[Evaluation of the use of care programs provided for under the law of 5 July 2011]. / Évaluation du recours au programme de soins prévu par la loi du 5 juillet 2011.

OBJECTIVES: The law of 5 July 2011 introduced the possibility of outpatient care without consent in the context of care programs (CP). Despite major ethical and legal issues and frequent recourse in France, few studies are available on the use of this mechanism. An in-depth review of practices involving a large sample of CP was essential. The main objective of this study was to look at their content, the clinical profile of the patients involved, and the progress of these CP. METHODS: We carried out a retrospective, observational study, including all the CP set up between January 1st, 2016 and December 31st, 2018 in the Sarthe department. Data strictly related to the CP (content, justification, duration, patient compliance, re-hospitalizations, etc.), and patient-related variables (socio-demographic characteristics, diagnosis, antecedents, etc.) were studied. RESULTS: We studied 559 CP, 70 % of which (n=391) in the context of "care by decision of the hospital director", with a wide disparity of recourse by psychiatric sector. One third of the hospitalizations without consent ended with a CP. They involved men (68.5 %, n=383), with a psychotic disorder (77.8 %, n=435), with a history of hospitalization (90 %, n=503), and with poor adherence to care (83.2 %, n=465). Cannabis use accounted for 41.3 % (n=231) of cases. Certificates initiating CP did not have a clear justification (34.6 %, n=251) or state a goal of adherence to treatment (16.5 %, n=120). The content of the different CP was homogeneous: 65.6% of medical consultations and 47.6 % with a nurse, 100 % mentioned treatment used. Their average duration was 3.4 months. Even though the CP were followed (69.9 %, n=391), 52.8% (n=295) ended with reintegration, mainly justified by symptomatic relapse (34.8 %, n=147), and new CP were put in place almost systematically (90.6 %, n=260). However, reintegrations were shorter than first-time admissions (26 vs. 95 days). When a decision was lifted (n=174), it was based on the criteria of clinical stability (35.7 %, n=120) and compliance with the CP (27.6 %, n=93). Half of hospitalizations in "care at the decision of the State representative" ended with a CP. These CP were longer (4.5 months) and with a higher rate of reintegration (62.2 %) than for those in "care at the decision of the hospital director". There was no significant difference of CP compliance according to the mode of psychiatric care. CONCLUSIONS: Our study allows a precise vision of patients concerned by CP: men with risk factors for psychiatric dangerousness, with a severe clinical profile. It also found a high rate of re-hospitalization despite good adherence with the CP which is in line with a device allowing the work of an alliance to care and interventions at the beginning of relapse. CP have poorly personalized content and are poorly justified by psychiatrists although it is a freedom-restricting measure, highlighting the need for increased awareness amongst psychiatrists of the legal framework of their practice regarding care without consent.

[Evaluation of injunction to care practices: A study of 119 cases]. / Évaluation des pratiques de l'injonction de soins : étude sur 119 sujets.

INTRODUCTION: The injunction to care (IC) is a new compulsory treatment created by the Act of June 17, 1998. Initially, this judicial tool concerned mainly sex offenders, but then the number of overall crimes requiring an IC began to dramatically rise. The judge can order this measure only if a psychiatric expertise has concluded to its potential opportunity. Then the convict must undergo a psychiatric follow-up after having served the sentence. The creation of a court-ordered treatment is based on the premise that many offenders are affected by psychiatric disorders. For the lawmaker, the aim is to lower the risk of recidivism. PURPOSES: The main purpose of this study is to assess the convicts concerned by the IC describing their sociodemographic characteristics, psychiatric diagnostics and criminal characteristics. The second purpose is to assess the efficiency of this measure regarding re-offending and specifically legal recidivism. METHODS: This is a retrospective and descriptive study concerning 119 subjects followed-up by two "coordinating doctors" in the department of Sarthe who could assess their psychiatric diagnostics and sociodemographic characteristics. They could also compare medical data with the judicial data for 78 of the subjects. RESULTS: The population was composed of 117 men (98.3%) aged 45 years old on average. They had a job in 37% of cases (n=44) and were single in 56.3% of cases (n=67). According to the DSM-IV-TR, only 29 subjects (24.4%) had an axis I disorder and 37.8% of the population had a pathological personality trait (non DSM-IV-TR categorized disorder). Furthermore, 51.3% (n=61) of the subjects were addicted (mainly alcohol). The medical follow-up was carried out by a psychiatrist in 83.2% of cases (n=99). The average duration of follow-up was five years. Among the 78 subjects for whom there was access to juridical data, 13 (16.7%) had committed a new offense during follow-up. Among them, seven had recidivated six of whom were initially sentenced for sexual offense. CONCLUSIONS: Most of the subjects in injunction to care had no axis I disorder but addictions and/or pathological personality traits. Nevertheless, the expert concluded the need of an IC. Personality and behavior disorders do not always require psychiatric care, and the management must be multidisciplinary. In France, the psychiatrist remains at the center of injunction to care measure. The addictology care is not developed whereas it is a population at risk and there is a lack of interactions between professionals (medical, social and judicial professionals). The IC is a measure that needs to be improved by means of better communication among the different professionals and a better global assessment of the subjects. Medical care must be a possible option but not a systematic treatment.

