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Background and Objectives Dental caries remain the preeminent oral disease of school-age children and most adults in developed countries. Main complications are loco regional abscesses, cellulitis and systemic bacterial grafts such as Osler endocarditis. In a 1-year period, we have identified about 60 infectious emergencies cases requiring hospitalisation at the Saint Vincent de Paul Hospital and surgery under general anaesthesia in emergency. In 2006, the delay between hospitalisation and oral care was up to 4 days when the child was admitted through the home emergency (HED) or paediatric department, while it was only half a day when the child was directly examined in the maxillo-facial department. Analysing those delays highlighted the increased dysfunctions induced by the absence of dental and paediatric maxillo-facial emergency in Paris. Therefore, our initial objective was to reduce the dental care delay, to relieve pain quickly, shorten hospitalisation and prevent severe complications. Activities We set up a multi-professional working group to write protocols, a regulating phone sheet and care algorithm for dental infectious emergencies. Documents have been approved by the concerned departments in June 2007 and program has been applied from that date on. We followed up management delay, and its reduction had an impact on the hospital stay. Results From that date on, the delay between admission of the child in the paediatric department and its access to care in maxillo-facial department never exceeded half a day. Discussion Encouraged by these results, we have undertaken similar evaluation process with other paediatric hospitals through sharing of experience. We can regret that this assessment does not directly measure the clinical impact on the patient but an intermediate result highly correlated to the clinical impact. Keeping care quality is related to residents and paramedics training ability, and to the presentation of updated results at the annual department meeting. Conclusion Objectives of this evaluation have been largely achieved, since the children referral from HED to maxillofacial department is faster. The applied protocols, easy to follow in the HED and paediatric departments helped shorten time management and thus prevent potential complications. Contexte et objectifs Les caries dentaires demeurent les maladies bucco-dentaires les plus frequentes des enfants d9âge scolaire et la plupart des adultes dans les pays developpes. Leurs principales complications sont loco regionale, abces ou cellulite, ou systemique par greffes bacteriennes telle que l9endocardite Osler. Nous avons recense environ 60 urgences infectieuses annuelles ayant necessite une hospitalisation a l9hopital Saint Vincent de Paul et une intervention chirurgicale sous anesthesie generale en urgence. Le delai entre hospitalisation et prise en charge stomatologique en 2006 allait jusqu9a 4 jours quand l9enfant etait admis par le biais du Service d9Accueil des urgences (SAU) ou du service de pediatrie, alors qu9il n9etait que d9une demi journee lorsqu9il etait examine directement en consultation de stomatologie. L9analyse du retard a la prise en charge a mis en evidence les dysfonctionnements majores par l9absence de garde en Stomatologie et Chirurgie maxillo-faciale pediatriques a Paris. Notre objectif initial a ete de reduire le retard de prise en charge stomatologique, soulager rapidement la douleur, ecourter la duree d9hospitalisation et de prevenir des complications graves. Programme Le programme a consiste en la reunion d9un groupe de travail multi professionnel, la redaction d9un protocole, d9une feuille de regulation telephonique, et d9un algorithme de prise en charge des urgences infectieuses stomatologiques. Les documents ont ete valides par les services concernes en Juin 2007 et le programme a ete mis en œuvre a partir de cette date. Nous avons suivi le delai de prise en charge stomatologique, sa reduction ayant un impact sur le sejour a l9hopital. Resultats Le delai entre l9admission de l9enfant en service de pediatrie et sa prise en charge stomatologique n9a plus jamais depasse la demi journee les jours ouvres depuis cette date. Discussion Encourages par ces resultats, nous avons entrepris dans le meme cadre nosologique une demarche d9evaluation identique avec d9autres Services pediatriques dans le cadre d9un partage d9experience. Cette evaluation ne mesure pas directement l9impact clinique sur le patient mais un resultat intermediaire fortement correlee a l9impact clinique. Maintenir la qualite des soins est lie a la capacite de formation des residents et le personnel paramedical et la presentation des resultats mis a jour lors de la reunion annuelle du service. Conclusion Objectifs de cette evaluation ont ete largement atteint, puisque l9orientation des enfants examines au SAU vers le service de chirurgie maxillo-faciale est plus rapide. Les protocoles appliques, faciles a suivre dans le SAU et services pediatriques ont permis de raccourcir le delai de prise en charge et donc de prevenir les complications potentielles.

