[Patient education in psychiatry: Representations of caregivers, patients and their families]. / Éducation thérapeutique en psychiatrie : représentations des soignants, des patients et des familles.

INTRODUCTION: Why do caregivers working in psychiatry seem to wonder about their practices, in front of the recent mediatisation of patient education in France? Do our educational practices meet the needs and the expectations of patients and their families? These questions led us to carry out this qualitative and prospective study concerning the representations of patient education of the main actors in psychiatry. OBJECTIVE: This work aims to assess the representations of patient education of the main actors in psychiatry, in particular to assess convergences and divergences. METHODS: This is a qualitative and prospective study. Qualitative data are speeches from caregivers working in psychiatry, patients suffering from a psychiatric pathology and their families. The three populations studied were defined by precise characteristics. The sample was diversified by a variable related to the study theme: experience or not in patient education. Speeches were collected during interviews, which were carried out by the same person. Interviews were semi-structured by a thematic guide, which defined the themes to be explored. The three main themes are: the concept of patient education, the objectives of patient education, and the caregiver/patient relationship. We analysed the content of the speeches with a lexical reference table that we elaborated from the literature of experts in patient education. We also realised a transverse analysis in order to assess convergences and divergences between the different speeches. RESULTS: Thirty-two interviews were realised with fifteen caregivers (six psychiatrists and nine nurses), ten patients and seven families. In the speeches of the different populations, we found the expected element of language for all the themes explored. Unexpected ideas were also found in the speeches of the various groups. We could find convergences and divergences concerning these unexpected ideas between and within each group. Regarding convergences, all the groups mentioned the unexpected idea of the problem of social representations of psychiatric diseases. The three groups also approached the need to develop the work with families. Patients and families entrusted their feeling that there would be a lack of exchange with some caregivers. Patients and caregivers evoked the paternalistic attitude of some caregivers. Finally, both caregivers and family approached their questions regarding the caregiver/patient relationship during care without the patient's consent. We found several divergences in the caregivers' speeches. These divergences seemed to be correlated with the experience in patient education in psychiatry. They concerned the scope of patient education in psychiatry, the differences perceived between patient education in psychiatry or in somatic cares, and the diagnostic announcement to the patient. This last unexpected idea was the main point of divergence between caregivers and patients. DISCUSSION: Results of this study showed that the representations of caregivers, patients and their families correlate with the experts' ideas regarding patient education. The analysis of the different speeches highlighted several unexpected ideas, which constitute themes of reflection about patient education. Some of these themes concern in particular the medical domain of psychiatry such as the questions about caregiver/patient relationship during care without the patient's consent and restraint. Another theme of psychiatry specific reflection is the differences perceived by some caregivers between their practices and the patient education in somatic care. Others themes of reflection highlighted all the medical specialities: the need to develop the work with families, the problem of the social representations of diseases, the scopes of patient education and the diagnostic announcement to the patient. CONCLUSION: This study highlighted several themes of reflection about patient education in psychiatry. We should include this theme of reflection in our practices in order to respond more precisely to the needs and the expectations of the patients and their families.

Persistence assessment of cyclohexyl- and norbornyl-derived ketones and their degradation products in different OECD screening tests.

The persistence of synthetic cyclohexyl- and norbornyl-derived ketones was assessed by using OECD 301F and 301D biodegradation tests. While cyclohexyl-derived ketones either reached or came close to the pass level (60%) after 60 d, the corresponding norbornyl derivatives yielded significantly less biodegradation (<40%). By analyzing extracts at 60 d, the key degradation products of four norbornyl derivatives were identified. Consistently, 2-bicyclo[2.2.1]heptane carboxylic acid was found as a principal degradation product with minor quantities of bicyclo[2.2.1]heptan-2-one and 2-bicyclo[2.2.1]heptane acetic acid. When the three degradation products were re-synthesized and tested individually for biodegradability, the former two were found to be ultimately biodegradable after 60 d in OECD 301D tests, thus proving non-persistence. Similarly, 2-bicyclo[2.2.1]heptane acetic acid was found to be degraded significantly, albeit with long lag phases exceeding 60 d in the case of freshwater inoculum, then ultimately reaching the pass level. On the other hand, norbornyl ketones were still only partially biodegradable in the same test. We conclude that despite the potential for ultimate biodegradation of norbornyl-derived ketones, current screening tests yield an incomplete picture of their biodegradability, particularly when applying strict OECD criteria. The appearance of long lag phases when re-testing norbornyl ketone degradation products underlines the importance of extending tests to well beyond 28 and even 60 d in the case of freshwater inocula.

