[Socio-demographic characteristics and health status of patients at a free-of-charge outpatient clinic in Paris]. / Analyse du profil socio-démographique et médical des patients de 5 permanences d'accès aux soins de santé (PASS) parisiennes.

PURPOSE: In the context of the French National Health Service, a free access to healthcare facilities (the PASS: "permanence d'accès aux soins de santé") has been implanted in 2000 for patients without health insurance or those dealing with financial hardship. There is few data about socio-demographic characteristics of the patients using these services. The objective of this study was to provide descriptive data about socio-demographic characteristics and motivation of those patients who use these clinics. METHODS: This descriptive cross-sectional study was conducted between April an May 2008, in 5 PASS clinics from academic tertiary hospitals in Paris. Descriptive data on patient were collected by general practitioners at the end of their consultations. RESULTS: This study included 581 patients. The mean age was 42 years, and 65% of patients were males. Only 50.9% declared a salary income and 38.5% had a health insurance. Half of the patients were homeless, and 80% were migrants. The main reasons to visit these health facilities were direct access (no appointment needed), being in financial difficulty and having a medical record in the same hospital. Half of the patients had one chronic disease at least, while only a third of them saw regularly a physician. A total of 834 diseases were found among the 581 patients, including 411 chronic diseases, and 17% of the patients had a psychologic or a psychiatric disorder. Prognosis was divided in three grades: good, low and poor. Almost a half of the patients were considered by the doctor as having a low or a poor prognosis if they would not receive a therapy. CONCLUSIONS: The findings of this study suggest that the PASS carry out their mission: most of the patients frequenting these facilities live under poor conditions and are in poor health status compared to the patients having access to conventional outpatient services.

[Qualitative and quantitative comparisons of three individual deprivation scores for outpatients attending a free hospital care clinic in Paris]. / Caractéristiques métrologiques et comparaison de trois outils de repérage de la précarité sociale dans une permanence d'accès aux soins de santé hospitalière à Paris.

BACKGROUND: Inequality in health care is a growing problem, leading to the development of different tools for the assessment of individual deprivation. In France, three tools are mainly used: Epices (which stands for "score for the evaluation of social deprivation and health inequities among the centers for medical examination"), a score called "Handicap social" and a screening tool built for medical consultations by Pascal et al. at Nantes' hospital. The purpose of this study was to make a metrological assessment of those tools and a quantitative comparison by using them on a single deprived population. METHODS: In order to assess the metrological properties of the three scores, we used the quality criteria published by Terwee et al. which are: content validity, internal consistency, criterion validity, construct validity, reproducibility (agreement and reliability), responsiveness, floor and ceiling effects and interpretability. For the comparison, we used data from the patients who had attended a free hospital outpatient clinic dedicated to socially deprived people in Paris, during one month in 2010. The "Handicap social" survey was first filled in by the 721 outpatients before being recoded to allow the comparison with the other scores. RESULTS: While the population of interest was quite well defined by all three scores, other quality criteria were less satisfactory. For this outpatient population, the "Handicap social" score classed 3.2% as non-deprived (class 1), 32.7% as socially deprived (class 2) and 64.7% as very deprived (class 3). With the Epices score, the rates of deprivation varied from 97.9% to 100% depending on the way the score was estimated. For the Pascal score, rates ranged from 83.4% to 88.1%. On a subgroup level, only the Pascal score showed statistically significant associations with gender, occupation, education and origin. CONCLUSION: These three scores have very different goal and meanings. They are not interchangeable. Users should be aware of their advantages and disadvantages in order to use them wisely. Much remains to be done to fully assess their metrological performances.

[Health of immigrant population of consultants at the Baudelaire outpatient clinic in Saint-Antoine hospital in Paris, France]. / La santé des migrants consultant la policlinique Baudelaire de l'hôpital Saint-Antoine à Paris, France.

