[Observational study of factors predictive of medication errors and of prioritization criteria in geriatric medication reconciliation]. / Étude observationnelle de facteurs prédictifs d'erreurs médicamenteuses et de critères de priorisation en conciliation médicamenteuse gériatrique.

OBJECTIVES: The geriatric population, often polymedicated, is exposed to the risk of adverse drug events. Medication reconciliation (MR), which is an interactive and pluriprofessional process, helps ensure continuity of care. The objective of this study was to analyze and to define relevant prioritization criteria for MR in older patients in order to avoid a maximum of medication errors. METHODS: A clinical audit of MR at the transition points of patient admission and discharge was conducted prospectively for 10 months. Patients were selected on the basis of a prioritization procedure already established in our structure, that is the presence of at least one of the three following criteria: originating from an hospital department, severe renal failure and prescription of at-risk drugs. RESULTS: The cohort of patients reconciled at admission included 136 patients. A total of 63 unintentional discrepancies (UDs) were identified, the majority of which (76.2%) involved drug omissions. Three criteria were identified as independent predictors of UDs risk on the entry prescription compared to the optimized drug assessment: rheumatological history, originating from an hospital department and hyponatremia. Hyponatremia was found in the present study to be the most relevant criterion that significantly increased the risk of having an UD on the patient's prescription, particularly a risk of treatment omission at admission. CONCLUSION: This study will allow to improve the prioritization criteria on the healthcare establishment's procedure and to implement MR in geriatric day hospitalization in order to strengthen the city-hospital link.

Comprehensive evaluation of using computerised provider order-entry system for hospital discharge orders.

BACKGROUND: Computerised prescriptions for Hospital Discharge Orders (HDO) are used world-wide to secure medication processes. OBJECTIVES: To evaluate physicians' adoption of computerised provider order-entry (CPOE) for HDO and the prescribing error rate of HDO in an acute medical care unit. SETTING: A prospective study was conducted in an internal medicine department over a six-month period. The use rate of CPOE for HDO edition, prescription lines concordance between CPOE-edited HDO, exit prescriptions transcribed in the discharge summary (DS), and prescribing error rate in CPOE-edited HDO were all evaluated. RESULTS: A total of 407 patients with HDO were included in the study. HDO were edited via CPOE system for 350 patients (86%), among which 124 (35%) were identically transcribed, 217 (62%) had discrepancies, and nine (3%) were not transcribed in the discharge summary (DS). Prescription errors were analysed using the total of 2,854 drugs prescribed on HDO. Although hospital pharmacists had signalled discrepancies and provided recommendations to the prescribers via alerting pharmaceutical interventions in CPOE 67 prescription errors (error rate of 2.3%) were found. Errors included 53 cases of refractory period disrespected, four cases of drug interactions, three cases of drug redundancies, and two cases of excessive dosage. CONCLUSION: This study highlights that most HDO were edited via the CPOE system. Together with pharmacist's interventions, the CPOE system contributed to reducing the prescription error rate in HDO. However, discrepancies in the recording process to DS were frequent, calling for reinforcement of error prevention strategies upon the integration of a CPOE system in the hospital's Electronic Health Records. Providing regular training for physicians is also a requirement.

Narrative enhancement and cognitive therapy (NECT) to improve social functioning in people with serious mental illness: study protocol for a stepped-wedge cluster randomized controlled trial.

BACKGROUND: Self-stigma is highly prevalent in serious mental illness (SMI) and is associated with poorer clinical and functional outcomes. Narrative enhancement and cognitive therapy (NECT) is a group-based intervention combining psychoeducation, cognitive restructuring and story-telling exercises to reduce self-stigma and its impact on recovery-related outcomes. Despite evidence of its effectiveness on self-stigma in schizophrenia-related disorders, it is unclear whether NECT can impact social functioning. METHODS: This is a 12-centre stepped-wedge cluster randomized controlled trial of NECT effectiveness on social functioning in SMI, compared to treatment as usual. One hundred and twenty participants diagnosed with schizophrenia, bipolar disorder or borderline personality disorder will be recruited across the 12 sites. The 12 centres participating to the study will be randomized into two groups: one group (group 1) receiving the intervention at the beginning of the study (T0) and one group (group 2) being a control group for the first 6 months and receiving the intervention after (T1). Outcomes will be compared in both groups at T0 and T1, and 6-month and 12-month outcomes for groups 1 and 2 will be measured without a control group at T2 (to evaluate the stability of the effects over time). Evaluations will be conducted by assessors blind to treatment allocation. The primary outcome is personal and social performance compared across randomization groups. Secondary outcomes include self-stigma, self-esteem, wellbeing, quality of life, illness severity, depressive symptoms and personal recovery. DISCUSSION: NECT is a promising intervention for reducing self-stigma and improving recovery-related outcomes in SMI. If shown to be effective in this trial, it is likely that NECT will be implemented in psychiatric rehabilitation services with subsequent implications for routine clinical practice. TRIAL REGISTRATION: ClinicalTrials.gov NCT03972735 . Trial registration date 31 May 2019.

