[ENVOL study on the medical management of varicella and its complications in French ambulatory care]. / Prise en charge de la varicelle et de ses complications en médecine ambulatoire en France: l'étude ENVOL.

OBJECTIVE: The authors had for aim to describe the management of varicella and its complications in French ambulatory care. METHODS: A descriptive prospective national survey was carried out in France on patients visiting a random sample of French GPs and pediatricians (investigators) having diagnosed varicella. During an inclusion period of 4 months, the investigators enrolled all patients (adults-children) who presented with varicella or varicella related complications, and who had not previously visited the investigator for this episode. Three questionnaires were used to record the data. RESULTS: One thousand two hundred patients were enrolled by 393 physicians 75% of whom were GPs. Ninety-four percent of patients were children under 13 years of age (group I). The sex ratio (M/F) was 1.1. The mean age was 3.5 years in group I and 23.8 years in patients over 13 years of age (group II). The mean length of the varicella episode was about 10.7 days. Most patients were given a pharmaceutical prescription on inclusion, 1% were also prescribed medical procedures, 0.3% were given local treatment, and 0.09% underwent physical therapy sessions. A proportion of 12.6% of patients visited their physician twice or more for the same episode. Six group I children were hospitalized. Eighty-seven patients presented with at least one complication i.e. 7.8% (95%CI=6.3-9.3) of all episodes, mainly bacterial superinfections. CONCLUSIONS: The rate of complications associated with varicella infection was higher than usually reported in France but in the same order of magnitude as in other developed countries. Bacterial superinfections were found to be the most frequent complications of varicella.

Effects of dyskinesias in Parkinson's disease on quality of life and health-related costs: a prospective European study.

The treatment of Parkinson's disease (PD) with l-DOPA leads to involuntary movements (dyskinesias). This 6-month observational study in three European countries in PD patients with various degrees of motor complications examined the effects of dyskinesias on the quality of life (QoL) of patients and health care costs. Retrospective and prospective health economic data were collected, and QoL of patients was measured using the Short Form-36 (SF-36) and the PD Quality of Life (PDQL) Scale. Regression analysis was used to estimate the adjusted effects of dyskinesias on QoL and costs, whilst accounting for the potentially confounding effects of disease progression, motor fluctuations and country. Increasing dyskinesia scores on either the Unified PD Rating Scale or the Goetz Dyskinesia Rating Scale were associated with significant reductions in QoL scores on the SF-36 and PDQL Scale. Increasing dyskinesia severity was also associated with increased depression scores on the Montgomery-Asberg Depression Rating Scale along with significant increases in health care costs. The effects of dyskinesia on QoL, depression and costs decreased but remained significant after adjustment for the confounding effects of disease progression and motor fluctuations. In conclusion, dyskinesias may adversely affect QoL and increase health care costs in patients with PD. Future studies should evaluate the potentially beneficial effects in terms of QoL and health care costs of strategies to delay the onset of, or the treatment of, dyskinesias.

Donepezil for the treatment of mild to moderate Alzheimer's disease in France: the economic implications.

In the present study, the socioeconomic impact of the use of the acetylcholinesterase inhibitor donepezil in patients with mild to moderate Alzheimer's disease (AD) living in France was examined. A model was created to extrapolate over a 3-year period the results from placebo-controlled trials together with epidemiological and prevalence data. Costs considered in the model were net societal costs associated with paid and unpaid assistance, general medical consumption and institutional care. The model suggested that delays in cognitive decline and functional dependence due to treatment reduced the time spent in institutional care and the burden on caregivers. Over a 3-year period, total net costs of caring for untreated patients with an initial Mini-Mental State Examination score ranging from 10 to 26 were EUR 53,206 compared with EUR 42,720 for a patient treated with donepezil--an annual cost saving of approximately EUR 3,500 per patient. Cost savings were mainly due to savings in unpaid caregiver time, which, apart from patient institutionalization, represented the most costly component of total care in this study but had no direct budgetary impact. Overall, these data suggest that donepezil is a cost-effective treatment for mild to moderately impaired AD patients living in France.

Economic evaluation of enoxaparin vs. placebo for the prevention of venous thromboembolism in acutely ill medical patients.

