[Patient education in psychiatry: Representations of caregivers, patients and their families]. / Éducation thérapeutique en psychiatrie : représentations des soignants, des patients et des familles.

INTRODUCTION: Why do caregivers working in psychiatry seem to wonder about their practices, in front of the recent mediatisation of patient education in France? Do our educational practices meet the needs and the expectations of patients and their families? These questions led us to carry out this qualitative and prospective study concerning the representations of patient education of the main actors in psychiatry. OBJECTIVE: This work aims to assess the representations of patient education of the main actors in psychiatry, in particular to assess convergences and divergences. METHODS: This is a qualitative and prospective study. Qualitative data are speeches from caregivers working in psychiatry, patients suffering from a psychiatric pathology and their families. The three populations studied were defined by precise characteristics. The sample was diversified by a variable related to the study theme: experience or not in patient education. Speeches were collected during interviews, which were carried out by the same person. Interviews were semi-structured by a thematic guide, which defined the themes to be explored. The three main themes are: the concept of patient education, the objectives of patient education, and the caregiver/patient relationship. We analysed the content of the speeches with a lexical reference table that we elaborated from the literature of experts in patient education. We also realised a transverse analysis in order to assess convergences and divergences between the different speeches. RESULTS: Thirty-two interviews were realised with fifteen caregivers (six psychiatrists and nine nurses), ten patients and seven families. In the speeches of the different populations, we found the expected element of language for all the themes explored. Unexpected ideas were also found in the speeches of the various groups. We could find convergences and divergences concerning these unexpected ideas between and within each group. Regarding convergences, all the groups mentioned the unexpected idea of the problem of social representations of psychiatric diseases. The three groups also approached the need to develop the work with families. Patients and families entrusted their feeling that there would be a lack of exchange with some caregivers. Patients and caregivers evoked the paternalistic attitude of some caregivers. Finally, both caregivers and family approached their questions regarding the caregiver/patient relationship during care without the patient's consent. We found several divergences in the caregivers' speeches. These divergences seemed to be correlated with the experience in patient education in psychiatry. They concerned the scope of patient education in psychiatry, the differences perceived between patient education in psychiatry or in somatic cares, and the diagnostic announcement to the patient. This last unexpected idea was the main point of divergence between caregivers and patients. DISCUSSION: Results of this study showed that the representations of caregivers, patients and their families correlate with the experts' ideas regarding patient education. The analysis of the different speeches highlighted several unexpected ideas, which constitute themes of reflection about patient education. Some of these themes concern in particular the medical domain of psychiatry such as the questions about caregiver/patient relationship during care without the patient's consent and restraint. Another theme of psychiatry specific reflection is the differences perceived by some caregivers between their practices and the patient education in somatic care. Others themes of reflection highlighted all the medical specialities: the need to develop the work with families, the problem of the social representations of diseases, the scopes of patient education and the diagnostic announcement to the patient. CONCLUSION: This study highlighted several themes of reflection about patient education in psychiatry. We should include this theme of reflection in our practices in order to respond more precisely to the needs and the expectations of the patients and their families.

Diagnosis and treatment of spontaneous group A streptococcal peritonitis.

BACKGROUND: Primary group A streptococcal peritonitis (PSAP) is a rare, fulminant and often fatal infection. The clinical manifestations include diffuse peritoneal signs with toxic shock syndrome and sometimes fasciitis. METHODS: Patients with PSAP diagnosed between December 2002 and December 2006 were studied retrospectively, focusing on the initial presentation, diagnosis, treatment and outcome. RESULTS: Six patients were identified (five women and one man). The clinical presentation was heterogeneous. All six patients had diffuse peritonitis, four had toxic shock syndrome on hospital admission and two patients also had fasciitis. All patients were treated surgically, and the final diagnosis was confirmed after operation. There were no deaths, but two patients had aesthetic sequelae owing to necrotizing fasciitis. CONCLUSION: PSAP is a rare condition, often requiring aggressive surgical treatment. Group A streptococcal peritonitis should be suspected in patients with no radiological evidence of a peritoneal portal of entry and no history of ascites.

Pain as the only consistent sign of acute appendicitis: lack of inflammatory signs does not exclude the diagnosis.

