[Assessment of tele-expertise among elderly subjects in retirement homes]. / Une expérience de télé-expertise en établissement d'hébergement de personnes âgées dépendantes (EHPAD).

BACKGROUND: Chronic wounds (leg ulcers, pressure ulcers, diabetic foot ulcers, etc.) constitute a real public health problem and engender high economic and human costs. Due to the declining physical and mental conditions of our elderly subjects and their rural environment, we created a computer program to assist with chronic wound management in elderly subjects living in retirement homes and to reduce the amount of ambulance transportation. MATERIALS AND METHODS: Each participating establishment was provided with a digital camera and its own secure e-mail address in order to allow photographs to be sent anonymously. Patients with chronic wounds entailing treatment difficulties were included. Details were recorded of the number of tele-expertise consultations given, the chronic wound type, the number of hospitalizations or medical consultations, and the number of ambulance trips avoided. The project was evaluated at 1 year. RESULTS: Of the 40 establishments invited to take part, 22 agreed to do so but only the first 10 respondents were accepted for participation in the pilot feasibility study. Funding ("Health and social prize" provided by the Haute-Vienne region Social Security Office - CPAM) was used to purchase the cameras. Beginning on 15 April 2010, 10 establishments for the elderly sent photographs of 34 patients presenting 26 chronic wounds and tele-expertise was provided for 10 pressure ulcers, two diabetic feet and 14 leg ulcers. CONCLUSION: Over a two-year period, this program helped avoid 20 trips for patients and enabled rapid hospitalization of nine patients by the university hospital by optimizing chronic wound management for patients residing in establishments for the elderly.

[Historic malignant tumour: 27 observations]. / Tumeur maligne historique: 27 cas.

BACKGROUND: When used in the French medical literature to describe a pathological state, the word "historic" normally refers to tumours of startling appearance because of their size. It is difficult to understand how a patient can allow such tumours to continue to grow. We attempt to define this concept. PATIENTS AND METHODS: Two dermatologists carried out a retrospective, independent and comparative selection of photographs taken between 1978 and 2008 of malignant cutaneous tumours of unusual size given the histological diagnosis. Socio-professional, demographic, clinical, histological psychological data, and details of treatment history and progress were collected. RESULTS: Twenty-seven patients (11 M, 16 F) of mean age 74 years (34-99 years) presented a "historic" tumour. Twelve patients lived in rural regions. Five patients were company executives. The average duration of development of the "historic" tumours was 4.5 years (6-420 months). The tumours were classed histologically as epidermoid carcinomas (nine) and melanomas (seven). The mean size was 13 cm (6-30 cm). Psychiatric problems, membership of sects or dementia were noted for 13 patients. Treatment consisted of chemotherapy, radiotherapy or, less frequently, surgery. Eighteen patients died on average 13 months after diagnosis. DISCUSSION: "Historic" malignant tumour (also described in the literature as "giant" tumour) is a real-life fact. No studies have been made of a series of such patients. Despite histological diagnosis, the size was associated with slow tumoral progress and/or late treatment, chiefly accounted for by psychiatric disorders. Socio-professional data indicate that "historic" tumours are equally common in urban and rural areas.

[Photodynamic therapy for the treatment of extramammary Paget's disease]. / Traitement de la maladie de Paget extramammaire par photothérapie dynamique topique.

BACKGROUND: The usual treatment for extramammary Paget's disease (EMPD) is surgery, but this approach may have grave functional and physical consequences, as well as high recurrence rates. Topical photodynamic therapy (PDT) offers an optional approach for EMPD; it has a high complete response rate and there is no dose restriction. The aim of this study was to evaluate the efficacy and safety of PDT in the treatment of EMPD. PATIENTS AND METHODS: This series of patients was seen at a single centre between 1 December 2005 and 31 December 2010. All patients with histologically confirmed EMPD were included. Patients received two courses of PDT 21 days apart: 3 hours after topical application of methyl aminolevulinic acid emulsion, they underwent illumination with red light (570-670 nm) at a dose of 37 J/cm(2) for 10 minutes. In the event of relapse, a further cycle was given at week 6. RESULTS: Eight patients (seven female, one male) of a mean age of 69 years were included. After two series of two illuminations, seven patients were in complete clinical remission at 3 months and one patient was in partial remission. Five patients were still in complete clinical remission at 6 months. All patients had relapsed after a mean 8.4 months (4-14 months). The limiting factor appears to be pain occurring during illumination. Patients reported satisfaction with the disappearance of symptoms and a notable improvement in quality of life. DISCUSSION: The complete clinical response rate to PDT at month 6, after two series of two illuminations, was equivalent to that for surgery. Although the recurrence rate was high, this treatment may be repeated without functional or physical consequences. PDT resulted in disappearance of pain and improved quality of life.

[Gardasil®-induced erythema nodosum]. / Erythème noueux induit par le Gardasil®.

Erythema nodosum is a panniculitis occurring more frequently in young women. We report a 16-year-old woman who presented with erythema nodosum that occurred following Gardasil® administration (vaccine against HPV types 6, 11, 16 and 18) and that is proposed to young female. This adverse effect is not a contraindication to the HPV vaccination because its benefit against the oncogene risk of Papillomavirus is documented.

High prevalence and risk factors of thromboembolism in stage IV melanoma.

