Thesis (Ph.D. (Health))--University of Western Sydney, 2007. / A thesis presented to the University of Western Sydney, College of Health and Science, School of Biomedical and Health Sciences, in fulfilment of the requirements for the degree of Doctor of Philosophy (Health). Includes bibliographies.

<b>BACKGROUND:</b> Evidence-based medicine has had a profound impact on healthcare. In the field of Plastic surgery, powerful examples include; less radical skin cancer excision margins and skin-sparing or even nipple-sparing mastectomies and microsurgical reconstruction. Sustained progression of the field, relies on the development of a high-quality evidence base, with strong use of peer-reviewed research protocols, which are publicly registered and completed studies transparently reported. The extent of compliance with these principles is currently unknown and the author hypothesised that it would be low. The author further hypothesised that registration could be improved by the development of a new global research registry and reporting quality can be improved by the mandatory implementation of reporting guidelines in a journal. <b>METHODS:</b> This thesis incorporated 11 studies. The first two studies used a literature review to determine; the levels of evidence, rates of study registration and protocol publication in the recent Plastic Surgery literature. Thirdly, the design, build and launch of a new global research registry to boost compliance with registration and to determine barriers to it using a survey amongst users. This would be followed by systematic reviews to determine compliance with the STROBE and PRISMA guidelines respectively. An analysis of each guide for authors (GFA) of the surgical journals listed in the Thomson Reuters journal citation report for surgery to determine support for reporting guidelines. The impact of the mandatory implementation of reporting guidelines in a surgical journal would be assessed using a before and after design. Finally, to develop a reporting guideline for surgical case reports (SCARE) and surgical case series (PROCESS) using a DELPHI consensus exercise amongst an expert panel. <b>RESULTS:</b> Protocols were registered in 4% of 595 recent research studies and 0.5% were published. There was a mean compliance of 12/22 for the STROBE guideline (n=94) and 16/27 for the PRISMA guideline (n=79). The Research Registry® was launched in February 2015. Analysis of the first 500 previously unregistered studies, showed they came from 57 countries and included 1.77 million patients. Key barriers to registration were a lack of awareness of the need to register and lack of time (n=149). In addition, 45% registered their study at the time of journal submission. The GFA analysis showed 62% didn’t mention reporting guidelines at all (n=193). Subsequent mandatory implementation in a single surgical journal, increased compliance with STROBE by 12% (n=152), with CONSORT by 40% (n=13) and with PRISMA by 58% (n=28). The SCARE and PROCESS reporting guidelines were developed and published in late 2016. According to Google Scholar, they have accumulated over 200 citations at the time of writing. <b>CONCLUSION:</b> Study registration, protocol use and reporting quality are poor in plastic surgery. Potential solutions to these long-standing problems have been developed and explored within this thesis. These include the development and use of the Research Registry® and the mandatory implementation of reporting guidelines, with both measures front-loaded within a gatekeeper framework for journals. It is now for Plastic Surgeons and the wider surgical community to pick up the gauntlet and drive forward high-quality research, evidence-based surgical practice and better outcomes for their patients and society at large.

