[Implication of emergency departments in the regulation of public hospitalizations]. / Place des services d'urgences dans la régulation des hospitalisations publiques.

PURPOSE: Emergency departments become a useful way to access to hospital care. Since these last years difficulties of hospitalization, mainly of the elderly, after visit to the emergency department, are on the increase. CURRENT KNOWLEDGE AND KEY POINTS: Emergency departments are an important mode of recruitment for hospital units, 4 patients to 10 are hospitalized from emergency departments. The difficulties of hospitalization starting at the emergency department are more important for the elderly. Actually, there are 2 type of hospital care, planed and non planed care. The development of observation units specific to the emergency departments allowed to resolve some of these difficulties. But they are limited by their small number of beds and the duration of hospitalization below to 36 h. Some hospitals developed polyvalent emergency short stay unit to hospitalize patients who visited emergency department without necessity to give them a specialized care. FUTURE PROSPECTS AND PROJECTS: This situation must allow us to purpose a better regulation of hospitalizations which includes emergency departments in a network system including the different hospital ways of taking care. A downstream way of care adapted to the emergency hospitalizations would be developed. This could include the emergency department, the observation unit and the emergency short stay unit in interface with internal medicine and general medicine units, geriatric unit and specialized units, all of them will be included in a town-hospital care network.

Medical student effect on emergency department length of stay.

STUDY OBJECTIVE: Taking advantage of a medical student strike, the authors evaluated the effect of medical students on emergency department length of stay (LOS). METHODS: ED LOS and patient characteristics were compared for the 4-day strike period and the same days the week before. Proportions were compared by using the Mann-Whitney U test and the chi(2) test (P <.05). RESULTS: Eight hundred thirty-one patients were studied. There was no significant difference between the study and control periods for the general patient characteristics or laboratory or radiologic investigations. Median LOS decreased by 24% (31 minutes, 95% confidence interval [CI] 24 to 38) during the strike (110 minutes [95% CI 65 to 178] to 79 minutes [95% CI 40 to 135], P <10(-4)). CONCLUSION: Medical students lengthen ED LOS. This should be explained to patients and should be considered as one justification for increasing medical staff in the teaching ED.

Understanding of medico-technical reports.

Medical practice produces much in the form of written text. The under-usage of this medical text for research is largely due to difficulties in processing the information. The objective of the Aristotle project is to build an automatic data system that is capable of producing a semantic representation of the text in a canonical form. Understanding the text requires identifying objects mentioned in the text, their properties, and the links between them. The nature of the syntactic process allows the connection, step-by-step, of two lexical units. This connection is immediately controlled by the Interpreter, which assumes the semantic process and queries a knowledge base. The syntactic-semantic Interpreter processes one sentence at a time. The Assembler module links the meaning of the different sentences and structures into the output's shape.

[The effect of "seniorization" on the prescription of biological tests in an admissions and emergency service]. / Impact de la "seniorisation" sur les prescriptions d'examens de biologie dans un service d'accueil et des urgences.

This prospective study compared the prescriptions of biological tests (PBT) for patients admitted to an Emergency medical service (EMS) of a University hospital, according as to whether the staff consisted either of medical residents only (study period P1) or of residents trained in emergency medicine and continuously supervised by a senior specialist (study period P2). During the one-month study periods, a total of 5,948 patients were admitted (2,781 during P1 and 3,167 during P2 respectively). Between P1 and P2 the rate of PBT decreased by 38.8% (P < 0.0001), the mean expenses for PBT per patient by 13.8% (P < 0.0001) and the total expenses by 53.4%. Teaching and training of residents in emergency medicine and supervision by a senior specialist improve the quality of care and decrease health care cost.

Influence of somatostatin on acute pancreatitis in rats.

OBJECTIVE: To assess the effect of two regimens of somatostatin on the morbidity and short term outcome of acute pancreatitis in rats. DESIGN: Randomised laboratory study. SETTING: Teaching hospital, France. ANIMALS: 24 male Wistar rats. INTERVENTIONS: Rats were randomised to 3 groups of 8, 2 of which were given somatostatin (one 25 microg/kg/hour by continuous infusion and one as a bolus injection of 5 microg before the infusion of 25 microg/kg/hour); the third (control) group was given 0.9% of saline 25 microg/kg/hour. Acute pancreatitis was induced by ligating the pancreatic duct at the junction with the duodenum. MAIN OUTCOME MEASURES: Serum amylase and lipase activities at 2 and 4 hours, and histological changes after 4 hours, at which time the animals were killed and the pancreas removed. RESULTS: Amylase and lipase activities were significantly lower in the somatostatin groups than in the control group throughout the experiment (p < 0.001). They were slightly but not significantly lower in the bolus group than the infusion group. The degree of necrosis and the extent of inflammatory infiltration were significantly less in the somatostatin groups (p < 0.008). CONCLUSION: Somatostatin has an early favourable effect on the course of experimentally induced pancreatitis in rats.

Diagnosis of nosocomial pneumonia in mechanically ventilated patients: repeatability of the bronchoalveolar lavage.

