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Large cohort studies suggest that high convective volumes associated with online hemodiafiltration may reduce the risk of mortality/morbidity compared to optimal high-flux hemodialysis. By contrast, intradialytic tolerance is not well studied. The aim of the FRENCHIE (French Convective versus Hemodialysis in Elderly) study was to compare high-flux hemodialysis and online hemodiafiltration in terms of intradialytic tolerance. In this prospective, open-label randomized controlled trial, 381 elderly chronic hemodialysis patients (over age 65) were randomly assigned in a one-to-one ratio to either high-flux hemodialysis or online hemodiafiltration. The primary outcome was intradialytic tolerance (day 30-day 120). Secondary outcomes included health-related quality of life, cardiovascular risk biomarkers, morbidity, and mortality. During the observational period for intradialytic tolerance, 85% and 84% of patients in high-flux hemodialysis and online hemodiafiltration arms, respectively, experienced at least one adverse event without significant difference between groups. As exploratory analysis, intradialytic tolerance was also studied, considering the sessions as a statistical unit according to treatment actually received. Over a total of 11,981 sessions, 2,935 were complicated by the occurrence of at least one adverse event, with a significantly lower occurrence in online hemodiafiltration with fewer episodes of intradialytic symptomatic hypotension and muscle cramps. By contrast, health-related quality of life, morbidity, and mortality were not different in both groups. An improvement in the control of metabolic bone disease biomarkers and β2-microglobulin level without change in serum albumin concentration was observed with online hemodiafiltration. Thus, overall outcomes favor online hemodiafiltration over high-flux hemodialysis in the elderly.

Quels rapports existent entre les orientations patronales et les formes d'action syndicale? L'auteur s'attache à cette question à partir des résultats d'une enquête menée auprès de 1 080 militants syndicaux français. Une typologie des formes d'action syndicale est mise à contribution dans l'analyse de ces rapports avec des partenaires différents quant à leurs orientations économiques, quant à leur statut (entreprises privées ou publiques) et quant à leur propension à la négociation. Cette mise en rapports fait ressortir les degrés de perméabilité des orientations des partenaires, variables selon les situations qui structurent leurs débats, et suggère quelques hypothèses pour rendre compte de la présence ou de l'absence de divergences dans leurs projets respectifs., What connection can be established between management orientations and different types of union action? The author examines this question on the basis of a survey that was carried out among 1 080 militant French unionists. A typology of the different forms of trade-unionism is the instrument used to analyse relations with managements presenting different characteristics in terms of economic orientation, status (public or private ownership), and readiness to negotiate. The analysis reveals how, according to the situation giving rise to the confrontation, the attitudes of labour and management may or may not coincide in their degree of concern about the long-term objectives of the enterprise, general socio-economic considerations, and self-interest respectively. Hypotheses are put forward to account for the presence or absence of conflict between the orientations of the two sides., ¿ Qué relaciones existen entre las orientaciones patronales y las formas de acción sindical? Para resolver esta cuestión, el autor se basa en los resultados de una encuesta realizada entre 1 080 sindicalistas militantes franceses. Utiliza una tipología de las formas de acción sindical, para analizar las relaciones con empresariados que se diferencian por su orientación económica, por su estatuto (de empresa particular o empresa del Estado), y por su propensión para la negociación. El análisis hace resaltar que, según la situación que originó la confrontación, la actitud de los sindicatos y del empresariado puede o no coincidir en cuanto al grado de preocupación por los objetivos a largo plazo de la empresa, las consideraciones socio-económicas, y los intereses individuales. Se sugieren hipótesis para explicar la presencia o ausencia de divergencias entre las orientaciones respectivas.