Submitted by Andrea Hayashi (deachan@gmail.com) on 2016-06-20T18:33:12Z No. of bitstreams: 1 DISSERTAÇÃO MARIA EDUARDA PUGA.pdf: 2245438 bytes, checksum: 53550b5cfa47aa4151d41ac6d60e069c (MD5) / Approved for entry into archive by Andrea Hayashi (deachan@gmail.com) on 2016-06-20T18:34:20Z (GMT) No. of bitstreams: 1 DISSERTAÇÃO MARIA EDUARDA PUGA.pdf: 2245438 bytes, checksum: 53550b5cfa47aa4151d41ac6d60e069c (MD5) / Made available in DSpace on 2016-06-20T18:34:20Z (GMT). No. of bitstreams: 1 DISSERTAÇÃO MARIA EDUARDA PUGA.pdf: 2245438 bytes, checksum: 53550b5cfa47aa4151d41ac6d60e069c (MD5) Previous issue date: 2007-12-10 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / O ensino médico no país é solicitado a adequar e reformular seus currículos. A inclusão da Medicina Baseada em Evidências nos currículos médicos vem ao encontro dessa realidade e responde aos requisitos exigidos pelas Diretrizes Curriculares Nacionais para os Cursos de Graduação em Medicina. Objetivos: avaliar a prevalência de instituições que incluem o ensino curricular de Medicina Baseada em Evidências (MBE) nas escolas médicas do Brasil e identificar as regiões do país onde essa cultura está disseminada. Método: estudo descritivo (Levantamento/Survey) dos currículos das 169 Escolas Médicas do Brasil cadastradas no site do INEP - Instituto Nacional de Estudos e Pesquisas Educacionais Anísio Teixeira, órgão ligado ao Ministério da Educação e responsável pelo acompanhamento de abertura, credenciamento e avaliação dos cursos de educação superior no Brasil. A análise dos resultados foi feita utilizando a divisão por regionais utilizada pela Associação Brasileira de Educação Médica (ABEM), ou seja, oito núcleos, como seguem: Norte, Nordeste, Centro-Oeste, Minas Gerais, Sul I, Sul II, São Paulo, Rio de Janeiro/Espírito Santo. Na primeira fase da pesquisa foram mapeadas todas as Escolas Médicas que estavam cadastradas no site do INEP e foram identificadas aquelas que já disponibilizam em seus currículos eletrônicos e que incluem a disciplina e a cultura da Medicina Baseada em Evidências. Na segunda fase, foi realizado contato via fax e e-mail para o envio de um questionário a todas as escolas médicas cadastradas no site do INEP. Resultados: Foram encontradas seis escolas que no site já disponibilizam em seus currículos o conteúdo de Medicina Baseada em Evidências. Das escolas cadastradas no INEP responderam ao questionário 49 escolas do total de 169, das quais somente 23 incluem a MBE em seus currículos. Conclusões: Foi possível constatar que em todas as regionais do país há pelo menos uma escola que desenvolve em seu currículo o ensino e a cultura da Medicina Baseada em Evidências. / Context: Medical schools in Brazil have been asked to adequate and reformulate their curriculums. The inclusion of Evidence Based Medicine into their curriculums have contemplated such reality and answered the requirements solicited by the Guidelines of Brazilian National Curriculum for the Graduation Courses in Medicine. Objectives: to evaluate the prevalence of institutions which include Evidence Based Medicine into their curricular teaching in the Brazilian Medical Schools, as well as identify their distributions across the regions where they are based on. Methods: Observational cross-sectional study (Survey) of curriculums from Brazilian Medical Schools registered on the website of Anísio Teixeira National Institute of Educational Studies and Researches (Instituto Nacional de Estudos e Pesquisas Educacionais Anísio Teixeira - INEP), a public organ bounded to the Education Ministry and responsible by following up the opening, accreditation and evaluation of graduation courses in Brazil. Data analysis were based on eight regional nucleus according to the Brazilian Association of Medical Education (Associação Brasileira de Educação Médica / ABEM) as follows: North, Northeast, Central-East, Minas Gerais, South I, South II, São Paulo, Rio de Janeiro, Rio de Janeiro/Espírito Santo. At first phase of the study, all Medical Schools accredited in the INEP website were mapped, being identified those which have included EBM in their electronic curriculums. At second phase, to all the same referred Medical Schools accredited by the INEP was sent a questionnaire by e-mail or fax. Six Medical Schools including the contents of EBM in their curriculums. Forth nine out of 169 medical schools accredited in the INEP website had answered the questionnaire, from which only 23 have already been including EBM in their curriculums. Conclusions: It was possible to conclude that all Brazilian regions have at least one Medical School including EBM into their curriculums.

