What can we learn from international comparisons of costs by DRG?

OBJECTIVES: The objective of this study was to compare costs data by diagnosis related group (DRG) between Belgium and Switzerland. Our hypotheses were that differences between countries can probably be explained by methodological differences in cost calculations, by differences in medical practices and by differences in cost structures within the two countries. METHODS: Classifications of DRG used in the two countries differ (AP-DRGs version 1.7 in Switzerland and APR-DRGs version 15.0 in Belgium). The first step of this study was to transform Belgian summaries into Swiss AP-DRGs. Belgian and Swiss data were calculated with a clinical costing methodology (full costing). Belgian and Swiss costs were converted into US$ PPP (purchasing power parity) in order to neutralize differences in purchasing power between countries. RESULTS: The results of this study showed higher costs in Switzerland despite standardization of cost data according to PPP. The difference is not explained by the case-mix index because this was similar for inliers between the two countries. The length of stay (LOS) was also quite similar for inliers between the two countries. The case-mix index was, however, higher for high outliers in Belgium, as reflected in a higher LOS for these patients. Higher costs in Switzerland are thus probably explained mainly by the higher number of agency staff by service in this country or because of differences in medical practices. CONCLUSIONS: It is possible to make international comparisons but only if there is standardization of the case-mix between countries and only if comparable accountancy methodologies are used. Harmonization of DRGs groups, nomenclature and accountancy is thus required.

Clinical outcome and cost of hospital vs home treatment of proximal deep vein thrombosis with a low-molecular-weight heparin: the Vascular Midi-Pyrenees study.

BACKGROUND: Low-molecular-weight heparins have been shown to be effective and safe in the treatment of deep vein thrombosis. To our knowledge, there have been no direct comparisons of such treatment on an outpatient vs an inpatient basis. OBJECTIVE: To conduct a randomized, comparative, multicenter trial to evaluate the clinical outcomes and treatment costs of deep vein thrombosis in the outpatient and inpatient settings. METHODS: Two hundred one patients presenting with proximal deep vein thrombosis, without known risk factors for pulmonary embolism or hemorrhagic complications, were randomized to receive a low-molecular-weight heparin at the registered dose followed by an oral anticoagulant for up to 6 months, either in the hospital for the first 10 days followed by treatment at home (n=102) or at home from the outset (n=99). The primary clinical outcome was the incidence of venous thromboembolism recurrence, pulmonary embolism, or major bleeding. The economic analysis was performed from the point of view of the health insurance company. Total costs of the 2 management strategies were calculated to compare the cost consequences during the first 10 days. RESULTS: No differences in clinical outcome were detectable between the 2 groups. There was no increase in the rates of primary efficacy outcome in the patients treated at home vs in the hospital (3.0% vs 3.9%), while a cost reduction of 56% was demonstrated for outpatient management. CONCLUSION: For patients with proximal deep vein thrombosis and no symptoms of pulmonary embolism or increased risk of major bleeding, home treatment using a low-molecular-weight heparin is an effective, safe, and cost-saving strategy.

L-Dopa-induced sedation: a double-blind cross-over controlled study versus triazolam and placebo in healthy volunteers.

Incidental case reports suggest that some parkinsonian patients treated with dopaminergic drugs complain of drowsiness but few controlled data are available. We compared the sedative effects of L-Dopa (200 mg + 50 mg benserazide, PO), triazolam (0.125 mg) and placebo in a randomized double-blind cross-over design in 22 healthy volunteers pretreated with domperidone (60 mg/day). Drowsiness was assessed using a visual analog scale (VAS), a computerized choice reaction time test (CRT) and an electro-oculogram (EOG). L-Dopa and triazolam induced significant drowsiness, compared to placebo, on VAS, CRT and some EOG parameters. After this first evaluation session, all subjects were chronically treated for 11 days with 600 mg/d of L-Dopa. Drowsiness induced by L-Dopa, triazolam or placebo was then tested again on three consecutive days to assess putative dopaminergic tolerance. After chronic L-Dopa treatment, triazolam-induced sedation remained unchanged while L-Dopa sedative effects were no longer significant except on the VAS, preventing the conclusion that tolerance occurred. These data suggest that an acute dose of L-Dopa induces sedation in L-Dopa-naive subjects. This sedative effect must be considered in clinical practice and when studying the effects of L-Dopa on motor or neuropsychological performance, especially in acute tests.