Analysis of C-myc amplification by the differential polymerase chain-reaction (d-PCR), study in breast-cancer.

c-myc proto-oncogene amplification seems to have a prognostic value in breast cancer. In this study, quantitative analysis of c-myc amplification was carried out by differential polymerase chain reaction technique (d-PCR) using beta-globin as the reference gene. d-PCR assessment showed coampIification products of c-myc and beta-globin depend on variations in reaction factors such as the genomic DNA concentration, the relative concentrations of the various amplimers, the thermostable DNA polymerase concentration and the number of cycles. However, amplification of c-myc can be estimated quantitatively. In addition, results of individual sets of d-PCR can be expressed on a standard reference scale. A clinical study of 309 patients with breast cancer found c-myc amplification, respectively in 19% (45/236) of primary tumour tissues, 21% (4/19) of subsequent second primary cancers, 36% (4/11) of tumours of patients with bilateral lesions, 40% (8/20) of local recurrence tumours and 22% (5/23) of metastatic lesions. Amplification of c-myc was observed more frequently in histological grades 2-3 (p<0.02), in ER negative (p<0.01) and PgR negative tumours (p<0.02), but was not associated with age, tumour size, nodal status, histology, cytosolic cathepsin D or pS2. d-PCR appears amenable to automation and should facilitate large scale, inter laboratory gene amplification studies.

Practical importance of breast microcalcifications: report on 112 cases.

The authors discuss the results of a diagnostic and therapeutic study of 112 cases of breast microcalcifications with no palpable lesions. The criteria in favor of obtaining a surgical specimen are discussed as a function of population characteristics and a review of the literature. Techniques for the localization of these lesions are defined. Decisions as to the necessity for ulterior treatment of the breast are based on certain criteria, and above all on the risk of evolution of invasive lesions with nodal involvement. The high quality of current mammograms has considerably increased the number of patients referred for biopsy. In the case of microcalcifications masking malignant lesions, the advances made in conservative treatment of breast cancer are not always applicable owing to the risks of failure with such conservative approaches.

Chest wall reconstruction after full thickness resection: an experience with 22 patients.

The authors present their experience of chest wall reconstruction after full thickness resection in 22 patients. The patients are from a series of 80 patients treated by chest wall resection from 1967 to 1989. Whether performed on breasts still in place, for recurrent disease, or for radiation-induced lesions (which are often associated), the defect created by complete resection of the chest wall layers causes difficulties. Large cutaneous flaps, often including the opposite breast were used at the beginning of the series. Then came omentum associated to Mersilene mesh and myocutaneous flaps. The results, in terms of comfort and local control are acceptable, even though surgery is only palliative for cancer patients. We feel that full thickness chest wall resection is the only effective treatment for some primary and recurrent malignant tumors and for extensive thoracic radionecroses. Such procedures are designed to improve the patient's quality of life even if they do not actually prolong survival. The goals guiding the reconstruction programme are: (1) the restoration of a stable parietal rigidity; and (2) the reconstruction of long lasting superficial layers.

A radiologic study of chronic radiation-induced injuries of the small intestine and colon.

On the basis of 144 radiation-induced intestinal and colorectal lesions seen in 109 patients, the authors review the radiologic aspects associated with such affections. Two points are emphasized: (1) the chronic and still active nature of radiation-induced injury which can explain the appearance of lesions more than 10 years after irradiation, and (2) the locoregional nature of the affection which warrants systematic exploration of the urinary tract by intravenous pyelography in addition to radiologic and endoscopic investigation of the digestive tract. The authors also advise an echography and/or CT scan to detect any neoplastic recurrence.

