[Quality insurance system establishment in the management of home-based chemotherapy: example of hospital at home "Assistance publique-Hôpitaux de Paris"]. / Mise en place d'un système d'assurance-qualité dans la prise en charge des chimiothérapies à domicile : exemple de l'hospitalisation à domicile « Assistance publique-Hôpitaux de Paris ¼

While home-based chemotherapy improves comfort and quality of life of patients, quality and safety conditions must be equivalent to hospital settings. In addition, organization is much more complex. At the hospital at home "Assistance publique-Hôpitaux de Paris", prescribers are potentially spread across 21 health facilities. The administration of chemotherapy is performed by about 300 nurses at the patient's home in Paris and its suburbs. Centralized preparations of chemotherapy began in September 2009 by the pharmacy department of Georges-Pompidou European hospital, with a progressive increase of the activity. This article describes the quality insurance system established with this new organization to meet the specific challenges of home therapy: choice of eligible anticancer drugs, computerized information systems and networking with other heath facilities, secure transport conditions, traceability from the prescription to the administration, security of administration. This experience can offer an important support for other centres in their approach of quality insurance for home chemotherapy.

[Treatment of polycythemia. II.--Comparison of hydroxyurea with pipobroman in 294 patients less than 65 years of age]. / Traitement des polyglobulies. II.--Comparaison de l'hydroxyurée et du pipobroman chez 294 malades âgés de moins de 65 ans.

AIMS: To compare by a prospective study in low risk polycythemia vera (PV) patients alone two drugs: hydroxyurea and pipobroman. Toxicity, efficiency, and leukemogenic potential were studied. PATIENTS: 294 patients with a documented PV, aged less than 65 years, have been included since 1980 in a prospective study comparing hydroxyurea and pipobroman. Blood cell counts were performed every two months and a clinical evaluation by a specialist was obtained every four or six months. RESULTS: Hematologic toxicity of both drugs was higher than expected, requiring strict surveillance. These drugs were tolerated in some (gastric pain and diarrhea on pipobroman, buccal aphtosis and chronic leg ulcers on hydroxyurea), leading to a change of arm in 10% of the cases. Hydroxyurea did not control the megakaryocitic hyperplasia in 40% of the cases, which probably explains a high rate of progression to myelofibrosis with myeloid metaplasia in this arm. Both drugs were leukemogenic with an actuarial risk of about 15% at the 15th year, not significantly lower than that observed in the 32P treated patients. A significant risk of cutaneous malignancy was observed in the hydroxyurea arm. The mean expectancy of life cannot yet be accurately evaluated, but seems significantly lower than that of the reference population. CONCLUSION: The treatment of PV by hydroxyurea or pipobroman has to account for these results less optimistic than those traditionally well-known to hematologists and internists.

Risk of leukaemia, carcinoma, and myelofibrosis in 32P- or chemotherapy-treated patients with polycythaemia vera: a prospective analysis of 682 cases. The "French Cooperative Group for the Study of Polycythaemias".

An analysis of the risk of progression towards leukemia, carcinoma and myelofibrosis was performed in 93 patients treated by 32P alone (PVSG protocols) since 1970-1979, 395 patients over the age of 65 years treated by 32P with or without maintenance therapy using hydroxyurea (French protocol) since 1980-1994, and 202 patients under the age of 65 treated by either hydroxyurea or pipobroman since 1980. The risk of leukemia, or myelodysplasia, or lymphoma in the 32P-treated patients was 10% at the 10th year, but increase after that time to reach a value of about 30% at the 20th year, in the surviving case. This risk was not dose-related. Despite a marked reduction of the cumulative 32P dose in the patients maintained by hydroxyurea, the actuarial risk was 19% at the 10th year. In the patients treated exclusively by non radio-mimetic agents (hydroxyurea or pipobroman) a risk of 10% at the 10th year was observed. The risk of carcinoma (excluding skin cancers) was about 15% at the 10th year in the 32P-treated cases, a value similar to that generally reported by the French statistics. There was no prevalence of digestive carcinomas. In contrast, the patients receiving 32P and hydroxyurea as maintenance had an excess risk: 29% at the 10th year. In the relatively young cases treated by non radio-mimetic agents, the risk was similar in both arms: 9% at the 10th year, similar to the expected incidence at this age. The risk of myelofibrosis with myeloid metaplasia was still relatively low at the 10th year, about 15% in all arms, but increased towards a value higher than 30% in the patients surviving at the 20th year. At the present time, but in only a few cases with long-term following, no myelo-fibrosis with splenic metaplasia has been observed in the pipobroman-treated cases. The present results, which need to be confirmed (the present analysis has been done in spring 95) suggest that:-the use of non radio-mimetic agents does not protect against leukemic transformation, which may be a consequence of the disease; rather than of the treatment,-maintenance therapy after initial use of 32P increases the risk of both leukemia and carcinoma,-and hydroxyurea does not delay the risk of developing myelo-fibrosis, in comparison with 32P alone.

