[Morbidity/mortality review: usefulness and shortcomings]. / Revue de mortalité et de morbidité (RMM): apports et freins.

GOAL: The Morbidity-Mortality Conference is a formalized exercise validated by the Haute Autorité de Santé (HAS) whose aim is to improve the quality and safety of care through periodic (weekly or monthly) analysis of deaths and complications. In France, no data is available concerning the implementation of the MMC methodology despite the interest of the National Institute of Healthcare Quality (HAS) in using the MMC as part of the physician recredentialling process and of hospital accreditation (mandatory in France since the laws of 2005 and 1997 respectively). We aimed to study the experience and perceptions of physicians with this specific methodology in the context of a large regional project aimed to improve clinical risk management. METHODS: A one page questionnaire with eight confidential questions and a space for free commentary was sent to 150 hospitals in the north of France. RESULTS: We received 83 responses from 29 hospitals (range: 1-14 responses per hospital). Analysis of unexpected adverse events is performed mainly in informal meetings (76%) and mandatory reports (77%); the MMC methodology is rarely used (11%). The analysis of adverse events is considered to be an important tool for the improvement of patient care and safety (90%) and continuing education (61%), and it results in modification of care protocols (70%) or organizational change (71%). Lack of knowledge of the MMC methodology (66%) and lack of available time (50%) are the main obstacles to the adoption of the MMC. Fear that the findings of the MMC could be available for use in litigation (1%) was not an obstacle. Physicians interested in implementing the MMC are motivated by a desire for improved patient safety (86%) and care management on the surgical service (54%). Self-responsibility is more important than the mandatory process for re-credentialing. CONCLUSION: The implementation of the MMC requires specific measures such as teaching and support.

Critical incidents related to invasive mechanical ventilation in the ICU: preliminary descriptive study.

OBJECTIVES: To establish a preliminary list of critical incidents (CIs) associated with mechanical ventilation and to describe a CI reporting method. DESIGN: A list of CIs was established based on a consensus among ICU caregivers. The list was compared to CIs collected prospectively during a predefined study period. SETTING: The clinical observations were conducted in two intensive care units. PATIENTS: All patients receiving mechanical ventilation were included. MEASUREMENTS AND RESULTS: The list of CIs included death and 62 other CI types categorized as immediately life-threatening, secondarily life-threatening, or non-life-threatening. The observational study identified 527 CIs in 137 patients. Virtually all non-life-threatening CIs were ascribed to failure to comply with safety rules or to equipment failure and 40% of life-threatening CIs to the course of the disease or to patient-related factors. The match between CI types on the list and CI types observed in the ICUs was excellent. CONCLUSIONS: Use of our reporting method to create a CI database in a multicenter study including ICUs with varying recruitment patterns may help to identify markers suitable for routine continuous use as part of a quality-assurance program.

[High-dose ifosfamide in patients with stage IV non-small cell lung cancer: phase II trial from the Groupe français de pneumo-cancérologie (GFPC)]. / Ifosfamide à forte dose chez des patients porteurs de cancers bronchiques non à petites cellules de stade IV: essai de phase II du Groupe français de pneumo-cancérologie (GFPC).

PURPOSE: To assess the toxicity and efficacy of high dose ifosfamide in stage IV NSCLC. METHODS: In a previous trial, we have determined maximum tolerated dose for 3-days ifosfamide treatment by 3-weeks schedule as 9 g/m2 according to hematologic tolerance. We therefore set up a phase II to study the toxicity and efficacy of this schedule in chemotherapy naive metastatic NSCLC. Ifosfamide (+ mesna 1 g/m2) was administered by a two hour infusion (3 g/m2) for three days every three weeks. Patients received three mesna bolus infusions (1 g/m2) at 4, 8 and 12 hours after the end of ifosfamide infusion. Antitumoral efficacy was performed after 2 cycles and treatment could be pursued for responding patients until disease progression. From september 1995 to January 1997, 31 patients have been included in this study. Median age was 60.7 years +/- 1.33 (41-70) for 27 males and 4 females. Patients (pts) presented metastases in lung for 10 pts, bone for 10 pts, liver for 6 pts, adrenal for 4 pts and multiorgan metastatic localisation for 1 patient. Seven patients were unassessable: 1 lost for follow-up, 1 sudden death, 5 treatment interruptions before evaluation time and 3 toxic deaths (9.6%). TOXICITY: neutropenia grade 4 (10 pts and 1 death), cardiotoxicity grade 4 (1 pt) and 2 deaths following neurotoxicity grade 4. We achieve 4 partial responses (13%, 95CI: 3.6-29.8), 10 progressive diseases (32.3%, 95CI: 16.7-51.4) and 10 stabilizations (32.3%, 95CI: 16.7-51.4). Median response duration was 91 days +/- 55 d. Median survival was 9.3 months, e.g. 280 days (8-863). Overall survival at one year is 48%. CONCLUSION: This modality of high dose ifosfamide is as effective as standard monotherapy schedules in stage IV NSCLC. Unexpected toxicities particularly hematological ones could be due to a short duration of fractionated treatment. Results in term of survival leads us to further evaluate ifosfamide monotherapy treatment on a 5-day schedule basis.