BACKGROUND: The clinical diagnosis of acute appendicitis in adults remains tricky, but radiological examinations are very helpful to determine the diagnosis even when the adult patient presents atypically. This study was designed to quantify the proportion of patients with a preoperative diagnosis of acute appendicitis that had isolated right lower quadrant pain without biological inflammatory signs and then to determine which imaging examination led to the determination of the diagnosis. METHODS: In this monocentric study based on retrospectively collected data, we analyzed a series of 326 patients with a preoperative diagnosis of acute appendicitis and isolated those who were afebrile and had isolated right lower quadrant pain and normal white blood cell counts and C-reactive protein levels. We determined whether the systematic ultrasonography examination was informative enough or a complementary intravenous contrast media computed tomography scan was necessary to determine the diagnosis, and whether the final pathological diagnosis fit the preoperative one. RESULTS: A total of 15.6% of the patients with a preoperative diagnosis of acute appendicitis had isolated rebound tenderness in the right lower quadrant, i.e., they were afebrile and their white blood cell counts and C-reactive protein levels were normal. In 96.1% of the cases, the ultrasonography examination, sometimes complemented by an intravenous contrasted computed tomography scan if the ultrasonography result was equivocal, fit the histopathological diagnosis of acute appendicitis. CONCLUSIONS: The diagnosis of acute appendicitis cannot be excluded when an adult patient presents with isolated rebound tenderness in the right lower quadrant even without fever and biological inflammatory signs. In our study, ultrasonography and computed tomography were very helpful when making the final diagnosis.

Elytrocele with and without a history of hysterectomy (303 defecography studies).

OBJECTIVE: To search for clinical risk factors and symptoms of elytrocele in female patients without hysterectomy. PATIENTS AND METHODS: Of 1060 women who underwent defecography, radiographic evidence of elytrocele was observed in 303. History-taking was standardized, and included obstetric, surgical and medical history as well as clinical symptoms and their duration. Group A comprised 192 women with hysterectomy while group B included 111 women with no history of hysterectomy; these two groups were compared. Group B was also compared with patients who had neither elytrocele nor hysterectomy (group C; n=516). RESULTS: Women in group B (no hysterectomy) were younger than those in group A (with hysterectomy) (57.9 years versus 62.8 years; p<0.05). Patients in group B had fewer obstetric (87.4% versus 97.9%; p=0.01) and abdominal (64.9 versus 82.3%; p=0.01) surgical events than those in group A, but more urinary tract surgery (18.9% versus 10.9%) and higher infant birth weights than patients in control group C. Six women (2%) had no surgical or obstetric history: mean age 42.7 years (20.6-74 years). Group B used protection against urinary soiling less often (17.3% versus 29.07%; p=0.017), but had more fecal soiling (23.4% versus 13.6%; p=0.033). Defecography showed that women in group B had more external rectal prolapse (17.7% versus 4.9%; p=0.003) and cystocele (48.6% versus 34.9%; p=0.019) than those in group A. CONCLUSIONS: This study was unable to identify risk factors of elytrocele in patients without hysterectomy except for a history of urinary tract surgery and higher infant birth weights. In some women, the elytrocele may be the result of significant rectal prolapse as part of a major pelvic floor disorder, predominantly in the posterior pelvis. Constitutional or congenital causes could also be involved as several young women free of any surgical or obstetric history nevertheless presented with an elytrocele.

[Gas gangrene of the abdominal wall due to underlying GI pathology: seven cases]. / Gangrène gazeuse extensive révélant une pathologie digestive: 7 observations.

OBJECTIVE: Gas gangrene of the abdominal wall is a rare clinical occurrence with high rates of morbidity and mortality. The primary source of the infection is often unknown. To analyze the primary underlying intestinal etiologies and diagnostic approaches of gas gangrene of the abdominal wall, and to highlight specific treatment problems, particularly that of constructing a colostomy exteriorized through a massively infected abdominal wall. PATIENTS AND METHODS: Seven cases of abdominal wall gas gangrene due to a gastrointestinal etiology were identified. (Cases arising from proctologic sources or related to recent abdominal surgery were excluded.) During the same period, 39 other patients presenting with abdominal wall gangrene from non-intestinal sources were treated. RESULTS: The etiologies were: perforated sigmoid diverticulitis (n=2), perforated appendicitis (n=1), acute pancreatitis with associated cecal perforation (n=1), and perforated colorectal cancer (n=3). Four of the seven patients died despite treatment (mortality of 57%). CONCLUSION: The clinical presentations of these seven cases demonstrate that a GI source must be suspected whenever a patient presents with abdominal wall gas gangrene, even when there are no specific GI symptoms. Imaging, particularly with CT scan, is essential both to visualize the extent of tissue necrosis and to reveal underlying primary GI pathology. This optimizes the surgical approach both by allowing for complete debridement and drainage of infected tissue, and by focussing the intervention on correction of the underlying primary GI source of infection.