Pain as the only consistent sign of acute appendicitis: lack of inflammatory signs does not exclude the diagnosis.

BACKGROUND: The clinical diagnosis of acute appendicitis in adults remains tricky, but radiological examinations are very helpful to determine the diagnosis even when the adult patient presents atypically. This study was designed to quantify the proportion of patients with a preoperative diagnosis of acute appendicitis that had isolated right lower quadrant pain without biological inflammatory signs and then to determine which imaging examination led to the determination of the diagnosis. METHODS: In this monocentric study based on retrospectively collected data, we analyzed a series of 326 patients with a preoperative diagnosis of acute appendicitis and isolated those who were afebrile and had isolated right lower quadrant pain and normal white blood cell counts and C-reactive protein levels. We determined whether the systematic ultrasonography examination was informative enough or a complementary intravenous contrast media computed tomography scan was necessary to determine the diagnosis, and whether the final pathological diagnosis fit the preoperative one. RESULTS: A total of 15.6% of the patients with a preoperative diagnosis of acute appendicitis had isolated rebound tenderness in the right lower quadrant, i.e., they were afebrile and their white blood cell counts and C-reactive protein levels were normal. In 96.1% of the cases, the ultrasonography examination, sometimes complemented by an intravenous contrasted computed tomography scan if the ultrasonography result was equivocal, fit the histopathological diagnosis of acute appendicitis. CONCLUSIONS: The diagnosis of acute appendicitis cannot be excluded when an adult patient presents with isolated rebound tenderness in the right lower quadrant even without fever and biological inflammatory signs. In our study, ultrasonography and computed tomography were very helpful when making the final diagnosis.

Diagnosis and treatment of spontaneous group A streptococcal peritonitis.

BACKGROUND: Primary group A streptococcal peritonitis (PSAP) is a rare, fulminant and often fatal infection. The clinical manifestations include diffuse peritoneal signs with toxic shock syndrome and sometimes fasciitis. METHODS: Patients with PSAP diagnosed between December 2002 and December 2006 were studied retrospectively, focusing on the initial presentation, diagnosis, treatment and outcome. RESULTS: Six patients were identified (five women and one man). The clinical presentation was heterogeneous. All six patients had diffuse peritonitis, four had toxic shock syndrome on hospital admission and two patients also had fasciitis. All patients were treated surgically, and the final diagnosis was confirmed after operation. There were no deaths, but two patients had aesthetic sequelae owing to necrotizing fasciitis. CONCLUSION: PSAP is a rare condition, often requiring aggressive surgical treatment. Group A streptococcal peritonitis should be suspected in patients with no radiological evidence of a peritoneal portal of entry and no history of ascites.

Elytrocele with and without a history of hysterectomy (303 defecography studies).

OBJECTIVE: To search for clinical risk factors and symptoms of elytrocele in female patients without hysterectomy. PATIENTS AND METHODS: Of 1060 women who underwent defecography, radiographic evidence of elytrocele was observed in 303. History-taking was standardized, and included obstetric, surgical and medical history as well as clinical symptoms and their duration. Group A comprised 192 women with hysterectomy while group B included 111 women with no history of hysterectomy; these two groups were compared. Group B was also compared with patients who had neither elytrocele nor hysterectomy (group C; n=516). RESULTS: Women in group B (no hysterectomy) were younger than those in group A (with hysterectomy) (57.9 years versus 62.8 years; p<0.05). Patients in group B had fewer obstetric (87.4% versus 97.9%; p=0.01) and abdominal (64.9 versus 82.3%; p=0.01) surgical events than those in group A, but more urinary tract surgery (18.9% versus 10.9%) and higher infant birth weights than patients in control group C. Six women (2%) had no surgical or obstetric history: mean age 42.7 years (20.6-74 years). Group B used protection against urinary soiling less often (17.3% versus 29.07%; p=0.017), but had more fecal soiling (23.4% versus 13.6%; p=0.033). Defecography showed that women in group B had more external rectal prolapse (17.7% versus 4.9%; p=0.003) and cystocele (48.6% versus 34.9%; p=0.019) than those in group A. CONCLUSIONS: This study was unable to identify risk factors of elytrocele in patients without hysterectomy except for a history of urinary tract surgery and higher infant birth weights. In some women, the elytrocele may be the result of significant rectal prolapse as part of a major pelvic floor disorder, predominantly in the posterior pelvis. Constitutional or congenital causes could also be involved as several young women free of any surgical or obstetric history nevertheless presented with an elytrocele.