[Two or three things about the PMSI in stomatology and maxillofacial surgery]. / Deux ou trois choses sur le PMSI en Stomatologie et Chirurgie Maxillo-Faciale.

The Information Systems Medicalization Program (PMSI in French) was created in 1985 for Public Health Service Hospitalisation Structures. It appeared to be directly derived from the North-American Diagnosis Related Groups (DRGs) system. Since them, the PMSI has been progressively developed in private structures as well. The authors have had the opportunity to use the latest version of the computer program which was elaborated in order to share the patients into more than 500 different groups of pathology. These groups were called "Homogeneous Patients Groups" (GHM in French). To each group corresponds a "Synthetic Activity Index" number (ISA in French). It is supposed to be representative of the average cost of the management of each kind of patients, based on the diagnosis and the surgery possibly done. Several astonishing findings have been made. Some of them can be summarized as mentioned below: In maxillofacial Surgery, each group (GHM) seems in fact to be extremely inhomogeneous: for example, total parotidectomy with preservation of the facial nerve belongs to the same group as accessory salivary gland exeresis. Total skin graft is in the same group as free composite osseous flap with vascular anastomosis. Coding a surgical procedure leads often to reduce the ISA number in comparison with the same patient without surgery: "impacted third molar" gives 754 points without surgery but only 658 if surgery is performed. Carcinologic surgery is wholly grouped in the same category, even for rather short procedures as isolated partial glossectomy. This group corresponds to a great number of ISA points (6486) while bimaxillary surgery or free flap transfer gives less than 2500 points. In conclusion, the use of the PMSI to allocate financial means can be extremely dangerous for maxillofacial surgery units and consequently for the quality of the medical care in our Specialty. Further studies are obviously necessary to complete a critical analysis of the current system and to improve it.

-Anesthesia and analgesia practice patterns in French obstetrical patients-. / Anesthésies et analgésies pratiquées dans les maternités françaises.

OBJECTIVE: To assess the rate of epidural analgesia (EA) for parturition and the techniques of anaesthesia for Caesarean section (CS). STUDY DESIGN: Retrospective study. PATIENTS: A series of 84,235 deliveries. METHODS: The series was extracted from a total of 770,054 deliveries carried out in 1991, according to the number of births in each hospital (1/1 if the births were < or = 100 per year, up to 1/25 if they were > or = 2,000 per year). The data analyzed included: anaesthesia technique, whether or not there was an anaesthetist on night duty at the hospital, birth rate in the hospital, type of hospital: university (UH), general (GH) or private (PH). For vaginal deliveries, the mode of labour commencement (spontaneous or induced), the multiplicity of pregnancies and a history of past CS were also noted. RESULTS: Vaginal deliveries: the overall rate of EA was 37.2%. EA were not carried out in 5% of maternity hospitals. In cases of spontaneous labour, the average rate was 32.1%, significantly less than for induced labour (59.6%, P < 0.0001) and in cases of previous CS (39%, P < 0.05). There was no statistical difference in cases of multiple pregnancies (35.7%). The average rate of EA was correlated to the number of annual births (P < 0.001) and was increased when the anaesthetist was present in hospital at night (P < 0.001). It was also significantly lower in GH (P < 0.001) than in UH or PH, which were equivalent. Scheduled CS: general anaesthesia (GA) was carried out at a significantly higher rate than regional anaesthesia (RA) (49.7% vs 48.4%, P < 0.05). In 15.1% of hospitals, RA was not available. The incidence of RA was influenced neither by the rate of annual births nor by the presence of the anaesthetist in the hospital during night. However, RA was significantly less frequent in GH (46.3%, P < 0.001) than in UH (48.6%) and in PH (53.6%) which were equivalent. CS during labour: the incidence of RA was significantly higher than GA (53.2% vs 44.1%, P < 0.001). In 17.1% of hospitals, RA was never carried out. The rate of RA was correlated to the size of the maternity hospital, and significantly higher (P < 0.001) when the anaesthetist was present in hospital during night. The differences between UH, GH and EP were the same than for scheduled CS. CONCLUSION: In France in 1991, the average rate of 37.2% for EA for obstetrics was high when compared to the rate in United Kingdom. It was equivalent to those in United States and Ontario, Canada. The discrepancies between hospitals were mainly related to structural and organizational factors. The influence of the size of the maternity hospital, the 24-hour service of EA was also shown in other studies. However, the difference between GA and UH and PH is a French particularity. The high rate of GA for CS differs largely with those in the UK or the USA. The time saving aspect of GA was probably an important factor for the choice of this technique. This study must be reactualized and enlarged to determine the demand of EA for labour by parturients and obstetricians.