L’expression dimension juridique de l’education peut-etre entendue comme etant celle de la place faite par l’education au droit et a son nier sens retenu, il faut determiner enseignement ou comme etant celle du droit applicable a l’education. Ce derce que l’on entend par droit applicable a l’education pour effectuer une analyse comparative entre les pays de langue francaise. En effet les regles constitutives de ce droit peuvent etre soit celles qui sont specialement concues et formulees pour l’education, soit celles qui, a des degres divers, incluent l’education dans leur champ d’application comme peuvent l’etre d’autres activites sociales, publiques ou privees, collectives ou individuelles. Dans leur situation actuelle, les systemes educatifs justifient trois constats. Le premier est celui d’une grande identite des divers systemes nationaux dans leurs demarches de recours au droit pour imposer des contraintes qui ont pour but d’apporter des satisfactions a des besoins collectifs consideres comme etant d’interet general par les decideurs politiques responsables. Le second est, par contre, le constat de l’existence d’une grande diversite des solutions nationales dans ce qui constitue l’organisation generale de la fonction educative: ici le poids des histoires nationales, celui des situations economiques et sociales, celui des grandes options ideologiques nationales affectent en profondeur le contenu des regles juridiques applicables. Mais le troisieme constat est que le mouvement recent d’interventions internationales dans le domaine de l’education, du fait d’instances mondiales ou regionales par les voies du droit international – traites, declarations, directives, recommandations – constitue un puissant facteur d’uniformisation, au moins au plan de grands principes et, progressivement sans doute, sur celui de leur mise en œuvre.

Building work on the A 16 motorway has revealed two early neolithic sites. The characteristics of the finds and particulary those of lithic items suggest that the two sites belong to the same period in the final phase of the Villeneuve-Saint-Germain group., La construction de l'autoroute A16 a permis de mettre en évidence deux occupations du Néolithique ancien. Les caractéristiques du mobilier archéologique, et particulièrement celles de l'industrie lithique, permettent de proposer une contemporanéité de ces deux occupations et de les attribuer à la phase finale du groupe de Villeneuve-Saint-Germain., Bostyn Françoise, Durand Jean Claude. Témoins de deux implantations du groupe de Villeneuve-Saint-Germain à la confluence Oise-Esches : les sites de Champagne-sur-Oise "Le Grand Marais" (Val-d'Oise) et de Chambly "La Fosse aux Moines" (Oise). In: Revue archéologique de Picardie, n°1-2, 1999. L'occupation du sol au Néolithique dans la vallée de l'Aisne / Le cimetière mérovingien de Montataire (Oise) / Un village-rue du Moyen Age: Dury (Somme) pp. 29-61.

La réflexion qu’il nous a été demandé de conduire en ouverture du colloque « Le droit à l’éducation : vers de nouveaux contenus pour le XXIe siècle », est objectivement délicate pour plusieurs raisons. La notion même de « contenus » justifie trois observations. En premier lieu, on notera que la littérature internationale des instances intervenant dans le secteur de l’éducation –l’UNESCO, la Banque mondiale, l’OCDE, le Conseil de l’Europe ou d’autres instances régionales – est relativement pau...

Specific types of human papillomaviruses (HPV) are associated with most cases of pre-invasive and invasive neoplasia of the uterine cervix. HLA phenotype influences susceptibility and resistance to viral infections and may therefore influence the course of HPV-associated tumors. Some data suggest that specific HLA class-II alleles may be associated with protection from or susceptibility to papillomavirus-associated lesions, but these results are still controversial. Using molecular probes, we looked for associations between specific DQAI, DQBI, DRBI HLA class-II alleles, HPV types and cervical cancer. The analysis was performed on a population of 126 patients with invasive cervical cancer. For HLA typing, 165 healthy individuals were taken as controls. The DRBI * 1301/02 allele frequency significantly decreased in patients (11%) as compared to controls (29%). This difference in frequency was dependent on the HPV-positive status of tumors and was no longer significant in the group of HPV-negative lesions. The same trends were observed with the DRBI * 1301/02-DQAI * 0103-DQBI * 0603 haplotype frequency. An increase in the frequency of the DRBI * 1401/07 and DRBI * 03 alleles was observed in patients under 40. Contrary to what has been reported in the literature, no increase in the DRBI * 15 allele frequency was observed in our series and only a slight increase in the DQBI * 03 frequency was found in patients (70%) compared to controls (58%). In our study, no positive correlations between cervical cancer in Frenchwomen and specific HLA DR-DQ haplotypes has been found. In contrast, a negative correlation between DRBI * 1301/02 alleles and HPV-positive tumors has been observed. This may suggest a protective effect of DR13 against HPV-associated lesions of the cervix. © 1996 Wiley-Liss, Inc.