Echographic aspects of thyroid and parotid localizations in non-Hodgkin lymphomas.

The authors present four observations of rare localizations of non-Hodgkin lymphomas (3 cases of lymphoma of the thyroid, 1 case of lymphoma of the parotid), all of which were studied by echography. In two of the thyroid localizations, the echographic pattern was identical to that observed for nodes in non-Hodgkin lymphomas, and thus differs from that of cysts and necrotized or cystic tumors. In the one case of secondary lymphoma of the thyroid, accompanied by diffuse enlargement of the gland but no histological proof, echography revealed only diffuse enlargement, without any anomaly in the echostructure. In the one case of lymphoma of the parotid, the echographic image was similar to that of a lymphomatous node, but it cannot be formally differentiated from the structure which can be observed for a mixed tumor or a cystic lymphangioma.

[Predictive factors of local recurrence of in situ intraductal carcinoma. Apropos of 217 cases]. / Facteurs prédictifs de récidives locales de carcinomes canalaires in situ. A propos de 217 cas.

The authors have reviewed 217 cases of pure intraductal carcinomas with a mean follow-up of 98 months (with 2 deaths out of 31 recurrences from which 35% into adenocarcinomas). The data concerning the diagnosis, the tumor size, the pathological type, the surgical treatment, more of less associated to radiation therapy are detailed. The aim of this work was to give a more reliable way or approaching the recurrence rate (31/217) to be able to apply a more conservative treatment to these cases. The lymph node dissection and removal seams to be useless in the in situ carcinomas. Concerning the tumor size, the local tumors can be treated by conservative surgical procedures and do not get any benefit from radiotherapy. The opposite is true concerning more largely invasive tumor. Concerning the histology, the non-comedocarcinomatous tumors get less benefit from radiotherapy than the comedocarcinomatous type. The study of the tumor limits and the reliquats seem to be useful. The treatment chosen and applied remains the major prognostic element in the probability of recurrence.

[Study of mdm2 gene amplification in primary breast tumors]. / Etude de l'amplification du gène mdm2 dans les tumeurs primitives du sein.

mdm2 (mouse double minute) protein seems lead to p53 inactivation and therefore might potentially play a role in carcinogenesis. We have studied mdm2 gene amplification from 239 primary breast cancer tissues. mdm2 gene was amplified in 10% of cases (25/239). mdm2 amplification was associated with c-erbB2 amplification (P < 10(-3)). No other correlation was found. However there was inverse correlation between c-erbB2 gene amplification and hormonal receptors (P < 10(-4)), only from patients without mdm2 gene amplification.

[Treatment of cancer of the anal canal with combination radiochemotherapy: apropos of 12 cases]. / Traitement des cancers du canal anal par association radio-chimiothérapie: à propos de 12 cas.

We present 12 patients (3 male, 9 female) aged from 53-88 years with squamous cell cancer of the anal canal treated with combined radiotherapy-chemotherapy (5 FU-mitomycin C); the distribution of the tumours was 2 T4, 6 T3, 3 T2, 1 T1). In 11 patients evaluated, complete remission was obtained in 8 with partial remission in 2 others. In spite of this good result with combined treatment, 4 patients had a recurrence between 9 and 26 months. Five patients survived and 2 died without disease (16-38 month), 3 patients died and one survived with disease. The small series confirms the efficacy of this combination which treated bulky tumours (T3-T4). It is necessary however to compare these results with radiation alone in a randomised trial.

[A comparative study of 4 sequential first-line chemotherapy protocols in locally advanced breast cancer]. / Etude comparative de 4 protocoles successifs de chimiothérapie première dans le cancer du sein localement avancé.