[Treatment of deep venous thrombosis at home: evolution from ideas to medical practice]. / Traitement des thromboses veineuses profondes à domicile: de l'évolution des idées á la pratique médicale.

The diagnosis of Deep Venous Thrombosis (DVT) by duplex ultrasound is absolutely possible out of specialized centers. Low Molecular Weight Heparins (LMWH) allow to obtain a greater efficacy and safety compared to Unfractionated Heparin (UFH). The control of LMWH is very reduced. Two studies have just been published on the topic of treatment of DVT at home. The group of patients treated at home with LMWH is not presenting more complications than the group of patients initially treated at the hospital with UFH. Nevertheless, these studies concern a very selective population of patients. Our center has been proceeding to a study for 4 years (1993-1997) in comparing the treatment at home of proximal DVT by LMWH then oral anticoagulant, to the initial treatment (10 days) in hospital by also using LMWH then oral anticoagulant. The first results show that there is no difference between both groups in terms of end-points: death, extension or recurrence of the thrombus, pulmonary embolism, bleeding. Therefore, the treatment of some type of proximal DVT is possible at home. Nevertheless, it is necessary to be very cautions as the population studied so far is a selected one. Etiologies of DVT are a constant obsessive fear. DVT or pulmonary embolism represents a real general disease which is going to progress along life. The intervention of a specialized center is always necessary. It is a work in team which must get the upper hand compared to an isolated medical action.

Detection of t(14;18) carrying cells in bone marrow and peripheral blood from patients affected by non-lymphoid diseases.

AIMS/BACKGROUND: To assess the presence of bcl-2/JH rearrangements in bone marrow and peripheral blood lymphocytes from patients affected by diseases other than malignant lymphomas. The t(14;18) (q32;q21) translocation, which juxtaposes the bcl-2 oncogene on chromosome 18 and the JH segment of the immunoglobulin heavy chain (IgH) genes on chromosome 14, is found frequently in follicular lymphomas. METHODS: A sensitive semi-nested polymerase chain reaction (PCR) was used to detect t(14;18) translocation in bone marrow aspirates and peripheral blood lymphocytes from 48 patients. In 137 additional individuals peripheral blood lymphocytes only were tested. RESULTS: Cells carrying bcl-2/JH rearrangements were detected in about a quarter of the bone marrow samples and half of the peripheral blood lymphocyte samples. In seven patients, t(14;18) positive cells were found in both the bone marrow and peripheral blood lymphocyte samples. The size of the PCR products and bcl-2/JH DNA sequence analysis showed that the same t(14;18) carrying clone was present in the bone marrow and the corresponding peripheral blood lymphocyte samples in three of these seven patients. Some patients had more than one bcl-2/JH rearrangement. There was no significant correlation between age and the translocation incidence. Cells carrying the t(14;18) translocation were present in peripheral blood lymphocyte samples with a similar incidence--between 47% and 52% in all age groups from 20 to 79 years. Patients older than 80 years had a lower (37%) but not significantly different incidence. CONCLUSIONS: These findings suggest that patients affected by non-lymphoid diseases may have several t(14;18) carrying cells and some of them undergo a clonal expansion. Whether individuals with t(14;18) positive cells are at a higher risk of lymphoid malignancies remains unanswered and further epidemiological studies are required.