[Court-ordered treatment: Analysing a complex practise through a literature review]. / Les soins pénalement ordonnés : analyse d'une pratique complexe à travers une revue de la littérature.

INTRODUCTION: In France, there are two main types of court-ordered treatment (COT) as far as mental health is concerned: obligations of treatment and injunctions of treatment. Obligations of treatment date back from 1958 whereas the law implementing injunctions of treatment is fairly recent as it was passed in 1998. Obligations and injunctions of treatment are two different types of COT that differ in terms of proceedings (obligations of treatment require no preliminary forensic psychiatric assessment; as for injunctions of treatment, they require the appointment of a coordinating medical doctor) and that are applied for different offences. However, both are psychiatric commitment procedures connecting the judicial, medical and social fields and their overall numbers have been on the rise. These common psychiatric practices have seldom been assessed and no review of the literature on the subject has ever been published. Better knowledge of such forensic practices is essential to their improvement and even to adjust the legal framework of these measures that are enjoying a boom. The purpose of this literature review is to define the prevalence of COT as well as the sociodemographic, criminal and psychiatric characteristics of those concerned by such measures. MATERIAL AND METHODS: A review of the French medical literature on COT was carried out using Science Direct up to December 2013. The results of seven studies were included and analysed. This was completed with a review of the articles listed in social sciences and law databases (Cairn and Dalloz). RESULTS: It has become increasingly frequent to rely on psychiatric teams to implement COT while at the same time public mental health services have to face a surge in activity with restricted financial means. Obligations of treatment are far more common (about 20,000 court orders a year) than injunctions of treatment (about 4000 measures are currently being enforced). However the latter have showed an increase of 506% over the 2000 decade. Both measures mainly concern men (83-99%) who are rather low on the social scale. In about half of these men, no mental disorder was found, however the prevalence of personality disorders ranged from 22 to 65% while that of psychotic disorders was low. Injunctions of treatment concerned sex offenders (90% of cases) whereas obligations of treatment concern non-sexual abusers (40-70%) rather than sex offenders (20-30%). DISCUSSION: Psychiatric research on COT is still thin on the ground and its methodology does not allow rigorous evaluation though the use of such measures is growing. When confronted with people who have not sought any care or treatment, healthcare professionals are at a loss. In France, training in forensic psychiatry is inadequate and specialised healthcare (particularly for sex offenders) need improving to reach the level of those found in many other European countries. The purpose of psychiatric treatment differs from that of lawmakers whose aim is to prevent recidivism. However, better treatment consistency requires setting up partnerships between justice, health and social services. To improve connections, there are various avenues of work such as, for instance, the creation of coordinating medical doctors for injunctions of treatment in France or European experiments using a multidisciplinary approach to prevent recidivism in sex offenders. The framework of such a partnership remains to be created as it is part and parcel of COT but has not been provided for in the law. Healthcare jurisdictions as defined in the 2009 French National Health Law might provide an appropriate framework for mental health and law professionals to collaborate.

[Postpartum urinary retention]. / Rétention vésicale du post-partum.

Postpartum urinary retention is an uncommon event that occurs in 0.7 to 0.9% of vaginal deliveries. An ignorance of this situation can lead to delayed diagnosis worsening the prognosis and to inadequate treatments. This complication is defined as the absence of spontaneous micturition within 6hours of vaginal delivery with a bladder volume above 400mL. The etiology depends on multiple factors. Because of physiological changes during pregnancy, the bladder is hypotonic with an increased post-void residual volume. The occurrence of a perineal neuropathy during delivery may cause a urinary retention. Risk factors are primiparity, prolonged labour, instrumental delivery and perineal lacerations. Treatment consists on clean intermittent catheterization and recovery occurs generally in 72hours. Persistent urinary retention is the principal short-term complication and should be treated by clean intermittent self-catheterization. Long-term consequences are poorly reported in the literature.

[Teaching and perception of urology by medical students at the end of the second cycle: an appraisal]. / Enseignement et perception de l'urologie à la fin du deuxième cycle des études médicales: état des lieux.

OBJECTIVES: Our purpose was to determine how the medical students from the second cycle perceived urology and what their learning methods were. MATERIAL AND METHODS: An e-questionnaire was sent to 1600 students in 16 teaching faculties during the last year of their second cycle. RESULTS: Overall, we obtained 590 answers (36.8%). In our population, 70.2% of the students were women. Of them, 24.1% had been already enrolled in an academic urology unit. Urology was defined as a medical, surgical and medico-surgical discipline by 3.7%, 37.8% and 58% of the students, respectively. Urology was considered as very important, important, not very important and not important at all by 5.1%, 54.4%, 37.5% and 2.4% of the students. The teaching methods used to learn urology were duplicated-notes for ENC preparation (45.3%), conferences for ENC (French national ranking exam) preparation (43.7%), courses of the national urology college (38.6%) and courses of the faculty (32%). The best mastered items were lithiasis disease (86.3%), voiding dysfunction (76.3%) and urological cancers (56.7%). On the contrary, only 34.7% and 28% considered their knowledge sufficient on the erectile dysfunctions and on renal transplantation. Lastly, 7.3% intended to become urologists. Having a work experience in a urology unit was significantly associated to the feeling of being prepared to become an intern (p<0.001) and to the project of becoming a urologist (p<0.001). CONCLUSION: Urology was considered like an important discipline by half of the students at the end of the second cycle even though it is under-represented in the national teaching programme for ENC. A third of the students used courses from the faculty to learn urology and a quarter of them had a work experience in a urology unit during their second cycle.

