Variation d'expression des récepteurs hormonaux et d'HER-2 dans l'évolution du cancer du sein : quelles implications en pratique clinique [Hormone receptors and HER-2 changes during breast cancer progression: clinical implications].

Breast cancer remains a major public health problem. Even if there is an increase in this cancer curability, metastatic breast cancer remains a lethal disease in the vast majority of cases. Therapeutic advances in the chemotherapeutic and targeted therapies fields induced an increase in survival, however the proportion of long survivors remains low. Phenotypic instability, an early process initiated during tumour progression, and continued on the metastatic stage of the disease, can be one of the putative hypotheses explaining these results. An increasing amount of scientific data are pledging for a reanalysis of the phenotypic profile regarding hormone receptors and HER-2 status of metastatic lesions in order to identify drugable targets and allow individualisation of the treatment of these metastatic breast cancer patients. Phenotypic changes between the primary tumour and the paired metastatic lymph nodes are a challenging pitfall, raising the question of which site has to be assessed in the adjuvant treatment decision process. This article presents a comprehensive analysis of the frequency of theses phenotypic changes altogether with new modalities to evaluate this phenotypic status.

Variations régionales du recours aux soins: quelques problèmes méthodologiques. [Regional variations in health services: various methodological problems].

Many studies show strong variation of health consumption between regions, suggesting that theses variations are related to the uncertainty of medical practice or to other factors related to health services or patients attitude. However the statistical interpretation of these variations is far from easy: apart from usual and specific information bias, there are statistical problems when observing incidence of events like health care consumption: it is in fact a rare event, which is observed within small population, and among regions with unequal number of person. Therefore, most of the variation reported might be well explained by a purely statistical phenomenon. This paper presents some aspects of this variability for three common indicators of variation, and suggest the use of ad hoc simulation to get statistical criteria.

«Où, quand, et comment ?» : Évolution des conduites agressives en football et en hockey sur glace

RésuméCette étude a pour objectif d'observer l'évolution des actes agressifs dans deux sports d'équipes en fonction de facteurs situationnels (périodes de jeu, lieu de la faute, état du score) et du type d'agressions (instrumentales, hostile). 60 matchs professionnels de football et de hockey sur glace ont été filmés puis analysés à l'aide de grilles d'observation différenciant les deux types d'agressions. Les résultats révèlent que dans ces deux sports, les agressions instrumentales sont plus fréquentes dans les zones importantes du terrain (milieu ou défense) ou lorsque le score est serré. En revanche, les agressions hostiles ne varient pas (ou peu) selon ces facteurs. Les résultats sont discutés au regard de la théorie de l'apprentissage social et de l'hypothèse frustration-agression.AbstractThis study aims at examining observed aggression in two team sports as a function of situational triggers (periods, zones of field, games score) and of type of aggression (instrumental, hostile). 60 soccer and ice hockey games were recorded and analyzed using a grid that differentiates the two types of aggression. The results revealed that theses two sports, instrumental aggressions were more frequent in important zones of field (neutral or defensive ones) and in tied score situations. However, no difference was found for hostile aggression according to these factors. The discussion focused on the social learning theory and frustration-aggression hypothesis.