[Risk management program in a health facility using a project approach: transfusion risk management]. / Un programme de gestion des risques dans l'établissement de santé à travers une démarche par projet: la gestion du risque transfusionnel.

Risk management in the hospital, which is one of the referentiels of the ANAES accreditation manual, may be considered on two levels. Firstly, risk management may be approached globally, in the same way as it is tackled in the accreditation process. Secondly, risk management may be more definite. A specific risk chosen in accordance with the priorities of a particular plan may be dealt with individually. In this respect, the tranfusion process allows the risk management method to be tested and developed. f1

[Coding problems in medical information in the framework of the medicalization of the hospital information system]. / Problèmes posés par le codage de l'information médicale dans le cadre du programme de médicalisation du système d'information hospitalier.

The authors review the difficulties presented by the description of medical data, on the basis of the french experience with the programme to medicalize the hospital information system. They explain the different steps in preparing a hospital discharge abstract, and the difficulties presented by each one. They particularly stress the phase of hierarchization in choosing the principal diagnosis. They propose some solutions to improve data quality and an approach based on medical practice patterns.

[Comparative serum pharmacokinetics of prednisone and prednisolone methylsulfobenzoate after oral administration]. / Pharmacocinétique sérique comparée de la prednisone et du méthylsulfobenzoate de prednisolone après administration orale.

Pharmacokinetic values of prednisone and prednisolone were measured in the serum of 6 healthy volunteers after oral administration of either prednisolone methylsulfobenzoate 30 mg or prednisone 30 mg. Peak serum concentrations of prednisolone obtained after dosing with prednisone occurred earlier and were higher (473 +/- 106 ng/ml) than those obtained after dosing with prednisolone methylsulfobenzoate (232 +/- 70 ng/ml; P less than 0.01). Similarly, areas under the 0-8 h concentration curves were significantly greater after dosing with prednisone than after dosing with prednisolone methylsulfobenzoate (prednisolone: P less than 0.001; prednisone: P less than 0.02). The differences may be due to prednisolone methylsulfobenzoate not being absorbed as well as prednisone. These kinetic data may warrant a reappraisal of the therapeutic equivalence of the two drugs taken for granted in France.

[Etiological diagnosis of syncope and brief loss of consciousness in patients over 65. Results of a multicenter prospective study of 188 cases]. / Diagnostic étiologique des lipothymies et pertes de connaissance brèves après 65 ans. Résultats d'une étude prospective multicentrique de 188 cas.

In a prospective multicentre study a series of 188 patients over 65 years of age admitted for syncope (90) or transient loss of consciousness (98) was collected. There were 120 women and 68 men; mean age was 78.7 +/- 6.6 years; 140 patients had a significant history mainly of arterial hypertension and coronary disease; 81 patients were taking drugs (4.1 on average) and notably diuretics, antihypertensive agents, antiarrhythmic agents, nitrites and psychotropic drugs. The most frequent diagnoses were arrhythmia (20.2 p. 100), postural hypotension (15.4 p. 100), reflex and vasodepressive syncope (12.2 p. 100) and coronary disease (5.3 p. 100). Taken together, these diagnoses could be divided into cardiac diseases (26.5 p. 100), extracardiac diseases (54.2 p. 100), diagnosis unknown (19 p. 100). The condition was iatrogenic in 45 patients (24 p. 100). The means by which the diagnosis was reached were studied: in two-thirds of the cases, careful physical examination and electrocardiography alone provided a diagnosis. Seven patients died during their stay in hospital. Among the 181 survivors 148 (81.7 p. 100) were discharged and returned home.

[1-year prognosis of syncope and brief loss of consciousness in patients over 65. A multicenter study of 188 cases]. / Pronostic à un an des lipothymies et pertes de connaissance brèves après 65 ans. Etude multicentrique de 188 cas.

