Comparison of real costs in the French healthcare system in newly diagnosed patients with pemphigus for first-line treatment with rituximab vs. standard corticosteroid regimen: data from a national multicentre trial.

BACKGROUND: Rituximab has been demonstrated to be highly effective as a first-line treatment for moderate-to-severe pemphigus; however, its high cost can be considered a limitation of this treatment. OBJECTIVES: To compare direct costs of two regimens, rituximab + short-term prednisone vs. prednisone alone, tested in the Ritux3 trial. METHODS: Patients were randomly assigned to receive 2 g of rituximab and two 500-mg maintenance infusions at month 12 and month 18 along with low doses of prednisone for 3-6 months, or high doses of prednisone alone tapered over 12-18 months. We estimated the direct costs related to (i) protocol (treatments, consultations, hospitalizations); (ii) unfavourable disease course (relapse); and (iii) adverse events in both treatment groups during a 3-year follow-up. RESULTS: Annual individual cost discrepancies related to drugs decreased from +€3597 to -€1589 from the first to the third year, which corresponded to an initially higher cost in the rituximab group, counterbalanced during follow-up by costs related to treatment of patients with persistent disease activity/relapses in the standard corticosteroid (CS) group. Individual costs relating to treatment of adverse events were higher in the standard CS group (€4352) than in the rituximab group (€2468). Overall, mean individual total cost over the 3 years of follow-up was €13 997 in the standard CS arm vs. €14 818 in the rituximab arm, corresponding to a difference of €821 more per patient (+6%). CONCLUSIONS: First-line treatment of pemphigus with rituximab results in a slightly greater cost compared with a standard CS regimen. What's already known about this topic Rituximab is the most effective treatment for moderate-to-severe pemphigus. Rituximab cost might be considered as a limitation of this treatment. What does this study add? After 3 years of follow-up, mean individual total cost for a patient with first-line treatment with rituximab was €14 818 vs. €13 997 with standard corticosteroids (CS), resulting in a slightly higher cost of €821 (+6%). The initially greater cost of rituximab was counterbalanced by costs related to management of flares/relapses in patients treated with a standard CS regimen.

[Pre-hospitalization unit: A simple organization and a place for internists to improve the non-scheduled hospitalization stream from emergencies]. / Unité d'attente d'hospitalisation : une organisation simple et une place pour les internistes pour améliorer la filière d'hospitalisation non programmée à partir des urgences.

INTRODUCTION: The adult emergency department at Rouen University hospital (CHU) welcomes over 100.000 patients per year. In order to streamline unscheduled hospital admissions from the emergency room (ER), a 20-bed pre-hospitalization unit and a centralized bed management system (bed manager, bed manager software, dedicated beds) have been put into place. PATIENTS AND METHODS: Emergency admissions have increased by (+3.5% between 2017 and 2018) with 20% direct hospitalization from the ER to other conventional units (2/3 in medicine, 1/3 in surgery). In 2018, 3450 patients, of which 54% aged over 75 years have been admitted in the pre-hospitalization unit with an average length of stay of 1.3±1.4 days: 35.4% stayed less than 24hours and 34.8% more than 48hours of which 5.2% stated more than 4 days, 132 patients (3.8%) died, 805 patients (23.3%) were discharged at home, 220 (6.4%) transferred to another facility, and 2287 (66.3%) were secondarily hospitalized in another hospital unit: more than 9 times out of 10 in a medicine unit (internal medicine 30%, geriatrics 27.9%, respiratory medicine 12.2%). This unscheduled emergency hospitalization allowed a daily hospitalization of 50 short stay inpatients beds. It has to be noted that the number of available inpatient beds clearly decreases during the week-ends. The main pathologies were respiratory infections (14.2%), heart diseases (9.7%), metabolic disorders (3.9%), and urinary tract infections (13.6%). CONCLUSION: This pre-hospitalization unit associated with a centralized bed management system has clearly improved the unscheduled hospital admissions, in particular concerning the emergency medical sector. The lack of inpatient beds at the week-end and the management of epidemic periods still remain a challenge that has to be taken up.

[Adrenalectomy for adrenal metastases: is the laparoscopic approach beneficial for all patients?]. / Surrénalectomie pour métastases surrénaliennes: la voie d'abord laparoscopique est-elle bénéfique pour tous les patients ?