The repeatability of the bronchoalveolar lavage (BAL) was assessed prospectively in 44 mechanically ventilated patients with suspected nosocomial pneumonia. Two BAL were performed in the same lung area (contiguous segment) during two fibroscopic procedures performed with a thirty minute interval. All the bronchoscopies were performed by the same operator. The statistical analysis looked out for bias (MacNemar test), agreement, and repeatability (kappa test). In the 44 patients studied, the qualitative repeatability (i.e., presence or absence of bacteria) was excellent (95.4%). However, in the 16 patients having at least one positive culture, these results were more controversial. The quantitative repeatability for bacteria (same log10 for both BAL of the same patient) was the lowest of all the results (26.7%). The distinction between presence and absence of bacterial pneumonia (based on the 10[4] cfu/ml threshold) showed a repeatability of 75% with no bias, an agreement of 47% and a just-significant kappa test (test = 1.97; p = 1.96 for a 5% risk error). BAL seems to have excellent repeatability when sterile. Its repeatability when positive needs further studies to be assessed.

Season of birth and schizophrenia: sex difference.

1. A statistically significant increased risk of schizophrenia for individuals born in winter has been reported. The increase risk is of the order of 5-15 percent. The seasonal effect is more marked among females. This winter birth effect suggests some environmental agents, probably a neuropathogen one, acting on the foetus. 2. The present study sought to test the environmental damage hypothesis by application of the family history of psychiatric disorder distinction to season of birth data divided according to sex and using a control population. 3. From computer records, all patients admitted to the psychiatric department of Marseilles Timone hospital between January 1984 and December 1989 who satisfied DSM III, DSM III R criteria for schizophrenia were identified. Patients were then classified into two groups: family history of psychiatric disorder versus no family history. Division according to the sex was carried on after two groups were formed. 4. The data show (I) a significant excess of births in the early months of the year (p < 0.05) for all patients with no family history of psychiatric disorder, (2) a significant excess of births for females (p < 0.05) with no family history. 5. These results provide indirect support for the neurodevelopmental theory of schizophrenia.

Effect of heavy smoking on nasal resistance.

Smoking is a part of our sociocultural environment. Its medical consequences are probably still underestimated. In this prospective clinical study, we explored the relationship between heavy smoking and nasal resistance. Anterior rhinomanometry was performed in 26 smokers and 26 non-smokers. Each group contained 13 men and 13 women. Analysis of variance of nasal resistance measurements using age and weight as covariables showed no significant difference between sexes. In contrast, a highly significant increase was noted between smokers and non-smokers. Age and weight had no influence on these results. Rhinomanometry proved to be an excellent method of detection for these modifications. Similar studies on the effects of passive smoking and of atmospheric and occupational pollutants should follow in the near future.

[Treatment of caustic burns of the esophagus with interferon gamma. Comparison with epidermal growth factor. Experimental study in rats]. / Traitement des brûlures caustiques de l'oesophage par l'interféron gamma. Comparaison avec l'epidermal growth factor. Etude expérimentale chez le rat.

OBJECTIVES: Effects of sequential use of epidermal growth factor followed by interferon gamma on healing response after severe oesophageal corrosive burns has been demonstrated. This sequential treatment improves the inflammatory response of the initial phase and prevents residual stenosis. The aim of this study was to evaluate the use of interferon gamma alone in the same condition. METHODS: The study was performed in 5 groups (n = 15) of Wistar rats: control, placebo, epidermal growth factor alone, interferon gamma alone and epidermal growth factor for 5 days followed by interferon gamma from the 6th to 20th day. The last 4 groups had an oesophageal injury caused by a solution of 2.5 N NaOH. The efficacy of treatment was assessed on days 2, 5 and 20 on: weight gain, oesophageal internal lumen, stenosis index: wall thickness/lumen diameter, collagen production. RESULTS: Interferon gamma significantly reduced residual stenosis frequency while it did not improves the initial healing process. A complete effect on the two healing phases was only observed in animals having the sequential treatment. CONCLUSIONS: These results could lead to clinical trial in man to evaluate efficacy of sequential treatment with epidermal growth factor-interferon gamma in oesophageal corrosive burns.

Thoracoscopy in pleural malignant mesothelioma: a prospective study of 188 consecutive patients. Part 2: Prognosis and staging.

BACKGROUND: Thoracoscopy appears to be essential in identifying tumors at the beginning of pleural disease. METHODS: Between 1973 and 1990, diagnostic thoracoscopy was carried out in a prospective series of 188 patients with malignant pleural mesothelioma (MPM). Biopsy samples were obtained in all cases, and diagnosis was confirmed by the French panel of mesothelioma specialists. In all patients we noted the degree of involvement of the parietal, diaphragmatic, or visceral pleura, and classified patients according to the Butchart system: Stage I (66 patients), II (110 patients), III (4 patients), and IV (8 patients). To assess prognostic factors, a multivariate analysis of clinical and endoscopic findings was performed according to the Cox model. RESULTS: The most favorable factors were absence of weight loss at the time of diagnosis, absence of involvement of the visceral pleura, Butchart Stage I, and epithelial histopathologic type. When Stage I patients were subdivided into two groups according to whether or not they displayed involvement of the visceral pleura, a significant difference in survival was noted (32.7 months versus 7 months, respectively; P < 0.001). CONCLUSIONS: Based on these findings, we propose to divide Butchart or Mattson Stage I into two subgroups, i.e., Stage IA in which only the parietal or diaphragmatic pleura is involved and Stage IB in which the visceral pleura is invaded. In the International Union Against Cancer (UICC) classification, T1 should be used for tumors restricted to the parietal or diaphragmatic pleura and T2 for tumors with additional involvement of the visceral pleura.