A comparative survey of antidepressant drug prescribing habits of general practitioners and psychiatrists.

OBJECTIVE: Clinical experience suggests important differences in prescriptions from general practitioners and specialists. This study investigated these differences and their determinants for antidepressant drug prescribing intentions by general practitioners and psychiatrists in France. STUDY PARTICIPANTS: In May 1995, a mail questionnaire was sent to a representative panel of 300 general practitioners and 100 psychiatrists from the Midi-Pyrenees area (South West France). Two types of questions were asked: the first concerned the type of antidepressants prescribed according to the characteristics of depression ('severe', with insomnia, anxiety, etc.) and the second, the factors influencing prescriptions (personal experience, adverse effects, clinical trials, cost, etc.). RESULTS: 151 general practitioners (51%) and 63 psychiatrists (63%) answered the questionnaire. The analysis showed large differences between the two groups of physicians. Serotoninergic antidepressants were reported to be the most common first-line drugs of choice in both groups of practitioners. General practitioners claimed to prescribe serotoninergic antidepressants more frequently than psychiatrists (74 vs 59%, p < 0.05). Psychiatrists were reported to prescribe higher dosages of antidepressants than general practitioners in 'severe' depression (109.7 vs 85.6mg daily, p < 0.001). General practitioners were reported to prescribe anxiolytic agents more frequently than psychiatrists (73 vs 54%, p < 0.05), and neuroleptic agents less frequently (1 vs 11%, p < 0.001). The factors reported to influence antidepressant prescription differed in the two groups of physicians. Postuniversity teaching, hospital specialist information and registered indication were considered more important by general practitioners than psychiatrists, who reported to be more influenced by patients' and colleagues' opinions. CONCLUSION: These results demonstrated that the differences in intention in prescribing between psychiatrists and general practitioners can be explained by a different approach to prescription since psychiatrists place more importance on human and clinical factors (patients' and colleagues' opinions) than general practitioners, who referred more to 'official' data (university, hospital and registered indications).

[Type of birth center and conditions of transfer of neonates under 1500 g or gestational age under 33 weeks]. / Lieux de naissance et conditions de transferts des enfants de moins de 1500 g ou d'âge gestationnel strictement inférieur à 33 semaines.

BACKGROUND: Perinatal care's organization has been widely discussed in France during this last decade. Until now, transfer of high-risk neonates from their birth maternity to a pediatric unit using mobile vehicles led by specialized teams is encouraged in this country. POPULATION AND METHODS: Retrospective analysis of the type of maternities of birth for a population of 717 newborns, weighing less than 1,500 g and/or of gestational age under 33 weeks, extracted from a sample of 84,279 births in 1991. RESULTS: Only 15.6% of studied births took place in a maternity including a special intensive care pediatric unit (international level 3); 58.7% of those newborns where transferred outborn. There was a significant difference between the immediate access of newborns to a level 3 pediatric unit according to the location-of birth: significantly fewer newborns were directly transferred to a level 3 unit when born in a facility that included a level 2 pediatric unit, compared with those born in facilities that included a level 1 or 3 pediatric unit. CONCLUSION: Strong efforts should be made to identify mothers at high risk of giving birth to extremely prematured babies or babies with a very low birthweight so that births could take place in maternities properly equipped for their care. Perinatal care's organization should be built on a hierarchical network of maternities and pediatric services related to the risk of the population. Accreditation of maternities and pediatric services could help moving towards this kind of organization.

