[Reverse abdominoplasty in the presence of bi-subcostal scar: Technical note]. / Abdominoplastie inversée en présence d'une cicatrice bi-sous-costale : note technique.

INTRODUCTION: The presence of horizontal supraumbilical scars increases the risk of vascular complications after a large abdominoplasty. We present here a technique of abdominal dermolipectomy with umbilical transposition called « reverse ¼, in the presence of a bi-subcostal scar. TECHNICAL NOTE: The reverse abdominoplasty technique consists in uninserting the umbilicus, detaching the supra-umbilical and sub-umbilical soft tissues by assessing the existing bi-subcostal scar in order to pull the skin upwards, and to remove the supra-umbilical excess skin, before bringing the umbilicus back to its proper position. DISCUSSION: This technique is a good alternative to perform an abdominal dermolipectomy in a patient with a history of bi-subcostal scarring without increasing the risk of abdominal skin necrosis, and without complicating or lengthening the conventional surgical procedure, provided that the upper redraping is achievable with sufficient upper excess skin and laxity.

Relevance of intraoperative ultrasound imaging for detecting foreign bodies in the hand: A series of 19 cases.

Radiolucent foreign bodies of the hand are frequent and may lead to pain, infection, hematoma and/or migration. Their diagnosis and removal can be difficult. The goal of this study was to assess the usefulness of intraoperative ultrasound imaging for detecting translucent foreign bodies in the hand to facilitate their removal. Our single-center retrospective study included 19 patients with preoperatively radiolucent but echogenic foreign bodies. An intraoperative ultrasound was performed to assist with and confirm the removal of the foreign body. The foreign bodies were vegetal in 15 cases, made of glass in 2 cases, rock in 1 case and undetermined in 1 case. The average length was 4.65 mm (min 1, max 16) and the average width 1.02 mm. All foreign bodies were visible during the intraoperative ultrasound and were no longer visible after their removal. Because intraoperative ultrasound imaging was able to guide the removal of all radiolucent foreign bodies in our study, it can be a useful tool for the removal of radiolucent foreign bodies.

[Results album]. / L'album des résultats.

This document is meant to be a practical guide for the surgeon, to assist him in informing the patient more easily. Different clinical results with different reconstructive techniques and different morphologies are presented. This document is not meant to be a catalogue, or to guarantee any result to the patient, but truly to assist as best as it can the surgeon and the patient in choosing together the most appropriate techniques on a visual basis.

[Breast reconstruction with temporary tissue expander]. / Reconstruction mammaire par prothèse d'expansion temporaire.

Tissue expansion in breast reconstruction is a technique based on a simple principle but subjected to numerous traps. Its success relies on the patient selection, a good preparation of the skin pocket, no rush during the inflating time, and a specific care during the definitive implant placement inside the skin pocket. This article aims to list and detail point-by-point the different surgical timings, their practical application, the pitfalls and the possible traps to avoid, in order to succeed in breast reconstruction using tissue expander.

How the reimbursement system may influence physicians' decisions results from focus groups interviews in France.

This paper analyzes how physicians' treatment choices are influenced by cost to the patient for four different diseases in France: mild hypertension, hay fever, dyspepsia and hormone replacement therapy (HRT). Five focus groups of physicians were conducted in the fall of 1998. The paper reviews the type of shifts and strategies physicians used to reduce the cost to the patient. In order to maintain access to care for the patients, the most common strategy used is to refer to different types of social structures in the health care system. However, a number of shifts related to drug or treatment choices were also identified such as prescription of older drugs, shifts to drugs having different drug coverage and cheaper drugs within a drug class. In a proportional system of copayment, the price level of the services (drugs or exams) clearly appeared as a determining factor to induce physicians' decision shifts. Overall, we also found that French physicians put higher priorities on the cost to society than on the cost to the patient in their treatment decisions.

The cost of prescription medicines to patients.

The study compares the cost-sharing (co-payment) arrangements for prescribed medicines in a sample of EU countries. Through a set of typical prescription scenarios, the cost burden to individual patients of prescriptions are examined, in the context of drug price, and from the perspective of therapeutic need. The cost to patients of medicines is consistently lower in some, and higher in other, countries, regardless of the type of prescription charge system. Fixed charge systems, as opposed to graduated co-payment systems, are obviously more likely to lead to similar charges for the treatment of comparable clinical conditions, but depending on the level of the charge, can result in the patient paying a higher charge than the price of the drug to the health organisation. Exemption from charges for prescription medicines, commonly relate to clinical condition and level of income. Some systems also have age-related criteria and apply ceilings to the total prescription cost burden borne by the patient. The impact on patient costs of specific policy formulations is discussed and a proposal is made for cost convergence for comparable therapies. The method used in this study may also provide a route for investigating model systems prior to implementation.

The use of clinical guidelines to improve medical practice: main issues in the United States.

