[Palliative care management of patients in a dermatology department]. / Prise en charge des malades en fin de vie dans un service de dermatologie.

BACKGROUND: The number of patients referred to French University dermatology departments for skin cancers has increased continuously for many years. The aim of this study was to assess the management and number of patients who died in our dermatology department over a 10-year period. PATIENTS AND METHODS: All cases of patients who died in our dermatology department from 1992 to 2002 were retrospectively assessed. Demographic data, past history, main diagnosis, duration of hospitalisation and main treatment given were recorded. RESULTS: The number of patients who died increased from 9 per year at the beginning of the study period to 25 per year at the end of this study. The mean age of patients remained unchanged at 66.5 years old. Forty-nine percent of patients in this study had metastatic melanoma, with no significant modification during the study period. Morphine-based drugs were used (mainly orally) in 41 percent of patients at the beginning of the study and in 56 percent (mainly via subcutaneous infusions) at the end of the study. Forty-five percent of patients were managed in close collaboration with the palliative care unit. CONCLUSION: This study showed a three-fold increase in the number of patients referred for end-of-life care in a dermatology department during a 10-year period. Most of these patients had disseminated malignant melanoma. Major changes in patient management occurred during this period.

[Transfusions of rhesus-incompatible platelet concentrates in Rouen University Hospital: procedures and consequences]. / Transfusions de concentrés plaquettaires Rhésus incompatible au CHU de Rouen: pratiques et conséquences.

INTRODUCTION: Guidelines for distribution and use of blood products have been established for both blood transfusion institution and hospitals, in particular for the use of Rh (D)-incompatible platelet concentrates. The aim of this study was to evaluate: 1) the rate of attribution for the Rh (D)-incompatible platelets concentrates, 2) the immunisation prophylaxis practices, 3) the immunological consequences using short and medium term follow-up of transfused patients. METHODS: Patients with Rh (D)-incompatible platelets concentrate administered during the year 2003 at Rouen University Hospital were retrospectively selected. Patients on transfusion were described. The relationship of various factors with the injection as well as the appearance of allo-immunization was statistically tested. RESULTS: During a year, 280 Rh (D)-incompatible platelets concentrates were administered to 67 patients. Immunisation prophylaxis by injection of Ig anti-D was not systematically performed. Four immunizations in the Rhesus group system were identified: 2 against D antigen (Ag), 1 against E Ag and 1 against C Ag. Immunisations against D Ag occurred for two younger women considered as immunodeficient. Immunization prophylaxis was more frequent in poly-transfused patients. However no difference was observed for the other factors. CONCLUSION: Compatibility concerning Rhesus (D) is not always possible. The immunization against red cells persists, in particular against the antigens of the Rhesus group system and moreover for the immunodeficient patients. Recommendations for immunization prophylaxis by injection of specific anti-D immune-globulin (Ig) could be reconsidered.

[Efficiency of hepatitis C virus screening before and after blood transfusion]. / Evaluation médicoéconomique du suivi sérologique péritransfusionnel du virus de l'hépatite C.

UNLABELLED: Efficiency of a viral hepatitis C screening strategy before and after blood transfusion has to be evaluated. METHODS: Four screening strategies were virtually applied to the population of transfused patients at Rouen University Hospital during 1996 and then compared : the first without any systematic HCV screening test; the second with systematic testing both before and 3 months after transfusion; the third with systematic testing both before and 6 months after transfusion ; the last defined as systematic testing before transfusion only. The efficacy (i.e. number of positive tests), the efficiency (i.e. average cost per positive test) and the marginal costs of moving from a strategy to another one were assessed using decision analysis. RESULTS: The efficacy of systematic screening test before transfusion only (361 per positive test), systematic testing both before and three months after (523 per positive test) or six months after (488 per positive test) transfusion was similar, but the efficacy of the strategy without any systematic screening test (385 per positive test) was lower. The systematization of screening test both before, and three months, or 6 months after transfusion lead to a marginal cost of 619 , and 559 per positive test respectively. The systematization of testing before transfusion only lead to a marginal cost of 343 per positive test. Adding systematic testing after transfusion lead to a marginal cost of 5824 per positive test. CONCLUSION: Systematic screening tests before transfusion only can be considered as the most efficient strategy.

[Survival after blood transfusion: a study at Rouen university hospital]. / Facteurs de survie à six mois des patients transfusés: étude au CHU de Rouen.