[Analysis of delivery facilities and conditions in 1991 in mothers of infants with birth weights below 1500 grams and/or gestational age under 33 weeks]. / Analyse des lieux et des conditions d'accouchement en 1991 des mères d'enfants dont le poids de naissance était inférieur à 1500 g et/ou l'âge gestationnel inférieur strictement à 33 sem.

AIMS: To identify maternities (in terms of level of activity and linkage with pediatric services) where, in 1991, mothers gave birth to infants of gestational age less than 33 weeks and/or with birth weight under 1500 g. To analyse factors linked to the probability of choosing a particular maternity as place of delivery for this population and measure the impact of maternal transferts on the rates of deliveries. To estimate the number of neonate transferts which could be avoided with simple recommendations. To propose policies that would allow France to come closer to the results of other reference countries in term of management of obstetrical and neonate care. MATERIAL AND METHOD: We extracted from a retrospective sample of 84,279 births (out of a total of 770,148), 717 infants meeting previously defined criteria and related to the population described above, using univariate and multivariate analysis and logistic regression. RESULTS: The Odds-ratio for a delivery to take place in a maternity with a volume of more than 2000 deliveries a year, compared with those doing less than 300 deliveries, is 4, 12. Only 15.8% of those deliveries took place in maternities linked to a level 3 pediatric unit (i.e where an intensive care neonates unit was located in the same building). 39.5% of births took place in level 1 maternities where no required pediatric service existed. Logistic regression techniques showed that the choice of a maternity for mother referral was more linked to the number of deliveries than to its level of pediatric services. In the studied population, 46% of the difference between the observed number of births in high volume maternities (compared to the expected number) could be explained by a maternal referral. The analysis of deliveries showed that for 34% of mothers who gave birth to a baby in a level 1 or 2 maternity, there was a possibility of being referred easily in a level 3 maternity. CONCLUSION: This study shows that the level of care of mothers at high risk of delivering a very premature and/or hypotrophic infant is far from international standards. Simple actions could double the number of births taking place in adapted maternities. We propose to both obstetricians and pediatrists, a common program to enhance the level of care.

[Cesarean sections in France: impact of organizational factors on different utilization rates]. / Césariennes en France: impact des facteurs organisationnels dans les variations de pratique.

In this study, we analysed the potential impact of organizational factors to explain the variation of cesarean sections' rates. We used a retrospective sample of 84,372 deliveries and two subsamples of low risk deliveries for cesarean sections. We determined different organisational factors that included: juridical and financial status of maternities, their architecture, the type of on-call for obstetricians, pediatrists and anesthetists, the annual number of deliveries and the level of pediatric staff and equipments of the maternities. We used multiple regression techniques to study the specific effect of each parameter, while controlling effects of age and parity of the mothers. We have found that even on the low risk samples, variation of rates were important. The type of on-call, the level of pediatric services and the architecture of maternities exerted a strong and significant effect on the rate of cesarean sections compared to the absence of impact of the number of deliveries. We discuss the reasons why, explaining the occurrence of those factors and then, stress the need to take into account the relevant factors for organizational audits. It appears that, in the context of the new regulation of the health system, these results should give obstetricians reasons to enhance their efforts to correct inefficient practices and to respect consensual guidelines and joint accreditation of obstetric and pediatric units.

Effect of intraperitoneal insulin delivery on growth hormone binding protein, insulin-like growth factor (IGF)-I, and IGF-binding protein-3 in IDDM.

