personal opinion on termination of pregnancy if so requested by consultees. Results on the influence of age and specialty evidenced their role on physicians' opinions. Indeed, 30 per cent of physicians opposed to pregnancy termination for one of the six fetal anomalies retained herein would modify their positions if diagnosis were possible in the first trimester of pregnancy.

PIP: In 1985, researchers from the Marseilles Genetic Centre in southern France surveyed general practitioners, gynecologists, obstetricians, and pediatricians on their acceptability of abortions after prenatal diagnosis. 34% (657) of general practitioners in the region responded as did 53% (196) of the specialists. A multivariate adjustment was necessary in this study because of the sociodemographic variables that are linked to the physicians' opinions. The researchers limited the variables to Down's, Turner, and Klinefelter syndromes; spina bifida; cystic fibrosis; and hemophilia. Overall justification for termination of pregnancy was highest for Down's syndrome (78%) and moral reasons were given by physicians who opposed. The lowest justification was for hemophilia (21%) and professional reasons were stated by those opposed. 44-52% of the physicians considered pregnancy termination justified for the remaining conditions. Significant variations existed among the type of practice for Turner and Klinefelter syndromes (p.01) and spina bifida (p.05). The mean age for physicians favoring termination of pregnancy for Turner and Klinefelter syndromes was younger than those who did not favor termination (p.01). The same was also true for spina bifida (p.05). Women refrained from expressing an opinion on abortion for hemophilia more often than men ((p.001). Yet women more often favored abortion for spina bifida than men (p.05). Gender did not affect responses on reasons for reserves, but older physicians more frequently stated religious reasons for reserves, but older physicians more frequently stated religious reasons than moral or professional reasons (p.01). As for physicians professing moral and/or religious reasons on average had a greater number of children (p.01). 29% of the respondents would change their positions, however, if prenatal diagnosis were done during the 1st trimester.

[Social diffusion of genetic counseling in the Provence Alpes-Côte d'Azur region]. / Diffusion sociale de la consultation de génétique en région Provence Alpes-Côte d'Azur.

Accessibility to medical care in general, and to new techniques in particular, is unequal as much from a social as a geographical standpoint. We have reconstituted the geographical distribution network for genetic consultation at Marseilles for consultees having benefitted from genetic counselling in 1983 (984 files). For the region (except the Alpes Maritimes) the incidence rate for this consultation was 13.6 per 10,000 women of child bearing age. A parallel study of doctors participating in the recruitment of these patients objectifies the essential role of obstetricians, gynaecologists as well as general practitioners and shows different directions for training and data for the medical profession liable to contribute to better prevention of handicaps of genetic origin.

[Dissemination of genetic counseling and prenatal diagnosis: impact of the physicians' knowledge]. / Diffusion du conseil génétique et du diagnostic prénatal: l'impact des connaissances des médecins.

This article presents a survey carried out among 2,549 doctors (general practitioners, pediatricians, obstetricians and gynecologists) practicing in two south of France "departements" (administrative subdivisions): Bouches-du-Rhône and Hautes-Alpes. The influence of socio-demographic and professional characteristics on knowledge of prenatal diagnosis indicators is studied here for each specialty. While knowledge among general practitioners is apparently a product of their formal education, among gynecologists and obstetricians the most important factor seems to be professional experience. In France, the GP is a central figure in referrals for genetic counselling and prenatal diagnosis, hence the importance of improving his training and possibilities of continuing education.

[The brain of Paul Broca (1824-1880). Correlation of pathological and computed tomography findings (author's transl)]. / Le cerveau de Paul Broca (1824-1880). Confrontation anatomo-pathologique et tomo-densitométrique.

This historical study briefly recalls the circumstances of Broca's death, and reports some new data concerning his autopsy, and an analysis of macroscopic, microscopic, and computed tomography appearances of his brain following its discovery by Huard. The authenticity of the origin of the brain was established, and the hypothesis the Broca's death was due to rupture of a vascular malformation or a cerebrovascular accident was confirmed.

[J.M. Charcot's gerontology]. / La gérontologie de J.M. Charcot.

Charcot always took a deep interest in diseases of old age and he found a large field of research in the Salpêtrière where there were some 5 000 old people. In 1867 he published his "Lecons sur les maladies des vieillards et les maladies chroniques" with chapters especially devoted to gout and rheumatism. The book, with additions, was translated into English in 1881. Charcot was interested in the forms of fever and he compared them in the child, the adult and the aged. He recommended that in old people rectal temperature be measured since it may be high while skin and axillary temperature are normal. Charcot distinguished: 1) diseases specific to old age, e.g. senile marasmus, cerebral atrophy, senile tremor. 2) diseases met at any age but more severe in the aged, e.g. respiratory diseases; 3) diseases to which old people oppose less resistance, e.g. tuberculosis, typhoid fever. Among many studies of Charcot on diseases of old age, the present paper recalls those devoted to pneumonia, asthma, tuberculosis, arterial, i.e. aneurysmal, embolic, atheromatous diseases, diseases of the liver, digestive and urinary tracts. In all those papers as well as in his bedside teaching. Charcot insisted that pathology was the basis of clinical practice: "tant vaut le pathologiste, tant vaut le clinicien".