UNLABELLED: The aim of this study was to estimate short term survival rate after blood transfusion according to various criteria. PATIENTS AND METHODS: Patients admitted and transfused from January, 1 until June, 30 1996 at Rouen university hospital were retrospectively included, and their status (alive or dead) was determined. The characteristics of patients admitted and transfused were compared to the overall population of inpatients. Independent factors associated with mortality six months after blood transfusion were evaluated using Cox model. RESULTS: During the study period, 1887 patients were transfused. These patients were older, more often admitted in surgical or in intensive care units, and had a longer duration of stay, than the overall inpatients population. The survival rate at six months in transfused patients was 76.1%. Mortality rate at six months was independently higher in patients aged 75 and older, in men, in patients admitted in intensive care units, or transfused with homologous fresh-frozen plasma or packed platelet blood cells. Mortality rate was lower in patients who underwent a surgical procedure, in children under 16, and in patients whose stay was classified in "Circulatory system disorders", "Musculoskeletal system and connective tissues disorders or trauma", or "Injuries, allergy or poisoning". CONCLUSION: In this study implemented in a teaching hospital inpatients receiving blood transfusion, the survival was mainly associated with the severity and characteristics of the diseases requiring transfusion.

Case fatality and health care costs in HIV-infected patients: evolution from 1992 to 2000 at Rouen University Hospital, France.

Vital prognosis in HIV-infected patients has been improved by new therapies, leading to an increase in treatment and outpatient costs but lower inpatient care costs. The aim of the study was to compare the health care costs between 1992-1996 (first half) and 1996-2000 (second half) in HIV-infected patients at Rouen University Hospital. Hospitalization costs (including inpatient and outpatient care), infectious complication treatment and antiretroviral therapy costs were evaluated from a National Health Insurance viewpoint. Between 1992 and 2000, 1212 patients were admitted at least once. Total expenditure increased between the two periods from 13,660 Euro to 27,567 Euro, i.e., a two-fold increase. During the same period, 125 deaths were avoided, and 3602 years of life were gained. The cost of one avoided death was 108,320 Euro and the cost per life-year gained was 3776 Euro.

[Factors affecting quality of care for elderly subjects undergoing surgery for hip fracture: review of the literature]. / Facteurs de qualité de la prise en charge des sujets âgés opérés d'une fracture de l'extrémité supérieure du fémur: revue de la littérature.

Hip fractures are one of the leading causes for admission of elderly subjects to healthcare facilities. Because of population aging, the incidence of hip fractures has increased considerably over the last years and will continue to increase in industrialized countries. Hip fracture in an elderly subject may be life threatening and has a significant functional and social impact not only because of the fracture itself, but also because of the risk of complications related to the patient's health status and the long hospital stay. The purpose of this work was to identify in the published literature professional practices, excepting the surgical procedure, associated with better early and long-term outcome in elderly patients with hip fracture. Questions raised concerning the patient's hospital stay include factors related to the preoperative phase (time to surgery, usefulness of traction), the operation itself (antibiotic prophylaxis, anesthesia technique), and the postoperative phase (prevention of venous thrombosis, malnutrition, episodes of confusion, duration of indwelling bladder catheter, correction of anemia, geriatric care during the stay in the orthopedic ward, early and intense rehabilitation, prevention of recurrence). Among these factors, several appear to be associated with better outcome, including long-term outcome--surgery as early as possible in light of the patient's general status, antibiotic prophylaxis in accordance with standard recommendations (SFAR), prevention of venous thrombosis with low-molecular-weight heparin initiated at admission and associated with elastic contention. Oral nutritional support is probably beneficial and should be proposed for all patients. Particular attention must be given to prevention of confusion in order to reduce the rate of institutionalization. The rythm of rehabilitation exercises should be at least five sessions per week. Finally, there are several methods, which are effective in preventing recurrence, taking into account osteoporosis, risk of falls. Preventive measures should be instituted for all patients undergoing surgery for hip fracture.

Mediastinitis after coronary artery bypass graft surgery: influence of the mammary grafting for diabetic patients.

Mediastinitis is a severe complication of coronary artery bypass graft surgery (CABG) particularly when harvesting internal mammary arteries (IMA). CABG in diabetic patients often uses two IMA because the saphenous graft is damaged. To our knowledge this risk of mediastinitis has not previously been reported in diabetic patients. All consecutive diabetic patients undergoing CABG over a three-year period from 1998 to 2000 were included in the study. Data recorded were: age, sex, duration of stay, whether one or two IMA were used, diagnosis of mediastinitis. Calculation of relative risk and analysis of trends by chi2 trend tests was also performed. In total 256 diabetic patients were included in the cohort. The incidence of mediastinitis was 4.3% (11/256). The risk of mediastinitis was higher in patients with two IMA than in patients with one IMA (relative risk 5.97, 95 CI 1.63-21.93, P=0.004). Age and sex were not confounding factors. No patients with mediastinitis died. Bilateral IMA grafting is associated with higher risk of mediastinitis in diabetic patients. The authors suggest that the risk of mediastinitis in diabetic patients should be taken into consideration when cardiac surgeons choose unilateral or bilateral IMA harvesting for surgery.

