Improving the mental health system for trauma victims in France.

France has a rich history of exposure to large-scale traumas such as wars, disasters and terrorist attacks, and psychiatric teams specialized in emergency interventions for mass trauma have been created across the territory. However, no public resources are dedicated for long-term interventions or for individual trauma cases. This letter describes how a government supported model of care has been created and implemented in 2019. A national centre for resources and resilience (CN2R) and 10 regional ambulatory services specializing in psychotraumatology were created with the aim of improving public mental health-care delivery while providing a comprehensive suite of services for trauma victims from the most immediate to longer-term considerations.

Chemical & biological therapeutic approaches to neurological disorders.

The Royal Society of Chemistry Biotechnology Group and Chemical Biology Interface Forum held a 1-day symposium, on April 19, 2010, on Chemical and Biological Therapeutic Approaches to Neurological Disorders, at the Royal Society of Chemistry, Burlington House, London. The purpose of the meeting, organized by Colin Bedford, Irene Francois and Klaus Rumpel, was to give an update of new developments regarding the genetics, biochemistry and pathophysiology of the major neurological disorders. These developments should facilitate the discovery of better clinical biomarkers and improved medicines for the diagnosis, monitoring and treatment of patients with neurological disease. The presentations and posters covered neurological disorders including Parkinson's disease, Alzheimer's disease, multiple sclerosis, schizophrenia, autism, epilepsy and pain. The majority of these psychiatric and neurological disorders cause long-term suffering and disability and thus create an important global public health problem. This was the central issue of a participative discussion that took place at the end of the meeting.

[Principles and stakes of external communication of healthcare networks: the case of heathcare networks for health services accessibility]. / Modalités et enjeux de la communication externe des réseaux de santé : l'expérience d'un réseau d'accès aux soins.

Healthcare networks which purpose is to manage patients through better coordination of the care, need to develop a communication strategy to be recognized by the public and by healthcare professionals and to be inserted in the healthcare landscape. We firstly will present legal requirements related to external communication of healthcare networks. Then, we will describe the different tools which can be used to communicate about healthcare networks in its area, with the example from a healthcare network for health services accessibility. In the French Public health code, the legal status and the ethical charter of the healthcare network have to be delivered to the healthcare professionals in its area and to the patients. Moreover, the example healthcare network informed collectively and individually the healthcare professionals of its area about its activities. It made it known to the public by the way of departmental prevention manifestations and health education sessions in community social associations. From these examples, we will conduct an ethical reflection on the modalities and stakes of the external communication of healthcare networks.

Glycomics: From glycobiology to diagnostics and therapeutics.

The Royal Society of Chemistry Biotechnology Group and Chemical Biology Forum held a two-day symposium on December 12-13, 2005, in London. The meeting was designed to give an overview of the exciting new technologies being applied to study complex carbohydrates from their sequence analysis, characterization and function through to the development of novel pharmacological approaches to diagnose and alleviate polysaccharide-mediated diseases. The meeting, which also included a poster session, highlighted the multidisciplinary nature of the research and development and the exciting advances being made in this field.

[Providing medical files to patients: analysis of 52 requests]. / Communication du dossier médical aux patients: analyse de 52 demandes.

BACKGROUND: Since enactment of a statute on 4 March 2002 to allow patients direct access to their medical files, the number of requests for these files has increased substantially. The objective of this survey was to learn the patients' motivations for requesting files, what they did with them once they received them, and the effects of this direct access on the patient and on the relationship and confidentiality between physician and patient. METHODS: A questionnaire was sent to 100 persons randomly selected among patients requesting their medical file from the Dijon University Hospital Center after the new law became effective. RESULTS: The response rate to this survey was 58%. In 75% of the cases, patients requested their own medical files. Their reasons varied: curiosity (38%), transfer of the file to another physician (35%), disagreement with the medical team (12%), death of a family member (10%). After receiving the file, 35% of the respondents read it with a physician and 13% with their attorney. In two thirds of the cases, the medical files were transmitted directly to a third party: physician (51%), attorney (34%), or insurance company (20%). The file provided patients with the information they wanted in 79% of cases and allowed them to sue the physician in 12%. Only a quarter of the persons requesting files met with the physician concerned before making their request. CONCLUSION: The disclosure of secret medical information can lead to serious consequences to patients, of which they are not necessarily aware. This may require that clear information about patient-doctor confidentiality be provided to persons requesting files.

