Search

Introduction les crises vaso-occlusives (CVO) constituent le principal motif de consultation et d´hospitalisation chez les enfants drépanocytaires et nécessite le plus souvent une prise en charge à domicile avant l´arrivée en consultation. Le but de cette étude était de décrire l´attitude thérapeutique à domicile des enfants drépanocytaires reçus en consultation pour des CVO. Méthodes il s´agissait d´une étude transversale descriptive et analytique, qui s´est déroulée aux urgences pédiatriques du Centre Mère et Enfant de la Fondation Chantal Biya sur une période de 4 mois allant de février à mai 2018. Nous avons procédé à un échantillonnage consécutif. Tous les patients drépanocytaires venus consulter pour CVO ont étés inclus. Résultats cent cinquante-deux patients ont été enrôlés dans l'étude. La tranche d´âge la plus représentée était celle de 5-10 ans. Quatre-vingt-deux patients (54%) arrivaient plus de 24h après le début des crises et 70 (46%) dans les 24 premières heures; 80% (n=122) de notre échantillon avaient eu un traitement antalgique à domicile. Nous avons retrouvé une escalade thérapeutique dans 31,2% de cas. Le recours aux médicaments de la prescription médicale (75,4%, n=92) prédominait au 1er recours. La posologie des antalgiques n´était pas correcte dans 67% de cas (surdosage dans 70% des cas). Seul 33% des antalgiques utilisés à domicile étaient administrés à de bonnes posologies. Conclusion l´étude démontre que la prise en charge des CVOs par les patients à domicile est inadéquate. Des mesures doivent être prises pour garantir que tout patient drépanocytaire puisse gérer efficacement les CVOs mineures à modérées à domicile.

Going back to the delisting of drugs for Alzheimer's disease under the double prism of the jurisprudence of the State Council and from a sidestep of ethics is a requirement about the persistence of still passionate debates: the patients and their families feel abandoned, practitioners in the field distraught, and learned societies alarming the public authorities and their instances without any response to date. How the only drugs available, in responder patients, to slow down the inexorable progression of Alzheimer's disease, can finally be defunded, after three Superior Health Authority reassessments (2007, 2011, 2016) and therefore virtually removed from the therapeutic panel of physicians, while their beneficial effects, although modest on cognition, remained very actual on other symptoms such as apathy or hallucinations? How can this decision not to be understood as a signal of a disengagement from the state? How to maintain the trusting relationships between the patients, their families and caregivers, made of worry and patience?

The French Addictovigilance Network aims to monitor all psychoactive substances with abuse potential including prescription drugs and other legal and illegal substances such as new psychoactive substances (NPS) and its consequences in humans. Created in 1990 through a network of regional addictovigilance centres covering the entire country, these pharmacologists with expertise in addictovigilance have developed interface with different partners (physicians, toxicologists, network of community pharmacies, addictology care centers…) and implemented several original tools of pharmacosurveillance (such as DRAMES [death related to the abuse of medicines] in strong collaboration with toxicologists or such OPPIDUM [observation of illegal products and misuse of psychotropic medications]), complementary to the spontaneous reporting. A such multidimensional approach including proactive surveillance by these tools and also among several heterogenous data sources (such as data from hospitals or claims database) is able to detect early addictovigilance signals and warnings as illustrated with three following examples: cannabis use and acute serious cardiovascular disorders, new synthetic opioids (ocfentanil, carfentanil) and severe opiate overdose or deaths, the diverted use of psychoactive drugs (codeine analgesics or sedative H1 antihistamines called purple drank) by adolescents and young adults. The choice of a broad strategy and the multifaceted system implemented by the French Addictovigilance Network using elements of pharmacology (fundamental, clinical, pharmacoepidemiology) expertise is an innovative method to detect early addictovigilance signals, and to describe its characteristics in order to increase awareness of psychoactive substances by patients, users and health professionals.