Profound and possibly primary "idiopathic CD4+ T lymphocytopenia" in a patient with fungal infections.

A profound and long-lasting reduction in circulating CD4+ T lymphocytes (< 80/microliters) was found in a 37-year-old man (without known risk factors for HIV infection) presenting with recurrent oral candidiasis who subsequently developed cryptococcal meningitis. Infection with HIV was ruled out by serological and virological studies. In vitro and in vivo cell-mediated immunity was severely impaired. Abnormal phenotypic patterns of both CD4+ and CD8+ cells were consistently observed. A systematic family survey revealed in some of his asymptomatic relatives several immunological abnormalities which may point to a genetically based primary immunodeficiency disorder.

[Failure of intravenous immunoglobulins in certain systemic diseases. 5 cases]. / Echec des immunoglobulines intraveineuses au cours de certaines maladies systémiques. 5 observations.

Human polyvalent immunoglobulins administered intravenously have shown to be effective in some immune diseases. We administered high dose-IV Ig (2g/kg/session) in five patients with severe chronic systemic diseases. Their condition did not improve, except in one case where a transient response was noticed. Considering the inconsistent results and high cost of IV Ig, double blind studies are required to determine the conditions in which high dose IV Ig may be more effective than conventional treatments.

[Long-term effects of splenectomy for immune thrombopenic purpura related to human immunodeficiency virus. A retrospective study from 2 groups, with and without splenectomy]. / Effets à long terme de la splénectomie pour purpura thrombopénique immunologique lié au virus de l'immunodéficience humaine. Etude rétrospective à partir de deux groupes, avec et sans splénectomie.

In order to evaluate the long-term effects of splenectomy in patients with human immunodeficiency virus-related immune thrombocytopenic purpura (ITP), we studied retrospectively two populations of patients: 21 had undergone splenectomy and 18 had not. At the time of diagnosis the first population had on average lower platelet counts than the second one. After a mean follow-up of 47 +/- 9 months the situation has been reversed: the population that underwent splenectomy had significantly higher platelet counts than that without splenectomy (190.600 +/- 55.300/mm3 versus 91.500 +/- 55.300/mm3, P less than 0.001). Moreover 76 percent of the patients with splenectomy versus 50 percent in the population without splenectomy were in complete remission of ITP at the last follow-up. It therefore seems that splenectomy had a statistically positive effect on platelet counts without worsening the immune status. Indeed, the clinical course towards AIDS was the same in both populations (35 percent in patients with splenectomy and 22 percent without, P = NS). Following splenectomy, the total blood lymphocytes count was increased, especially the CD8 population, while the CD4 count remains unchanged; these findings seem to be a common feature after splenectomy.

[Association of Kaposi's sarcoma with acute myeloblastic leukemia. Apropos of a case]. / Association d'un sarcome de Kaposi à une leucémie aiguë myéloblastique. A propos d'un cas.

The authors report the case of a 73-year-old woman from Central Europe with acute myeloid leukemia and Kaposi's sarcoma. The two diseases were discovered simultaneously. The inefficacy of leukemia chemotherapy and the widespread cutaneous diffusion of the Kaposi's sarcoma explain the unfavorable outcome. The different pathogenic hypotheses which can account for the association of these two different malignancies are reviewed.

[Early syphilitic hepatitis. Two cases]. / Hépatites de la syphilis preécoce. Deux observations.

Two patients are presented as cases of secondary syphilitic hepatitis. Clinical and biological signs coincided with usual description of this affection. Syphilitic serological tests were all very positive. These two patients were homosexual men. In one case, we have found treponema in hepatic biopsy, underelectron microscope only, which confirmed the diagnosis. Evolution of both patients was improved by anti-syphilitic penicillin the rapy. Thus, this is an important diagnosis, which should not missed, because of the good prognosis of this affection with specific treatment, and because of the increasing frequency of syphilis for 20 years.