Made available in DSpace on 2014-06-11T19:31:32Z (GMT). No. of bitstreams: 0 Previous issue date: 2013-01-23Bitstream added on 2014-06-13T21:02:43Z : No. of bitstreams: 1 000742511.pdf: 13643718 bytes, checksum: ac8685e3c20826d9f415d3e11b9be9d7 (MD5) / A Colaboração Cochrane (CC) é uma organização internacional que tem como objetivo ajudar profissionais da área da saúde a tomar decisões clínicas bem informadas através da preparação, manutenção e promoção da acessibilidade às revisões sistemáticas sobre os efeitos das intervenções, sensibilidade e especificidade de testes diagnósticos em saúde e associação de fatores de risco e ocorrência de determinada doença. Entretanto, alguns estudos apontaram a constante ausência ou insuficiência de evidências nas revisões sistemáticas da Colaboração Cochrane para a tomada de decisão clínica. Verificar a proporção de revisões sistemáticas completas do grupo de Odontologia da Colaboração Cochrane que permitem ou não a aplicação prática dos resultados, cujos autores consideram reunir evidências suficientes para recomendá-las ou desestimulá-las. Estudo sistemático de revisões da Biblioteca Cochrane, edição 8, 2013. Foram incluídas todas as revisões sistemáticas completas do grupo de Odontologia que preencheram os critérios de inclusão deste trabalho.143 revisões sistemáticas foram analisadas, o que correspondeu a 100% da totalidade disponível na Biblioteca pertinente ao grupo de Odontologia da Colaboração Cochrane. Evidências que apoiam a intervenção 22,38% (95% IC 16 - 29); evidências contra a intervenção 6,29% (95% IC 3 - 10); ausência de evidências 71,33% (95% IC 64 - 78). O total de revisões sistemáticas que recomendam a realização de mais estudos foi de 140 (97,90 %) (95% IC, 96 – 100). A média do número de estudos incluídos foi de 13 e o total de meta-análises incluído nas revisões sistemáticas avaliadas foi de 161. Somente 28,67% das revisões sistemáticas completas do grupo de Odontologia da Colaboração Cochrane mostraram evidências suficientes para recomendar ou desestimular o tratamento de interesse e ainda, sugeriam novos... / The Cochrane Collaboration (CC) is an international organization that aims to help health care professionals to making clinical decisions well informed by preparing, supporting and promoting the accessibility of systematic reviews about the intervention effects, sensibility and specificity of diagnostic health tests and association of risk factors and occurrence of a particular disease. However, some studies indicated the constant absence or insufficient evidences in systematic reviews from the Cochrane Collaboration to making clinical decision. To determine the proportion of complete systematic reviews of the Cochrane Collaboration Dentistry Group which allow or not the practical application of the results, which author consider bring enough evidence to recommend or discourage them. Systematic study of the reviews from Cochrane Library, Issue 8, 2013. Was included all the complete systematic reviews of the Dentistry Group who met inclusion criteria for this study. 143 systematic reviews were analyzed, corresponding to 100% of all available of the Library pertinent to the Cochrane Collaboration dentistry Group. Evidences supporting intervention 22,38% (95% IC 16 – 29); evidence against intervention 6,29% (95% IC 3 - 10); absence of evidence 71,33% (95% IC 64 - 78). The total of systematic reviews that recommend further studies was 140 (97,90 %) (95% IC, 96 – 100). The mean of included studies was 13 and the total of meta-analyzes included in systematic reviews evaluated was 161. Only 28,67 of the complete systematic reviews of the the Cochrane Collaboration Dentistry Group showed sufficient evidence to recommend or discourage the treatment of interest and also suggested further studies, or be, none of them showed consistent results. In 71,33% of them still absence, failing to provide to the user the best way to making clinical decision in Dentistry

Made available in DSpace on 2015-01-26T13:21:21Z (GMT). No. of bitstreams: 0 Previous issue date: 2014-08-15Bitstream added on 2015-01-26T13:30:38Z : No. of bitstreams: 1 000797509.pdf: 12107418 bytes, checksum: 4ab5519bf5f9d2869fb4e982a2678a96 (MD5) / As revisões sistemáticas da Colaboração Cochrane visam oferecer informações atualizadas, objetivas e com evidências consistentes para a prática clínica e para o estabelecimento de políticas de saúde. Entretanto, verifica-se frequentemente uma inconsistência de evidências e incapacidade de gerar recomendações. O objetivo desse estudo foi analisar as revisões sistemáticas do Grupo Anestesiologia da Colaboração Cochrane e mapear sua utilidade para a prática clínica e para a pesquisa científica. Realizou-se estudo transversal com análise de todas as revisões sistemáticas publicadas no Grupo Anestesiologia da Colaboração Cochrane até fevereiro de 2014, verificando-se qual o tipo de recomendação para a prática clínica e para a pesquisa científica, por meio da análise das conclusões de seus autores. Os valores são apresentados em porcentagem e intervalo de confiança de 95%. Além disso, computou-se o número de ensaios clínicos e meta-análises por revisão sistemática. 