Low plasma insulin-like growth factor (IGF)-I despite high circulating growth hormone (GH) in insulin-dependent diabetes mellitus (IDDM) indicate a hepatic GH resistance. This state may be reflected by the reduction of the circulating GH binding protein (GHBP), corresponding to the extracellular domain of the GH receptor, and the reduction of insulin-like growth factor binding protein (IGFBP)-3, major IGF-I binding protein, upregulated by GH. We carried out two studies. In the first, plasma GHBP activity was compared in patients with IDDM on continuous subcutaneous insulin infusion (CSII) or on conventional therapy and in healthy subjects. In the second study, the 18 patients on CSII at baseline were then treated by continuous intraperitoneal insulin infusion with an implantable pump (CPII) and prospectively studied for GH-IGF-I axis. Although HbA1c was lower in patients on CSII than in those on conventional therapy, GHBP was similarly reduced in both when compared to control subjects (10.2 +/- 0.8 and 11.6 +/- 0.9% vs 21.0 +/- 1.3, p < 0.01). CPII for 12 months resulted in: a slight and transient improvement in HbA1c (Time (T)0: 7.6 +/- 0.2%, T3: 7.1 +/- 0.2%, T12: 7.5 +/- 0.2%, p < 0.02), improvement in GHBP (T0: 10.2 +/- 0.8%, T12: 15.5 +/- 1.5, p < 0.0001), near-normalization of IGF-I (T0: 89.4 +/- 8.8 ng/ml, T12: 146.9 +/- 15.6, p < 0.002) and normalization of IGFBP-3 (T0: 1974 +/- 121 ng/ml, T12: 3534 +/- 305, p < 0.0001). The hepatic GH resistance profile in IDDM does not seem to be related to glycaemic control, but partly to insufficient portal insulinization. Intraperitoneal insulin delivery, allowing primary portal venous absorption, may influence GH sensitivity, and improve hepatic IGF-I and IGFBP-3 generation.

D-dimer test and diagnosis of deep vein thrombosis: a comparative study of 7 assays.

The current D-Dimer ELISA methods provide high sensitivity and negative predictive value for the diagnosis of deep vein thrombosis but these methods are not suitable for emergency or for individual determination. We have evaluated the performance of 3 newly available fast D-Dimer assays (Vidas D-Di, BioMérieux; Instant IA D-Di, Stago; Nycocard D-Dimer, Nycomed) in comparison with 3 classic ELISA methods (Stago, Organon, Behring) and a Latex agglutination technique (Stago). One-hundred-and-seventy-one patients suspected of presenting a first episode of deep vein thrombosis were investigated. A deep vein thrombosis was detected in 75 patients (43.8%) by ultrasonic duplex scanning of the lower limbs; in 11 of them the thrombi were distal and very limited in size (< 2 cm). We compared the performance of the tests by calculating their sensitivity, specificity, positive and negative predictive value for different cut-off levels and by calculating the area under ROC curves. The concordance of the different methods was evaluated by calculating the kappa coefficient. The performances of the 3 classic ELISA and of the Vidas D-Di were comparable and kappa coefficients indicated a good concordance between the results provided by these assays. Their sensitivity slightly declined for detection of the very small thrombi. Instant IA D-Di had a non-significantly lower sensitivity and negative predictive value than the 4 previous assays; however its performance was excellent for out-patients. As expected, the Latex assay had too low a sensitivity and negative predictive value to be recommended. In our hands, Nycocard D-Dimer also exhibited low sensitivity and negative predictive value, which were significantly improved when the plasma samples were tested by the manufacturer. Thus significant progress has been made, allowing clinical studies to be planned to compare the safety and cost-effectiveness of D-Dimer strategy to those of the conventional methods for the diagnosis of venous thrombosis.

Plasma DNA as a marker of cancerous cell death. Investigations in patients suffering from lung cancer and in nude mice bearing human tumours.