Bat rabies surveillance in France, from 1989 through May 2005.

In France, the passive surveillance of lyssaviruses in bats started in 1989, with the first positive case found in the East of the country. In 2000, the French bat rabies surveillance network in France was improved on the basis of the one used for the surveillance of fox rabies. The objectives of this network are to improve bat rabies surveillance by increasing the number of specimens and to provide an estimation of rabies incidence in bat populations across the country. The surveillance network is principally constituted by the network of local Veterinary Services and by the National Bat Conservationists Network (French Society for the Study and Protection of Mammals). From 1989 to through 2004, 21 autochtonous rabies cases were diagnosed out of the 934 French bat cadavers found. The laboratory techniques used for diagnosis, recommended by WHO and OIE, were fluorescent antibody test (FAT), rabies tissue culture infection test (RTCIT) on murine neuroblastoma cells, and the mouse inoculation test (MIT). All 21 cases were diagnosed in serotine bats (Eptesicus serotinus) and were due to European bat lyssavirus type 1 (EBLV-1), genotype 5, infection.

In vitro susceptibility testing of Candida and Aspergillus spp. to voriconazole and other antifungal agents using Etest: results of a French multicentre study.

Minimum inhibitory concentrations (MICs) of the antifungal agent voriconazole were determined using the Etest and compared with those of amphotericin B, itraconazole and fluconazole using 1986 clinical isolates of Candida spp. Voriconazole MICs were also compared with those of amphotericin B and itraconazole using 391 clinical isolates of Aspergillus spp. Voriconazole was found to have more potent activity and lower MIC values than amphotericin B, itraconazole and fluconazole against C. albicans, C. tropicalis, C. parapsilosis and C. kefyr. Against C. glabrata and C. krusei, voriconazole was more active than either of the other two azole antifungals but had similar activity to amphotericin B. For species of Aspergillus, MIC values of voriconazole were lower than those of amphotericin B and itraconazole against A. fumigatus and A. flavus, and were similar to those of amphotericin B against A. niger. Against A. terreus, MIC values for voriconazole and itraconazole were similar. A. terreus is known to be resistant to amphotericin B, and this was reflected in higher MIC values compared with those of voriconazole and itraconazole. Voriconazole therefore compares very favourably with other antifungal agents against a large number of clinical isolates of Candida and Aspergillus spp.

Persistence assessment of cyclohexyl- and norbornyl-derived ketones and their degradation products in different OECD screening tests.

The persistence of synthetic cyclohexyl- and norbornyl-derived ketones was assessed by using OECD 301F and 301D biodegradation tests. While cyclohexyl-derived ketones either reached or came close to the pass level (60%) after 60 d, the corresponding norbornyl derivatives yielded significantly less biodegradation (<40%). By analyzing extracts at 60 d, the key degradation products of four norbornyl derivatives were identified. Consistently, 2-bicyclo[2.2.1]heptane carboxylic acid was found as a principal degradation product with minor quantities of bicyclo[2.2.1]heptan-2-one and 2-bicyclo[2.2.1]heptane acetic acid. When the three degradation products were re-synthesized and tested individually for biodegradability, the former two were found to be ultimately biodegradable after 60 d in OECD 301D tests, thus proving non-persistence. Similarly, 2-bicyclo[2.2.1]heptane acetic acid was found to be degraded significantly, albeit with long lag phases exceeding 60 d in the case of freshwater inoculum, then ultimately reaching the pass level. On the other hand, norbornyl ketones were still only partially biodegradable in the same test. We conclude that despite the potential for ultimate biodegradation of norbornyl-derived ketones, current screening tests yield an incomplete picture of their biodegradability, particularly when applying strict OECD criteria. The appearance of long lag phases when re-testing norbornyl ketone degradation products underlines the importance of extending tests to well beyond 28 and even 60 d in the case of freshwater inocula.