BACKGROUND. The objective of this study was to evaluate the feasibility, morbidity, and efficacy of unilateral laparoscopic ovarian transposition on the preservation of hormonal function in premenopausal patients requiring pelvic irradiation (external and/or intracavity by brachytherapy). METHODS. This prospective study was based on 20 patients : 17 presenting with cervical cancer, 2 with Hodgkin's disease, and 1 with ependymoma of the cauda equina. The operative technique consisted of releasing the right ovary from its pelvic attachments, and placing it as high and as laterally as possible in the right paracolic gutter, after creating a pedicle on the infundibulopelvic ligament. The follow-up of ovarian function was more than 1 year for 14 patients. RESULTS. The therapeutic protocol was not modified as a result of ovarian transposition. No intraoperative or postoperative complications were observed. The mean dose of irradiation received by the transposed ovary was 1.75 gray (Gy) (range : 0.4-3.7). Mean follow-up was 2 years. Two cases of menopause (14.7%), in the only 2 patients older than age 40 years, were observed among the 14 patients followed for more than 1 year. The success rate was 100% for patients younger than age 40 years. CONCLUSIONS. Laparoscopic ovarian transposition is a simple and reliable method, which does not complicate subsequent therapeutic protocol. Its short term efficiency is comparable to results obtained by laparotomy, with a lesser morbidity. Although long term evaluation is necessary, laparoscopic surgery should be considered as an alternative to laparotomy for ovarian transposition.

Immediate breast reconstruction (IBR) by prosthesis is frequently proposed after mastectomy. However, due to the morbidity of this operation, especially the early implant removal rate, its indications remain controversial.We have performed 141 IBR by prosthesis (saline or gel-filled implant, tissue expander) in a homogeneous population of patients with extensive intraductal or microinvasive carcinoma, diagnosed after an initial local excision. This prospective study was designed to assess the feasibility and morbidity of IBR for an "ideal" population, allowing wide cutaneous preservation, without preoperative or postoperative treatment.The early prosthesis removal rate (2 months) was 0.7%, with only 2.1% of early surgical revisions and 3% of lymphoceles. Cutaneous complications (5%) were significantly correlated with the type of incision. Cosmetic results at 1 year were good or very good in 66% of cases, similar to the percentage observed after delayed reconstruction by prosthesis.In this selected population, IBR by prosthesis did not induce any additional morbidity compared with mastectomy without reconstruction. IBR by prosthesis can be systematically proposed in cases of extensive intraductal or microinvasive carcinoma.

BACKGROUND The clinicopathologic features of infiltrating lobular carcinoma (ILC), which represents 5% to 15% of all breast cancers, are still controversial. In particular, the high frequency of multicentric lesions has led to questioning of the effectiveness of conservative treatment for this type of cancer. By studying a large number of cases, we aimed to compare the clinicopathological features of ILC with those of nonlobular infiltrating carcinoma (NLIC) and to assess the advisability of conservative therapy in the management of ILC. METHODS The population analyzed included 726 cases of ILC, 249 cases of mixed ILC/invasive ductal carcinoma (ILC/IDC), and 10,061 cases of NLIC. The age of patients, TNM status, estrogen- and progesterone-receptor status (ER, PR), and histologic grades of the 3 groups were compared. The follow-up was carried out on a subgroup of 5846 cases. RESULTS At diagnosis, ILC tumors were found to be larger on average and were detected in patients older than those with NLIC, but the degree of lymph node involvement was lower in patients with ILC than in NLIC. In ILC, tumors are more frequently grade I and ER-positive than in NLIC. Multicentric lesions were not significantly more frequent in ILC than in NLIC. The overall survival, locoregional control, disease free interval, and metastatic spread rates were not different among the three groups neither by univariate nor multivariate analysis, but the pattern of metastatic dissemination was different. In 480 cases of ILC considered for conservation therapy, the local recurrence and overall survival rates were similar to those observed for IDC. CONCLUSIONS Our analysis specifies the clinicopathological features of ILC and confirms that conservation therapy may be an appropriate treatment for this type of cancer. Cancer 1996;77:113-20.