[Gas gangrene of the abdominal wall due to underlying GI pathology: seven cases]. / Gangrène gazeuse extensive révélant une pathologie digestive: 7 observations.

OBJECTIVE: Gas gangrene of the abdominal wall is a rare clinical occurrence with high rates of morbidity and mortality. The primary source of the infection is often unknown. To analyze the primary underlying intestinal etiologies and diagnostic approaches of gas gangrene of the abdominal wall, and to highlight specific treatment problems, particularly that of constructing a colostomy exteriorized through a massively infected abdominal wall. PATIENTS AND METHODS: Seven cases of abdominal wall gas gangrene due to a gastrointestinal etiology were identified. (Cases arising from proctologic sources or related to recent abdominal surgery were excluded.) During the same period, 39 other patients presenting with abdominal wall gangrene from non-intestinal sources were treated. RESULTS: The etiologies were: perforated sigmoid diverticulitis (n=2), perforated appendicitis (n=1), acute pancreatitis with associated cecal perforation (n=1), and perforated colorectal cancer (n=3). Four of the seven patients died despite treatment (mortality of 57%). CONCLUSION: The clinical presentations of these seven cases demonstrate that a GI source must be suspected whenever a patient presents with abdominal wall gas gangrene, even when there are no specific GI symptoms. Imaging, particularly with CT scan, is essential both to visualize the extent of tissue necrosis and to reveal underlying primary GI pathology. This optimizes the surgical approach both by allowing for complete debridement and drainage of infected tissue, and by focussing the intervention on correction of the underlying primary GI source of infection.

Portal venous gas detected on computed tomography in emergency situations: surgery is still necessary.

BACKGROUND: Portal venous gas (PVG) has been reported to be associated with lethal surgical diagnosis. Recent studies tend to confirm the clinical significance of gas in the portal vein; however, some patients are managed without surgical treatment. The aim of this study was to assess both the diagnoses and the treatment of patients with PVG in an emergency surgical setting. MATERIALS AND METHODS: We performed a retrospective chart review of 15 patients with PVG in the emergency setting detected by computed tomography (CT) between July 1999 and July 2004. Characteristics assessed included age, sex, clinical presentation, first CT diagnosis of both PVG and the underlying pathology, American Society of Anesthesiologists (ASA) score, surgical findings, final clinical diagnosis, duration of hospitalization, and evolution of the illness/mortality. All patients were examined one month after operation. RESULTS: This series of 5 women and 10 men ranged in age from 38 to 90 years at the time they underwent emergency surgical treatment. The mean preoperative ASA score was 4.20. Computed tomography diagnosed the underlying pathology in all cases: bowel obstruction (4 cases), bowel necrosis (9 cases), and diffuse peritonitis (2 cases). The mean length of hospital stay was 12.4 days. The mortality rate was 46.6%; (7 patients). CONCLUSIONS: A wide range of pathologies can generate PVG. Computed tomography can detect both the presence of gas and the underlying pathology. In emergency situations, all the diagnosed causal pathologies required a surgical procedure without delay. We report that the prognosis was related to the pathology itself and was not influenced by the presence of PVG.

Bat rabies surveillance in France, from 1989 through May 2005.

In France, the passive surveillance of lyssaviruses in bats started in 1989, with the first positive case found in the East of the country. In 2000, the French bat rabies surveillance network in France was improved on the basis of the one used for the surveillance of fox rabies. The objectives of this network are to improve bat rabies surveillance by increasing the number of specimens and to provide an estimation of rabies incidence in bat populations across the country. The surveillance network is principally constituted by the network of local Veterinary Services and by the National Bat Conservationists Network (French Society for the Study and Protection of Mammals). From 1989 to through 2004, 21 autochtonous rabies cases were diagnosed out of the 934 French bat cadavers found. The laboratory techniques used for diagnosis, recommended by WHO and OIE, were fluorescent antibody test (FAT), rabies tissue culture infection test (RTCIT) on murine neuroblastoma cells, and the mouse inoculation test (MIT). All 21 cases were diagnosed in serotine bats (Eptesicus serotinus) and were due to European bat lyssavirus type 1 (EBLV-1), genotype 5, infection.