Medication errors at the administration stage in an intensive care unit.

OBJECTIVE: To assess the type, frequency and potential clinical significance of medication-administration errors. DESIGN: Prospective study using the observation technique as described by the American Society of HealthSystem Pharmacists but eliminating the disguised aspect. SETTING: Medical intensive care unit (ICU) in a university hospital. PATIENTS AND PARTICIPANTS: 2009 medication administration interventions by nurses. INTERVENTIONS: Pharmacist-performed observation of preparation and administration of medication by nurses, comparison with the original medical order and comparison with the data available in the literature. MEASUREMENTS AND RESULTS: 132 (6.6% of 2009 observed events) errors were detected. Their distribution is as follows: 41 dose errors, 29 wrong rate, 24 wrong preparation technique, 19 physicochemical incompatibility, 10 wrong administration technique and 9 wrong time errors. No fatal errors were observed, but 26 of 132 errors were potentially life-threatening and 55 potentially significant. CONCLUSION: According to this first observation-based study of medication administration errors in a European ICU, these errors were due to deficiencies in the overall organisation of the hospital medication track, in patient follow-up and in staff training.

Cost-effectiveness of urinary dipsticks to screen asymptomatic catheter-associated urinary infections in an intensive care unit.

OBJECTIVE: To assess the cost-effectiveness of urinary dipsticks (UDs) to screen asymptomatic catheterized patients for quantitative urine. DESIGN: Prospective comparison of UD with quantitative urine culture (QUC) (reference technique) and cost-effectiveness analysis performed from the hospital's perspective. SETTING: Medical intensive care unit (ICU) of the Besançon University Hospital (France). PATIENTS AND PARTICIPANTS: All consecutive, asymptomatic, catheterized patients. INTERVENTIONS: Urinary dipsticks (Multistix 8-SG) were analyzed by the reflectance spectrophotometric method (Clinitek 50). Sensitivity (Se), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) of four combinations of the leukocyte (L) test pad and the nitrite (N) test pad were calculated: L and N, L or N, L alone and N alone. A micro-costing technique was used to determine the direct medical cost of each strategy. The calculated cost-effectiveness ratio was the incremental cost-effectiveness (ICE) ratio. MEASUREMENTS AND RESULTS: Three hundred thirty-nine urine samples taken from 144 patients were analyzed. The incidence of asymptomatic catheter-associated urinary tract infections (CAUTIs) was 31.3% (> or =10(5) organisms/ml). The L or N combination was the best detector of asymptomatic CAUTI: Se=87.2%, Sp=61.6%, PPV=30.6% and NPV=96.1%. The cost of QUC strategy and UD strategy was EUR 21.5 and EUR 12.6 per test, respectively. The ICE ratio of QUCs was EUR 69.5 per case of detected CAUTI. CONCLUSION: The UD is a cost-effective test for screening asymptomatic catheterized patients for quantitative urine culture in a medical ICU.

Advantages of using a bank of allogenic keratinocytes for the rapid coverage of extensive and deep second-degree burns.

In 1975, serial subculture of human keratinocytes was first described. Clinical application of this discovery was made possible after the preparation of these cells into epithelial sheets. In 1981, the earliest application of cultured autologous epithelia was made for the treatment of extensive third-degree burns. Although the most important advantage is the large surface area obtained from a relatively small biopsy of healthy skin from the patient, a disadvantage is the delay, which is too long, especially for the treatment of extensive deep burns. This delay leads to denutrition and infection of the burn wounds, which in turn risks the life of the patient and jeopardizes the engraftment of the cultures. More recently, allogenic cultured epidermis, obtained more quickly from donor skin, has been described in the treatment of leg ulcers, repair of skin donor site harvested for split thickness autograft, dermatological diseases and in second-degree burns, although limited to certain areas. In this last case, grafted cells act by stimulation of epithelialisation from the adnexal appendages. To be able rapidly to treat patients suffering extensive and deep second-degree burns, a bank of allogenic keratinocytes has been created, with due attention to safety and security. The paper demonstrates the advantages of using allogenic keratinocytes in the first phase of treatment of a 97% deep second-degree burn patient awaiting autologous cultured keratinocytes. The time required for complete healing achieved using such a strategy is compared with the results obtained after treatment using autologous sheets of two patients burnt on 80% and 82% of their total body area. The treatment of these two latter patients is relatively long and complicated by potentially lethal problems. In the 97% burnt patient, however, the clinical course is shorter and without complication. Moreover, autologous and allogenic cultured epithelia give good aesthetic results, without the mesh aspect obtained with a split-thickness autograft, and also without the discomfort for the patient of removing a sample of skin. Deep second-degree burns are an application of choice for the cultured epithelia, as the presence of the dermis avoids retractions responsible for functional complications usually observed in third-degree burns where dermis is absent. Because of the safety of the bank of allogenic keratinocytes, the treatment of extensive and deep second-degree burns has become safer and faster, with better functional and aesthetic results.