The collation of information from Early Bronze Age domestic and mortuary contexts in an area 60 kilometres long in the downstream Marne valley, east of Paris, has made it possible to flesh out the hitherto thin research literature. Recent developments such as the excavation of increasingly large surfaces, the characterisation of regional series and the considerable amount of information gained through preventive archaeology have made it possible to better understand a period hitherto best known in the region because of the discovery of a limited number of metal objects. This article organises the information, looking at a dozen archaeological indicators and considering fifteen domestic and mortuary sites. The position of these sites, usually in the valley bottom, sometimes on the slopes, but rarely on the edge of the plateau, is studied. The settlements can be divided into two categories. Firstly, those which have between one and a dozen pits and abundant material, such as the Grand Godet site at Villeneuve-le-Roi. Secondly, the sites on which there are apsidal buildings which do not respect a common alignment. The mortuary sites contain crouched burials in large pits aligned north south or north west/ south east. The pits contain no artefacts and the dating evidence comes merely from radiocarbon analysis. There is little pottery but ovoid or barrel-shaped narrow-necked vases with an everted rim have been found. There are also carinated vases with handles. The applied decoration subdivides into arched cordons, of which some of the principal forms are discussed, horizontal smooth or thumbed cordons, applied strips and pellets. The principal decoration is achieved by the use of a cord larger than that used for Beaker pottery but also through the use of micro-perforations. Last but not least, the comparative frequency of aligned or superposed thumbed decoration is remarkable. The ten radiocarbon dates from both funerary and domestic contexts are from the first four centuries of the second millennium BC. A susceptibility to both Atlantic and continental influences is noteworthy. The building structures are comparable with southern examples whereas the abundance of arched cordon decoration shows a clear northern influence. The latter also influences the various mortuary practices, with the exception of cremation and monumental tombs., Le regroupement des données domestiques et funéraires au Bronze ancien, dans la zone aval de la vallée de la Marne sur près de 60 km à l’est de Paris, permet d’étoffer une documentation jusque-là indigente. Les récents développements liés à l’extension des surfaces décapées, la caractérisation des séries régionales, enfin la recherche exhaustive des données de l’archéologie préventive permettent d’étayer une période qui n’était connue dans la région que par quelques objets métalliques. Le présent article hiérarchise les données par la revue d’une dizaine d’indices archéologiques, et par une discussion sur une quinzaine de sites domestiques et funéraires. Elle porte sur leur implantation, essentiellement en fond de vallée, parfois sur les coteaux et rarement sur les rebords de plateau. Les sites domestiques se répartissent en deux catégories : ceux qui présentent une à une douzaine de fosses, comme celui du Grand Godet à Villeneuve-le-Roi, dont le matériel détritique est relativement abondant, et ceux qui révèlent les plans de bâtiments en abside d’orientations diverses. Les sites funéraires regroupent des inhumations repliées dans de larges fosses, sans matériel, d’orientation préférentielle nord-sud à nord-ouest/ sud-est. Les datations ne reposent que sur une série de datations radiocarbone. Le matériel, peu abondant, est représenté par des vases fermés à col divergent, ovoïdes ou en tonneau, mais aussi par quelques rares vases ansés à carène. Les éléments plastiques se scindent en cordons arciformes, dont quelques types principaux sont analysés, en cordons horizontaux lisses ou décorés de digitations espacées, mais aussi en languettes et boutons. Les décorations principales sont effectuées à l’aide d’une cordelette plus large que celle du Campaniforme, mais aussi par l’utilisation de la technique du micropointillé. Enfin, la relative abondance des digitations en ligne ou couvrante est notable. Dix datations radiocarbone étayent la discussion. Elles couvrent les quatre premiers siècles du deuxième millénaire et concernent le funéraire et le domestique. On constate une certaine ambivalence entre le monde atlantique et continental. L’architecture des bâtiments semble se référer aux productions méridionales, tandis que l’abondance des cordons arciformes montre une relation septentrionale indéniable. Ce fait trouve un écho dans les modes funéraires diversifiés excluant, dans l’état de la recherche, le monumentalisme et l’incinération., Brunet Paul, Charamond Christian, Charamond Corinne, Cottiaux Richard, Couturier David, Delattre Valérie, Durand Jean-Claude, Durbet Gilles, Gosselin Renaud, Lafage Françoise, Lanchon Yves, Monchablon Cécile, Samzun Anaïck. De la fin du Campaniforme à l’aube du Bronze moyen dans la basse vallée de Marne. In: Bulletin de la Société préhistorique française, tome 106, n°2, 2009. pp. 329-356.