Causal explanations and scientific realism in particle physics

Particle physics studies highly complex processes which cannot be directly observed. Scientific realism claims that we are nevertheless warranted in believing that these processes really occur and that the objects involved in them really exist. This dissertation defends a version of scientific realism, called causal realism, in the context of particle physics. I start by introducing the central theses and arguments in the recent philosophical debate on scientific realism (chapter 1), with a special focus on an important presupposition of the debate, namely common sense realism. Chapter 2 then discusses entity realism, which introduces a crucial element into the debate by emphasizing the importance of experiments in defending scientific realism. Most of the chapter is concerned with Ian Hacking's position, but I also argue that Nancy Cartwright's version of entity realism is ultimately preferable as a basis for further development. In chapter 3,1 take a step back and consider the question whether the realism debate is worth pursuing at all. Arthur Fine has given a negative answer to that question, proposing his natural ontologica! attitude as an alternative to both realism and antirealism. I argue that the debate (in particular the realist side of it) is in fact less vicious than Fine presents it. The second part of my work (chapters 4-6) develops, illustrates and defends causal realism. The key idea is that inference to the best explanation is reliable in some cases, but not in others. Chapter 4 characterizes the difference between these two kinds of cases in terms of three criteria which distinguish causal from theoretical warrant. In order to flesh out this distinction, chapter 5 then applies it to a concrete case from the history of particle physics, the discovery of the neutrino. This case study shows that the distinction between causal and theoretical warrant is crucial for understanding what it means to "directly detect" a new particle. But the distinction is also an effective tool against what I take to be the presently most powerful objection to scientific realism: Kyle Stanford's argument from unconceived alternatives. I respond to this argument in chapter 6, and I illustrate my response with a discussion of Jean Perrin's experimental work concerning the atomic hypothesis. In the final part of the dissertation, I turn to the specific challenges posed to realism by quantum theories. One of these challenges comes from the experimental violations of Bell's inequalities, which indicate a failure of locality in the quantum domain. I show in chapter 7 how causal realism can further our understanding of quantum non-locality by taking account of some recent experimental results. Another challenge to realism in quantum mechanics comes from delayed-choice experiments, which seem to imply that certain aspects of what happens in an experiment can be influenced by later choices of the experimenter. Chapter 8 analyzes these experiments and argues that they do not warrant the antirealist conclusions which some commentators draw from them. It pays particular attention to the case of delayed-choice entanglement swapping and the corresponding question whether entanglement is a real physical relation. In chapter 9,1 finally address relativistic quantum theories. It is often claimed that these theories are incompatible with a particle ontology, and this calls into question causal realism's commitment to localizable and countable entities. I defend the commitments of causal realism against these objections, and I conclude with some remarks connecting the interpretation of quantum field theory to more general metaphysical issues confronting causal realism.

Caractéristiques de la clientèle des structures à bas seuil d'accès pour toxicomanes mettant à disposition du matériel d'injection stérile en Suisse [Characteristics of attenders of low threshold syringe-exchange centers providing sterile syringes in Switzerland].

BACKGROUND: The objectives of the present study were to evaluate Aids prevention in drug users attending low threshold centres providing sterile injection equipment in Switzerland, to identify the characteristics of these users, and to monitor the progress of indicators of drug-related harm. METHODS: This paper presents results from a cross-sectional survey carried out in 1994. RESULTS: The mean age of attenders was 28 years, and women represented 27% of the sample. 75% of attenders used a combination of hard drugs (heroin and cocaine). Mean duration of heroin consumption was 8 years, and of cocaine 7 years; 76% of attenders had a fixed abode, but only 34% had stable employment; 45% were being treated with methadone; 9% had shared their injection material in the last 6 months; 24% always used condoms in the case of a stable relationship, and 71% in casual relationships. In a cluster analysis constructed on the basis of multiple correspondence analysis, two distinct profiles of users emerge: highly marginalised users with a high level of consumption (21%); irregular users, better integrated socially, of which the majority are under methadone treatment (79%). CONCLUSION: Theses centres play a major role in Aids prevention. Nevertheless, efforts to improve the hygiene conditions of drug injection in Switzerland should be pursued and extended. At the same time, prevention of HIV sexual transmissions should be reinforced.

