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The structure of the side chain of the 3 alpha, 7 alpha, 12 alpha-trihydroxy-5 beta-C29 dicarboxylic bile acid occurring in body fluids of infants with coprostanic acidemia was investigated by means of mass spectrometry and nuclear magnetic resonance spectroscopy. The findings identified this bile acid as 3 alpha, 7 alpha, 12 alpha-trihydroxy-27a, 27b-dihomo-5 beta-cholestane-26,27b-dioic acid (3 alpha, 7 alpha, 12 alpha-trihydroxy-27-carboxymethyl-5 beta-cholestan-26-oic acid).

In the French health system, social security is the same for both public and private hospitals regardless of their status. In terms of number of patients screened, diagnosed, or treated, independant medicine is the most important sector in the French oncology. The multitude of organizations representing private hospitals or independant oncologists, physicians, radiologists or pathologists have a common organization, the National Union for Private Hospital Oncology (UNHPC). It bases its action on two founding postulates to ensure the quality of the oncology practice : the medical and managerial cultures are complementary and should be articulated ; the quality of organizations is as important as professional competence.

In medicine, as in oncological radiotherapy, as elsewhere, the precept of quality has no meaning if it is not defined. In France as everywhere radiotherapy has its forces and its weaknesses. As in every country, its future seems assured by its character cost effective as by its capacity to make progress in the triple point of view of its equipment, its professions and its organization. However, the French radiotherapy is in crisis. The professionals saw clearly. For more than 10 years they had recalled the medical authorities to their responsibilities concerning the demographic trends for the radiotherapists and the physicists, the renovation of the equipment, the modernization of the organizations, the promotion of the evaluation of procedures and outcomes and the development of a greater fairness in the financings. But the delay taken, the setting under pressure of the professionals by the State, its services, its agencies and the media following the recent accidents cause numerous perverse effects and worried the staff. The accident of Epinal was the starting fact of an effort of professionalisation of the risk management, but also of a disturbed period favourable with a certain confusion of minds, discouragement and protective behaviors. The risks felt by the professionals then seem especially to come from the authorities and the media. It appears that the topic of quality is at the center of all these speeches. Under this vocable, it is in fact the respect of the procedures related to the requirement of security which is privileged by the State and its representatives. The apparent security seems to override the real quality of the practices. Thus, time came for a clarification of the quality and security concepts, of organizations which contribute to it and for the development of a clear strategy bringing together the interprofessionnal actors. In this context, the implication of the College and especially of the Société française de radiothérapie oncologique is a requirement.

Introduction: The aim of this article was to evaluate the role of hyperthermic intraperitoneal chemotherapy (HIPEC), associated or not to cytoreductive surgery (CS) in the treatment of different stages of advanced gastric cancer (AGC)., Patients and Methods: Thirty seven patients with AGC who underwent 43 HIPEC from June 1992 to February 2007 were included. HIPEC used Mitomycin-C and Cisplatin for 60-90 min at 41-43 degrees C intra-abdominal temperature. The main endpoints were long-term survivals, morbidity and mortality rates., Results: Eleven patients had no demonstrable sign of PC and constituted the Prophylactic-group, while 26 patients had macroscopic PC (PC-group). Five patients were Gilly 1 or 2 (nodules <0.5 cm) and 21 Gilly 3 or 4 (nodules >or=0.5 cm). In the PC-group a complete curative CS was achieved before HIPEC in 8 (PC-curative subgroup) and a palliative HIPEC in 18 patients (PC-palliative subgroup). The overall 30-days mortality was 5% (2 patients). Two patients in the Prophylactic group died within 6 months after hospital discharge (overall mortality 11%). The estimated risk of death per procedure was 9%. Ten patients (27%) presented one or more complications. The median survival was 23.4 months in the Prophylactic group, and 6.6 months in the PC-group (p<0.05). The median survival in the PC-curative subgroup was 15 vs 3.9 months in the PC-palliative subgroup (p=0.007). The median survival according to Gilly classification was significantly different (Gilly 1&2 vs Gilly 3&4, 15 vs 4 months respectively, p=0.014). The global recurrence rates between the Prophylactic group and the PC-curative subgroup at 2years were 36% vs 50% respectively. The median delay to recurrence was 18.5 vs 9.7 months respectively., Conclusion: HIPEC might be useful to improve the survival in selected patients with ACG only when a complete cytoreduction can be achieved. Despite encouraging data, prospective studies, based on larger cohorts of patients are required to assess the role of this procedure as a prophylactic treatment in patients with AGC.

