[Difficulties to GPs in determining the medical time of personal incapacity in daily life]. / Difficultés rencontrées par les médecins généralistes sur la détermination de l'incapacité totale de travail.

OBJECTIVE: Identifying the principal difficulties to general physicians in the administrative region of Loire-Atlantique to determining the medical time of personal incapacity in daily life named ITT in French legislation linked to wounds. METHODS: A study was performed by an anonym self-assessment questionnaire including 200 GPs. The study was divided in five sections (doctor's profile, self evaluation of establishing medical description of violence and evaluating ITT, questions about theoretical knowledge of ITT, medical difficulties during the assessment of wounds, and free medical comments). RESULTS: The answer rate was 50,5% of included GPs. 90,4% of medical doctor drafted medical certificate for assault victims. Only 55% of GPs fixed ITT systematically. They were influenced by the importance of assault. They express difficulties about the psychological troubles following assault. These two results were the most medical difficulties during their evaluation. DISCUSSION: The legal consequences of while incapacity is not sufficiency mastered. The psychological troubles resulting of assault is difficult to estimating for a lot of GPs. The medical doctors collect the patient pressure to increase time of personal incapacity in daily life. Lack of academic training and absence of legal ITT references are reproached by GPs. CONCLUSION: Medical certificate of stoppage work is now known as different as the time of personal incapacity for GPs. This way, we think that the evaluation of the ITT has to remain an act of GPs. if difficulties are reported by GPs, the medical testifying will be improved by references and tables which do not exist this day on the subject.

Asylum seekers alleging torture in their countries: Evaluation of a French center.

MATERIALS AND METHODS: Over a 6-year period, 570 survivors gave consent to this study and were examined by forensic medical doctors in academic French hospital. They evaluated with the aim of cataloguing the physical evidence of torture. Sociological data, declared violence (single physical altercation, repeated physical violence less than one year or more than one year, incarceration not more than one week or more than 1 week), and method of violence (blows by blunt object, crushing, burns, electrical shocks, attempted drowning, smothering, incision, or gunshot) were studied. An association between victims' statements and physical evidence of torture was determined. RESULTS: 70% were male with an average age of 31.9 years and ages between 1 and 70 years old. Dagestan, Guinea-Conakry and Guinea-Bissau were the countries most represented among asylum seekers. Beatings were reported by 27.89%, confinement was reported by 40.22%, and repeated violence by 30.16% of refugees. The average time interval between the first assault and forensic evaluation was 53 months. Forms of torture reported included: blunt force trauma (82.51%) truncheon blows (27.50%), arm incision (30%), and burns (16.3%). Statistically, truncheon blows were experienced more often by males in confinement due to political conflict. The use of crushing methods and electrical shocks also were experienced more often by males during confinement. Victims who had received incision wounds were significantly younger. Gunshots were statistically associated with male survivors of political conflict. Men experienced drowning and electrical shocks while in confinement in the Balkans, Asia, and Russia. Electrical shocks were reported by males during confinement and in northern Caucasus countries. The association was significant between assertions of burns and the presence of cutaneous scars (p = 0.0105); similarly, assertions of incision wounds were significantly corroborated by evidence of scars (p = 0.0009). DISCUSSION: Asylum seekers assessed were usually young men. Beatings with blunt objects were the most often reported form of torture used during episodes of repeated violence and during confinement. Assertions of burns were not associated with any particular circumstances. Electrical shocks were reported during confinement and most often in countries of the northern Caucasus. Attempted drowning, smothering, and shocking were noted, but these methods typically do not leave physical evidence. Wounds resulting from burns and incisions usually leave scars that corroborate refugee statements. Torture by crushing and gunshot were reported by asylum seekers for the first time. CONCLUSION: Investigation of the types of torture and circumstances under which torture occurs is critical for efficient forensic evaluation of claims of torture experienced by asylum seekers.

Sarcoidosis diagnosed in elderly subjects: retrospective study of 30 cases.