[Evaluation of decision-making by CCPPRBs]. / Evaluation du mécanisme de production des avis donnés par les CCPPRB.

OBJECTIVES: The aim of this study was to analyse the way in which 19 committees for the protection of people participating in biomedical research (CCPPRBs) develop their opinions and to determine whether the legitimacy of the decisions taken is based on detailed discussion by the various members of the committee. METHODS: An independent evaluator visited 19 CCPPRBs and attended two sessions at each centre. He investigated the functioning of the CCPPRBs both theoretically and in practice during the sessions, using a standardised data collection grid. RESULTS: The ethics of discussion are difficult to implement in these committees for four reasons: (i) a lack of training of the members; (ii) comments during sessions are rare (15% of all comments); (iii) too many dossiers are dealt with per session, resulting in some dossiers not being discussed in session; and (iv) there are too few nonscientific members, with the scientific members and the president playing a predominant role in the debates.

Decisions concerning potentially life-sustaining treatments in paediatric nephrology: a multicentre study in French-speaking countries.

BACKGROUND: Few studies have looked at how decisions are made to withhold or to withdraw potentially life-sustaining treatments (LST) in paediatric nephrology. The aim of this work was to evaluate such practices in all nephrology centres in French-speaking European countries, so that guidelines could be discussed and drawn up by professionals. METHODS: We used semi-directed interviews to question health care professionals prospectively. We also retrospectively analysed the medical files of all children (n = 50) for whom a decision to withhold or to withdraw LST had been made in the last 5 years. The doctors (n = 31) who had been involved in the decision-making process were interviewed. RESULTS: All 31 of the French-speaking paediatric nephrology centres in Europe were included in this study. Of these, 18 had made decisions in the previous 5 years about withholding or withdrawing LST. Resultant quality of life, based on long-term living conditions, was the principal criterion used to make the decisions. Relational aspects of life and the child's prognosis were also considered. The decision-making processes were not always collective, even though interactions between doctors and the rest of the medical team seemed to be key elements to them. The parents' involvement in the decision-making process differed between centres. CONCLUSIONS: The criteria used to decide whether to withhold or to withdraw LST are not standardized, and no specific guidelines exist.

Prenatal diagnosis of cerebral malformation with an uncertain prognosis: a study concerning couple's information and consequences on pregnancy.

UNLABELLED: Fetal ultrasound (FU) is used during almost all pregnancies and makes a large contribution to the identification of fetal malformation. It is particularly difficult to announce a malformation, particularly those affecting the brain, because there are often doubts concerning both the diagnosis and the prognosis. AIM: The aim of this study was to analyze how imaging for prenatal screening is organized and how couples are managed and supported. We concentrated on the procedures used to inform couples: content, method of delivery and consequences. METHOD: Study amongst large multidisciplinary centers in Paris and the Paris region, by semi-directed interviews using a questionnaire. RESULTS: We showed that it is difficult to standardize the way in which information is supplied before and after the examination, and that doctors tend to recommend abortion when the prognosis is uncertain. DISCUSSION: These results provide information that will help decision-making concerning a standardized procedure allowing couples to benefit from all the capacities of prenatal screening, particularly when the diagnosis and prognosis are uncertain. There is a need for multidisciplinary teams to support and to accompany the decision concerning whether to have an abortion or to continue the pregnancy.

[Domestic violence: what are the difficulties for practitioners? Analysis of interviews among 19 practitioners within a town-hospital care network aimed at a global approach of patients]. / Violences conjugales, quelles difficultés pour les médecins? Analyse d'entretiens avec 19 médecins d'un réseau de soins ville-hôpital orienté vers la prise en charge globale des personnes.

OBJECTIVE: Using a qualitative approach of medical practice, the aim of this study was to specify the difficulties and pitfalls that practitioners are confronted with regarding persons suffering from domestic violence. METHODS: Nineteen practitioners agreed to participate in an assessment of their attitude towards the recognition and management of domestic violence. These practitioners were aware of the medico-social dimension of their practice. A questionnaire was proposed during an interview conducted in all participants by the same investigator. The interviews were reviewed and analysed by two assessors. In the case of discordance, a second reading was made so that a consensus could be reached. RESULTS: The interview lasted a mean of 40 minutes. The practitioners interviewed (11 men and 8 women) were 29 to 60 years old and had practiced for 6 months to 36 years. They all knew of such violence, notably through its physical impact, but this did not permit them to recognise all the forms of violence. The medico-legal tools at their disposal are not clearly understood and are often not adapted to the demands of their female patients. CONCLUSION: The notion of global management required in such cases must be developed and specified in medical training, because the recognition and management of "battered women" is a question of personal dignity.