Pneumatocele formation in adult Escherichia coli pneumonia revealed by pneumothorax.

Pulmonary pneumatoceles are a rare complication of nosocomial pneumonia. They occur most often in staphylococcal infections and are hence more frequent in children. We report the case of an immunocompromised adult who shortly after digestive surgery developed Escherichia coli pneumonia which evolved rapidly towards pneumatocele formation revealed by pneumothorax.

In vitro susceptibility testing of Candida and Aspergillus spp. to voriconazole and other antifungal agents using Etest: results of a French multicentre study.

Minimum inhibitory concentrations (MICs) of the antifungal agent voriconazole were determined using the Etest and compared with those of amphotericin B, itraconazole and fluconazole using 1986 clinical isolates of Candida spp. Voriconazole MICs were also compared with those of amphotericin B and itraconazole using 391 clinical isolates of Aspergillus spp. Voriconazole was found to have more potent activity and lower MIC values than amphotericin B, itraconazole and fluconazole against C. albicans, C. tropicalis, C. parapsilosis and C. kefyr. Against C. glabrata and C. krusei, voriconazole was more active than either of the other two azole antifungals but had similar activity to amphotericin B. For species of Aspergillus, MIC values of voriconazole were lower than those of amphotericin B and itraconazole against A. fumigatus and A. flavus, and were similar to those of amphotericin B against A. niger. Against A. terreus, MIC values for voriconazole and itraconazole were similar. A. terreus is known to be resistant to amphotericin B, and this was reflected in higher MIC values compared with those of voriconazole and itraconazole. Voriconazole therefore compares very favourably with other antifungal agents against a large number of clinical isolates of Candida and Aspergillus spp.

[Abdominal wound injuries: diagnosis and treatment. Report of 79 cases]. / Les plaies pénétrantes de l'abdomen, conduite diagnostique et thérapeutique. A propos de 79 patients.

INTRODUCTION: - Traditionally, penetrating abdominal wounds justify routine laparotomy. However, this policy can be adapted to mechanism of injury (stab or firearm) and accuracy of imaging procedures if they eliminate visceral injury thus allowing close follow up. PATIENTS AND METHODS: Retrospective study of 79 patients (May 1995-May 2002) with a penetrating abdominal wound: (47 (59%) stab wounds and 32 (41 %) firearm wounds). Correlation between imaging and surgical findings, treatment, post-operative course were studied. RESULTS: Sixty-eight patients were operated on from the outset, and 11 underwent close follow-up. Of the 11 patients who had follow-up, (9 after stab wound and 2 after firearm wound), two had to be operated (1 in each group). Correlation between imaging and surgical findings was good in 34 (72%) patients after stab wound and in 21 (80%) after firearm wound; the mean number of visceral injuries was 1 and 3 respectively. Six patients (8%) died (mortality: 2% and 16% respectively), 12 (15%) had postoperative complications. CONCLUSION: Penetrating abdominal stab wounds can be treated by close follow-up if imaging excludes visceral injury. Firearm wounds still justify routine laparotomy due to both multiplicity of visceral injuries and bad prognosis.

Development of a hemi-nested RT-PCR method for the specific determination of European Bat Lyssavirus 1. Comparison with other rabies diagnostic methods.

A simplified hemi-nested reverse transcriptase polymerase chain reaction (hnRT-PCR) has been developed to determine specifically the European Bat Lyssavirus 1 (EBLV-1) nucleoprotein gene. The specificity of this method was determined by using the seven genotypes of lyssavirus by RT-PCR, Southern blot and sequence analysis. Compared to the rabies diagnostic methods, the hnRT-PCR showed a higher sensitivity for the detection of small amounts of EBLV-1 virus. In view of these results, we suggest this new hnRT-PCR should be performed for the epidemiological survey of bat colonies, also providing rapid detection and genotyping of EBLV-1 until now encountered in all naturally infected bats in France.