115 revisões foram analisadas. Evidências que apoiam a intervenção, com recomendação para a realização de mais estudos ou sem recomendação para mais estudos: 32,2% [IC 95% 23,7; 40,7] e 2,6% [IC 95% 0; 5,5], respectivamente. Evidências contrárias a intervenção, com recomendação para realização de mais estudos ou sem recomendação para mais estudos: 6,1% [IC 95% 1,7; 10,4] e 1,7 [IC 95% 0; 4,0], respectivamente. Ausência de evidências, com recomendação para a realização de mais estudos ou sem recomendação para mais estudos: 57,4% [IC 95% 48,4; 66,4] e 0%, respectivamente. Do total, 95,7% das revisões sugerem a realização de mais estudos independentemente dos resultados obtidos. O número médio de ensaios clínicos nas revisões foi de 19,6, variando entre zero e 737 e o número médio de meta-análises foi igual a 9,3, variando entre entre zero e 92. A maioria das revisões sistemáticas do Grupo de ... / Cochrane Collaboration systematic reviews aim to offer updated, objective and consistent information for clinical practice and in order to settle Health policies. However, inconsistence of evidence, as well as inability of raising recommendations is being observed. The aim of this study is to analyze the systematic reviews of Cochrane Collaboration Anesthesia Group and to map its use for clinical practice and scientific research. Methods: A systematic study was conducted, having the analyzes of all systematic reviews of Cochrane Collaboration Anesthesia Group until February, 2014, and then validating which recommendation for clinical practice, based on the author’s conclusions, would be more suitable. Data are shown in percentage and 95% confidence interval (CI). Besides, the number of clinical assays and meta-analyzes per systematic review is demonstrated. Results: 115 systematic reviews were analyzed. There is enough evidence to support recommendation either with or without the need of more studies, as in 32.2% and 2.6% [CI 95% 23.7; 40.7], respectively. Evidences that were opposite to interventions, with or without the need of further studies, consisted in 6.1% [CI 95% 1.7; 10.4] and 1.7% [IC 95% 0; 4.0], respectively. Absence of evidence, with or without the need of other studies, was found in 57.4% [CI 95% 48.4; 66.4] e 0%, respectively. Of all, 95.7% of the reviews suggest that independently of the results, more studies are needed to be made. The average number of clinical assays in the reviews was 19.6, ranging from zero to 737, and the average number of meta-analyzes was 9.3, ranging from zero to 92. Conclusion: Most of the systematic reviews of Cochrane Collaboration Anesthesia Group results in lack of evidence or insufficient evidence in order to recommend interventions for clinical practice, thus highlighting the need of new controlled and randomized clinical studies

The utilisation of near-infrared Raman spectroscopy for the discrimination of cancers and pre-cancers from normal tissue in the acro-digestive tract has been evaluated. A commercially available Raman microspectrometer has been modified to provide optimum throughput, sensitivity and fluorescence suppression for epithelial tissue measurements. Laser excitation at 830nm was demonstrated to be optimum. High quality (SN ratio 15-20) NIR-Raman spectra have been acquired from oesophageal and laryngeal tissues in time scales under 30 seconds. Pathological groupings covering the full range of normal and neoplastic tissues in the organs of interest have been studied. Both fresh (snap frozen) and formalin fixed tissue samples were investigated, firstly to indicate whether tissue-types can be distinguished in vivo and secondly to demonstrate the use of Raman spectroscopy as a tool for classification in the pathology lab. Results using multivariate statistical techniques to distinguish between spectra from specimens exhibiting different tissue pathologies have been extremely promising. Cross-validation of the spectral predictive models has shown that three groups of larynx tissue can be separated with sensitivities and specificities of between 86 and 90% and 87 and 95% respectively. Oesophageal prediction models have demonstrated sensitivities and specificities of 84 to 97% and 93 to 98% respectively for a three-group consensus model and 73 to 100% and 92 to 100% for an eight-group consensus model. Epithelial tissues including stomach, tonsil, endometrium, bladder and prostate have been studied to identify further tissues where Raman spectroscopy may be employed for detection of disease. Spectra were similar to those obtained from oesophagus and larynx, although sufficiently different for distinct discriminant models to be required. This work has demonstrated the generic nature of Raman spectroscopy for the detection and classification of cancers and pre-cancerous lesions in many tissues. The evidence provided by this study indicates that utilisation of Raman spectroscopy for non-invasive detection and classification of disease is a distinct possibility. Potential difficulties in the transferability from in vitro to in vivo have been evaluated and no significant barriers have been observed. However, further in vivo probe development and optimisation will be required before 'optical biopsy' with Raman spectroscopy can become a reality.