Advantages of using TEM when analysing asbestos in ambient air

Asbestos is an industrial term to describe some fibrous silicate minerals, which belong to the amphiboles or serpentines group. Six minerals are defined as asbestos including: chrysotile (white asbestos), amosite (grunerite, brown asbestos), crocidolite (riebeckite, blue asbestos), anthophyllite, tremolite and actonolite, but only in their fibrous form. In 1973, the IARC (International Agency for Research on Cancer) classified the asbestos minerals as carcinogenic substances (IARC,1973). The Swiss threshold limit (VME) is 0.01 fibre/ml (SUVA, 2007). Asbestos in Switzerland has been prohibited since 1990, but this doesn't mean we are over asbestos. Up to 20'000 tonnes/year of asbestos was imported between the end of WWII and 1990. Today, all this asbestos is still present in buildings renovated or built during that period of time. During restorations, asbestos fibres can be emitted into the air. The quantification of the emission has to be evaluated accurately. To define the exact risk on workers or on the population is quite hard, as many factors must be considered. The methods to detect asbestos in the air or in materials are still being discussed today. Even though the EPA 600 method (EPA, 1993) has proved itself for the analysis of bulk materials, the method for air analysis is more problematic. In Switzerland, the recommended method is VDI 3492 using a scanning electron microscopy (SEM), but we have encountered many identifications problems with this method. For instance, overloaded filters or long-term exposed filters cannot be analysed. This is why the Institute for Work and Health (IST) has adapted the ISO10312 method: ambient air - determination of asbestos fibres - direct-transfer transmission electron microscopy (TEM) method (ISO, 1995). Quality controls have already be done at a French institute (INRS), which validate our practical experiences. The direct-transfer from MEC's filters on TEM's supports (grids) is a delicate part of the preparation for analysis and requires a lot of trials in the laboratory. IST managed to do proper grid preparations after about two years of development. In addition to the preparation of samples, the micro-analysis (EDX), the micro-diffraction and the morphologic analysis (figure 1.a-c) are also to be mastered. Theses are the three elements, which prove the different features of asbestos identification. The SEM isn't able to associate those three analyses. The TEM is also able to make the difference between artificial and natural fibres that have very similar chemical compositions as well as differentiate types of asbestos. Finally the experiments concluded by IST show that TEM is the best method to quantify and identify asbestos in the air.

Ammonia-induced toxicity in developing brain cells and strategies for neuroprotection

