[Codification procedures for medical acts and diagnostic procedures in dermatology and allergology]. / Comment coder les actes et les diagnostics en dermato-allergologie ?

For a number of years, the French health system has utilized an activity-based fee scale (T2A) with remuneration of technical acts based on a coding system (CCAM). In this article, we present the nomenclature of the various clinical and biological acts undertaken in dermatology and allergology.

[Human immunodeficiency virus infection in patients over 60 years of age. A cohort study of 31 patients followed-up at the Regional University Hospital Center of Bordeaux]. / Infection par le virus de l'immunodéficience humaine chez les personnes âgées de plus de 60 ans. Une étude de cohorte de 31 patients suivis au CHRU de Bordeaux. Le Groupe d'Epidémiologie Clinique du SIDA en Aquitaine.

Thirty-one patients aged 60 years or more and infected with the human immunodeficiency virus type 1 (HIV-1) were followed up retrospectively and prospectively at the Regional University Hospital of Bordeaux. These patients represented 2.3 percent of all HIV infected patients followed up by the AIDS Clinical Epidemiology Group of Aquitaine. The male-to-female sex ratio was 1.4/1. Contamination resulted from blood transfusion in 58 percent of the cases. In 45.2 percent of these patients the belated diagnosis was revealed by a pathology pointing to AIDS. The most frequent clinical signs were candidiasis, herpes zoster or neurological manifestations which created a difficult differential diagnosis problem with senile dementia. The prognosis of the HIV infection was severe, with a 39.7 percent probability of survival at 18 months (confidence limits 95 percent: 18.6%, 60.8%). This prognosis could be improved by an earlier diagnosis and by a treatment suitable for elderly people.

[Medico-economic impact of the Program of Medicalization of the Information System on hospital stay for myocardial infarction: influence of the quality of data collection and hospitalization length]. / Impact médico-économique du PMSI sur les séjours pour infarctus du myocarde: influence de la qualité du recueil et de la durée d'hospitalisation.

The aim of the Medicalisation Program of the Information System was to describe the activity of hospital for budget allocation. This work concerned the whole hospitalizations in the unit of intensive care of cardiology of Dijon for a myocardial infarction (MI) during the 1st half of 1998 (59 patients). The objectives of this study were: 1) the estimate of the real cost of MI management; 2) the comparison of this cost with the reference cost, determined from the data of the National Basis of Costs (BNC); 3) the economic impact of the quality of coding. The real global cost of MI was estimated at 2,323,542 FF (average by patient: 39,382 +/- 15,718 FF). Sixty eight per cent of the costs are directly related to the standing fixed overheads; in contrast, the medical and the therapeutic acts accounted for only 32% of the estimated real cost. A 52% over-estimation was highlighted between the estimated real cost and the cost of reference (p < 0.001). The errors of coding accounted for an under-estimation of only 3.6% of the cost of reference. The duration of hospitalization was significantly higher than the stay length taken from the national reference database (12.9 +/- 5.4 versus 9.2 +/- 2.1 days; p < 0.001), and was mainly responsible for these discrepancies of costs.

[Melanoma in organ transplant patients]. / Mélanome chez le transplanté.

OBJECTIVE: The incidence of cutaneous melanoma has rapidly increased in the white population over the last decades. It has been estimated that the incidence doubles world-wide every 10 years. Different risk factors have been identified, including immunosuppression. The aim of our study-was to determine the relative risk of developing melanoma in the organ transplant population and the clinical and histological features of their melanomas. PATIENTS AND METHODS: This retrospective study was conducted with the collaboration of 9 University Hospital Centers: Besançon, Brest, Caen, Dijon, Lille, Lyon, Nantes, Paris (Pitié-Salpétrière) and Rennes. A questionnaire was sent to the different departments of dermatology of these hospitals to obtain information on patients who had presented a melanoma after a transplantation between 1971 and 1997. During this period, there were 12,477 organ transplant recipients in the transplantation units of these 9 hospitals. Average follow-up for these patients was about 5 years and the average duration of immunosuppressive therapy was about 4.5 years. RESULTS: Among 12,477 organ transplant recipients, we found 17 cases of melanoma but no data could be obtain on one case: 14 occurred in renal transplant recipients and 3 in cardiac transplant recipients. Clinical and histological data were only available in 16 patients. The average time between transplantation and diagnosis of melanoma was 63 months, but it was 5 times shorter for 2 patients who had a past history of melanoma before transplantation. Two patients had a mucosal melanoma; for the cutaneous melanomas, 2 appeared on Dubreuilh melanosis, 2 were in situ melanomas, 7 were superficial spreading melanomas and 3 were nodular melanomas. The histological review of 11 cutaneous melanomas revealed a precursor nevus in 6 cases and a weak or no stroma reaction in 7/7 cases. Complete excision of the melanoma was performed in all patients except one with anorectal melanoma. Four patients died of visceral metastasis within a mean 15 months. The other 12 patients are still alive with a mean 3 year course since tumor treatment. We tried to determine the relative risk of developing melanoma in the renal transplant population (14 cases). The number of expected cases of melanoma was 5.54, giving a relative risk of 2.5. DISCUSSION: Only 4 studies have shown an increase in the incidence of melanoma in the renal transplant population: approximately 2 to 5-fold. In our study, the 2.5-fold increase in melanoma was estimated with an average 5 year follow-up and an average 5 year immunosuppressive therapy. This is probably an underestimation of risk because we were unable to make an exhaustive collection of cases of melanomas even though transplant recipients undergo more physical examinations than a reference population. The mean latency period from transplantation to melanoma diagnosis was 63 months, as in other studies. Histological examination showed that a precursor nevus is frequent with weak host cellular response to the tumor. The prognosis of these melanomas remains difficult to predict, but in our study, it would not appear to be as poor as expected. Discontinuation of immunosuppressive therapy would not appear to be necessary except in the presence of metastasis. Finally, our study demonstrates the importance of good patient follow-up, even after graft rejection due to the persistent risk of melanoma.