Between 1977 and 1994, our center administered successively 4 different chemotherapy regimens to 242 evaluable patients with locally advanced breast cancer. Patients with inflammatory signs were excluded. Sixty-eight patients were treated by AVCF (A (adriamycine) + V (vincristine) + C (cytoxan) + F (5FU)), 47 by AECF (A + E (vindesine) + C + F), 81 by CAFP (C + A + F + P (prednisone)) and 46 by AN (A + N (vinorelbine)). The mean number of cycle was 3. One hundred and twenty-five patients (52.5%) responded to chemotherapy and we recorded 35 complete response (14.7%). The response rates at the different combinations were respectively: AVCF: 29.4%, AECF: 53.2%, CAFP: 64.9%, AN: 65.2%, and were independent of tumor size, grade and receptor status. The response rate at the AVCF regimen was significantly worse than the others (p = 0.0005). Breast conserving surgery was performed in 31 patients (14%) and 17 patients (8%) had a complete response. Among the 35 patients with complete response, 21 were treated by radiotherapy alone. Local recurrence occurred in 19 patients (7.9%) and 96 (40%) had advanced disease. The mean follow-up of AVCF regimen was 150 months, 115 months for AECF, 111 for CAFP and 42 months for AN. The disease-free survival and the overall survival were significantly better with AECF, CAFP and AN regimens (DFS p < 0.04, OS p < 0.02). Survival was better in those patients with an objective response (p = 0.002) or with non-affected axillary node at the time of surgery. Our study showed already that AVCF combination was significantly lower than AECF, CAFP, AN in terms of response rate, disease-free survival and overall survival. Waiting the results of randomized studies about the impact of neoadjuvant chemotherapy on survival, we look for chemotherapy regimen improving the rate of conservative surgery.

[Breast cancer: the role of scintigraphy in the initial evaluation and follow-up of patients with small tumors (T less than or equal to 3 cm)]. / Cancer du sein: place de la scintigraphie dans le bilan initial et le suivi de patients porteuses de petites tumeurs (T less than or equal to 3 cm).

To evaluate the utility of bone scans for the follow-up of patients with small breast cancers (T less than or equal to 3 cm), the files for 133 patients whose disease was diagnosed between Jan. 1, 1979 and Dec. 31, 1980 were reviewed. At initial presentation, two of these patients already had bone metastases. During their disease course, 30 patients developed metastases and 16 of them had at least one bone metastasis. In 7 of these 16 cases, the bone metastasis was solitary; in 4 cases bone lesions were symptomatic. A total of 178 bone scans were performed during the follow-up of these 133 patients; 16 of these scans were positive, but only 4 examinations allowed the diagnosis of bone metastasis. Despite the slight prognostic value of initial bone scanning in this series, the technique is of little value unless it is combined with clinical examinations aimed at early detection of disease recurrence or metastasis. Except as part of clinical trial protocols, systematic bone scans appear unnecessary for the staging and follow-up of patients with small breast cancers.

Hepatic oil embolization following lymphangiography. A report of 12 cases.

The authors report on 12 personal observations of lymphoportal fistulas, which represented 0.24% of their series of lymphographies. This rare complication of lymphography has no clinical or biological liver manifestations. Review of 71 cases in the literature confirmed that hepatic oil embolization only occurs when there are lymphatic masses, with or without associated thrombosis of the inferior vena cava.

Subcutaneous mastectomy. A review of 130 cases.

Subcutaneous mastectomy (SCM) is discussed in connection with 130 such procedures performed on 108 patients. Seventy-nine malignant breast lesions and 51 benign breast lesions were operated on by this technique, which lies midway between conservative therapy and classical ablation. Conservation of the nipple-areola complex depends on the results of intraoperative biopsy; flaps are reduced when necessary. Breast volume is usually reconstituted using a prosthesis. Eleven of the 79 malignant breast lesions recurred locally (13.6%): generalization of postoperative irradiation thus seems justified, as in conservative therapy protocols. The 5-year survival rate of 83% is comparable to that of other treatment techniques for T1-T2 cancers. Cosmetic results have been improved, and the fact that SCM may give a better result than reconstruction after mastectomy must be kept in mind. However, the technique is only indicated for those cases which would otherwise be suitable for conservative surgery, were it not for the need to resect the gland because of a diffuse pathology.

[Strategy and results in the treatment of squamous cell carcinoma of the anal canal. A review of 51 cases (author's transl)]. / Stratégie et résultats dans le traitement des épithéliomas malpighiens du canal anal. A propos de 51 cas.