Genetic analysis of European bat lyssavirus type 1 isolates from France.

European bat lyssavirus type 1a (EBLV-1a) was first identified in central France from a serotine bat (Eptesicus serotinus) collected at the end of 2002. Rabies was diagnosed by reference rabies diagnosis methods and molecular tools. Phylogenetic analysis of 14 viral isolates obtained from French bats infected with EBLV-1 between 1989 and the end of 2002 against 47 nucleoprotein sequences showed a north-west to east distribution of EBLV-1a virus and a south to north distribution of EBLV-1b virus, isolates of which could be divided into two groups: group 1 in north-eastern France and group 2 in central and north-western France.

[Three-luminal nasojejunal tube in digestive surgery: preliminary feasibility study]. / Sonde nasojéjunale triple lumière en chirurgie digestive: étude préliminaire de faisabilité.

STUDY AIM: The benefit of enteral nutrition is an established fact for severely burned or multiple injured patients with a reduction of septic morbidity. Enteral nutrition is now possible in upper gastrointestinal tract surgery with the development of nasojejunal triple lumen tube and we report a new application with an operative placement. The aim of the study was to evaluate the nasojejunal triple lumen tube in digestive surgery. MATERIAL AND METHODS: From November 1999 to August 2001, a nasojejunal triple lumen tube was placed during surgery for high surgical risk patients (n = 17) or under radioscopic control for the treatment of post operative complications (n = 6). RESULTS: The surgical placement was possible in all cases. The radioscopic placement failed in two cases, one of which being solved with endoscopic procedure. There was no morbidity during the tube placement. Four patients were excluded because of early post operative death (n = 3) or premature removal of the tube by the patient (n = 1). The enteral nutrition was early in 18 patients and its mean duration was 18.2 days (range 3-75). Technical problems occurred in 9 patients and the replacement of the tube was necessary in 8 cases. CONCLUSION: The nasojejunal triple lumen tube is a feasible, safe and relatively well-tolerated procedure in upper gastrointestinal tract surgery.

[IMesenteric and mesocolic cystic lymphangiomas. Diagnostic and therapeutic management]. / Les lymphangiomes kystiques du mésentère et du méso-côlon. Prise en charge diagnostique et thérapeutique.

STUDY AIM: Study of clinical, diagnostic and therapeutic aspects of mesenteric and mesocolic cystic lymphangiomas. MATERIAL AND METHODS: 15 cases were retrospectively analysed: 5 adults (mean age 36.8 years, range 26 to 46) and 10 children (mean age 23 months, range 0 to 5 years). Diagnosis was prenatal in 1 case. Symptoms were: abdominal pain (80%), fever (20%), abdominal mass (46%), occlusive syndrome (33%), chylous ascitis 1 case. Tumours were mesenteric (86%) or mesocolic (13%). RESULTS: Complete resection was performed in 11 cases (including 10 bowel resections), incomplete resections in 3 and doxycycline sclerotherapy once. Mean follow-up is 5 years. One recurrence occurred 6 years after complete resection and 1 tumour increased after incomplete resection. Patient treated by sclerotherapy was non symptomatic with a 3.5 years follow-up after last injection. CONCLUSION: Mesenteric and mesocolic cystic lymphangiomas are congenital benign tumours. Complete resection should be performed whenever possible. Intracystic sclerotherapy with doxycyclin is possible for unresectable lymphangiomas.

Grafting of large pieces of human reconstructed skin in a porcine model.

Present techniques can save about 25% of patients burnt over more than 90% of their body surface. However, problems of functional and aesthetic repair arise, which are often resolved only by major therapeutic procedures. Current advances in skin substitutes permit the cultivation, from a skin biopsy, of large surfaces of in vitro human reconstructed skin (HRS). Our model, obtained by the co-culture of fibroblasts and keratinocytes on a dermal substrate composed of collagen-glycosaminoglycan-chitosan, reproduces, in vitro, a tissue close to human skin, which could play a role in reconstructive surgery. The objectives of this experiment were to assess whether it is possible to perform large HRS grafts and to evaluate the preliminary cosmetic results. We used four immunosuppressed female pigs. Full-thickness skin resections of 50-100 cm(2)were performed on the dorsa of the animals. The defects were grafted with between one and six pieces of HRS under tied-over dressings. At day 14, we found a soft and smooth surface of good transparent healthy pink skin, which was very easy to distinguish from the surrounding tissues. The junctions between different pieces of living skin were not visible. Immunohistological studies with specific anti-human keratin 14 antibodies confirmed the graft take: 7 days after grafting the human epidermis was attached to the living dermis and showed good organisation with a basal cell layer and suprabasal cells; 28 days after grafting the human epidermis seemed to be replaced by pig epidermis. This study highlights the possibility of grafting large surfaces with HRS using a routine operating technique.