OBJECTIVES: This paper presents an economic evaluation of a strategy of thromboprophylaxis in acutely ill medical patients with enoxaparin 40 mg vs. no intervention in the context of the French Health System. METHODS: The evaluation used a decision-analysis model to simulate the results of a hypothetical naturalistic, long-term study reflecting the usual care pattern for the patients. The short-term outcomes were derived from an international, double-blind, placebo-controlled randomized clinical study performed in 1102 patients older than 40 years. Treatment was scheduled to last 10 +/- 4 days and primary outcome was venous thromboembolism events rates between days 1 and 14 assessed clinically or through systematic contrast venography. RESULTS: For an hypothetical cohort of 1000 hospitalized medical patients, the model suggested that the prophylaxis strategy would avoid between 1 and 10 deaths (median 4) and between 60 and 127 cases of venous thromboembolism events (median 94). By including or not the costs associated with long-term complications (post-phlebitis syndrome), the net extra cost per patient was estimated as a net saving or 35,857 Euros (Euro), respectively. The corresponding cost-effectiveness ratios in terms of cost per avoided death were a net saving or Euro 8102 (median value), respectively. CONCLUSIONS: Thromboprophylaxis with enoxaparin in hospitalized acutely ill patients over 40 years of age appears to be an efficient strategy using French cost data.

[Maternal mortality and referral maternities in Morocco: how to (re)motivate professionals?]. / Mortalité maternelle et maternités de référence au Maroc: comment (re)motiver les professionnels?

The very high rates of maternal mortality and perinatal mortality, as well as the deficiencies and dysfunctions observed in maternity hospitals, which play the role of referential maternity wards, led the Moroccan Minister of Public Health to implement a project in order to improve the quality of care of parturient women and new-borns. This project included 8 provinces in the country. The strategy chosen was "the team approach to resolving health problems", which is a learning process which leads local teams to implement and evaluate projects they have developed themselves. This pedagogical approach, which is carried out over a period of more than a year, proved itself to be very motivating and mobilising for the professionals included, despite the obstacles that were encountered. It also contributed to creating a true team spirit. Most activities planned within these projects were carried out and many indicators improved.

[Contributions to the sociologic analysis of the impact of sickle cell disease on families from Northern Tunisia]. / Contribution à l'analyse sociologique des répercussions de la drépanocytose dans des familles du nord Tunisien.

The improvement of the conditions of care and quality of life of people living with drepanocytosis now constitutes a major concern of health authorities and voluntary groups (associations of sick people and their parents). In order to examine the conditions and methods of care for children living with drepanocytosis in the Bizerte region of Northern Tunisia and to understand the problems and difficulties experienced by them and their families in their daily lives, an anthropological study was carried out in the region between January 16 and February 12, 1997. Thirty-three interviews were carried out with families of infected children. The interviews were semi-directive using a pre-established protocol (interview guide). Thirty interviews were then analysed. A multitude of information concerning various medical and psycho-social aspects of drepanocytosis in the region were revealed. The data were regrouped into the following categories: circumstances of discovering the illness; explicative model of the illness as perceived by the people interviewed; conditions and methods of care of the sick child; degree of satisfaction with the health care system; psychological profile of the children interviewed; educational level of the children interviewed; repercussions the illness has on the family; impact of the illness on household budget; suggestions and comments of the people interviewed. In light of the information collected, various actions have been proposed with the goal of improving the conditions of care and quality of life of people living with drepanocytosis in the region.

[Fragile X syndrome is still unrecognized: efficacy of molecular diagnosis in mentally retarded probands]. / Le syndrome X fragile est encore méconnu: efficacité du diagnostic moléculaire chez les proposants avec retard mental.