In this retrospective study of 51 patients treated for squamous cell carcinoma of the anal canal some aspects of the natural history are touched upon. The authors also discuss their results and define their current therapeutic approach. It is a rare lesion; only 2-3% of all colorectal cancers with a predominance for women (4 to 1) and of 2 histological varieties. The epidermoid type (74%) is made more prevalent though the basal layer type (26%). The prognosis is very poor once the stage T, is passed. The simultaneous finding of a primary lesion and associated inguinal lymphadenopathy is of serious consequences. The proposed therapeutic schema consists of: --Radiotherapy exclusively for T1 lesions. --Preoperative radiotherapy and abdominoperineal resection for all large lesions T3-T4. --For the intermediate T2 lesion: initially radiotherapy (2,500-4,000 rads) followed by careful reevaluation under general anesthesia to define whether further curie-therapy or surgical resection when an unsatisfactory response.

[Trend towards conservative surgery for intraductal carcinomas of the breast. (Retrospective study of 165 cases)]. / Evolution vers une chirurgie conservatrice des carcinomes intra-canalaires du sein. (Etude rétrospective sur 165 cas).

One hundred and sixty-five intraductal, non invasive breast carcinomas in 162 patients were reviewed. The mean follow-up was 75 months. Recurrence rates seem to be influenced by the therapeutic approach: 4.8% following mastectomy (4 cases out of 83); 16% following breast conserving surgery associated with radiotherapy (4 cases of 25); 22.8% following subcutaneous mastectomy (8 cases out of 35); 50% following breast conserving surgery alone (11 cases out of 35). When considering the clinical and radiological sizes of the tumor in the group of tumor excision and breast irradiation, additional information is gained. When the size is less than 25 mm the recurrence rate drops to 6.6% (1 case out of 15). When the lesions are extensive a subcutaneous mastectomy followed by irradiation (with or without a breast implant) might be an interesting alternative to modified radical mastectomy.

[Intra-epithelial cancer of the cervix uteri. Epidemiological and therapeutic evolution. Apropos of 207 cases]. / Cancer intra-épithélial du col utérin. Evolution épidémiologique et thérapeutique. A propos de 207 cas.

Through a retrospective study of 207 CIN III of the cervix uteri, with a medial follow-up of 6 years, the authors are showing the evolution in the management of that pathology. Different reasons are invoked: 1) the practice of systematic Papanicolaou smears reveals dysplasia of the cervix in younger women, justifying treatments that preserve obstetrical future; 2) the histological classification is now well established, the old terminologies is being replaced by the international term of CIN III. 3) the colposcopy can localize the transformation zone, allowing more conservative treatments. The treatment of reference was initially hysterectomy and is now conization for non-menopausal women; but this conservative evolution is not yet finished.

[Repair of chest wall defects after full thickness surgical resection]. / La réparation des pertes de substances de la paroi thoracique après résection chirurgicale de pleine épaisseur.

The authors discuss the development of their approach to the repair of full-thickness chest wall resection based on a series of twenty-two patients operated between 1967 and 1989. The defect resulting from resection of all tissue planes, either for breast in situ, recurrences, radiation lesions or primary tumours, raises difficult problems. Mammary or cutaneous autoplasties, performed during the early years, have become less frequent, essentially because of the development of musculo-cutaneous flaps (pectoralis major, rectus abdominis, latissimus dorsi) which provide global anatomical and functional repair. The greater omentum island flap, used since 1974, still occupies an important place because of its plastic and trophic qualities in irradiated regions. When chest wall rigidity is compromised, Mersilene patch remains the material of choice. The quality of the results obtained in terms of comfort justifies the use of this major surgery which is now well defined.

[Echography in tumor pathology of uterus (author's transl)]. / L'échographie en pathologie tumorale de l'utérus.

Based on the study of 234 cases of uterine tumor pathology, the authors attempt to define the role and limits of echography. In the case of uterine cancers, the major role of echography concerns postoperative surveillance, except for cancers of the corpus uteri for which it allows exact measurement of the size of the uterus and thus the optimization of radiotherapy. Fibromas are easily detected by echography, but in the case of submucosal or subserosal forms this technique can give false negative (submucosal forms) or erroneous diagnosis of an ovarian tumor (subserosal fibroma). Only the tumoral forms of endometriosis uterina can be recognized using echography, generally showing up as small transsonic images; infiltrating forms cannot be visualized. Echographic diagnosis of uterine polyps is often difficult. Echography has become the foremost complementary procedure following clinical examination. However, a negative uterine echogram in the presence of warning signs and in particular menorrhagia systematically warrants obtention of a hysterography to detect a polyp, a submocusal fibroma, endometrial lesions or an infiltrating cancer of the corpus uteri.