Plasma DNA that circulates mainly as mononucleosomes is a cell death marker. Its significance and prognostic value in cancer as compared to other tumour markers was investigated in 68 patients hospitalised for lung cancers. Prognostic values of the various studied parameters were evaluated using the Cox's model. The cellular origin of plasma DNA was further investigated in nude mice transplanted with human lung adenocarcinoma. Plasma DNA concentrations were increased in cancer patients as compared to normal subjects (P < 0.01). They were higher in patients with extended (Stage 4) disease than in patients with limited stage disease (P < 0.05). Plasma DNA concentrations, serum lactate dehydrogenase activities and neuron-specific enolase concentrations were correlated all together in small cell lung carcinoma (SCLC) and in non-SCLC. Similar relationships were found between survival and each of these three cell death/tumour markers (P < 0.02-0.005). Plasma DNA from mice bearing human tumour hybridised with both mouse and human plasma DNA, while plasma DNA from endotoxin-injected mice hybridised only with mouse plasma DNA. In conclusion, in patients suffering from lung cancer, plasma DNA as well as LDH and NSE represent cell death markers that are correlated with survival. At a time when apoptosis pathways appear to be potential targets for cancer therapy, plasma DNA is a cell death/tumour marker that should be taken into account in studying the cancerous process in human diseases.

Evidence for activation of both adrenergic and cholinergic nervous pathways by yohimbine, an alpha 2-adrenoceptor antagonist.

Adrenoceptors are involved in the control of the activity of the autonomic nervous system and especially the sympathetic nervous system. Activation of alpha 2-adrenoceptors decreases sympathetic tone whereas their blockade has an opposite effect. However, previous investigations have shown that yohimbine (a potent alpha 2-adrenoceptor antagonist) increases salivary secretion through activation of cholinergic pathways. The aim of the present experiment was to investigate the involvement of both the sympathetic and the parasympathetic system in several pharmacological effects of yohimbine. For this purpose, salivary secretion and various endocrino-metabolic parameters (noradrenaline and insulin secretions, lipomobilization) were evaluated in conscious fasting dogs before and after blockade of either the sympathetic (with the beta-adrenoceptor antagonist agent nadolol) or the parasympathetic (with the anticholinergic agent atropine) systems. Yohimbine alone (0.4 mg.kg-1, i.v.) increased within 5-15 minutes, plasma noradrenaline (600%), insulin levels (300%), free-fatty acids (79%) and salivary secretion (143%). Atropine (0.2 mg.kg-1, i.v.) suppressed yohimbine-induced salivary secretion (90%) but did not significantly modify the yohimbine induced changes in noradrenaline (312%), insulin (277%) and free-fatty acids (102%) plasma levels. Administration of nadolol (1 mg.kg-1, i.v.) did not change the magnitude of the increase in both noradrenaline plasma levels (550%) and salivary secretion (300%) induced by yohimbine. However, nadolol totally blunted the increase in insulin (15%) and free-fatty acids (4%) plasma levels. These results show that yohimbine-induced increase in salivary secretion is a cholinergic effect whereas the increase in insulin and free fatty acids can be explained by an increase in sympathetic tone.(ABSTRACT TRUNCATED AT 250 WORDS)

[Explanatory indicators of the length of stay in a pneumology department]. / Indicateurs explicatifs de la durée de séjour dans un service de pneumologie.

BACKGROUND: Utilization of Diagnosis Related Groups (DRGs') for hospital payments in France. OBJECTIVES: To search the variations and the explicative factors of length of stay in a pneumologic unit, to analyse the relevance of the indicators by using the DRG's and the supplementary variables in a medical and economical perspective. SETTING: Pneumologic unit of Limoges' teaching hospital. METHODS: From 1-4-93 to 31-5-94, a prospective study analysed 1081 stays (one-day-longer) by the medical unit summary and by some variables describing the stay (planned admission, appropriateness), the patient (physical mobility at entrance, severity of disease), the procedures (physiotherapy, social needs). Statistical tests associated univariate analysis, linear and logistic regressions, hierarchic segmentation. RESULTS: DRG's explain 23% of logarithm length of stay. The mathematical model has separated five variables, which are associated with an increase of length of stay (age, number of procedures, physical mobility at entrance, social complexity, intensity of physiotherapy), one associated with a decrease of length of stay (planned admission). CONCLUSION: DRG's, alone, do not describe the dispersion of the length of stay, which is usually used to assess the consumption of resources during an hospitalization. The record of supplementary variables needs further studies, to improve the patients' classification.