The use of clinical guidelines has become a key issue in the US health care system. In contrast to European systems, where such initiatives usually are controlled by one administrative agency, in the US there is a pluralistic approach and many kinds of guidelines coexist, initiated by health professions, managed care organizations, state or federal agencies, hospitals, and insurers. This paper reviews the main trends, indicating that guidelines will play an increasingly prominent role: use of institution-based guidelines vs national, professional, or state-based guidelines; use of more decision-support systems made possible by computerization and changes in cost containment strategies. Combining quality of care objectives with the business objectives of institutions increases the likelihood of a wider adoption by physicians. Several issues, such as the legal implications or the conflict of objectives, illustrate limits in the use of such standards to judge individual cases; however, most recent developments tend to reconcile individual decisions and what is known from probabilities on representative samples. By bringing such information into the decision process between physician and patient, the use of guidelines challenges the traditional asymmetry of information between professionals and patients. In a context of increasing health care costs, clinical guidelines represent a very useful tool for debating rationing issues and standard benefit packages, in order to make the system more equitable. Evaluations of the effectiveness of clinical guidelines on performance are contradictory, but when rigorous evaluations exist, clinical guidelines are found to be effective. The amount of improvement, however, may vary considerably.

A critical review of the remuneration systems for pharmacists.

This paper provides a critical review of different systems of remunerations of pharmacists which exist in various countries: the percentage mark-up, the graduated mark-up, the capitation system, the fee for service system and mixed system. In these different systems, we refer to the various ways the provisions of pharmaceutical services are paid and reimbursed rather than how persons who physically deliver the services are paid. Therefore, the differences among various types of remuneration may not impact directly the level of responsibility and motivations of the various employees or owners in contact with the patient. The dispensing service remains the essential service of the pharmacist in all systems. However, according to the types of remuneration, the revenue of the pharmacist can be more or less linked to the volume and the price of drugs. Capitation systems, professional allowance and fees in particular can be used to shift the objective of the pharmacist towards increased professionalism. In each system, policy makers, when they can negotiate with the whole national profession, can use the remuneration system to achieve public policy objectives such as cost containment, better drug use, or provisions of large packages of services. This paper discusses to what extent each system can contribute to such objectives. In order to achieve public policy objectives, it may be time to shift the valuation of pharmaceutical services towards more safe and effective therapy instead of safe and effective drugs.

The Chinese medicines market: moving towards a market system?

This paper presents a review of the Chinese pharmaceutical policy in order to analyse the forms of effective market competition introduced or not in the system. Registration, pricing and trade are three areas showing the limits on competition. The government limits the duration of the registration procedure to three years, which leaves some opportunities for challengers to market similar products afterwards. The pricing system in place is a maximum price ceiling. The price structure reveals a net difference of treatment between foreign products and domestic products. With respect to trading policy, the government applies a selective licensing policy for exports and imposes variable custom taxes on a product-by-product basis on imports. At a micro level, the Chinese market has instant market conditions with fair trade where manufacturers, importers and distributors can meet. Different cost-sharing experiments between the state, the working units and the patients also introduce more sensitivity to prices from the consumer. Such a duality between the limits imposed on competition by public policy tools and the experiments or market conditions in place at the level of the organisations underlines the ambiguity of the move towards a market economy in the Chinese pharmaceutical market.

The use of prescription charges.

This paper makes a contribution concerning the effectiveness of the direct payment for drugs by the patient through a review of the most important empirical US and UK contributions. It confirms that the demand for prescription drugs, and even the demand for OTC to a lesser extent, is reduced by a direct contribution from the patient. The price elasticities which measure the scope of the decrease of drug consumption, range however at low levels from -0.1/or -0.2 to -0.6 [1]. In order to be able to draw some policy conclusions from these studies, the health analyst will also want to have clinical or quality assessments of the changes of consumption or the health conditions of the patient. Some of the works reviewed offer some preliminary answers, but on a limited share of the population (the Medicaid population in the USA). Applied to some non-essential medications, however, this type of work highlights the phenomena of substitution between drugs, lack of change in overall drug use and uncertain changes in the quality of prescribing. This review paper will allow the policy makers to discuss some areas of change for various types of direct payments of the patient, and the use of unique versus selective schemes.

HLA-and Gm-linked genes affecting the degradation rate of antigens (sheep red blood cells) endocytized by macrophages.

Phagocytosis and catabolism of sheep red blood cells by human peripheral blood phagocytes were studied in 100 normal caucasoid subjects (44 males and 56 females). Both phenomena are highly reproducible, and their indices seem to be biological constants. There is no correlation between these two indices and the indices do not have a correlation with ABO or Rh markers. Further, the phagocytic index has no correlation with HLA and GM markers. However, a low speed of degradation is significantly correlated (p = 0.001) with the HLA-DR3 antigen, and most of the low degraders are significantly correlated (p = 0.006) with both DR3 and Gm 3,23,11 (probably Gm homozygous). Thus the gradient of antigen degradation could be related to an interaction between MHC and Gm immunoglobulin genes, as is found in the mouse [Biozzi's high (H) and low (L) responder strains.