STUDY OBJECTIVE: This study investigated the clinical features and disease course of sarcoidosis diagnosed in patients > 70 years of age. METHODS: A retrospective analysis was made of cases treated at the University Hospital in Nantes, France, between 1986 and 2000. The diagnosis of sarcoidosis was confirmed histopathologically. Cases involving progressive cancer and active tuberculosis were excluded. RESULTS: Thirty white patients with sarcoidosis diagnosed after age 70 years (mean, 74 years) were included. An alteration of general health (asthenia and/or anorexia and/or weight loss) was frequent (53%) and characteristic of the systemic form of the disease. Dyspnea was a fairly common sign (23%). The intrathoracic form of sarcoidosis was most frequent (43.3%). Diagnosis was difficult and lengthy, and symptomatology was atypical. Accessory salivary gland biopsy was an important contributing factor to diagnosis (70.6% were positive). Oral corticosteroid therapy was often required (60.7%). The disease course was satisfactory overall (81.8% of cases), but only for 50% of patients in intrathoracic stage IV. CONCLUSIONS: The clinical presentation of sarcoidosis in elderly subjects is mainly characterized by an alteration of general health. Diagnosis is difficult and should include accessory salivary gland biopsy. Therapy frequently involves corticosteroids. Overall prognosis is similar to that for young subjects.

Informing patients about serious side effects of drugs. A 2001 survey of 341 French rheumatologists.

OBJECTIVES: In May 2001, we surveyed French rheumatologists to determine how they inform their patients about serious side effects of drugs. RESULTS: Of the 600 rheumatologists invited to participate in the study, 341 completed and returned the questionnaire. Most respondents believed that full information on patients would become the rule (mean, 62.1 +/- 28.3, the items being scored on a 100-point scale where 0 was "not at all" and 100 "absolutely"). The answer to this item varied little across age groups. Respondents felt that patient information fell primarily on the physician, (78 +/- 23), followed by pharmaceutical companies (64 +/- 32) and pharmacists (46 +/- 33). The respondents believed that full information of patients about side effects would primarily benefit physicians (51 +/- 32), followed by pharmaceutical companies (43 +/- 30) and patients (38 +/- 28). The reaction of patients to information on drug-related risks was described as "always favorable" by 2% of the respondents and as "fairly often favorable" by 55%. Among respondents, 9% always gave information on serious side effects, 66% fairly often, and 4% never; 2% always communicated information on the approximate frequency of serious adverse events, 21% fairly often, and 33% never. Similarly, 3% of the respondents always warned their patients of lethal risks, 11% fairly often, and 44% never. When evaluated on a 100-point scale (0, not at all knowledgeable; 100, very knowledgeable), knowledge of serious side effects of drugs for musculoskeletal conditions was 73 +/- 23, whereas knowledge of the frequency of these effects was only 52 +/- 22. Eight percent of the respondents always recommended that patients read the package insert, 27% fairly often, and 32% never. Conversely, the possible adverse effects of not taking the treatment were always specified by 21% of the respondents and fairly often by 88%.

A case of atypical chronic subdural hematoma: a spontaneous rupture of dural lymphoma nodule.

In forensic medicine, a chronic subdural hematoma (SDH) usually results from trauma, sometimes minimal for elderly people. The case reported here is a forensic medical description of an atypical chronic subdural hematoma. A woman aged of 40-year-old died following a coma. The autopsy and histological analyses revealed the hemorrhagic disintegration of a lymphoid nodule, a metastasis from generalized lymphoma. The combination of chronic symptomatic SDH and a tumor of the dura mater have been described, but are very rare. The possibility of trauma, even minimal, has never been excluded in these cases. In fact, the clinical picture of these patients suggested a significant movement of the brain within the cranial cavity due to the physiological decrease in brain volume. In the reported case, this particular process was excluded since the spontaneous hemorrhagic effusion produced by the meningeal lymphoid nodule was the cause of the chronic SDH. This pathophysiological explanation was possible because the entire brain and meninges were removed for histological analysis. Trauma, even minimal trauma, is not always involved in the formation of a chronic SDH.