Social and health data on the immigrant population remain scarce in France, especially concerning those in irregular situation. The Baudelaire outpatient clinic in Saint- Antoine hospital in Paris (PASS, i.e. specific free medicosocial care for the poor, the uninsured or the undocumented patients) treats a majority of immigrants, a lot of them being in an irregular residence status. The objectives of this study were to describe the social and health status of the immigrant consultants, to compare regular and undocumented migrants and to describe their main reasons for migration. A cross-sectional, descriptive, survey among the immigrant consultants has been performed among this outpatient clinic in April and May 2009. In total, 536 patients were included. Their age mean was 45 years, 62% are male, 49% are in an irregular situation and they have been in France for 12 years in average (19 years for the regular immigrants and 5 years for the undocumented). More than 20% had no health insurance. A majority (55%) of patients were suffering from a chronic disease. The more frequent ones were hypertension (20%), type 2 diabetes (11.6%), chronic infectious diseases - HIV, HBV, HCV - (7%). Reasons for immigration were mostly economical (39%), family (19%) and political (17%). Health reasons were at the 4th rank and concerned 9% of the patients. The main chronic diseases observed among this population are similar to those of the general population of consultants in primary health care, except for the chronic infectious diseases, which are more frequent. Immigration for health reasons represents only a small proportion of all immigration reasons. For this population, free clinics like the one investigated here constitute unique, irreplaceable, access points in the French healthcare system.

[Migration, health and access to care in Mayotte Island in 2007: lessons learned from a representative survey]. / Migration, santé et recours aux soins à Mayotte en 2007: enseignements d'une enquête représentative en population générale.

BACKGROUND: Mayotte Island, located in the Indian Ocean, is a French overseas departmental community with certain specificities: recent development of sanitary institutions, significant immigration, free access to care for legal residents but with co-payments for irregular residents, the absence of many of the social benefits which exist in mainland France and poor or non-existent health information systems. We report here the first population-based survey describing the links between health, migration and healthcare utilization in this territory. METHODS: Cross sectional population-based study using a three-stage random sample (geographic areas, households, individuals). In all, 2105 individuals were interviewed either in French, Shimaore or Kibushi (response rate=96%), using a questionnaire adapted to the context of Mayotte Island after a preliminary qualitative survey. Descriptive analyses and logistic regression models were performed. RESULTS: Foreigners make up 40% of the Mayotte population (total 186,452 inhabitants), of which one-quarter are children born in Mayotte and 80% have no regular residence status. The median length of residence of migrant foreigners is 10 years. Foreigners represent a majority of the female population, of the 20 to 35 years old population and of the urban areas. Main determinants for migration were economical (50%) or family-related (26%). Health was stated as a cause of migration by 11% of migrants. The social situation of foreigners is more precarious and their perceived health poorer than those of the French. Their access to care is also perceived as more difficult. We did not observe any notable difference in terms of frequency of healthcare attendance over the last 12 months between the two groups, but foreigners have consulted less often private GPs and more often traditional practitioners than French. CONCLUSION: In this overseas French island, the migrant population is numerous and resident for a long time. Their main motivations to immigrate are economic and family-related. They report hurdles to healthcare related with their precarious living conditions, including their illegal residence status.

Pedunculopontine nucleus stimulation induces monocular oscillopsia.

Two patients with Parkinson's disease with pedunculopontine nucleus (PPN) stimulation for gait impairments reported "trembling vision" during the setting of the electrical parameters, although there was no clinically observable abnormal eye movement. Oculomotor recordings revealed frequency locked voltage dependent vertical or oblique movements of the eye ipsilateral to the active contact, suggesting current spreading to the mesencephalic oculomotor fibres. These results emphasise the difficulty of stimulating this mesencephalic region.

Dynamic echo-planar MR imaging of the diaphragm for a 3D dynamic analysis.

The purpose of this study was to prove the feasibility of 3D reconstructions of the diaphragm during the respiratory cycle using EPI sequences (EPI acquisition, 270 ms/image, on a healthy subject breathing spontaneously and at 0.1 Hz). Continuously recorded respiratory signal allowed for retrospective synchronization with respiratory phases for reconstruction of successive diaphragm surfaces using a specifically designed software. Displacements, area and volume changes of the diaphragm were quantified. Our measurements were comparable with the data in the literature. Reconstructed surfaces allowed in vivo diaphragm dynamic evaluation in terms of displacements, area and volume variations. EPI has adequate spatial and temporal resolution for studying diaphragm dynamics during natural breathing.

Deep brain stimulation of the corpus luysi (subthalamic nucleus) and other targets in Parkinson's disease. Extension to new indications such as dystonia and epilepsy.

