[Design, implementation and evaluation of an educational approach for patients with PICC line and midline]. / Conception, réalisation et évaluation d'une démarche éducative auprès des patients porteurs de PICC line et midline.

OBJECTIVES: Design the competency framework and an interview guide for patients with PICC line or midline. Develop a patient satisfaction evaluation questionnaire. METHODS: A multidisciplinary team has developed a reference system for the skills of patients with PICC line or midline. The skills are classified in three categories: knowledge, know-how and attitudes. An interview guide was written in order to transmit the priority skills, determined beforehand, to the patient. A second multidisciplinary team designed a questionnaire to evaluate patient satisfaction. RESULTS: The competency framework includes nine competencies: four, knowledge-based; three, know-how-based and two, attitude-based. Among these competencies, five were considered to be priorities. The interview guide is a tool that allows care professionals to transmit the priority skills to patients. The satisfaction questionnaire explores the information received by the patient, the passage through the interventional technical platform, the end of the management before the return home, and the overall satisfaction of the patients with the course of the device placement. Over a 6-month period, 276 patients responded with a high satisfaction rate. CONCLUSIONS: The PICC line or midline patient's competency framework has made it possible to list all the skills that patients should acquire. The interview guide serves as a support for the care teams in the patient education process. This work could be used by other establishments to develop the educational process around these vascular access devices.

[Contribution of computer-aided design for the conception of custom-made implants in Pectus Excavatum surgical treatment. Experience of the Nantes plastic surgery unit]. / Apport de la conception assistée par ordinateur (CAO) à la réalisation des implants thoraciques sur mesure pour correction des pectus excavatum. Expérience du CHU de Nantes.

INTRODUCTION: Pectus excavatum is the most common congenital chest malformation and is a common reason for consultation in plastic surgery. Our attitude is most often a filling of the depression with a custom-made silicone prosthesis. The objective of this work was to evaluate the interest of computer-aided design (CAD) of implants compared to the conventional plaster molds method. PATIENTS AND METHODS: We have collected all the cases of custom-made silicone implants to treat funnel chests in our plastic surgery department. The quality of the results was evaluated by the patient, and in a blind manner by the surgical team using photographs and standardized surveys. The pre-operative delays, the operating time and length of hospital stays, the number of surgical recoveries, and the post-operative surgical outcomes were recorded. RESULTS: Between 1990 and 2016, we designed 29 silicone thoracic implants in our department. Before 2012, implants were made from plaster chest molds (n=13). After this date, implants were designed by CAD (n=16). Patients rated their results as "good" or "excellent" in 77% and 86% of cases respectively in the plaster and CAD groups. The surgical team's ratings for CAD implant reconstructions were better than in the plaster group: 8.17 versus 6.96 (P=0.001). CAD implants were significantly less detectable than the plaster group implants. The operating time was reduced in the CAO group: 60.2 compared to 74.7minutes in the plaster group (P=0.04), as was the length of hospitalization: 3.5 versus 5.3 days (P=0.01). There were no significant differences between the two groups in terms of post-operative complications. CONCLUSION: The management of pectus excavatum by a custom-made silicone implant is a minimally invasive method that provides good cosmetic results. The design of these implants is facilitated and qualitatively improved by CAD.

[Hospital production cost of repetitive transcranial magnetic stimulation (rTMS) in the treatment of depression]. / Coût de production hospitalier de la stimulation magnétique transcrânienne répétée (rTMS) dans le traitement de la dépression.