The main objective of this study was to evaluate if the increasing number of repeated abortions in France is linked to a failure to reassess post-abortion contraceptive methods.This is a multicentered, descriptive, retrospective study of post-abortion contraceptive practices of patients who underwent a repeated volontary abortion between September one and December 31, 2017, in four abortion centers, in public hospitals in the Alpes-Maritimes and East Var.Of the 217 patients who participated to the study, 78.8% used a different contraceptive method post-abortion vs. the method used during the conception. Only 51.8% of long-acting reversible contraception (LARC) prescribed have been used at the post abortion consultation.The repeated abortion may be partly explained by a transient or prolonged absence of contraception. Screening for breaks in the contraceptive history is therefore essential to adapt and maintain contraception at each stage of the patient's life. Some of the professional practices which do not favour an early placement of LARC devices prescribed at the time of abortion, contrary to the new recommendations. The evolution of professional practices still seems necessary to try to help reduce the repeated use of abortion.

Benzodiazepine use remains high in France in 2015, especially among the elders. However, encouraging trend is observed regarding hypnotic benzodiazepines initiation: between 2008 and 2015, incident use of hypnotics, including that of Z-drugs, decreased while incident use of anxiolytics remained stable. Most of new benzodiazepine users (86 %) had treatment duration that complies with guidelines. Owing to the high number of user initiating a treatment each year and associated risks, the remaining 14 % of long-term users is of concern. Roughly half of benzodiazepine users presented with comorbidities and concurrent medications increasing the risk of adverse drug reactions, especially central nervous system depressant effects.

Dans un contexte de ressources limitées, les assureurs et les établissements de santé doivent prendre la difficile décision d’inscrire ou non des nouveaux médicaments onéreux sur les listes des produits assurés. Notre mémoire aborde ce problème en étudiant le cas des anticancéreux onéreux au Québec. Il se penche sur les critères scientifiques et principes éthiques à considérer puis sur le contexte dans lequel les décisions sont prises. Premièrement, nous identifions, analysons et évaluons les critères et principes pharmacoéconomiques et éthiques qui sont ou devraient être considérés lorsqu’il s’agit d’inscrire un médicament onéreux. Deuxièmement, nous cherchons à identifier les éléments organisationnels (structure des agences d’évaluation et des régimes publics d’assurance) favorisant une couverture accessible, efficiente et équitable. Troisièmement, nous analysons de quelle manière l’industrie pharmaceutique essaie d’influencer les décisions d’inscription. Quatrièmement, nous nous penchons sur l’influence des groupes de patients et sur les conflits d’intérêts pouvant découler de leur financement par l’industrie. Cinquièmement, nous procédons à une analyse des articles de journaux qui soulèvent la question de l’accès aux anticancéreux onéreux. Notre étude démontre que la limitation de l’accès à des anticancéreux onéreux est justifiée sur le plan pharmacoéconomique et éthique. Elle conclut aussi qu’au Québec, de manière générale, l’organisation de l’agence d’évaluation des médicaments et la structure des régimes d’assurance favorisent un accès efficient et équitable aux anticancéreux onéreux. Cependant, notre étude révèle que de nombreuses forces économiques et politiques poussent en sens contraire. En effet, l’industrie pharmaceutique, des groupes de patients influents et les contenus médiatiques défendent l’idée d’un accès illimité aux médicaments, peu importe le prix, ce qui menace le caractère efficient, équitable et pérenne du financement des médicaments., In a context of limited resources, insurers and hospitals must make the difficult decision whether or not to register expensive new drugs on the lists of insured products. Our thesis addresses this problem by studying the case of expensive anticancer drugs in Quebec. It looks at the scientific criteria and ethical principles to be considered and at the context in which decisions are made. First, we identify, analyze and evaluate the pharmaco-economic and ethical criteria and principles that are or should be considered when registering an expensive drug. Second, we seek to identify organizational factors (the structure of assessment agencies and public insurance plans) that promote accessible, efficient and equitable coverage. Third, we analyze how the pharmaceutical industry is trying to influence registration decisions. Fourth, we examine the influence of patient groups and the conflicts of interest that may arise from industry funding. Fifth, we analyze newspaper articles that raise the issue of access to expensive cancer drugs. Our study demonstrates that limiting access to expensive cancer drugs is economically and ethically justified. It also concludes that in Quebec, in general, the organization of the drug evaluation agency and the structure of the insurance plans promote efficient and equitable access to expensive cancer drugs. However, our study reveals that many economic and political forces are pushing in the opposite direction. Indeed, the pharmaceutical industry, influential patient groups and media content advocate the idea of unlimited access to medicines regardless of price, which threatens the efficiency, fairness and sustainability of drug funding.