Widely meshed autograft associated with cultured autologous epithelium for the treatment of major burns in children: report of 12 cases.

This is a retrospective study of the combination of widely meshed autograft and autologous cultured keratinocytes. We used this method faced with the lack of allogenic skin, as an alternate to the Cuono method. Twelve children suffering extensive burn injury (deep burns of 60%+/-16 of the total body surface) underwent this grafting procedure. The surgical treatment consisted of an early surgical excision, with an immediate coverage by autografts as much as possible. When cultured epithelium was available, a large mesh autograft was applied and covered with cultured epidermis sheets during the same operative procedure. The rate of take was of 84% (+/- 12). No secondary graft loss was observed. This means of coverage appeared reliable and resistant. On average, this method allowed the epidermization of 30% (+/-9) of the total body surface of the children. The average hospital stay of the children was 64+/-20 days. All the children recovered to lead a normal life. The school delay after rehabilitation is one year. This technique is an alternative to Cuono's method when allografts are missing. The combination of autograft and autologous cultured epidermis sheets appeared more effective than one of these techniques applied alone, as if the suggested coupling induced a synergy.

Genetic analysis of European bat lyssavirus type 1 isolates from France.

European bat lyssavirus type 1a (EBLV-1a) was first identified in central France from a serotine bat (Eptesicus serotinus) collected at the end of 2002. Rabies was diagnosed by reference rabies diagnosis methods and molecular tools. Phylogenetic analysis of 14 viral isolates obtained from French bats infected with EBLV-1 between 1989 and the end of 2002 against 47 nucleoprotein sequences showed a north-west to east distribution of EBLV-1a virus and a south to north distribution of EBLV-1b virus, isolates of which could be divided into two groups: group 1 in north-eastern France and group 2 in central and north-western France.

[Multiple sclerosis: cost of the illness]. / Sclérose en plaques: coût de la maladie.

Economic assessments for multiple sclerosis (MS) first appeared in the nineties. Drug costs were initially marginal before the recent introduction of interferon-beta. To evaluate the burden of MS, economic studies were carried out in addition to specific cost-of-illness studies. Like other chronic illnesses, MS patients can have mild to moderate or severe disabilities. This led to the need for indirect cost analysis. We interrogated the Medline database from 1985 to 2001 to select cost-of-illness studies. We present our findings here by type of methodology used, health care system and level of disability. We found that indirect costs are related to patient age at symptom onset (20-40 years). In most counties, excepting the United Kingdom, hospital costs dominate direct costs. Finally, MS costs are related to the stage of the disease.

[Triple association: extramembranous glomerulonephritis, renal adenocarcinoma and splenic hamartoma. Apropos of a case]. / Triple association: glomérulonéphrite extramembraneuse, adénocarcinome rénal et hamartome splénique. A propos d'un cas.

We report the case of a 36 year old woman who presented a renal cell carcinoma, associated to a membranous nephropathy as a paraneoplastic syndrome. The concomitant association with a splenic hamartoma was probably fortuitous. Five years after nephrectomy, the patient was asymptomatic and her proteinuria was very low. We studied in the literature 93 cases which reported a such association between cancer, nephrotic syndrome and membranous nephropathy. Carcinoma of the lung and adenocarcinoma of the gastrointestinal tract are the most frequently implicated. This association can occur at every age and more often in men (75%) than in women. The survival is directly linked to the evolution of the cancer. Proteinuria and membranous nephropathy can totally disappear after surgical resection of the carcinoma. The glomerular injury is mediated by immune complexes composed at least in part of tumour associated antigens. The development of several types of glomerular injury in patients with carcinoma have been described but membranous glomerulonephritis is the most commonly observed.