Chronic high frequency (130 Hz) stimulation (HFS) of the thalamic target Vim, first used in our group in 1987 as a treatment of tremor of various origins, has been used over the last ten years in 137 patients. Since 1993, this method has been extended to two other targets (subthalamic nucleus (STN): 137 patients and the medial pallidum (GPi): 12 patients), based on recent experimental data in rats and monkeys. STN appears to be a target of major interest, able to control the three cardinal symptoms and to allow the decrease or suppression of levodopa treatment, which then also suppresses levodopa induced dyskinesias. The stereotactic technique is based on the determination of the target using ventriculography, MRI and electrophysiology, with both microrecording of single neuron activity and microstimulation inducing therapeutic symptom suppression and side effects. Chronic electrodes are then placed bilaterally at the best physiologically defined location and then connected to implantable stimulators (either 2 Itrel II or the new double channel Kinetra), operated at 130-185 Hz, 60 ms pulse width, 2.5 to 3.5 volts. There was no operative mortality and permanent morbidity was observed in 3 patients. The mechanisms of action of HFS are not fully understood, but are definitely related to high frequency and are probably different depending on the target. Inhibition of cellular activity or of neural network functions could be induced, by jamming of a retroactive loop for tremor, or by shutdown of neurotransmitter release in STN. Mechanisms within an individual target are also probably different for tremor or for other symptom alleviation. All cardinal symptoms are alleviated from tremor to akinesia and rigidity. This strong improvement allows the decrease of the drug dosage to approximately 30% of the preoperative level, which suppresses the levodopa-induced dyskinesias. The off period dystonias are also suppressed as well as freezings and falls. The effects remain stable over more than 5 years and in the same period, the off stimulation-off medication UPDRS remains stable and does not increase at the usual rate The low rate of permanent complications, the minor side effects and their immediate reversibility, the possibility of bilateral implantation in one session and the long-term persistence of symptom relief are strong arguments which support chronic HFS of STN as the method of choice when a surgical procedure is indicated for the treatment of Parkinson's disease and even more when a bilateral procedure is necessary. Recent data show that STN stimulation could be useful in the treatment of dystonia as well as some forms of epilepsy. It is therefore possible that DBS in STN as well as in other targets could become a potent therapeutic tool in the near future for neurological disorders.

Impact of early-untreated HIV infection on chronic hepatitis C in intravenous drug users: a case-control study.

OBJECTIVE: The impact of early-untreated HIV infection on chronic hepatitis C was determined in a case-control study, aimed at limiting factors associated with the progression of immunodeficiency. METHODS: HIV-infected patients attending for a medical examination during 1995-1996 were systematically screened for: previous intravenous drug use without other HIV or Hepatitis C virus (HCV) risk factor, CD4 cell count > 200/microl, no AIDS, no antiretroviral treatment, positive anti-HCV antibody, negative hepatitis B surface antigen, abnormal aminotransferase activity. Thirty-eight consecutive eligible HIV-infected patients (cases) were included. Thirty-eight HCV-infected patients without HIV infection whose unique risk factor was intravenous drug use (controls) were paired to cases according to age, sex, and duration of HCV infection. RESULTS: Cases and controls had similar ages, sex ratios, duration of HCV infection, and alcohol intake. They were infected predominantly by genotypes 1 and 3. Viraemia was higher in cases than in controls. METAVIR histological scores of activity and fibrosis in cases versus controls were 2.2 +/- 0.8 versus 1.6 +/- 0.7 (P = 0.0008) and 1.8 +/- 1 versus 1.5 +/- 0.8 (P = 0.06), respectively. The percentage of cirrhosis was higher in cases, without reaching statistical difference. The progression rate of fibrosis was higher in cases. Age at contamination and METAVIR activity score were significantly associated with the progression of fibrosis in cases. CONCLUSION: Early-untreated HIV infection is associated with higher HCV viraemia and more severe liver injury in intravenous drug users with chronic hepatitis C.

The use of a semi-customized phantom for verification of conformal plans.