A l’occasion d’une enquete de terrain dans trois entreprises russes de Rostov‑sur‑le‑Don (une manufacture de cigarettes, une banque, une usine de reparation de locomotives), Pierre Rolle nous presente une analyse du changement qui deborde largement ses etudes de cas. L’objectif ambitieux de l’auteur est en effet de mettre en relation l’evolution des formes de production et de relations de travail et les changements politico‑economiques de la societe russe. Au‑dela de la description des atelie...

CLAUDE DURAND This article deals with the modes of state intervention in socialist enterprises during the first years of the ongoing economic reforms. State intervention in the export policy of firms, in technical investment processes and in growth decisions is studied for the garment industries in Bulgaria and Hungary and for the mechanics and telecommunication industries in Bulgaria. During the period studied, we see a wide diffusion of power scattered between multiple institutions with poor coordination. The rigidity of rules and procedures ends up being replaced by the activity of pressure groups and informal relations., Résumé : Cet article porte sur les modalités de l'intervention de l'Etat dans les entreprises socialistes dans les premières années des réformes économiques en cours. Sont étudiés dans des entreprises bulgares et hongroises d'habillement et dans les entreprises bulgares de mécanique et de télécommunications, comment l'Etat intervient dans la politique d'exportation des entreprises, dans les processus d'investissement technique et dans les décisions de développement. La période étudiée révèle une grande diffusion du pouvoir entre une multiplicité d'organismes mal coordonnés. Le jeu des groupes de pression et les relations informelles finissent par se substituer à la rigidité des règles et des procédures., Durand Claude. Les modalités de l'intervention de l'État dans les entreprises socialistes. Étude de cas en Bulgarie. In: Sociétés contemporaines N°2, Juin 1990. Europe de l'Est des sociétés en mutation. pp. 93-102.

International audience

Protective devices against vectors are used by travelers in malaria-endemic areas but their efficacy for protection against mosquitoes has rarely been evaluated. The level of exposure to malaria transmission of 205 soldiers deployed in Africa and the efficacy of their anti-vector prophylaxis was evaluated by comparison of their IgM and IgG responses against five pre-erythrocytic Plasmodium falciparum antigens (circumsporozoite protein, sporozoite threonine- and asparagine-rich protein, sporozoite- and liver-stage antigen, liver stage antigen 1, and SR11.1) before and at the end of their deployment, and three months after returning to France for 106 of these soldiers. The immune responses increased significantly during the mission in 35% (95% confidence interval = 28-42%) of the individuals. The permanent use of insecticide-treated bed nets and long-sleeve battle dress at night were associated with protective efficacy. The analysis of these antibody responses was sensitive enough to evaluate exposure to malaria transmission and the efficacy of anti-vector devices in travelers using antimalarial chemoprophylaxis.