BACKGROUND: The fragile X mental retardation syndrome is the most common cause of inherited mental retardation. Identification of the unstable mutation responsible for the disease has allowed the design of a fully reliable molecular test for the diagnosis of the disease and for genetic counselling (identification of clinically normal carriers and prenatal diagnosis). We started in July 1991 to search for the mutation in mentally retarded probands, with no known cause for their phenotype. We present the results of a 42-month experience. POPULATION AND METHODS: One thousand and one hundred fourty-nine probands were analysed. In case of a positive diagnosis, an extension of the molecular study to relatives was proposed. DNA samples were studied by Southern blot following EcoRI or EcoRI + EagI digestion. Clinical data were collected from referring clinicians. RESULTS: Seventy-three carriers of a full mutation were identified, belonging to 52 families. The mean age of the fragile X probands was 16 +/- 14 years, which is very surprising for a disease that causes significant manifestations by the age of 2 to 3 years. This indicates an insufficient knowledge about this disease in France. Most of the demands for the test were from clinical geneticists. This diagnosis is of major importance for genetic counselling, as illustrated by the following study of 108 women at risk in these families. CONCLUSIONS: The importance of an early diagnosis followed by an extended family study, for carrier screening and prevention of this severe disease, justifies molecular testing on any child with mental retardation or significant language delay of unknown cause, in the absence of clinical signs formally excluding a fragile X diagnosis.

An outbreak of hepatitis A in a French day-care center and efforts to combat it.

An outbreak of hepatitis A in a French day-care center was identified during a survey of risk factors for such events in a sample of 210 centers. In the period between 29 March and 9 July 1994, 17 cases were diagnosed in the center (anti-HAV IgM serum antibody) including 11 children aged 2-3 (attack rate = 55.5% of class), 2 staff members, 3 parents and 1 educator-parent (secondary attack rate = 27.6%). The source case was probably a classmate of Case 1's older brother, who was diagnosed earlier in the spring. Intensive hygiene measures and the organisational features of the clinic limited all transmission except by direct physical contact with infected children. Vaccination of staff was begun too late to be effective; gamma-globulin prophylaxis might have been administered but was not. This is the first documented outbreak of the disease in a French center.

[Recurrent respiratory infections in patients with chronic obstructive bronchitis: medical treatment and costs]. / Infections respiratoires récidivantes du sujet atteint de bronchite chronique obstructive: prise en charge médicale et coûts.

The objective of this study is to describe usual medical management and costs associated with recurrent respiratory infections in subjects with chronic obstructive bronchitis in France. A prospective survey was performed in Autumn 1994 on a national sample of private practice pulmonologists (N = 71). Two hundred forty-four patients, presenting at least one infection of the lower respiratory tract, were included. Bronchitis was the most frequent acute exacerbation observed (94%). Pneumonia concerned 9% of the patients. Biological tests, X-rays and pulmonary function tests were prescribed for, respectively, 59, 65 and 45% of the patients. Following the visit, 15 patients were hospitalized (6%). The direct medical cost per acute exacerbation was estimated 3,289 francs (1994 value) of which 60% were hospital-related. An average 10.4 day sick-leave was prescribed to 21% of patients in employment. For those patients, this sick-leave was associated to an extra-cost of 1,264-1,876 francs for Social Security and of 0-2,553 francs out of pocket per episode varying according to their Benefit Regimen.

[Requests for prenatal diagnosis from parents of children with cystic fibrosis]. / Recours au diagnostic prénatal chez les parents d'enfants atteints de mucoviscidose.

The request for prenatal diagnosis of cystic fibrosis has been evaluated by an interview during a visit at a cystic fibrosis clinic among 32 couples whose one or several children are affected. Six couples resorted to the procedure between June 1984 and October 1985. In all the cases, in these families the only child (or children) alive was affected. The diagnosis of the disease in the first affected child reduces the number of children planned by the family. The significant use of the test, since its availability points to the existence of a real demand from the parents.

[Hospitals transfers of children of Maghreb countries. Reflections on current problems and short- and long-term solutions]. / Les transferts sanitaires d'enfants des pays du Maghreb. Réflexion sur les problèmes actuels et sur les solutions à court et à long terme.

Every year, several thousands of North African children receive transfers to France for hospitalization. The need for these medical transfers is linked to a rapidly expending population, improving diagnostic techniques and inadequate therapeutic technology. Affected children are referred most often for cardiac and oncological diseases. Efforts have been made to discern the medical indications for such transfers, to facilitate the acceptance by social aid agencies and to provide the best possible psychosocial and educational settings for the children involved. Yet, many problems remain, such as advanced disease states and associated diseases at the time of transfer, affective disorders, worsened by the prolonged stay in hospital. Solutions must be found for these problems. Examples would include close collaboration between referred North African and French medical teams, and the existence in France of cultural environment sensitive to the needs to the North African patients. Because transfers are responsible for a high financial and affective cost, and for a dependent relationship between countries, long-term solutions must be considered and could include the transfer of technology and cooperation in research rather than medical care.