[Assessment off-label prescribing in Dermatology]. / Evaluation des prescriptions hors AMM en Dermatologie.

INTRODUCTION: The official policy of the French National Health Insurance system is to deny reimbursement for drugs prescribed for off-label indications. The objectives of this study were 1) to quantify the use of off-label prescriptions by physicians from a hospital department of dermatology in France; 2) to characterize these off-label prescriptions; 3) to assess data from the literature on the appropriateness of these off-label prescriptions. PATIENTS AND METHODS: For each patient consulting between February 1 and April 1, 2001, the symptom or the disease that was treated and the type of prescription were recorded on standard forms. RESULTS: Eighty six percent of prescriptions were labelled, 14 p. 100 were off-labelled. Inflammatory and hypersensitivity dermatoses were the most frequent indications of off-label prescriptions (26 p. 100). Treatments which most frequently corresponded to off-label prescriptions were topical corticosteroids and methotrexate. Examination of the literature showed that 70 p. 100 of the off-label prescriptions were not based on strong data from evidence-based-medicine. Many off-label prescriptions were made by the most graduate physicians. DISCUSSION: This study showed a great number of off-label prescriptions in dermatology. These prescriptions were often related to rare diseases that were managed by senior dermatologists. These off-label prescriptions were rarely in accordance with data from evidence-based-medicine.

[Survey on the activity of hospital departments of dermatology in France]. / Enquête sur l'activité des services de Dermatologie hospitaliers français.

INTRODUCTION: The Collège des Enseignants de Dermatologie de France initiated a study to assess the activity of the departments of dermatology in French hospitals. We report the results of this survey. MATERIAL AND METHODS: The study was conducted during a randomly selected week in the year 2000. An anonymous questionnaire was sent to all the departments of dermatology in the hospitals in France and was completed for each patient leaving the hospital during that week. The data collected were: the type of establishment, admission method, hospitalization method, type of pathology, motive for hospitalization, length of hospitalization and type of treatment used. RESULTS: The response rate was of 96 p. 100 for the University hospital centers and 80 p. 100 for the non-university hospitals. The number of patients treated per year was of 65 628 for the University hospitals and of 16,000 for the others. Ninety percent of the hospitalizations corresponded to direct admissions. The pathologies at the origin of the majority of yearly hospitalizations were, for the University hospitals: melanoma, leg ulcers, highly specialized dermatoses and systemic diseases and for the other hospitals: leg ulcers, HIV infection, highly specialized dermatoses and erysipela. The pathologies requiring the greatest number of hospitalization days were melanoma, leg ulcers, erysipela and highly specialized dermatoses. DISCUSSION: This study shows that the activity in the departments of dermatology is centered on pathologies that are clearly severe in terms of Public Health (oncology, infectious diseases and angiology). It also shows the efforts made for the management of patients in out-patient settings.

[Quality of data acceptable for perinatal epidemiology surveillance: assessment of the health certificate at birth and the national obstetrics medical file. Study in three Seine-Maritime maternal wards]. / Qualité des données utilisables pour une surveillance épidémiologique périnatale: évaluation du certificat de santé à la naissance et du dossier obstétrical national. Etude dans trois maternités de Seine-Maritime (France).

Data from several sources could be used for perinatal epidemiology surveillance aimed at an assessment of regional programs such as those proposed by the Superior Committee for Public Health. A retrospective study of 561 births was conducted in three maternity wards in the French Seine Maritime department in order to evaluate the reliability of two data sources: the national obstetrics medical file and the health certificate at birth. The delivery room records were used as the gold standard. The sensitivity of the obstetrics file was better than that of the health certificate. With the obstetrics file, it was possible to identify almost all the vaginal route interventions, almost all the premature births and all the cesareans. With the health certificate, 39-58% of the vaginal route interventions, 61% of the premature births and 61-72% of the cesareans performed in the three wards studied were identified. The quality of data in the obstetrics file appears to be better than that in the health certificate but only concerns 40% of births in the geographical area studied. Inversely, the health certificate is theoretically delivered for all births (actually delivered for 93%). Integrating these two information systems could be an optimum solution.