We have developed a technique for inverse treatment planning of prostate therapy designed to improve the degree of conformation between the dose distribution and the target volume. We compared the inverse plan with a "standard" four-field box technique as well as a four-field technique using oblique fields ("cross technique"). We validated the dosimetry of the inverse plan using Fricke gel solution in phantom specifically designed for this purpose. The phantom is a Plexiglas tank with a cross section, which approximates the dimensions of the pelvis. Anatomical data from computed tomography (CT) images of a patient were used to simulate organs in our phantom. This allows us to calculate dose distributions with the external geometry of the phantom and internal anatomy of the patient. Dose-volume histograms (DVHs) for the three different plans were calculated. The phantom containing the Fricke gel was irradiated according to the inverse plan. Magnetic resonance (MR) images was used to determine the dose distribution delivered to the phantom. We observe, on DVHs, that the inverse plan significantly reduces the dose to the rectum and the bladder but slightly increases the inhomogeneity inside the target volume. Correlation is good between isodoses on MR images and calculated isodoses. We conclude that inverse planning software can greatly improve the conformal degree of treatment to the prostate. This technique could be applied to other complex anatomic sites at which dose to organs at risk is a limiting factor and increased dose to the target volume is indicated. Our phantom and the Fricke gel solution are convenient to carry out validation of conformal treatments.

[A paraneoplastic acrosyndrome]. / Un acrosyndrome paranéoplasique.

BACKGROUND: Paraneoplastic digital ischemia is an uncommon complication of metastatic adenocarcinomas. CASE REPORT: Two years after remission of an uterine adenocarcinoma, the patient developed an acrosyndrome involving all four limbs with digital ischemia. Recurrent carcinoma was evidenced by a very high antinuclear antibody titer. Chemotherapy improved the acrosyndrome. DISCUSSION: Vasomotor disorders which developed in older subjects with no other signs of autoimmune disorders should suggest a neoplastic origin. Icshemia of the fingers would be caused by vasculitis. An elevated antinuclear antibody titer may be a supplementary argument suggesting a neoplastic etiology.

[Access to social coverage of uninsured patients attending a hospital clinic: a historical cohort study at the Baudelaire outpatient clinic in Paris]. / Accès à une couverture sociale des patients non assurés consultant en milieu hospitalier: une étude de cohorte historique au sein de la consultation "Baudelaire" à Paris.

BACKGROUND: In France health insurance coverage is universal (see note at the end of the text), nevertheless some people remain uninsured. In this high-risk population, the lack of insurance coverage contributes to the aggravation of health, by reducing access to medical care. In 1992, the Baudelaire consultation was incorporated into the outpatient clinic of Saint-Antoine hospital (Paris, France), to provide the uninsured with the same access as any other patient--but free of charge--to medical care. Social care was also provided in particular by assisting the uninsured in applying for insurance coverage. Our objectives were to quantify the delay in obtaining insurance coverage and to study whether the sociodemographic characteristics of these patients were associated with inequalities in terms of delays. METHODS: All patients attending the consultation for the first time in 1994 were included (n = 623). Because of differences linked to the French social security system, analysis was performed into two groups according to the existence of a prior insurance coverage. Delay in obtaining or recovering insurance coverage was considered as the key variable. The socio-demographic factors linked to the rates of access to insurance coverage were determined using Cox proportional hazards regression models. We also examined the factors linked with the existence of a prior insurance coverage by logistic regression modeling. RESULTS: Within one year 96% of the patients who had had insurance coverage in the past, and 63% of the patients who had not, were insured. No factor, whether nationality, educational level, socio-professional category, family situation, type of housing, made of income was found to be linked with obtaining or recovering insurance coverage. However, nearly all these factors were related with the existence of prior insurance coverage. CONCLUSIONS: Our approach of systematically providing social care allows 70% of uninsured patients to obtain insurance coverage within one year. This approach probably contributes to an improvement by facilitating access to mainstream health care. Moreover, no difference in delay in obtaining insurance coverage was found associated with sociodemographic characteristics.

[Mixed corticomedullary tumor]. / Tumeur mixte corticomédullaire.