BACKGROUND: Patients with cancer are at a high risk of thromboembolism (TE), which contributes to morbidity and mortality. Several case reports of thromboembolic events have been reported in patients with melanoma in the literature. OBJECTIVE: The aim of this study was to evaluate the prevalence of venous thromboembolism (VTE) in stage IV melanoma and determine risk factors, outcomes associated with the development of VTE and the number of haemorrhagic complications in patients under anti-coagulant treatment. PATIENTS AND METHODS: In this retrospective study, we included all consecutive patients with stage IV melanoma among 290 patients followed-up in the department of Dermatology each year between January 2005 and 31 December 2007. The diagnosis of VTE was confirmed by venous ultrasound, pulmonary perfusion-ventilation technetium scan and angiography. The primary outcome was to evaluate the number of TE diagnosed in stage IV melanoma patients. The secondary outcomes were to study the influence of TE on survival, its prevalence according to metastatic sites and to evaluate the number of haemorrhagic complications. RESULTS: Twenty-four VTE events were found [25.2% (CI: 16.5-34)]. Eighteen VTE were deep venous thrombosis in lower limbs associated with pulmonary embolism (PE) in 50% of cases. Twenty-five percent were asymptomatic and were revealed in the pulmonary scan performed for follow-up. Eight percent of VTE events revealed stage IV melanoma. Seventeen patients developed thrombosis at home after stopping heparin prophylaxis. Seven thrombotic events occurred during oral anti-coagulant therapy. CONCLUSION: We found as high a prevalence of VTE in stage IV melanoma as in lung and gastrointestinal cancers. All patients suffered thrombotic events when they were treated with chemotherapy and at home when they stopped heparin prophylaxis. Therefore, heparin prophylaxis should be maintained at home.

[The value of photodynamic therapy in the treatment of Bowen's disease]. / Intérêt de la photothérapie dynamique topique dans la prise en charge de la maladie de Bowen.

BACKGROUND: While the standard treatments for Bowen's disease (BD) (surgery, cryotherapy and antimitotic agents) are efficient, they are associated with extensive scarring. In this paper we confirm that photodynamic therapy using topical aminolevulinic acid provides effective treatment for this disease. PATIENTS AND METHODS: Twenty-two patients with a total of 38 cases of BD were included in this retrospective single-centre study between 2001 and 2006. They were treated with photodynamic therapy using topical aminolevulinic acid (Metvix. The study criteria consisted of patient age and gender, site and area of lesions, number of patients with multiple patches of BD and/or large lesions, tolerance of the treatment, clinical response and quality of wound healing at 3, 6 and 12 months. Annual follow-up was conducted for five years. The probability of remission up to 60 months after treatment was determined by means of survival analysis based on the variable-interval actuarial method. RESULTS: Seven men and 15 women of median age: 76 years (interquartile range: [69-82]) with 38 cases of Bowen's diseases were treated with photodynamic therapy. In terms of frequency, lesions were seen predominantly on the lower limbs (N=24) and face (N=10). Other lesions were seen on the trunk or back (N=4). The mean surface area of lesions was 8.62 cm2 (1-96 cm2). Eight patients were presenting multiple patches of BD (> or = three lesions), and large lesions were noted in 11 cases. The most common adverse effect was an immediate burning sensation, described by 32% of patients (n=7). Treatment was effective, with remission being achieved in all patients at 3 months of follow-up. Wound healing was optimal and without atrophy or cosmetic sequelae. The remission rate was 100% at 6 months, 95% at 12 months and 85% at 24 months. DISCUSSION: This open retrospective study confirmed the good efficacy of photodynamic therapy in the treatment of BD in terms of both clinical remission and cosmetic results. It enables easier treatment of large and/or multiple lesions than surgery. It is more suitable for elderly patients than either topical anticancer drugs, which require prolonged compliance, or surgery and cryotherapy, both of which result in slow-healing postoperative wounds. CONCLUSION: Since photodynamic therapy is a very costly therapeutic method, we feel that dynamic phototherapy should be used only for large and/or multifocal lesions or for lesions of the lower limbs in patients with chronic venous insufficiency.

[Abrupt onset of papulovesicular lesions: diagnostic features and outcome]. / Eruptions varioliformes aiguës: aspects diagnostiques et évolutifs.

INTRODUCTION: Abrupt onset of papular lesions, with ulcero necrotic evolution could refers to many dermatitis. Febrile ulceronecrotic Mucha-Habermann disease is an unusual severe form of pityriasis lichenoides and varioliform acuta (PLEVA) characterized with ulceronecrotic eruption potentially associated with high fever and systemic symptoms leading to death. Lymphomatoid papulosis is a recurrent papulonodular eruption with an initial presentation close to PLEVA. While this disorder usually has a benign course, about 10% of the patients develop lymphoproliferative disorders such as CD30+ lymphoma. EXEGESIS: The authors reported an acute form of PLEVA in a young man hospitalized in internal medicine unit with fever and ulcero-necrotic papulo-vesicular lesions. Treatment with tetracycline was successful. They also report a case of lymphomatoïd pustulosis that occurred in a 34 years old woman with an extensive nodulo-pustular eruption characterized by central necrosis and ulceration. Histopathological examination revealed CD30 lymphocytic infiltration leading to diagnosis. CONCLUSION: Theses two dermatosis, uncommon and clinically similar, are both characterized with an unpredictable evolution that to be known by internist.