[Simulation training for urinary drainage improves skill retention]. / Simulation et rétention des acquisitions : application au drainage vésical.

INTRODUCTION: Urethral and suprapubic catheterizations are the two methods for urinary drainage. Systematic simulation training could improve the performance and reduce iatrogenic complications. The aim of the study was to evaluate the skills retention using simulation training. MATERIALS AND METHODS: It was an experimental study of the effect of urinary drainage simulation based skills on medical students in order to compare active and passive training methods. On the first session, randomization was proceeded. Then, the participant performed one of the two workshops (urethral or suprapubic catheterization) on a male mannequin. The maximal performance was 40 points on the assessment form. Both workshops were performed on the second (one month) and third sessions (six months). RESULTS: Eighteen participants were included. Main performance was 28.7/40 (23-34.2) at the first session. All the participants improved the performance on the second session with a significant difference (P<0.01) between passive 32.5 (26-36.5) and active participants 36.1/40 (34.5-39). On the third session, a similar difference was observed between passive and active participants (32.5 versus 30.4, P non significant). CONCLUSION: Simulation training seems to improve long-term skill retention of urinary drainage for inexperienced medical students. This preliminary study suggests to incorporate urinary drainage simulation training into all medical school curricula. LEVEL OF EVIDENCE: 4.

[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.

[Dermohypodermitis on the face revealing TIBOLA]. / Dermohypodermite de la face révélatrice d'un syndrome TIBOLA.

Tick-borne lymphadenopathy (TIBOLA) is an emerging rickettsiosis in Europe, transmitted by the Dermacentor tick. This syndrome is defined as the association of an inoculation eschar on the scalp that may be surrounded by an erythema scalp, fever, and painful cervical lymphadenopathy in colder months. Children and women are at higher risk for TIBOLA. We report the case of a 9 year-old French child with an acute hemifacial edema and erythema revealing TIBOLA. Early empirical antibiotic therapy should be prescribed in any suspected TIBOLA, before confirmation of the diagnosis. The recommended treatment is doxycycline or macrolide.

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.

[Clinical characteristics, outcome of scleromyxoedema: a retrospective multicentre study]. / Caractéristiques cliniques et évolutives du scléromyxœdème : étude rétrospective multicentrique.

BACKGROUND: scleromyxoedema is characterized by dermal mucin deposition associated with a monoclonal gammopathy. This is a rare disease, mostly reported as isolated cases. There is limited data regarding the course and prognosis of the disease. The aim of this study was to determine the clinical characteristics and course of scleromyxoedema. PATIENTS AND METHODS: this was a retrospective study in patients from five French university hospitals between 1987 and 2007. Data were collected using a standardized questionnaire. The inclusion criteria were based on the disease diagnosis criteria proposed by Rongioletti and Rebora: (1) generalized, papular and sclerodermiform skin eruption, (2) mucin deposition in the dermis, fibroblastic proliferation and skin fibrosis, (3) presence of a monoclonal gammopathy, (4) absence of thyroid disease. RESULTS: eight patients were included. The mean age at disease onset was 51.5 years (range: 35-67). The mean time from primary symptoms and diagnosis was 41.6 months (range: 4-120). Seven patients had extra-cutaneous involvement: four with peripheral neuropathy and three with interstitial pneumonia. The mean follow-up time was 9 years. Four patients improved: two experienced partial remission and two complete remission. Complete remission was obtained under treatment with dexamethasone (one patient) and thalidomide (one patient). One patient presented a myeloma and one patient presented encephalopathy leading to death. DISCUSSION: our study shows the frequency of extra-cutaneous involvement and shows that complete remission occurs in some patients.

Photosensitivity associated with selective serotonin reuptake inhibitors.

Selective serotonin reuptake inhibitors (SSRIs) are a widely prescribed group of antidepressants. We report three cases of photosensitivity induced by fluvoxamine and paroxetine. These photoallergic reactions suggest cross-reactivity between different molecules. Methylation metabolism could explain common photosensitization. Although these drugs are widely prescribed, such photosensitization is rare. Nevertheless, we consider that clinicians and patients should be aware of the risk of photosensitization and these drugs should be stopped before phototherapy or prolonged sun exposure.