In the past two decades, nonpalpable breast cancer incidence has greatly increased by routine screening mammography. Microcalcifications are the most frequent radiological feature.Between 1964 and 1994, 789 breast cancers revealed by clustered microcalcifications without palpable mass were treated at Institut Curie. Patients who had a past history of breast cancer or a contralateral cancer were eliminated like those with lobular carcinoma in situ. The definitive treatment was decided on the margins of the initial excision and the presence of microcalcifications on postoperative mammograms.Mean follow-up of the patients was 77 months (9-358). The treatment was conservative in 49.5% and radical in 50.5%. Histologically, 43.5% of the lesions were intraductal carcinoma, 25.5% were microinvasive and 31% were infiltrating cancers. Five and ten years overall survival were 98% and 92.5% respectively, 50% of the patients died from their breast cancer. This survival was identical for intraductal, microinvasive and invasive carcinomas without lymph node metastasis, but was less favorable in patients with node metastasis. There were no survival differences for the two treatment modalities, although local recurrences were more frequent in the conservative one. The 5-year recurrence rate was 3.5% for intraductal subtype, 4.4% for microinvasive and 6% for invasive cancers. The difference was not statistically significant.Under the impact of mammographic screening, sizable proportions of breast cancer patients are being seen in a totally nonpalpable state with either a very small invasive, microinvasive or intraductal breast cancer. These lesions have an excellent prognosis, and can benefit from less aggressive treatments. In the case of diffuse microcalcifications, where a radical treatment is indicated, skin sparing mastectomy can be easily done followed by immediate reconstructive surgery.

International audience

Salanova Laure. Du Néolithique final à l'Age du Bronze ancien dans le Centre Nord de la France. In: Bulletin de la Société préhistorique française, tome 98, n°1, 2001. pp. 131-132.

Archaeological excavations carried out under the direction of G. Le Coz between October and November 1994 during the construction of an underground carpark in Rue Marollet, Rueil-Malmaison (Hauts-de-Seine, Hot 1 of the ZAC Noblet IV) revealed structures dating from the Neolithic to modern times. This article concerns the unexpected discovery —particularly remarkable in view of the highly developed urban tissue of this region — of a building in the Danubian tradition, flanked by two lateral pits and some secondary pits. Although the excavation yielded very little lithic material orfaunal remains, there was some decorated pottery relating to the late phase of the Villeneuve-Saint-Germain culture, which complements the small amount of information we have on this culture in this area of the Paris Basin., Une fouille archéologique préventive réalisée dans le cadre d'un projet de parking souterrain rue Marollet à Rueil-Malmaison (Hauts-de-Seine, îlot 1 de la Z.A.C. Noblet IV), entre octobre et novembre 1994, sous la direction de G. Le Coz, a permis de mettre au jour des structures dont l'âge s'échelonne du Néolithique à l'époque moderne. L'objet de cet article est la découverte inattendue, et quelque peu exceptionnelle compte tenu du contexte fortement urbanisé de cette région, d'un bâtiment de tradition danubienne, flanqué de deux fosses latérales et de quelques fosses annexes. La fouille a livré peu de mobilier lithique et de faune, mais des céramiques décorées se rapportant à la phase évoluée du Villeneuve-Saint- Germain, ce qui complète le peu d'informations que nous possédons sur cette culture dans cette partie du Bassin parisien., Le Coz Guy, Bostyn Françoise, Durand Jean-Claude, Bridault Anne. Le bâtiment du groupe de Villeneuve-Saint-Germain de Rueil-Malmaison "rue Marollet" (Hauts-de-Seine). In: Bulletin de la Société préhistorique française, tome 97, n°3, 2000. pp. 419-431.