BACKGROUND: Repetitive transcranial magnetic stimulation (rTMS) is an effective and well-tolerated treatment in resistant depression with mild to moderate intensity. This indication has not yet been approved in France. The cost and medico-economic value of rTMS in psychiatry remains unknown. The aim of this preliminary study was to assess rTMS cost production analysis as an in-hospital treatment for depression. METHODS: The methodology, derived from analytical accounts, was validated by a multidisciplinary task force (clinicians, public health doctors, pharmacists, administrative officials and health economist). It was pragmatic, based on official and institutional documentary sources and from field practice. It included equipment, staff, and structure costs, to get an estimate as close to reality as possible. First, we estimated the production cost of rTMS session, based on our annual activity. We then estimated the cost of a cure, which includes 15 sessions. A sensitivity analysis was also performed. RESULTS: The hospital production cost of a cure for treating depression was estimated at € 1932.94 (€ 503.55 for equipment, € 1082.75 for the staff, and € 346.65 for structural expenses). CONCLUSION: This cost-estimate has resulted from an innovative, pragmatic, and cooperative approach. It is slightly higher but more comprehensive than the costs estimated by the few international studies. However, it is limited due to structure-specific problems and activity. This work could be repeated in other circumstances in order to obtain a more general estimate, potentially helpful for determining an official price for the French health care system. Moreover, budgetary constraints and public health choices should be taken into consideration.

[Cost-effectiveness analysis of vacuum-assisted closure in the surgical wound bed preparation of soft tissue injuries]. / Evaluation coût-efficacité de la thérapie par pression négative dans la préparation chirurgicale des pertes de substance cutanée.

This work proposes, from the point of view of the University Hospital Center of Nantes (acute care), a cost-effectiveness assessment of negative pressure wound therapy (NPWT), in comparison with moist wound therapy, in the surgical preparation of cutaneous defects requiring reconstructive surgery. This retrospective study was realized after data collection from patient files with hospitalization for the management of open-leg fractures with a view to reconstructive surgery by graft or flap (Cauchoix II or III). Effectiveness criteria, after debridement and NWPT initiation, was the time period required for preparing the wound for definitive reconstructive surgery closure by flap or graft. NWPT is compared, over the same 2000 to 2006 period, to the only existing therapeutic alternative, that is to say moist wound therapy. Only direct costs in relation with consumed resources dedicated to each medical strategy were taken into account. A Mann-Whitney U nonparametric test and boostrap technique have been used for statistical and sensitivity analysis. Twenty-five patients were recruited for the two medical strategies. Wound preparation time is significantly shorter for patient treated with NPWT (p=0.026 Mann-Whitney U-test) and is equal to 20 days less on average for time period required for preparing the wound for reconstructive surgery. Hospitalization costs is very significantly lower for patients being treated with NPWT (p=0.02). In absolute value, this cost is reduced on the average by 6000 euro per patient (i.e. by more than 60%). The incremental cost-effectiveness ratio is of the order of 164 euro per day of wound preparation for surgery gained.

Risks of reusing coronary angioplasty catheters: results of an experimental study.

This experimental study was conducted to evaluate the microbiological and mechanical risks of reusing angioplasty catheters after decontamination and resterilization. The catheters studied were decontaminated in an ultrasound chamber, rinsed, dried, wrapped, and resterilized at 25 or 35 Kgray. Sterility checks performed on catheters cut into three segments concerned bacteria, mushrooms, yeasts, and pyrogens. The surface condition of the balloons was studied by scanning electron microscopy. The mechanical properties analyzed were balloon diameter and bursting pressure and the mean resistance of the catheter body to breakage. Seventy angioplasty catheters of three different types (rapid exchange, coaxial, and on-wire balloon catheter) were tested. Decontamination proved insufficient owing to the persistence of cellular elements on the balloon surface and the presence of pyrogens. Sterility of the material was not ensured with an irradiation of 25 Kgray. It was probable but not certain with 35 Kgray, since an inhibitory effect on micro-organism growth was noted. Mechanical properties were not modified significantly. Our results do not favor the reuse of coronary angioplasty catheters. Better decontamination is desirable but difficult to obtain because of the adhesion of cellular elements to the polymers composing the catheters. Although our results are not necessarily applicable to all resterilization protocols, they indicate that teams desiring to reuse angioplasty material should first test the validity of their procedure for decontamination and resterilization.