Introduction 80 % des patients se presentant aux urgences sont douloureux. Ces douleurs sont le plus souvent des douleurs aigues et supposees nociceptives. Objectif Le but de cette etude est d’etudier la prevalence des douleurs neuropathiques (DN) aux urgences en utilisant le questionnaire DN4. Materiel et methode Durant 15 jours, 24 heures sur 24 et 7 jours sur 7, des auditeurs ont interroge les patients se presentant aux urgences de Cochin et ont pose le questionnaire DN4. Pour chaque patient ont ete releves les antecedents, traitements, eventuelles intoxications associees. Resultats Sur 1 942 passages, 882 patients ont ete interroges (45 %). 684 questionnaires ont ete exploitables (67 refus et 131 exclus). Sur 565 patients se declarant douloureux, (82,6 % des passages), 107 patients (soit 19,1 %) ont eu un score DN4 superieur ou egal 4 donc evocateur de douleur neuropathique. Les principaux facteurs associes aux douleurs neuropathiques etaient : des douleurs aigues (98 %), post-traumatiques (52 %), une prise chronique de medicaments (33 %), des plaies (22,6 %), la presence d’une douleur radiculaire ou d’une tendinite (21 %), une infection chronique (HIV ou hepatite dans 14,1 %). La presence de toxiques, l’antecedent de cancer ou de diabete ne sont que peu presents (respectivement 2 %, 5,6 % et 2,8 %). Conclusion Cette etude a donc permis de mettre en evidence une prevalence insoupconnee de douleurs neuropathiques repondant aux criteres du DN4. Il parait necessaire qu’un depistage plus systematique des DN soit effectue aux urgences afin d’optimiser le traitement de la douleur aux urgences.

Since the early 2000’s, oral anticancer drugs (OADs) are increasingly available especially for the treatment of breast cancer. This route of chemotherapy administration allows patients to take oral tablets at home improving their quality-of-life. We estimate that 10 to 34% of breast tumors over-express the HER2 protein (HER2+) that increases the risk of developing metastasis. Two anti-HER2 targeted therapies are currently available: trastuzumab, a monoclonal antibody administered intravenously and lapatinib, a tyrosine kinase inhibitor administered orally. According to the recommendations of the National Agency for Accreditation and Evaluation in Health (ANAES, 2003), OADs should be administered when their efficacy is equivalent to the one of intravenous forms taken at hospital. In the current practice of oncologists, OADs seem to be underused in some cases. The medical brakes to the use of OADs (i.e. adherence, management of side effects) are well known. Nonetheless, OADs induce additional hospital healthcare resources which are not taken into account in the hospital payment system that is based on the nature and the quantity of medical activities performed (i.e. per-case payment system (PPS)). We assume that the current model of PPS represents an economic barrier to the use of OADs and which induces a disparity of access between oral and intravenous cancer treatments. The objective of this thesis was to determine the role of the PPS on the patient access to OADs based on a medico-economic evaluation of the economical and organizational impacts of OADs on the health care system. A literature review has highlighted the role of the funding of care on the access to OADs in the French and US healthcare systems. From an analysis of the national hospital database (PMSI database), we have quantified the economic implications of chemotherapy administration that is the second hospital activity in volume after hemodialysis. Earnings associated with chemotherapy sessions have been estimated at 108 million Euros in 2010 for all private and public institutions in France. This analysis also allowed us to simulate the transfer of resources allocation from hospital to community setting induced by the substitution of chemotherapy sessions by the use of OADs. A model comparing the cost of intravenous anticancer drug (trastuzumab) to OADs (lapatinib and capecitabine) in the treatment of HER2+ metastatic breast cancer confirmed the lower costs for OADs (€ 17,165 versus € 36,077 per year per patient). The higher acquisition cost of OADs was offset by the cost savings in terms of medical transportation and hospital resources. Despite this negative budget impact for hospitals, a preference study (Discrete Choice Experiment) conducted among 203 physicians showed that the efficacy of cancer treatment remained the main determinant of the therapeutic decision (β=2.214, p