The concept of continuous and global care is acknowledged today by all as inherent to modern medicine. A working group gathered to propose models for the coordination of supportive care for all severe illnesses in the various private and public health care centres. The supportive care are defined as: "all care and supports necessary for ill people, at the same time as specific treatments, along all severe illnesses". This definition is inspired by that of "supportive care" given in 1990 by the MASCC (Multinational Association for Supportive Care in Cancer): "The total medical, nursing and psychosocial help which the patients need besides the specific treatment". It integrates as much the field of cure with possible after-effects as that of palliative care, the definition of which is clarified (initial and terminal palliative phases). Such a coordination is justified by the pluridisciplinarity and hyperspecialisation of the professionals, by a poor communication between the teams, by the administrative difficulties encountered by the teams participating in the supportive care. The working group insists on the fact that the supportive care is not a new speciality. He proposes the creation of units. departments or pole of responsibility of supportive care with a "basic coordination" involving the activities of chronic pain, palliative care, psycho-oncology, and social care. This coordination can be extended, according to the "history" and missions of health care centres. Service done with the implementation of a "unique counter" for the patients and the teams is an important point. The structure has to comply with the terms and conditions of contract (Consultation, Unit or Centre of chronic pain, structures of palliative care, of psycho-oncology, of nutrition, of social care). A common technical organization is one of the interests. The structure has to set up strong links with the private practitioners, the networks, the home medical care (HAD) and the nurses services at home (SSIAD), when they exist, to guarantee the continuity of the supportive care under all its aspects and in order to take into account the preferences of the patients. According to Hospital 2007 propositions, the extended, flexible and general purpose Group of Sanitary Cooperation (GCS) meets the necessities inherent to the structures of supportive care within the territories of health because it can be established between one or several health care centres and the private health professionals, thus favouring the cooperation between public and private health care centres. PSPH and general medicine.

The aim of this study was to check the clinical predictive variables of the variance of the total cost by GHM for patients undergoing chemotherapy. 10 different hospitals registered 537 hospital stays and 1,535 day care sessions. The initial disease, metastases, other pathologies, participation to randomised trial were recorded. Each day health status, pain, stage of the protocol and the drugs, use of catheter, pump or chamber implant were noted. Work was measured separately for physicians and nurses per 24 hours using a visual analogy scale. Lab tests and drugs were recorded for each patient. The cost of the drugs explain 98% of the variance of the total cost for the day care and 50% for the hospitalisations. For the latter, beside the cost of drugs, the length of stay, labor, initial disease, age, pain and associated pathology are predictive variables. According to this results, we conclude that the drugs for chemotherapy should be paid separately. No other change should be made for day care. DRG for hospitalized patients should take into account initial disease, age and pain.

3-Methyl-substituted fatty acids are first oxidatively decarboxylated (alpha-oxidation) before they are degraded further via beta-oxidation. We synthesized [1-14C]phytanic and 3-[1-14C]methylmargaric acids in order to study their alpha-oxidation in isolated rat hepatocytes, rat liver homogenates and subcellular fractions. alpha-Oxidation was measured as the production of radioactive CO2. In isolated hepatocytes, maximal rates of alpha-oxidation amounted to 7 and 10 nmol/min x 10(8) cells with phytanic acid and 3-methylmargaric acid, respectively. At equimolar substrate concentrations, alpha-oxidation of branched fatty acids was approximately 10- to 15-fold slower than the beta-oxidation of the straight chain palmitate. In whole liver homogenates, rates of alpha-oxidation that equaled 60 to 70% of those observed in the hepatocytes were obtained. Optimum rates required O2, NADPH, Fe3+, and ATP. Fe3+ could be replaced by Fe2+ and ATP could be replaced by a number of other phosphorylated nucleosides and even inorganic phosphate without loss of activity. NADH could substitute for NADPH but not always with full restoration of activity. A variety of other cofactors and metal ions was either inhibitory or without effect. Scavengers of reactive oxygen species, known to be formed during the NADPH-dependent microsomal reduction of ferric-phosphate complexes, were without effect on alpha-oxidation. No evidence was found for the accumulation of NADPH-dependent or Fe(3+)-dependent reaction intermediates. Subcellular fractionation of liver homogenates demonstrated that alpha-oxidation was located predominantly, if not exclusively, in the endoplasmic reticulum. alpha-Oxidation, measured in microsomal fractions, was not inhibited by CO, cytochrome c, or ferricyanide, indicating that NADPH cytochrome P450 reductase and cytochrome P450 are not involved in alpha-oxidation. Our results indicate that, contrary to current belief, alpha-oxidation is catalyzed by the endoplasmic reticulum. The cofactor requirements suggest that alpha-oxidation involves the reduction of Fe3+ by electrons from NADPH and that it is stimulated by phosphate ions and nucleotides.