[Diagnostic and therapeutic management of the benign prostatic hyperplasia by the general practitioners in the Maine-et-Loire]. / Evaluation des pratiques des médecins généralistes du Maine et Loire concernant l'hypertrophie bénigne de la prostate.

AIM: To assess the diagnosis and therapeutic management of the benign prostatic hyperplasia (BPH) by the general practitioners (GPs) in the Maine-et-Loire. PATIENT AND METHODS: A questionnaire evaluating the management of BPH was sent to the 686 GPs of the Maine-et-Loire between March and June 2008. RESULTS: One hundred and seventy-one GPs answered. Among them 24% were women, 35.1% worked in urban areas, 34.5% worked in semi-urban areas and 30.4% worked in rural areas. 17.5 % had been working less than 10 years, 29.2% had been working between 10 and 20 years and 53.2% had been working more than 20 years. The medical interview, the digital rectal examination (DRE) and the assay of the prostatic serum antigen (PSA) were performed by more than 90% of the GPs whereas the ultrasound scan and the international prostatic score symptom (IPSS) were respectively used by only 15,2 and 69,6% of them. Phytotherapy, alphablockers and inhibitors of 5 alpha reductase were respectively prescribed by 85.4, 95.3 and 53.8% of the GPs. 96.5% of the GPs addressed the patient to a urologist after the failure of the first line treatment. There were no differences according to the working environment. Women performed less DRE (p<0.0001) and sent more patients to urologist than men (p=0.0197). Finally, 88.9% of the GPs were interested in having an update on the last recommendations. CONCLUSION: The GPs diagnosed BPH and initiated the first line treatment. In case of failure, they sent the patients to a urologist. Their primary treatment management was not really in adequation with the recommendations. The recent therapeutic innovations may explain this discordance between the clinical practice and the recommendations. It is noteworthy that most of the GPs who answered this survey were keen in having an update on the recent advances in the BPH management.

[Evidence-based medicine and French medical students: an appraisal]. / Evidence-based medicine et étudiants en médecine français : état des lieux.

INTRODUCTION: Nowadays, evidence-based medicine (EBM) is essential to learn and to practice medicine. The aim of the current study was to investigate the baseline level of knowledge of French students regarding EBM. MATERIALS AND METHODS: Between April and May2008, a questionnaire was sent by e-mail to 900students in their last year of medical study. RESULTS: On 327 answers, 297 (91%), 94 (29%) and 85 (26%) students declared they read, write and speak medical English. Ninety (28%) read an article of a French medical review once a month and 43 (13%) read an article of an international medical review once a month. Three hundred and eleven (95%) knew the bases of medical research on the Internet and 219 (67%) used them. Twenty-four (7%) had already participated in a editorial staff of a medical article, 7 (2%) had been co-authors. Two hundred and seventy-two (83%) had made an oral presentation during a medical staff and 3 (1%) during a congress. Finally, 237 (73%) understood the interest of the critical analysis of an article at the ECN and 70 (21%) thought they were prepared. CONCLUSION: The incapacity of learning EBM is one of the limits of the French medical training system. The introduction of the reading critical of an article at the ECN is the concrete beginning of an answer to this problem.

[Evaluation of the practical skills of final year medical students: example of bladder catheterization]. / Evaluation des compétences pratiques en fin de deuxième cycle des études médicales: exemple du drainage du bas appareil urinaire.

INTRODUCTION: When performed incorrectly, bladder catheterization can cause iatrogenic complications, especially urinary tract infections and trauma. The objective of this study was to determine the capacity of final year medical students to perform the various bladder catheterization techniques. MATERIAL AND METHODS: Between January and March 2007, a catheterization self-administered questionnaire was sent by e-mail to a representative sample of final year medical students, two months before the national classifying examination. RESULTS: Two hundred and seventy-seven questionnaires were returned and analysed. Seventy-two students (26%) considered that they were able to perform bladder catheterization in males and 106 (38.3%) in females at the end of their medical training. Seventy-one out of 277 (25.5%) students had completed an urology term during their training and 53.5% of them considered that they had acquired the indwelling catheter technique in males (p<0.001) versus 39 (54.9%) in females (p<0.001). Seventy-three students (26.4%) considered that they were able to perform intermittent catheterization in males or females and only one student was able to perform suprapubic catheterization. CONCLUSION: Teaching of catheterization procedures is inappropriate during medical training and young doctors consider themselves unable to perform these techniques at the end of their training. This is unfortunate, as all doctors should be able to perform catheterization as part of their daily practice, especially in hospital. This study indicates the need for improved teaching of essential medical procedures during undergraduate medical training.