BACKGROUND: Pheochromocytoma and primary hyperaldosteronism rarely occur simultaneously. Few cases have been reported in the literature. CASE REPORT: A patient explored for hypertension was found to have hypokalemia related to primary hyperaldosteronism. Pathology examination of the ablated adrenal showed a co-existing pheochromocytoma suspected at history taking although urine catecholamines were normal. DISCUSSION: Different pathogenic hypothesis have been proposed. Such dual tumors could be a simple coincidence, occur in a particular genetic setting, be related to direct contact between cortical and medullary tissue leading to reactional cortical hyperplasia, pheochromocytoma produced factors stimulating aldosterone synthesis, or factor X, a substance produced by cortical adenomas and favoring growth of the pheochromocytoma.

A new out-patient care facility for HIV-infected destitute populations in Paris, France.

In France, the entire population theoretically has access to health coverage, but in fact a section of the poorest population does not. Institutions have therefore been set up to provide medical care for the destitute. The objectives of this study were to describe the social characteristics of the HIV-positive destitute population attending an out-patient clinic providing free health care for the destitute in a Paris University Hospital, to compare their clinical-epidemiological characteristics with those of non-destitute HIV-positive patients, and to evaluate the quality of their care. We performed a historical prospective study wherein a cohort of 115 HIV-positive destitute patients (defined as having no health coverage at their first consultation) was compared with a control cohort of 183 HIV-positive non-destitute patients attending the same clinic. Ninety-five per cent of the destitute patients had no stable employment, 32% had no source of income, 75% had no permanent residence and 27% were i.v. drug abusers. Fifty-nine per cent were foreigners, most of whom had legal residence papers and had been in France for more than 3 years. When comparing the control and the destitute groups, the latter had a three times greater risk of developing tuberculosis (RH = 3.2, CI 95% = [1.1-9.4]). Medical compliance, access to antiretroviral treatment and hospitalization were identical in both groups. No difference was observed in terms of occurrence of a new AIDS-related disease during follow-up when full-blown AIDS before entry, CD4 count at entry and transmission group were taken into account in multivariate analysis. From the moment that destitute patients attended this adapted medico-social facility, their access to care was the same as, if not better than, that of the other patients. The development of out-patient medico-social facilities for HIV-positive destitute patients must be a public health priority even for those countries theoretically providing generalized health coverage.

[Access to health care for destitute persons at Public Assistance Hospitals in Paris]. / L'accès aux soins des personnes démunies à l'Assistance Publique--Hôpitaux de Paris.

All legal French residents are entitled to health care. The 1992 regulatory measures, which create a contractual agreement between the government and public medical institutions, aim at facilitating access to health care by resolving the financial obstacles to accessing health care. The Assistance Publique-Hôpitaux de Paris (AP-HP) has set up a medical reception center in several hospitals since 1993. This system is integrated in the general structure of each hospital: in some cases, there is a single and centralized unit; in other cases, all departments of the hospital, including the emergency room, are involved in caring for destitute patients. Whatever the type of the structure may be, social workers are a key element to helping the patients recover their social rights. Thirty to seventy-percent of patients visiting these centers regain access to social and health care coverage. The epidemiological survey of the active file of patients revealed that 70% are male, more than 50% are non-French nationals, half of which do not have legal immigration status in France. Homeless people represent 40 to 80% of the population. The average age is around 35. The number of medical visits varies greatly from one hospital to another and range from 20 to 60 per month. The reasons for visiting the center and the identified medical disorders are strongly related to the patients' life conditions and vary significantly with the risk factors related to the social and economic situation. The frequency of some diseases (psychiatric disorders, tuberculosis, infections by the HIV and HCV) is higher in this population than in general population. Delayed visits to the medical center represents a severity factor. The hospitals' mission statement is not only to ensure that patients facing a precarious social and professional situation have equal access to health care, but also to help such patients recover their social rights, facilitate their integration in the society and fight against social exclusion.

[Legal and social management of precariousness]. / Prise en charge juridique et sociale de la précarité.

Health regulations now applicable in France maintain, in principle, the right to health care for all, including those who are in the most precarious situations. Physicians are responsible for knowing the laws and regulations in this regard. Nevertheless, the number of persons in such situations is clearly increasing. The causes are always multiple and require application of medical and social mechanisms. Causes can include recent social rupture, precariousness having become chronic, irregularity of the administrative situation and the labyrinth of procedures to complete. Chronic diseases themselves are factors in precarious situations. Rather than being reserved to a few specialised units, social approaches to precarious situations should be integrated into the daily activity of private and public health services.