[Clinical practices appraisal in the second certification process of French healthcare organisations]. / L'évaluation des pratiques professionnelles dans la deuxième procédure de certification des établissements de santé.

Second certification process of healthcare organisations (V2) has a main challenge: clinical care improvement through strengthening of clinical practices appraisal (CPA). The approach is based on standards focused on CPA. Besides a specified policy devoted to clinical practices appraisal (Table 1 - standard 6c), CPA in V2 has 3 key objectives: appropriateness of hospitalization and acts, a priori and a posteriori management of healthcare-related risk and clinical practices related to specific diseases. First results show that issues the more evaluated by healthcare organisations are appropriateness of antibiotics and anti-thrombosis orders (Table 1 - 44c), safety in medication management, urinary catheterization and seclusion (Table 1 - 45a), adverse events such as falls and bedsores (Table 1 - 45b). Regarding diseases (Table 1 - 46), cancer, coronary disease, stroke and diabetes are the more evaluated in medicine, cancer, antibiotic prophylaxis and hip prosthesis in surgery, delivery and cesarean section in obstetrics, suicide in psychiatry, pain and nutrition in long term care or readaptation. CPA in V2 is in tune with current French law context which makes mandatory individual CPA and continuous medical training, while physicians'accreditation of at-risk specialties is a voluntary process.

[Educating patients about heart failure in community hospitals: it is possible...]. / Education des patients concernant l'insuffisance cardiaque en centre hospitalier général: c'est possible....

Prognosis for heart failure is linked to patient's compliance. Compliance is also dependent from patient education about his disease and treatment. Therapeutic education could be done in a community hospital but needs a lot of time. However, therapeutic education for heart failure patients becomes more and more essential in clinical practice and improves patient knowledge and implication and hospitalization duration.

Cushing's syndrome in medullary thyroid carcinoma.

Ectopic ACTH secretion is a rare cause of hypercortisolism. Induced metabolic disturbances are often serious, and the management of such patients may be difficult. We report here our experience with four medullary thyroid carcinoma (MTC) patients with distant metastases in whom an ectopic ACTH syndrome occurred. The clinical presentation was significant by the severity and the rapidity of the hypercortisolism. Diagnosis and follow-up were realized by measurements of plasma cortisol, urinary free cortisol, urinary 17-hydroxycorticosteroid, plasma ACTH, plasma LPH, serum calcitonin and carcino-embryonic antigen. Initial treatment with adrenalytic medical therapy failed to control the disease. Only bilateral adrenalectomy cured the excessive cortisol production, and for a long time despite tumor progression. In conclusion, bilateral adrenalectomy should be considered in MTC patients with Cushing's syndrome even at the stage of distant spread. In fact, with regard to the slow growth rate of most MTC's, they may survive for years.

Treatment of advanced medullary thyroid cancer with an alternating combination of 5 FU-streptozocin and 5 FU-dacarbazine. The Groupe d'Etude des Tumeurs a Calcitonine (GETC).

Combinations of 5-fluorouracil (5-FU) and streptozocin and 5-FU and dacarbazine were given alternately to 20 patients with metastatic medullary thyroid carcinoma. Three partial responses and 11 long-term stabilizations were observed. No unexpected toxicity occurred.

Selective venous sampling catheterisation for localisation of persisting medullary thyroid carcinoma.

Selective venous sampling catheterisation was performed in 19 patients with medullary thyroid carcinoma without known distant metastases for persistent hypercalcitoninaemia after surgery. Calcitonin (CT) gradients were found in the neck and/or the mediastinum in 18 patients and in five patients at distant sites also. After venous catheterisation, 13 patients were subjected to repeat surgery. Neck and/or mediastinal tumour foci were found in 12 patients at the sites of the CT gradients. Of these, nine patients had only cervicomediastinal CT gradients: after reoperation, the serum CT level normalised in one, significantly decreased in five, and did not change in three, and no neck relapse occurred after a mean follow-up of 5.3 years. Distant metastases emerged clinically in all five patients with distant gradients and in only one of the 14 patients with no distant gradient. In conclusion, selective venous catheterisation is the most sensitive tool for the localisation of residual disease and for the early detection of distant metastases. However, in patients with only local disease, biochemical cure is rarely obtained after reoperation.

Association of peroxidase enzyme defect and low thyroglobulin content in a case of endemic cretinism.

Neurological endemic cretinism is highly prevalent in severe endemic goiter areas. Often associated to euthyroid goiter, it is probably related to iodine deficiency. However the exact pathogenetic mechanism is yet unclear. We report the biochemical study of thyroid tissue obtained from a 26 year-old female cretin with a grade III multinodular goiter, neurological signs and euthyroidism. After surgery, thyroid tissue was analysed: iodoproteins where characterized by gel filtration, electrophoresis, sedimentation coefficient and antigenicity. Iodoalbumin was predominant while thyroglobulin was quantitatively reduced and poorly iodinated. In vitro, iodination with hog thyroid peroxidase was normal. There was no difference in peroxidase affinity for iodide in the oxidation reaction but a significantly reduced ability to iodinate in vitro thyroglobulin and free tyrosine. Oxidation of acetyltyrosilamide into bityrosine was also markedly reduced. These abnormal findings are known to occur in sporadic cases with or without hypothyroidism. The neurological defects could be linked to transient hypothyroidism during the critical period of nervous system maturation, however a role of iodine deficiency per se cannot be ruled out.

[Results of the surgical treatment of Basedow's disease. Apropos of 30 cases]. / Résultats du traitement chirurgical de la maladie de Basedow. A propos de 30 cas.

Thyroid function was evaluated after thyroidectomy in 30 cases of Graves' disease. 15 patients were euthyroid, 6 of them were TRH non responsive suggesting a risk of relapse. Indeed, the 3 proven cases of relapse were TRH non responsive before relapse and remained so after treatment. The severe iodine deficiency in Algeria did not seem to increase the frequency of post-operative hypothyroidism. Neither did the duration of carbimazole therapy, the severity of thyroid lymphocytic infiltration or thyroid antibodies titer. Thyroid remnant size, although difficult to estimate, appears to be inversely related to post-operative TSH values.