RESUME L'hyperammonémie est particulièrement toxique pour le cerveau des jeunes patients et entraîne une atrophie corticale, un élargissement des ventricules et des défauts de myélinisation, responsables de retards mentaux et développementaux. Les traitements actuels se limitent à diminuer le plus rapidement possible le taux d'ammoniaque dans l'organisme. L'utilisation de traitements neuroprotecteurs pendant les crises d'hyperammonémie permettrait de contrecarrer les effets neurologiques de l'ammoniaque et de prévenir l'apparition des troubles neurologiques. Au cours de cette thèse, nous avons testé trois stratégies de neuroprotection sur des cultures de cellules en agrégats issues du cortex d'embryons de rats et traitées à l'ammoniaque. - Nous avons tout d'abord testé si l'inhibition de protéines intracellulaires impliquées dans le déclenchement de la mort cellulaire pouvait protéger les cellules de la toxicité de l'ammoniaque. Nous avons montré que L'exposition à l'ammoniaque altérait la viabilité des neurones et des oligodendrocytes, et activait les caspases, la calpaïne et la kinase-5 dépendante des cyclines (cdk5) associée à son activateur p25. Alors que l'inhibition pharmacologique des caspases et de la calpaïne n'a pas permis de protéger les cellules cérébrales, un inhibiteur de la cdk5, appelé roscovitine, a réduit significativement la mort neuronale. L'inhibition de la cdk5 semble donc être une stratégie thérapeutique prometteuse pour prévenir 1es effets toxiques de 1'ammoniaque sur les neurones. - Nous avons ensuite étudié les mécanismes neuroprotecteurs déclenchés par le cerveau en réponse à la toxicité de l'ammoniaque. Nous avons montré que l'ammoniaque induisait la synthèse du facteur neurotrophique ciliaire (CNTF) par les astrocytes, via l'activation de la protéine kinase (MIAPK) p38. D'autre part, l'ajout de CNTF a permis de protéger les oligodendrocytes mais pas les neurones des cultures exposées à l'ammoniaque, via les voies de signalisations JAK/STAT, SAPK/JNK et c-jun. - Dans une dernière partie, nous avons voulu contrecarrer, par l'ajout de créatine, le déficit énergétique cérébral induit par l'ammoniaque. La créatine a permis de protéger des cellules de type astrocytaire mais pas les cellules cérébrales en agrégats. Cette thèse amis en évidence que les stratégies de neuroprotection chez les patients hyperammonémiques nécessiteront de cibler plusieurs voies de signalisation afin de protéger tous les types cellulaires du cerveau. Summary : In pediatric patients, hyperammonemia is mainly caused by urea cycle disorders or other inborn errors of metabolism, and leads to neurological injury with cortical atrophy, ventricular enlargement and demyelination. Children rescued from neonatal hyperammonemia show significant risk of mental retardation and developmental disabilities. The mainstay of therapy is limited to ammonia lowering through dietary restriction and alternative pathway treatments. However, the possibility of using treatments in a neuroprotective goal may be useful to improve the neurological outcome of patients. Thus, the main objective of this work was to investigate intracellular and extracellular signaling pathways altered by ammonia tonicity, so as to identify new potential therapeutic targets. Experiments were conducted in reaggregated developing brain cell cultures exposed to ammonia, as a model for the developing CNS of hyperammonemic young patients. Theses strategies of neuroprotection were tested: - The first strategy consisted in inhibiting intracellular proteins triggering cell death. Our data indicated that ammonia exposure altered the viability of neurons and oligodendrocytes. Apoptosis and proteins involved in the trigger of apoptosis, such as caspases, calpain and cyclin-dependent kinase-5 (cdk5) with its activator p25, were activated by ammonia exposure. While caspases and calpain inhibitors exhibited no protective effects, roscovitine, a cdk5 inhibitor, reduced ammonia-induced neuronal death. This work revealed that inhibition of cdk5 seems a promising strategy to prevent the toxic effects of ammonia on neurons. - The second strategy consisted in mimicking, the endogenous protective mechanisms triggered by ammonia in the brain. Ammonia exposure caused an increase of the ciliary neurotrophic factor (CNTF) expression, through the activation of the p38 mitogen-activated protein kinase (MAPK) in astrocytes. Treatment of cultures exposed to ammonia with exogenous CNTF demonstrated strong protective effects on oligodendrocytes but not on neurons. These protective effects seemed to involve JAK/STAT, SAPK/JNK and c-jun proteins. - The third strategy consisted in preventing the ammonia-induced cerebral energy deficit with creatine. Creatine treatment protected the survival of astrocyte-like cells through MAPKs pathways. In contrast, it had no protective effects in reaggregated developing brain cell cultures exposed to ammonia. The present study suggests that neuroprotective strategies should optimally be directed at multiple targets to prevent ammonia-induced alterations of the different brain cell types.

Affaires de patrons, usages de la frontière : géographie des réseaux marchands entre Niger, Bénin et Nigéria