INTRODUCTION: Laparoscopy has become the gold-standard approach for excision of benign adrenal tumors but the question of its safety for malignant lesions is still controversial. Our aim was to evaluate the oncologic outcome of laparoscopic adrenalectomy for adrenal metastasis and to look for predictors of a negative surgical outcome. PATIENTS AND METHODS: We retrospectively reviewed the charts of all patients who underwent laparoscopic adrenalectomy for suspicion of adrenal metastasis between 2007 and 2013 at a single academic institution. Recurrence-free survival (RFS) and cancer-specific survival (CSS) were estimated using the Kaplan-Meier method. Univariate analysis was performed to determine risk factors of negative surgical outcome (positive surgical margins, complications, conversion, significant blood loss) and predictors of RFS and CSS. RESULTS: Thirteen patients underwent 14 laparoscopic adrenalectomies. All patients were operated by a single highly experienced surgeon. Complications occurred in 2 patients (15%): 2 blood transfusions (Clavien-score=2). There were 3 positive surgical margins (21%). Mean length of hospital stay was 4.3 days. Unadjusted RFS and CSS were respectively 48.4% and 83.3% at 1 year, 39.5% and 66.7% at 5 years. In univariate analysis, tumor size was the only risk factor of complication (P=.009) and conversion (P=0.009). Capsule invasion and tumor size were risk factors of positive surgical margins (P=0.01 and P<0.0001). One hundred percent of complications, conversion and positive surgical margins occurred in tumor>7.5 cm on preoperative CT-scan. No predictors of RFS and CSS was found in univariate analysis. CONCLUSION: Laparoscopic adrenalectomy for adrenal metastasis achieves good surgical and oncologic outcomes. When performed by highly experienced surgeon, complications and positive surgical margins occur only in tumors>7.5 cm. These patients may benefit from an open surgical approach.

Indicator organism sources and coastal water quality: a catchment study on the island of Jersey.

Compliance monitoring of bathing waters at La Grève de Lecq on the North coast of Jersey revealed a significant deterioration in water quality between 1992 and 1993, as indexed by presumptive coliform, presumptive Escherichia coli and streptococci concentrations. During the 1993 bathing season the beach failed to attain the compliance with the EC Guideline criteria for presumptive E. coli and streptococci. A bacteriological survey of the stream catchment draining to the beach revealed that: (i) concentrations of faecal indicator organisms were enhanced at high discharge after rainfall; and (ii) a captive water fowl population, which expanded between 1990 and 1993, was a potential source of faecal pollution. Strategies for catchment management are discussed.

Legacy systems: managing evolution through integration in a distributed and object-oriented computing environment.

Legacy systems are crucial for organizations since they support key functionalities. But they become obsolete with aging and the apparition of new techniques. Managing their evolution is a key issue in software engineering. This paper presents a strategy that has been developed at Broussais University Hospital in Paris to make a legacy system devoted to the management of health care units evolve towards a new up-to-date software. A two-phase evolution pathway is described. The first phase consists in separating the interface from the data storage and application control and in using a communication channel between the individualized components. The second phase proposes to use an object-oriented DBMS in place of the homegrown system. An application example for the management of hypertensive patients is described.

[Thermal isolation of the heart by means of a plastic foam pad during surgical cooling of the heart: experimental study]. / Isolation thermique du coeur par patin de mousse plastique au cours de la réfrigération chirurgicale du coeur. Etude expérimentale.

Maintenance of myocardial cooling during aortic clamping is a problem encountered currently during heart surgery. A plastic foam isolation pad was studied. Eight animals (pigs weighing 50 kg) were placed on extracorporeal circulation, 4 of them constituting the control group (A). Two coronary injections of a cardioplegic solutions were administered, the first at the time of aortic clamping and the second 30 minutes later. The myocardium of the 4 animals in the treated group (B) was isolated with the foam pad, and this significantly prolonged the "cold" effect of the cardioplegic. Ten minutes after injection of the cardioplegic, temperature of the total myocardial mass with isolation was between 10.7 and 12 degrees C, as against 16 to 18 degrees C in the reference group (p less than 0.05). By the 20th minute, the isolated myocardium was at approximately 15 degrees C as against 22 degrees C in group A (p less than 0.01). Finally, by the 30th minute, temperature in group B was 17 degrees C as against 23 degrees C in group A (p less than 0.01). Reheating of the heart was significantly slowed by thermal isolation, though the limit of 15 degrees C was reached by the 20th minute. To ensure that myocardial temperature remains below this limit when the foam pad is employed, further injections of cardioplegic solutions are necessary every 20 minutes.