L'A. avance quelques remarques a propos de la recherche effectuee par Y. Lemel, M. Oberti et F. Reillier, exposee dans la presente livraison de « Sociologie du travail ». La delimitation de la periode observee exclut selon lui une periode fructueuse que furent les annees soixante. Il resitue le contexte du debat sur la stratification sociale a cette epoque au coeur du clivage entre fonctionnalisme americain et les differents courants de la sociologie europeenne, et rappelle que l'un des enjeux de ce debat n'etait rien moins que la constitution d'une theorie de la societe. Il evoque ensuite de possibles biais inherents au choix de la methode. Enfin, il suggere que l'abandon relatif de l'interet pour la structure sociale d'ensemble correspond a un retrait par rapport aux theories globalisantes, mais que la conflictualite conserve toute son actualite en periode d'aggravation des inegalites sociales

Durand Claude et Koléva Svetla, Putting Back in Service the Nuclear Reactor in Kozloduy (Bulgaria) The case of the Kozloduy reactor in Bulgaria shows the risks and difficulties associated with nuclear reactors of Russian origin. The assistance given by the French government's electrical utility monopoly, EDF, was impeded by its inability to impose decision-making authority., Koléva Svetla, Durand Claude. La réhabilitation de la centrale nucléaire de Kozloduy en Bulgarie. Les limites d'une intervention. In: L'Homme et la société, N. 119, 1996. Violence privée et politique. pp. 115-128.

Cet ouvrage est une monographie du mouvement ouvrier de Longwy dans la periode de desindustrialisation du bassin siderurgique lorrain. L’auteur montre comment une profession fiere et puissante « du Pantheon ouvrier » se trouve desagregee par les plans de restructuration de la siderurgie. La demarche est presentee en grandes phases suivant l’evolution historique des luttes. L’histoire documentaire de la naissance du syndicalisme a Longwy montre que les premieres organisations ouvrieres de mass...

Seit zwanzig Jahren werden die Vor- und Nachteile quantitativer und qualitativer Methoden gegeneinander abgewogen. Quantitative Methoden erlauben Beschreibungen, die von subjektiven Interpretationen unabhangig sind. Sie gewahrleisten scheinbar Objektivitat und profitieren von der Reputation des (wissenschaftlichen) Beweises.

La commission du medicament et des dispositifs medicaux steriles (COMEDIMS) est chargee d’etablir la liste des medicaments references dans l’etablissement de sante. Ces choix locaux resultent d’une evaluation decentralisee des medicaments, qui fait suite a une evaluation centralisee. Comment s’articulent ces deux evaluations ? En quoi le service medical rendu (SMR) et l’amelioration du service medical rendu (ASMR), evalues au niveau national par la Haute autorite de sante (HAS) sont-ils utiles au niveau local ? Une analyse de la disponibilite des avis de la commission de la transparence (CT), ainsi que des niveaux de SMR et d’ASMR des medicaments references au CHU de Toulouse en 2005 a ete realisee. Le nombre de specialites pharmaceutiques referencees est 1.696, âge moyen 13,4 annees [6,5], et prix unitaire moyen 48,4 € [194,2]. Un avis de la CT est disponible pour 733 medicaments references, soit 43,2 %. Parmi les medicaments ayant un avis, 98,1 % des avis evaluent explicitement un niveau de SMR, et 60,1 % un niveau d’ASMR. L’anciennete moyenne des avis est 29,7 mois [21,9]. Parmi les medicaments references ayant fait l’objet d’une evaluation du SMR, 93 % ont un SMR important. L’ASMR n’est evaluee explicitement que pour 16 % des medicaments references. Parmi eux, 17 % ont une ASMR niveau I ou II, 15 % niveau III, 13 % niveau IV, et 38 % niveau V. Les avis de la CT constituent une source d’information irremplacable sur l’interet relatif des specialites pharmaceutiques ; neanmoins, l’evaluation de la HAS necessite d’etre completee, actualisee et adaptee au niveau local.