Résumé L'objectif de la thèse est de comprendre le mode d'organisation économique spécifique aux petits centres urbains qui composent les espaces frontaliers sahéliens, en s'interrogeant sur leur concurrence ou leur complémentarité éventuelle à l'intérieur d'un régime de spatialité particulier. En s'appuyant sur l'exemple du carrefour économique de Gaya-Malanville-Kamba situé à la frontière entre le Niger, le Bénin et le Nigeria, il questionne le rôle de la ville-frontière ainsi que le jeu des acteurs marchands localement dominants, à partir de quatre grandes interrogations : Quelles sont les spécificités de l'Afrique sahélienne qui obligent à renouveler les approches géographiques de l'espace marchand? Quels sont les facteurs déterminants de l'activité économique frontalière? Les formes d'organisation de l'espace qui concourent à la structuration de l'économie sont-elles concurrentes ou coopératives? Les logiques économiques frontalières sont-elles compatibles avec l'orientation des programmes de développement adoptés par les pays sahéliens et leurs partenaires bi- ou multilatéraux? Dans une première partie, un modèle territorial de l'Afrique sahélienne permet de rendre compte de la prédominance des logiques circulatoires sur les logiques productives, une propriété essentielle de toute organisation économique confrontée à l'instabilité climatique. Dans une seconde partie, l'étude considère les facteurs déterminants de l'activité économique frontalière que sont le degré d'enclavement des territoires, la libre circulation des biens et des personnes, les relations concurrentielles ou coopératives qui lient les marchés ainsi que les liens clientélistes qui unissent patron et obligés. Une troisième partie est consacrée aux productions agricoles de tente organisées sous forme de coopératives paysannes ou d'initiatives privées. Une quatrième partie s'intéresse aux réseaux de l'import-export et du commerce de détail qui bénéficient de l'augmentation des besoins engendrée par l'urbanisation sahélienne. L'économie spatiale qui résulte de ces flux est organisée selon deux logiques distinctes : d'une part, les opportunités relatives à la production agricole conduisent certains investisseurs à intensifier l'irrigation pour satisfaire la demande des marchés urbains, d'autre part, les acteurs du capitalisme marchand, actifs dans l'import-export et la vente de détail, développent des réseaux informels et mobiles qui se jouent des différentiels nationaux. Les activités commerciales des villes-marchés connaissent alors des fluctuations liées aux entreprises productives et circulatoires de ces patrons, lesquelles concourent à l'organisation territoriale générale de l>Afrique sahélienne. Ces logiques évoluent dans un contexte fortement marqué par les politiques des institutions financières internationales, des agences bilatérales de coopération et des ONGs. Celles-ci se donnent pour ambition de transformer les économies, les systèmes politiques et les organisations sociales sahéliennes, en faisant la promotion du libéralisme, de la bonne gouvernance et de la société civile. Ces axes directeurs, qui constituent le champ de bataille contemporain du développement, forment un ensemble dans lequel la spécificité sahélienne notamment frontalière est rarement prise en compte. C'est pourquoi l'étude conclut en faveur d'un renouvellement des politiques de développement appliquées aux espaces frontaliers. Trois grands axes d'intervention peuvent alors être dégagés, lesquels permettent de réconcilier des acteurs et des logiques longtemps dissociés: ceux des espaces séparés par une limite administrative, ceux de la sphère urbaine et rurale et ceux du capitalisme marchand et de l'investissement agricole, en renforçant la coopération économique transfrontalière, en prenant en considération les interactions croissantes entre villes et campagnes et en appuyant les activités marchandes. Abstract: Urbanisation in West Africa is recent and fast. If only 10 % of the total population was living in urban areas in 1950, this proportion reached 40 % in 2000 and will be estimated to 60 % in 2025. Small and intermediate cities, located between the countryside and large metropolis, are particularly concerned with this process. They are nowadays considered as efficient vectors of local economic development because of fiscal or monetary disparities between states, which enable businessmen to develop particular skills based on local urban networks. The majority of theses networks are informal and extremely flexible, like in the Gaya - Malanville - Kamba region, located between Niger, Benin and Nigeria. Evidence show that this economic space is characterised by high potentialities (climatic and hydrological conditions, location on main economic West African axis) and few constraints (remoteness of some potentially high productive areas). In this context, this PhD deals with the economic relationships between the three market cities. Focusing on the links that unite the businessmen of the local markets - called patron; - it reveals the extreme flexibility of their strategies as well as the deeply informal nature of their activities. Through the analysis of examples taken from the commerce of agricultural products, import and export flows and detail activities, it studies the changes that have taken place in the city centres of Gaya, Malanville and Kamba. Meanwhile, this research shows how these cities represent a border economical area based on rival and complementary connections. In the first Part, it was necessary to reconsider the usual spatial analysis devoted to the question of economic centrality. As a matter of fact, the organisation of West African economic spaces is very flexible and mobile. Centrality is always precarious because of seasonal or temporary reasons. This is why the first chapters are devoted to the study of the specificity of the Sahelian territoriality. Two main elements are relevant: first the population diversity and second, the urban-rural linkages. In the second part, the study considers three main factors on which the cross-border economic networks are dependent: enclosure that prevents goods to reach the markets, administrative constraints that limit free trade between states and cities and the concurrent or complementary relationships between markets. A third part deals with the clientelist ties engaged between the patrons and their clients with the hypothesis that these relationships are based on reciprocity and inequality. A fourth part is devoted to' the study of the spatial organisation of commercial goods across the borders, as far as the agriculture commercial products, the import-export merchandises and the retail products are concerned. This leads to the conclusion that the economic activity is directly linked to urban growth. However, the study notices that there is a lack of efficient policies dealing with strengthening the business sector and improving the cross-border cooperation. This particularity allows us to favour new local development approaches, which would take into account the important potential of private economical actors. In the same time, the commercial flows should be regulated with the help of public policies, as long as they are specifically adapted to the problems that these areas have to deal with.