[Pancreatic pseudotumor caused by isolated tuberculous retro-duodenopancreatic adenopathy. Apropos of a case]. / Pseudotumeur pancréatique par adénopathie tuberculeuse rétro-duodéno-pancréatique isolée. A propos d'un cas.

The authors report the case of 32 year old woman with tuberculous lymph nodes of the common bile duct which simulated a tumor of the head of the pancreas. Despite modern radiological investigation (US, CT scan, IRM, US with aspiration biopsy), laparotomy was necessary to establish the diagnosis and to perform simple drainage.

[Diverticulosis and Crohn's disease of the sigmoid]. / Diverticulose et maladie de Crohn sigmoïdienne.

Crohn's disease and diverticulitis of the sigmoid may be combined in old patients, this association could lead to difficulties in diagnosis and treatment. Three cases of Crohn's colitis associated with diverticula, two females and one male, aged between 66 and 80 years are reported by the authors. In a review of the literature, some clinical, radiological and endoscopic findings may suggest the diagnosis, which guides subsequent treatment. A high morbidity is observed after surgery. In our series, sigmoidectomy cured both Crohn's colitis and diverticulitis.

[Acute obstruction of the esophagus by mucilage followed by perforation. Apropos of a case]. / Obstruction aiguë de l'oesophage par mucilage suivie de perforation. A propos d'un cas.

The authors report an iatrogenic case of lower esophageal perforation which occurred after a Heimlich procedure performed for a acute drug-induced oesophageal obstruction (mucilage). Esophageal repair, drainage and Nissen procedure to prevent gastro-esophageal reflux were successfully performed via an abdominal approach.

[Three-luminal nasojejunal tube in digestive surgery: preliminary feasibility study]. / Sonde nasojéjunale triple lumière en chirurgie digestive: étude préliminaire de faisabilité.

STUDY AIM: The benefit of enteral nutrition is an established fact for severely burned or multiple injured patients with a reduction of septic morbidity. Enteral nutrition is now possible in upper gastrointestinal tract surgery with the development of nasojejunal triple lumen tube and we report a new application with an operative placement. The aim of the study was to evaluate the nasojejunal triple lumen tube in digestive surgery. MATERIAL AND METHODS: From November 1999 to August 2001, a nasojejunal triple lumen tube was placed during surgery for high surgical risk patients (n = 17) or under radioscopic control for the treatment of post operative complications (n = 6). RESULTS: The surgical placement was possible in all cases. The radioscopic placement failed in two cases, one of which being solved with endoscopic procedure. There was no morbidity during the tube placement. Four patients were excluded because of early post operative death (n = 3) or premature removal of the tube by the patient (n = 1). The enteral nutrition was early in 18 patients and its mean duration was 18.2 days (range 3-75). Technical problems occurred in 9 patients and the replacement of the tube was necessary in 8 cases. CONCLUSION: The nasojejunal triple lumen tube is a feasible, safe and relatively well-tolerated procedure in upper gastrointestinal tract surgery.

[Hepatic portal venous gas]. / L'aéroportie.

STUDY OBJECTIVE: Hepatic portal venous gas is a radiological symptom associated with a poor prognosis (75% to 90% mortality). The aim of this retrospective study was to report 7 cases observed over a 2-year period. PATIENTS AND METHOD: From June 1997 to November 1999, hepatic portal venous gas was diagnosed in 6 patients by CT scan and in one patient by echosonography. It was not detected in any case by plain abdominal X-rays. Three patients had small bowel obstruction with necrosis, three had extensive superior mesenteric infarction and one had preperforative necrosis of the colon. RESULTS: One patient with extensive intestinal infarction and a metastatic head and neck cancer was not operated. Two patients were operated, but the extensive mesenteric infarction was not amenable to surgical management. Three of the 7 patients died, while the other four patients survived after resection of the necrotic small intestine (n = 3) and left colectomy extended to the transverse colon (n = 1). CONCLUSION: Hepatic portal venous gas was associated with intestinal necrosis in the seven cases of this series. The severity of portal venous gas is only correlated with the severity of the disease causing portal venous gas.