The structure of the side chain of the 3 alpha, 7 alpha, 12 alpha-trihydroxy-5 beta-C29 dicarboxylic bile acid occurring in body fluids of infants with coprostanic acidemia was investigated by means of mass spectrometry and nuclear magnetic resonance spectroscopy. The findings identified this bile acid as 3 alpha, 7 alpha, 12 alpha-trihydroxy-27a, 27b-dihomo-5 beta-cholestane-26,27b-dioic acid (3 alpha, 7 alpha, 12 alpha-trihydroxy-27-carboxymethyl-5 beta-cholestan-26-oic acid).

By-products were formed on analysis of beta-muricholic acid (3 alpha, 6 beta, 7 beta-trihydroxy-5 beta-cholan-24-oic acid) in biological samples by a method involving acid-catalyzed solvolysis of sulfate esters in acetone-methanol, followed by perchloric acid-catalyzed acetylation with acetic anhydride-acetic acid. These products have been identified by mass spectrometry and nuclear magnetic resonance as methyl 3-0,6-0-diacetyl-7-0-(1-methyl-3-oxo-1-butenyl)- and methyl 3-0,7-0-diacetyl-6-0-(1-methyl-3-oxo-1-butenyl)-beta-muricholate, methyl 3-0, 6-0-diacetyl- and methyl 3-0, 7-0-diacetyl-beta-muricholate, and a methyl diacetoxy-cholen-24-oate.

The three isomeric cholic acid-monosulfates were synthetized and characterized. Cholic acid-3-sulfate was obtained by reacting cholic acid for 2 min with chlorosulfonic acid in pyridine and chromatography of the resulting bile salt mixture on Sephadex LH-20. The 7- and the 12-monosulfate were prepared by sulfation of the corresponding monohydroxy-diacetates followed by removal of the acetyl groups by alkaline hydrolysis and purification by chromatography on Sephadex LH-20. On TLC in n-butanol-acetic acid-water (10:1:1, v/v) the Rf values were 0.59 for cholic acid-3-sulfate, 0.52 for cholic acid-7-sulfate and 0.48 for cholic acid-12-sulfate. The time required for complete solvolysis at 37 degrees C in acid methanol-acetone (1:9) was 3 h for cholic acid-3-sulfate, 12 h for the 12-monosulfate and 18 h for the 7-monosulfate.

Acute intermittent porphyria is one of three severe hepatic porphyrias. Clinical manifestations include intermittent acute attacks of abdominal pain and neuropathy with an occasionally outcome. These attacks are often precipitated by endogenous (menstrual cycle and pregnancy in women) or exogenous factors (porphyrinogenic drugs). An epidural analgesia was performed during the labour of a pregnant woman with acute intermittent porphyria just after an acute attack of abdominal pain. Analgesia was obtained using procaine and fentanyl. The choice of drugs was based on available clinical reports and experimental studies of the porphyrinogenicity of drugs in animal models (rat in vivo and chick embryo in ovo).

The structure of the bile acids in serum of infants with coprostanic acidemia was further investigated. The identity of 3 alpha-hydroxy-5 beta-cholestan-26-oic acid and 3 beta-hydroxy-5-cholesten-26-oic acid was confirmed. The biosynthesis of the 3 alpha, 7 alpha, 12 alpha-trihydroxy-5 beta-C29 dicarboxylic bile acid does not start from beta-sitosterol.

The isomeric monosulfates of chenodeoxycholate, deoxycholate, and their taurine or glycine conjugates, were synthesized and characterized. Reaction with chlorosulfonic acid in pyridine for 2 minutes mainly afforded the 3-monosulfates. To prepare the 7- or the 12-monosulfates, the 3-hydroxyl group was protected by carbethoxylation prior to sulfation of the 7- or 12-hydroxyl group for 24 h to 5 days; after sulfation, the protecting 3-carbethoxy function was removed by mild alkaline hydrolysis. The crude bile salt monosulfates were purified by chromatography on silica gel and on Sephadex LH-20 and were crystallized from methanolethanol-ethyl acetate. The results of elemental analysis demonstrated that the compounds were disodium dihydroxy bile salt monosulfates. Thin layer chromatography of the sulfates, and gas-liquid chromatography after oxidation and solvolysis, showed that the substances were pure and that the sulfate group was at the expected position.