The programme for combating diarrhoeal diseases in Haiti.

PIP: A national program for controlling diarrhea and promoting breastfeeding was launched by the Haitian Government in July 1983 with the aim of reducing the diarrhea mortality rate by 50% over a 3-year period. After almost 2 years of operation, the program is judged to have been successful in terms of the implementation of activities, the preparation and distribution of educational materials, and the mobilization of health workers and volunteers. In 1984, 6875 medical and paramedical personnel, 5500 national scouts, and 5283 people on the community level were trained in oral rehydration techniques. Over 600,000 packets of oral rehydration serum were sold or distributed by a total of 2311 distribution sites. Successes achieved are considered to be due to a combination of institutional, community, multisectorial, and commerical approaches. Although the statistics from 1984 suggest significant program activity, the results of such activities have not been evaluated. For example, the program's impact on the incidence of diarrhea and dehydration or mortality caused by diarrhea remains unknown. Moreover, the 2md aspect of the program--promotion of breastfeeding--has been neglected to date and will be the focus of a separate campaign scheduled to begin in June 1985. There is some evidence that other priorities of the Ministry of Public Health and Population, including vaccinations, nutrition, family planning, and the fight against tuberculosis and malaria, received dwindling attention during the period of the campaign against diarrhea. This seems to reflect the phasic approach of health authorities.^ieng

Family planning training and community needs.

PIP: Training programs in family planning should be reoriented to reflect educational objectives and training methods that are of relevance for the future activities and tasks of workers, and to include greater attention to psychosocial aspects and the identification of community needs and resources. This article reviews the overall methodological principles involved in teaching or leaning family planning, reviews and analyzes the functions and tasks of different categories of family planning workers, and outlines the methodology of community diagnosis. Teaching of family planning is based on the same prinicples as teaching any other aspect of health: defining tasks and educational activities, planning an evaluation system, preparing and implementing an educational program, and implementing evaluation. Educational objectives are directly derived from tasks which workers will be called upon to accomplish. The application of the methodology can lead to improved training of health workers only if the training system is closely related to the health problems of the community. Different categories of family planning workers include physicians, nurses and midwives, auxiliary workers, community development agents, and others, and the main activities involved concern administration; getting to know the community; recruiting clients; clinical, educational, management and supervisory, evaluation, and research activities; and the psychosocial dimension of family planning activities. A possible methodology for the distribution of activities and tasks among the different categories of workers involves constructing a table which lists activities, corresponding tasks, and categories of workers, taking into account legal restrictions, manpower constraints, local community custom, and similar factors. A community diagnosis of family planning needs involves identifying problems, needs, and resources; establishing priorities; defining objectives for action; establishing the plan of action; and evaluation. Direct links should be maintained between the community diagnosis and training.^ieng

Training health personnel in the area of breast-feeding.

One of the key factors in the prevalence and duration of breastfeeding is the position taken by health personnel, and the practices adopted in hospitals and health centers. It is thus important that health personnel be made aware of their crucial influence in this domain, and be prepared to provide the necessary information and support 1st to pregnant women in their choice of mode of infant feeding, and then to those who choose to breastfeed. The author analyzes the moments which are critical in the decision to breastfeed and in successful lactation, and recommends on this basis the various elements which should be included in the training of the different categories of health personnel. The successful promotion of breastfeeding depends not only on their acquisition of knowledge in the management of breastfeeding, but also on their attitudes.

Elements for a policy promoting breast feeding.

PIP: The development of a policy for promoting breast feeding, in light of its declining practice, is discussed. In order to reverse the decline, it is important that legislative measures be taken to allow breast-feeding without economic disadvantage, that the public be educated to the desirability of breast-feeding, that health services be reorganized to encourage breast-feeding, and that health personnel be trained to promote a positive attiude toward breast-feeding.^ieng