International audience; Objectives:This study had two main aims: (i) document the experience of community pharmacists receiving a spontaneous request for ibuprofen and oral pseudoephedrine, and their use of pharmaceutical records, and (ii) explore patients’ perceptions of pharmaceutical records and pharmaceutical interventions.Methods:The study was conducted over two weeks between February and April 2014 in 482 community pharmacies and 8 French faculties of pharmacy. It was based on data collected by pharmacy team focus groups during patient telephone interviews using standardized question grids. Textual and thematic analyses were made of the patient responses.Results:Four pharmacy team focus groups carried out 49 telephone interviews. Examination of the practice of the groups showed that pharmaceutical interventions, although incompletely registered, are performed on a daily basis and enhance the value of the pharmacist's function. Analysis of the telephone interviews also showed the importance of the advisory role of the pharmacist in dispensing an optional medical prescription. The thematic analysis of the results identified a positive response of patients to pharmaceutical interventions if made by their regular pharmacist and accompanied by explanatory information. The focus groups and patients agreed that pharmaceutical records were not consulted often enough.Conclusion:This study underlines the need for greater safety in the use of optional medical prescription drugs. Promoting responsible self-medication in compliance with proper use should include systematic reference to a PR and informed dialogue with the patient.; Objectifs :La présente étude a eu deux objectifs principaux : (i) explorer le vécu des équipes officinales face aux interventions pharmaceutiques et à l’utilisation du dossier pharmaceutique, lors d’une demande spontanée d’ibuprofène ou de pseudoéphédrine per os (ii) connaître la perception du dossier pharmaceutique et des interventions pharmaceutiques par les patients.Méthodes :L’étude s’est déroulée sur deux semaines entre février et avril 2014 dans 482 officines de 8 facultés de pharmacie françaises. Elle a reposé sur des focus group d’équipes officinales et des entretiens téléphoniques de patients à l’aide de grilles d’entretien standardisés. Les verbatim ont fait l’objet d’une analyse de données textuelles et d’une analyse thématique.Résultats :Quatre focus groups et 49 entretiens téléphoniques ont été réalisés. L’analyse du vécu des équipes officinales a montré que l’intervention pharmaceutique, bien qu’insuffisamment tracée, fait partie du quotidien de l’exercice officinal et valorise l’acte de dispensation. L’analyse des entretiens téléphoniques des patients appuie ce ressenti, en soulignant la démarche d’accompagnement du dispensateur. L’analyse thématique des résultats identifie un élément essentiel du vécu des patients : ils ressentent positivement les interventions pharmaceutiques si le pharmacien est leur pharmacien habituel et si celui-ci formule des explications à visée éducative. En outre, équipes officinales et patients s’accordent sur le fait que le dossier pharmaceutique est insuffisamment utilisé.Conclusion :Cette étude s’inscrit dans une perspective de renforcement de la sécurité d’emploi des médicaments d’automédication, en promouvant le recours systématique au dossier pharmaceutique, à l’appui du dialogue avec le patient.