A mastite lactacional é um processo inflamatório da mama que pode, ou não ser acompanhada de infecção, causa manifestações clínicas desconfortáveis, contribuindo para o desmame precoce, onerando os custos no cuidado, tornando-se um problema de saúde pública. Este estudo teve como objetivo propor uma nova ficha de registro para mulheres que internam por mastite lactacional no município de Ribeirão Preto, com base na prática assistencial e evidências científicas. Foi desenvolvido em três fases, a primeira buscou informações para o tratamento de mulheres que necessitaram de internação na rede pública hospitalar do município de Ribeirão Preto em registros do projeto \"Floresce uma vida\", vinculado ao Programa de Aleitamento Materno de Ribeirão Preto e em prontuários médicos, a segunda visou a buscar evidências científicas para o tratamento de mastite lactacional através de revisão integrativa de literatura e a terceira fase constou de uma nova proposta de ficha para registro de mulheres que necessitam de internação no município de Ribeirão Preto. A fase I mostrou o perfil de 114 mulheres internadas para tratamento de mastite lactacional na rede pública de referência entre os anos de 2009 a 2013. As características dos dados sociodemográficos não coincidem com o que vem sendo descrito na literatura atual. Em relação aos dados obstétricos o estudo mostrou que as mais acometidas são as primíparas e que a maioria teve alguma intercorrência frente à amamentação antes da necessidade de internação, 62 (54,4%) mulheres tiveram abscesso mamário, 27 (51,9%) tiveram resultado de Staphylococcus aureus e 21(18,4%) desmamaram em consequência do abscesso. A terapêutica para mastite lactacional uniu medicação tópica, sistêmica e terapêutica complementar. A fase II selecionou nove artigos que respondiam à questão do estudo entre 2000-2013, as terapêuticas encontradas para mastite lactacional foram alternativas com probióticos, convencional e para abscessos. A fase III validou a nova \"Ficha de registro da assistência à mulher na amamentação durante a internação por intercorrências mamárias\" com a concordância de especialistas entre 80% e 100%. Este estudo uniu a prática assistencial e evidências científicas como base na formulação de um instrumento com o objetivo de identificar práticas não aceitáveis para mastite lactacional, proporcionando aos profissionais de saúde melhores informações no desenvolvimento de sua prática clínica / Lactational Mastitis is an inflammation of the breast that may or may not be accompanied by infection, cause uncomfortable clinical manifestations, contributing to early weaning, burdening the cost in care, making it a public health problem. This study aimed to propose a new record form to women hospitalized for lactational mastitis in Ribeirão Preto, based on care practice and scientific evidence. Was developed in three phases, the first information sought for the treatment of women who required hospitalization in the public health hospitals in Ribeirão Preto in the \"Bloom a Life\" project, linked to the Breastfeeding Program of Ribeirão Preto, and hospital records, the second aimed sought scientific evidence for the treatment of lactational mastitis through integrative literature review and the third phase included a new proposal of a record form for women who require hospitalization in Ribeirão Preto. Phase I showed the profile of 114 women hospitalized for treatment of lactation mastitis in public reference hospitals between the years 2009 and 2013. A Sociodemographics characteristic of the data does not coincide with what has been described in the literature. Regarding obstetric data the study showed that the most affected are the primiparous women and the majority had some complication towards breastfeeding before hospitalization, 62 (54.4%) women had breast abscess, 27 (51.9%) of the breast milk was colonized by Staphylococcus aureus and 21 (18.4%) weaned as a result of the abscess. The treatment for lactational mastitis attached topical, systemic therapy and complementary medicine. Phase II selected nine articles that answered the question of the study between 2000-2013, the therapeutic lactational mastitis were with three categories: alternate with probiotics, conventional and abscesses. Phase III validated the new \"Registration Card assisting women with breastfeeding during hospitalization for breast complications\" with the agreement of experts from 80% to 100%. This study joined the healthcare practice and scientific evidence as a basis in formulating an instrument in order to identify unacceptable practices for lactational mastitis, providing healthcare professionals information on the development of best clinical practice