[The free delivery of drugs during hospital consultations]. / Activité de délivrance gratuite des médicaments en consultation hospitalière.

INTRODUCTION: In France, the access to treatment has become a priority and a right. Hence, the supply of care has been reorganised in order to improve the management of the health scourges for all the patients, whether they can pay for what they need or not. The free delivery of drugs (FDD) is part of the services offered by the public hospitals for the low income patients or those who do not yet benefit from social security coverage. As such, it is inscribed within the context of the right to treatment and is a corner stone to a new mission of the public hospital services and care networks. METHOD: The polyclinic of the Max Fourestier hospital is one of hospitals in the Paris area that supplies medical and surgical consultations to the population and provides drugs free of charge. From April 1, 1999 to the end of June 2000, all the FDD were studied for all the non-hospitalised outpatients who came to the consultations with a prescription for drugs, which could not be supplied in a pharmacy because of lack of revenues or social security coverage. RESULTS: The diseases encountered in the context of FDD were the same as those of the general population. No specificity was revealed in the prescriptions related to vulnerability. If it were necessary, this would confirm the fact that the management of persons in difficulty should be integrated in the provisions of common rights. The treatments concerned were essential, and for some persons life saving, and justifying the interest of FDD without which the health of these individuals would rapidly decline. Furthermore, this study shows the need for careful management of FDD in order to avoid the anarchical and uncontrolled delivery of several prescriptions, source of deleterious drug interactions and iatrogenia. This is the reason for the recommendation to all the staff delivering free drugs that they systematically ask the patients to meet a referring physician and contact the hospital pharmacist when necessary. COMMENTS: The FDD request is an ideal occasion for a physician to meet the patient and, because of the professional secrecy, to learn more of the patient's life style, and reveal, other than the diseases, the patients risk factors or elements of vulnerability that interact with the general state of health. The access to rights, on the occasion of FDD, is a fundamental public health strategy, since it provides the patient with access to preventive and primary care health measures. This is why we propose that FDD, other than the medical consultation, become systematically coupled with a consultation with a social care worker, to permit the rapid return of the patients to their common rights. CONCLUSION: Free drug delivery should not be conceived as a traditional pharmaceutical delivery, it should be the pretext for the reintegration of persons to their social rights and with a strategy of improved medical care. Organised in this manner, FDD is a precious tool for access to care and prevention, but also to the construction of a social relationship.

[Medical ethics, a counter-weight to the logics of the Perruche decree]. / L'éthique médicale, un contre-poids à la logique de l'arrêt Perruche.

FROM A CONTRACTUAL LOGIC TO A PROBABILISTIC APPROACH: Since 1936, reflections on the relationship between the physician and the patient have progressed within the context of a contractual legal concept. Its contents have been based more on jurisprudence than on the physicians' reflections with regard to their practice. Associated with this contractual logic, some confusion exists between a lesion, a medical concept, and a handicap, which is the social consequence of one's status of health. This has been reinforced by the scientific progress made in medicine, which privileges a probabilistic approach based on scientific data, rather than the uncertainty, inscribed in the dialogue and singularity of the encounter. REGARDING THE PERRUCHE DECREE: We analyzed the reports submitted to the court of cessation regarding the Perruche affair, together with the first chapter of the law concerning the rights of the patients and the quality of health system, by studying the extent to which this decision was inscribed or not in the continuity of past legal decisions, and whether the characteristics described above were present. In this decree, the predominating contractual logic is that the notion of handicap is not analyzed, and the scientific and probabilistic conception of medical practice is involved in the debate. THE NECESSITY FOR REFLECTION: Our discussion insists on the necessity of constructing a reflection on the medical presentation; society cannot accept that this be reduced to the strict respect of the elements of the contract, defined by legal decisions. It should be carefully thought out by health professionals, and in collaboration with human science.