[One year follow-up of patients with bullous pemphigoid]. / Profil évolutif des patients atteints de pemphigoïde bulleuse au cours de la première année de traitement.

BACKGROUND: Since high doses of superpotent topical corticosteroids (CS) have been shown to improve the survival of bullous pemphigoid (BP) patients and to be more effective than oral CS, few studies have described the long-term course of the disease of these patients. We report the course of BP in the Limoges region of France based on patients diagnosed successively between 2002 and 2004. PATIENTS AND METHODS: This was a retrospective, single-centre study of 54 BP patients diagnosed with BP, conducted by the Department of Dermatology of the Limoges University Hospital over a 3-year period. We investigated epidemiological data, initial symptoms, type of treatment received and outcome at six and 12 months. The two primary end-points were disease control at month 12 and the combined outcome of deaths and relapse over the one-year follow-up period. We calculated the number of deaths, patients lost to follow-up, relapses, and remission at months 6 and 12. RESULTS: Between January 2002 and December 2004, 54 new BP patients were diagnosed in the Limoges Department of Dermatology: 18 male and 36 female, median age 84 years. Forty patients were treated with superpotent topical CS, 14 required adjuvant immunosuppressant treatment (oral CS, methotrexate, dapsone, mycophenolate mofetil, leflunomide). Over the first 6 months, 28 patients could not be further investigated due to death (n = 20) or loss to follow-up (n = 8). In the 26 patients evaluable for treatment efficacy at month 6, control of the disease was achieved in 17 patients, and nine relapses were seen. The one-year Kaplan-Meier survival rate was 56%. Among the 23 patients evaluable at month 12, control of disease was achieved in 13 patients (complete remission without treatment, n = 2; remission with immunosuppressant treatment, n = 8). Therapeutic failure was concluded for 16 patients, eight of whom presented two relapses during the first year of follow-up. CONCLUSION: Despite recent therapeutic recommendations for BP, the prognosis of this disease remains severe. The risk of relapse and mortality rates observed in this study should prompt the development of new therapeutic strategies to supplant superpotent topical CS and reduce the morbidity and mortality associated with the disease.

[Calciphylaxis treated by cinacalcet: a medical alternative to parathyroidectomy]. / Le traitement de la calciphylaxie par cinacalcet: une alternative médicale à la parathyroïdectomie.

Calciphylaxis is a rare necrotizing calcifying arteriolopathy, with a poor prognosis, for which there is currently no effective treatment. One of the major challenges of the therapy is normalizing the calcium-phosphate balance. Therefore, cinacalcet, which inhibit the production of parathormone by negative feedback, was considered a treatment option to control the evolution of calciphylaxis in a dialysed patient suffering from cholangiocarcinoma.

[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.

[Radiation induced skin reactions]. / Réactions cutanées induites par la radiothérapie.

Radiotherapy is one of the most important treatment modality of cancers. Skin secondary effects are well known. Cutaneous complications are described. Physiopathogenic mechanisms are reported. Many preventative and treatment options have been used with varying degrees of evidence of success. Information of patients, further research studies and a multidisciplinary approach are necessary to increase the management of radiation induced skin reactions.

[Herpetic recurrent upper limb lymphangitis]. / Lymphangite récurrente du membre supérieur d'origine herpétique.

Upper limb lymphangitis often complicates varied wounds on the hand or forearm and improvement is obtained in a few days with adapted antibiotic therapy. A 28-year-old woman presented since few years episodes of lymphangitis of the arm associated with vesicles on an erythematous base, on the palmar face of the first phalanx of the index finger, spontaneous relief within 10 days, without antibiotic therapy. Herpetic origin was confirmed on viral culture. No primary infection neither recurrence was noted. Because of the recurrences, a prophylactic treatment with valaciclovir was instituted. There was no reported recurrence at two years follow-up. Upper limb lymphangitis rarely complicates herpetic whitlow in immunocompetent patient. Clinicians should be aware of viral lymphangitis, which is often overlooked and associated with diagnostic errors and treatment delay.