Orientador: Maria Conceição da Costa / Dissertação (mestrado) - Universidade Estadual de Campinas, Instituto de Estudos da Linguagem / Made available in DSpace on 2018-08-23T14:29:00Z (GMT). No. of bitstreams: 1 Santos_PatriciaAlinedos_M.pdf: 1076582 bytes, checksum: 5aea0c7ffc50b065114babc299c4944e (MD5) Previous issue date: 2013 / Resumo: Este trabalho analisa mudanças na área médica que se inter-relacionam com o campo do jornalismo em saúde, tendo como referencial os Estudos Sociais da Ciência e Tecnologia (ESCT). O enfoque nesta dissertação é a Medicina Baseada em Evidências (MBE), abordagem na qual estudos clínicos com base em amostras populacionais são usados para a tomada de decisão na área médica. A MBE vem sendo incorporada formalmente na literatura médica desde os anos 1990, a partir do Canadá, Estados Unidos e Reino Unido e, atualmente, forma um conjunto de práticas adotadas em nível global, inclusive no Brasil. Essa perspectiva tem redefinido a racionalidade biomédica e clínica; tem influenciado as relações de poder nos diversos âmbitos da saúde, como as políticas públicas e os papéis dos profissionais e do paciente. O impacto da MBE vai além da produção e uso do conhecimento científico na medicina chegando às atividades de popularização do conhecimento sobre saúde. O jornalismo, como parte da dinâmica de difusão da ciência, também é permeado pelas novas configurações formadas no campo da saúde e, sobretudo, participa da elaboração da noção que a sociedade constrói sobre a área. Neste estudo, analisamos processos de trabalho de jornalistas e identificamos relações com as mudanças trazidas pela MBE. Essa influência no modo de fazer jornalismo se dá principalmente na seleção de temas para matérias jornalísticas, as pautas. Para esta pesquisa de método qualitativo foram realizadas seis entrevistas, a partir de um questionário semi-estruturado, com editores e repórteres de saúde que atuam em veículos impressos de circulação nacional. De forma mais ampla, a partir de experiências e sentidos pessoais desse grupo chegamos à sua representação da pesquisa em saúde com o objetivo de contribuir para a análise crítica da MBE em suas relações com a sociedade / Abstract: This work analyzes changes in the medical field that interrelate with health journalism taking the Social Studies of Science and Technology (SSST) as a reference. The focus of this thesis is the Evidence-Based Medicine (EBM), an approach in which clinical studies based on population samples are used for decision making in the medical field. EBM has been formally incorporated in the medical literature since the 1990s. It started in Canada, United States and United Kingdom, and currently forms a set of practices globally adopted, including in Brazil. This perspective has redefined the biomedical and clinical rationality. It has influenced power relations in different spheres of health, such as public policies, the roles of patients and medical professionals. The impact of EBM goes beyond the production and use of scientific knowledge in medicine reaching activities of knowledge popularization about health. Journalism is part of the dynamic for science diffusion and also pervaded by new configurations shaped in the field of health and, especially, it participates in the health notion constructed by the society. In this study, we analyze work processes of journalism to identify relations with the changes brought by EBM. This influence in the news making happens mainly in the selection of topics for news stories. For this research, we used the qualitative method and made six interviews with a semi-structured questionnaire. We questioned health editors and reporters working with the main national print media. In a wider view, from personal experiences and meanings of this group we could get to their representation of health research in order to contribute to the critical analysis of EBM in its relations with the society / Mestrado / Divulgação Científica e Cultural / Mestra em Divulgação Científica e Cultural

The utilisation of near-infraredR aman spectroscopyfo r the discrimination of cancersa nd pre-cancers from normal tissue in the acro-digestive tract has been evaluated. A commercially available Raman microspectrometehr as been modified to provide optimum throughput, sensitivity and fluorescence suppression for epithelial tissue measurements. Laser excitation at 830nmw as demonstratedto be optimum. High quality (SN ratio 15-20) NIR-Raman spectrah ave been acquired from oesophageaal nd laryngeal tissues in time scales under 30 seconds. Pathological groupings covering the full range of normal and neoplastic tissues in the organs of interest have been studied. Both fresh (snap frozen) and formalin fixed tissue samples were investigated,f irstly to indicate whether tissue-typesc an be distinguishedi n vivo and secondlyt o demonstrateth e use of Raman spectroscopya s a tool for classificationi n the pathology lab. Results using