Cardiologie [Cardiology]

Heart failure and atrial fibrillation are the main problems in general cardiology. Our therapeutic reflections summarize new ideas in the treatment of theses pathologies but we will not forget importance of PCI. All these therapies have proven now the clinical benefit but also reduction in more morbidity and mortality. Cardiac resynchronisation therapy has shown promising results. The art of medicine to develop will be to better identify the patients benefiting from this therapy. Interventional cardiology is focusing on the acute coronary syndrome. Not only rapid intervention but also the stent technology allow significant modification of endothelial tissue reaction and therefore improve the general benefit for the patient.

Rhumatologie. Anti-TNF alpha: quels risques infectieux? Recommandations pratiques [Rheumatology. TNF alpha-inhibitors: infection risks? Practical recommendations].

Anti-TNF alpha are immunomodulatory treatments prescribed for some rheumatologic inflammatory diseases (ex: spondylarthropathy, rheumatoid polyarthritis). The randomised studies suggested that anti-TNF alpha therapy is associated with an overall risk of infectious diseases. The results of the observational studies are more reassuring. In this article, we will describe some results of theses studies and propose some practical recommendations in use of the anti-TNF alpha therapy.

Assistance au suicide en hôpital de soins aigus: sommes-nous prêts [Physician-assisted suicide in university hospital: are we ready?]

Assisting people to commit suicide has generated a passionate public debate. In exceptional situations, access to this support can be granted to the demanders in a hospital environment. So did the CHUV and the academic hospitals of Geneva draw up a procedure permitting, in principle, the access to an assistance to commit suicide. Two recent clinical situations experienced in the CHUV's Service of internal medicine have created a lot of discussions, doubts and revealed, sometimes, divergent positions. By the light of this clinical cases, we wished to share the perspective of the internist in charge of the ethician, of the chaplain, of the medical director, of the psychiatrist and of the palliative care responsible. Theses complex situations illustrate the deep ambivalence felt by the clinicians confronted to situations which require a multidisciplinary approach.

Anévrismes complexes de l'aorte abdominale: la chirurgie ouverte est-elle obsolète [The complex aortic abdominal aneurysm: is open surgery old fashion?].

Open surgery is still the main treatment of complex abdominal aortic aneurysm. Nevertheless, this approach is associated with major complications and high mortality rate. Therefore the fenestrated endograft has been used to treat the juxtarenal aneurysms. Unfortunately, no randomised controlled study is available to assess the efficacy of such devices. Moreover, the costs are still prohibitive to generalise this approach. Alternative treatments such as chimney or sandwich technique are being evaluated in order to avoid theses disadvantages. The aim of this paper is to present the endovascular approach to treat juxtarenal aneurysm and to emphasize that this option should be used only by highly specialized vascular centres.

Mieux vivre le lymphoedème: le présent et l'avenir [To live with lymphoedema: present and future]

Everything must be done to prevent and take care of lymphoedema as soon as possible to avoid its progression and its negative impact on patient's psychology and quality of life. The physical limitations and the socio-occupational incidence of lymphoedema must not be neglected. For theses reasons, it is important to promote the education of lymphology and its therapy. Since April 2008, the service of angiology of our university hospital (CHUV) has developed a multidisciplinary consultation for diagnosing and managing oedemas particularly primary and secondary lymphoedemas.