[Roles and missions of the reliable person at the hospital: Insufficiently known by the patients]. / Rôles et missions de la personne de confiance à l'hôpital : insuffisamment connus par les malades Enquête semi-directive chez 95 patients du CHU de Nantes.

INTRODUCTION: The law of March 4th, 2002 allows the patient hospitalized to appoint a reliable person who can support him, help him and represent him throughout his disease. This possibility must be necessarily proposed by hospitals. The roles and the missions entrusted to this reliable person do not stop becoming more marked since. OBJECTIVE: A study was realized to know if the hospitalized patients knew that is a reliable person and if yes how had they learnt him? The study tried to know who is or would then be appointed and who are or would be and would be the roles and missions which appear to him important? METHOD: By one question semi-directive distributed to the patients hospitalized in units of pointed care, following care and the long-term care of Nantes (France), these estimated the roles and the missions awarded to the reliable person by the legal texts. RESULTS: A meadow of a patient on two does not know who is a reliable person. A direct relative (parent children, spouse and not the regular doctor) is or would be indicated. The reliable person is a help considered very important by the patients. More than 8 patients on 10 estimate him very precious audience in the accompaniment during the hospitalization and in the respect for their last wills more than in the direct support. The patients of more than 65 years old and retired know less well this reliable person. The information delivered to the reliable person has to be the object for the patient of a real partnership with the teams of care. DISCUSSION: The information and the knowledge by the patients and the nursing of the roles and the missions of the reliable person are clearly insufficient. Establishments in other did not take all the measure of this obligation to propose his name. An initial and continuous training nursing on its subject would be necessary. CONCLUSION: The patients grant a big importance for this reliable person and this study shows that the patients would tune him a lot of importance if hospital departments answered their obligations.

Withholding or withdrawing dialysis in the elderly: the perspective of a western region of France.

BACKGROUND: In the US and Canada, dialysis discontinuation is one of the more frequent causes of death in elderly patients on haemodialysis, particularly after the age of 75. The aim of this study was to analyse the practices of some French nephrologists, 17 of whom (in six nephrology units) were interviewed for this study. METHODS: A questionnaire was formulated on the basis of a bibliographical search of the topic. A series of questions, initially open and then more targeted, regarding scientific and non-scientific factors influencing the decision to discontinue or refuse haemodialysis in elderly patients, were put to nephrologists. RESULTS: Psychological and physical deterioration emerged as the principal factors governing decisions to refuse or discontinue treatment. The interviewees felt that severe dementia (15 out of 17 nephrologists), irreversible neurological sequelae of a CVA (11 out of 17) and, paradoxically, patient refusal (10 out of 17) were factors to be taken into account in the decision to discontinue haemodialysis. Although the main reasons for refusing dialysis were cognitive disorders, severe dementia and irreversible neurological conditions, none of these factors where actually found to be in and of themselves decisive. CONCLUSIONS: This study has shown that refusing or discontinuing dialysis are practices accepted by the vast majority of nephrologists in one region of France. Patient refusal is not a basis for denial or discontinuation of dialysis in elderly patients. Our investigation has demonstrated a consensus regarding decisions to refuse or discontinue dialysis.

[Giant cell arteritis after the age of 75]. / Maladie de Horton chez le sujet âgé de plus de 75 ans.

Despite its increasing incidence giant cell arteritis is not well detected in the elderly. Response to corticosteroid treatment is the same before and after the age of 75, but there are many steroid-induced side effects, particularly bone fractures, in the elderly. Therefore, it is important to reduce the corticosteroid load in elderly and frail people. In this cases, 0.3 to 0.5mg/kg, or 15 to 25mg daily prednisone-equivalent dose at start seems to be enough to prevent blindness in simple forms. This dose has to be rapidly reduced whenever the C-reactive protein remains moderately elevated. Moreover, an anti-agregant or anticoagulant treatment must be associated at the beginning of steroid treatment to prevent ischemic complications, as well as biphosphonates, which could prevent corticosteroid-induced osteoporosis.