The one-year outcome of syncope and transient loss of consciousness was studied prospectively in 188 patients aged over 65 admitted to internal medicine departments. Thirty-seven patients (19.6 p. 100) died. This mortality rate at one year was 2.34 times higher than that of a non-hospitalized french population of the same age group (standardized mortality ratio, SMR = 2.34, P less than 0.001). The frequency of sudden death (7 cases) was much higher than that observed in the reference population (0.05 expected deaths, P less than 0.0001). Overmortality was clearly apparent in groups with an initial diagnosis of heart disease (SMR = 2.36, P less than 0.01) or neurological disease (SMR = 4.25, P less than 0.001). The relapse rate was 28 p. 100 globally and up to 43 p. 100 in cardiac patients. In the group with iatrogenic symptoms treatment was appropriately corrected in 86 p. 100 of the patients, and none of these relapsed. One year after the initial episode 11 p. 100 of the surviving patients had been institutionalized.

[Evaluation of an information document about patients and transfusion]. / Evaluation du document d'information des patients sur la transfusion.

OBJECTIVE: To evaluate the understanding of written information contained in the information sheet for patients intended to receive an homologous transfusion and to know their opinion about this document. TYPE OF THE STUDY: A prospective cohort survey carried out by people unrelated to clinical units and transfusion services. METHODS: A document divided in two parts, the first one summarized, the second detailed, was distributed to transfused adult patients. The patients were hospitalized in the general surgery and orthopedic wards of two hospitals and in the hematology and oncology wards of two different hospitals. A questionnaire was filled out in the presence of the inquirer. RESULTS: Sixty one subjects have been enrolled, among them 53 considered the information as adequate; 53 as comforting and neutral. 53 patients considered a written information as essential and 52 estimated that both part of the information sheet (summarized and detailed) were mandatory. Conversely, a more in depth investigation revealed there was a gap between patients statements and their true understanding. CONCLUSION: The value of a written information for the patients is confirmed by the study. In addition, patients were not generally worried by this information. The partition of the document has been appreciated. It is noteworthy that a gap exist between the patient's perception of the information and their actual level of understanding.

[Hospital information systems ineffectiveness in costing ambulatory chemotherapy in pulmonary oncology]. / Insuffisance de la valorisation PMSI de la chimiothérapie ambulatoire en oncologie pulmonaire.

The real cost of medical consumption was compared with the proportion of medication consumption of (the) GHM n(o) 681 (homogeneous group of patients, chemotherapy for cancer in day care) in the French case mix system (PMSI). For those patients in our thoracic oncology unit (Sainte-Marguerite Hospital, Marseille, France), the real medication cost was calculated from prices paid by the hospital, then compared to the expected expenditures for the medication consumption of the GHM 681, i.e. 678 French francs (24.1% of the 225 ISA points (synthetic activity index)). Over a period of 2 months in 1998, 87 patients (mean age 63 +/- 11) had 194 chemotherapy sessions in day care, with multi-drug therapy in 38 cases. Vinorelbine or gemcitabine represented 81% of the single drug chemotherapy. In 84% of the single drug and 76% of the multi-drug chemotherapy, the real cost of medication consumption was above the allocated budget. The mean cost for single drug chemotherapy was 1722 FF and 2920 FF for multi-drug chemotherapy. The budget allocated by the PMSI shows a deficit in the most cases. To avoid a restriction in the use of some drugs, it appears that the French system of budget evaluation needs to be improved.

[Fertility preservation among patients with cancer: report of a French regional practical experience]. / Préservation de la fertilité en oncologie : bilan des pratiques en Région PACA-Corse.

OBJECTIVE: Improvement in cancer treatments has led to reconsider the importance of quality of life after cancer, especially concerning maintening the potential of fertility since it is often altered after healing. Our objective was to estimate the knowledge and practices of the physicians in the field of Oncology in a French Region (Provence Alpes- Côte d'Azur). PATIENTS AND METHOD: Prospective survey, conducted between January and April 2012, amongst oncologists working in Provence Alpes Côte d'Azur region, through questionnaires distributed during multidisciplinary meetings in oncology. RESULTS: Among 225 replies, 54% of the physicians had sent no patient to any oncofertility consultation during the previous six months (n=120). Besides, 33% of the oncologists (n=68) declared they had difficulties in addressing their patients to oncofertility consultation, and 58% of them (n=39) considered they lacked information on techniques and indications of fertility preservation. CONCLUSION: This study provides an estimation of the current practices in PACA region concerning oncofertility and underlines the physicians' need of information. In this context, the regional oncology network has set up a regional network « cancer and fertility ¼ in order to facilitate the access to fertility preservation prior to any potentially sterilizing treatment for all patients.

Familial articular chondrocalcinosis in Quebec.

The existence of articular chondrocalcinosis was documented in 9 members of 3 generations of a Quebec family. No associated or secondary forms of the disease were found. The clinical manifestations appeared early in life, and extensive radiologic involvement was apparent. We determined that genetic transmission was dominant, either autosomal or sex-linked, and not related to the HLA system.