Incidence and risk factors of preparation errors in a centralized cytotoxic preparation unit.

OBJECTIVE: A major objective of centralized preparation is to improve the quality of the final product, and thus their safety for the patient. Few data are available concerning errors occurring during preparation and the risk factors associated with the errors. To assess risk factors associated with preparation errors in a centralized cytotoxic preparation unit. DESIGN: Medication errors were detected during preparation (self-education by technicians) or at the time of control (qualitative and semi-quantitative). For each preparation, several potential risk factors were studied. Univariate analysis was carried out using Chi-2 or Fisher exact tests. Variables with p < 0.15 associated in univariate analysis were entered in a stepwise regression model. In an overall analysis, all types of error were considered. In a second analysis, only major errors (errors associated with drug, dose or major incompatibility) were studied. RESULTS: Analysis included 30,819 preparations. Overall and major error rates were respectively 0.45% and 0.19%. The number of bottles (more than one), the volume of active solution (more than 50 ml) and the daily workload were the major risk factors identified by successive univariate and multivariate analysis. CONCLUSION: Low rates of medication errors compared to previous studies were reported. Major preparation errors were principally related to drug labeling (dose/bottle and concentration) and workload. Preparation mistakes appeared to have many causes. These results could be used to revise the general organization and determine a suitable purchasing policy.

Risk factors for catheter-associated bacteriuria in a medical intensive care unit.

In a prospective study including 137 consecutive catheterised patients in a medical intensive care unit, the following variables were analysed as possible risk factors for catheter-associated bacteriuria, defined as a quantitative culture with > or = 10(5) organisms/ml: age, sex, simplified acute and physiologic score at admission, duration of catheterisation, diabetes mellitus, immunosuppression, neurologic disorders and prior systemic antibiotic exposure during hospitalisation. The frequency of catheter-associated bacteriuria was 30.7%. By multivariate analysis, female sex (odds ratio [OR], 5.1; 95% confidence interval [CI], 1.9-13.5; P=0.001) and a duration of catheterisation >11 days (OR, 19.4; 95% CI, 5.5-68.7; P=0.0001) were risk factors for catheter-associated bacteriuria, and prior antibiotic exposure was a protective factor (OR, 0.06; 95% CI, 0.019-0.21; P=0.0001).

[Cultured epidermis for the treatment of severe burns. A 2-year study (18 patients)]. / Les cultures d'épiderme pour le traitement des grands brûlés. Etude sur deux ans (18 patients).

AIM OF THE STUDY: For fifteen years, Edouard Herriot Burn Center has been using cultured epidermis provided by an hospital Laboratory. This means of production results in great freedom for their application compared with the centers who have to buy the cultured epidermis. In order to evaluate our clinical results, a two-year study has been performed. MATERIAL AND METHODS: Eighteen patients suffering acute burns were concerned. The average burned area was 68% of the total body surface (range 49 to 88). The average age was 31.6 years, ranging from 1 to 58, including two children. Even autologous or allogenic epidermis was used. In our series cultured epidermis was grafted according four different strategies. It was the preparation of the wound bed by skin allografts, the association of widely meshed auto-graft with cultured epidermis, the stimulation of the healing of extensive deep second degree burns with allogenic epidermis, and the coverage of skin auto-graft donor sites. RESULTS: Two patients died. For the survivors, the average hospital stay was 60 days (range 22 to 90), and on average 70 days over 70% TBSA burns. Cultured epidermis allowed the definitive coverage of 17% of the total body surface of the patients. This study supports the importance of a careful preparation of the patient for the engraftment of cultured epidermis. CONCLUSION: In our opinion, in spite of the difficulties of handling of cultured epidermis, they represent a precious means of coverage for the rapid and definitive healing of extensive burns over 70% TBSA.