multivariate statistical techniques to distinguish between spectra from specimens exhibiting different tissue pathologies have been extremely promising. Crossvalidation of the spectral predictive models has shown that three groups of larynx tissue can be separated with sensitivities and specificities of between 86 and 90% and 87 and 95% respectively. Oesophageal prediction models have demonstrated sensitivities and specificities of 84 to 97% and 93 to 98% respectively for a three-group consensus model and 73 to 100% and 92 to 100% for an eight-groupc onsensusm odel. Epithelial tissues including stomach, tonsil, endometrium, bladder and prostate have been studiedt o identify further tissuesw hereR amans pectroscopym ay be employedf or detection of disease.S pectraw ere similar to those obtainedf rom oesophagusa nd larynx, although sufficiently different for distinct discriminant models to be required. This work has demonstratedth e genericn atureo f Ramans pectroscopyfo r the detectiona nd classification of cancersa nd pre-cancerousle sionsi n many tissues.T he evidencep rovided by this study indicatest hat utilisation of Ramans pectroscopyfo r non-invasived etectiona nd classification of diseaseis a distinct possibility. Potentiald ifficulties in the transferabilityf rom in vitro to in vivo have been evaluated and no significant barriers have been observed. However, further in vivo probe development and optimisation will be required before 'optical biopsy' with Ramans pectroscopyc anb ecomea reality.

Les recommandations de bonne pratique, issues de la médecine des preuves, s’insèrent dans un processus ancien visant à asseoir la légitimité médicale sur la science et se sont déployées en tant qu’instrument politique de rationalisation des pratiques.Comment rencontrent-elles les valeurs professionnelles et l’exercice de la médecine ?La question est traitée dans le cadre de la médecine générale et de l’hypertension artérielle (HTA) dont la mise en recommandations est exemplaire de la construction d’un risque en santé publique.La première partie s’intéresse à l’origine de la médecine des preuves et en quoi ce mouvement est porteur de continuité et de modification dans les relations entre Médecine et État, au sein de la profession, entre médecin et patient.La seconde partie, centrée sur une microsociologie des consultations de patients hypertendus, montre que les recommandations constituent un appui pour le travail médical de prise de conscience par le patient de la réalité pathologique de l’HTA et des risques cardiovasculaires associés. Mais le généraliste inscrit son action dans la durée et, sous influence du patient, négocie et fait des compromis voire déroge aux « bonnes pratiques », considérant que ce qui n’est pas réalisable aujourd’hui le sera demain.Les recommandations sont intégrées dans les pratiques sous forme d’un modèle hybride associant la référence aux données scientifiques et l’adaptation à la singularité de la situation. La figure du patient statistique porté par la médecine des preuves est confrontée à la réalité sociale de l’individu plus ou moins doté d’autonomie et de ressources dont il s’agit pour le médecin d’acquérir la confiance et de la conserver. / Best practice recommendations, stemming from evidence based medicine, are part of a well versed process aiming to claim medical legitimacy based on science and are used as policy tools in practice. How do they relate to professional values, and to the practice of medicine?This question is examined within the framework of recommendations regarding the treatment, control and prevention of arterial hypertension (AH) in general practice which can be said to exemplify the construction of a public health risk.The first part of this work is centred on the origins of evidence based medicine, and the way in which it brings continuity as well as change to the relationships between: medical professionals; the institution of medicine and the state; doctors and patients.The second part, a microsociological study of GP consultations with hypertensive patients, shows that recommendations are used to reinforce the doctor’s efforts to increase patients’ awareness of AH and the ensuing cardiovascular risks. However, GPs use their influence over a long time period and, influenced by their patients, they negotiate, compromise and even disregard some of the best practice recommendations, considering that what may not be achievable in the present, may be achievable in the long term. Recommendations are therefore used in practice in hybrid form, where science is merged with an adaptation to each unique situation. The ‘average patient’ as the basic unit of evidence based medicine is opposed with the social reality of an individual with a certain level of autonomy and resources whose trust the doctor needs to gain and maintain.