In 2012, cost-effectiveness has been formally introduced in the French legislation as a criterion to determine the price of prescription drugs. Cost-effectiveness is requested to claim for reimbursement of drugs expected to provide a therapeutic benefit and to have a significant impact on Social Insurance budget. Cost-effectiveness estimates the incremental cost and effectiveness produced by an intervention in comparison to other interventions that could have been used. The thesis is an empirical analysis of delegation relationships in the regulation of reimbursed drugs in France. The thesis analyses three different applications of cost-effectiveness evaluation to highlight the issues surrounding the use of economic calculation and the risks that are associated with it through three questions: 1) does the cost-effectiveness evaluation expose the regulator to regulation capture? 2) Is the contribution of the cost-effectiveness evaluation enhanced in a regulatory framed process? 3) Could complementary evaluations enrich cost-effectiveness evaluation and favour its usage via the clarification of the issues surrounding the decision? The thesis documents the benefit provided by the introduction of the cost-effectiveness criteria. The actual risk of regulation capture could be limited through a more transparent process of evaluation and through a clarification of the objectives of the regulation.; Le législateur français a intégré le critère d’efficience dans la détermination du prix du médicament remboursable en 2012. L’efficience des médicaments doit être documentée pour les produits susceptibles d’apporter un bénéfice thérapeutique important et d’avoir un impact significatif sur les dépenses d’assurance maladie. Elle vise à mesurer le coût du gain marginal en santé produit par une intervention, par rapport au coût et à l’efficacité d’une autre intervention substituable. La thèse se situe dans une perspective d’analyse empirique des relations de délégation à l’œuvre dans la régulation du médicament, en vue de son accès au remboursement et de la fixation de son prix en France. Elle se fonde sur une analyse de trois applications de l’évaluation de l’efficience reflétant un approfondissement progressif de l’évaluation économique de l’intervention de santé dans trois contextes institutionnels distincts. Leur comparaison permet d’identifier les enjeux soulevés par la mise en œuvre de la régulation, les facteurs de son efficacité et les risques associés au regard du cadre théorique de la théorie des incitations en se posant successivement les questions suivantes : 1) L’information produite par le calcul économique expose-t-elle le décideur à un risque de manipulation de l’outil ? 2) L’apport du calcul économique est-il amélioré dans un processus d’évaluation contraint? 3) Des approches complémentaires peuvent-elles enrichir l’évaluation économique et en améliorer l’usage en révélant d’autres déterminants de la décision en santé? Les travaux de la thèse mettent en évidence l’apport du critère d’efficience pour améliorer l’information du décideur. Le risque, réel, de capture de régulation peut être limité par un processus d’évaluation plus transparent et par une explicitation des enjeux de la décision et des objectifs de la régulation.

In 2009, the French Act "Hospital, Patients, Health and Territories" (loi "Hôpital, Patients, Santé et Territoires") reorganized the outpatient care pathway and defined missions aimed at improving cooperation between pharmaceutical and medical professionals. Five years later, we conducted a survey among community pharmacists in order to assess the appropriation of these missions and the way cooperation was implemented. We also aimed to investigate factors that could hamper or ease the development of these activities in order to identify actions needed to improve pharmacists' involvement.In partnership with the local health authorities "Agence régionale de santé", we conducted a survey via an online questionnaire sent to pharmacy holders in July 2014 in Aquitaine region. Information was collected about the pharmacies, involvement in collaborative activities, and barriers to cooperation.Overall, 20% (249) of pharmacists responded to the survey. They owned predominantly rural pharmacies (46%) or neighborhood pharmacies (41%), with two pharmacists per pharmacy (48%). Regarding collaborative activities, the majority of pharmacists (78%) had conducted interviews with their patients taking vitamin K antagonist therapy and they were willing to continue (87%). The implication was less common concerning other actions such as referent pharmacist for nursing homes (19%) or activities relating to therapeutic educational programs for patients with chronic conditions (34%). The vast majority of respondents (85%) were not aware of opportunities to become a correspondent pharmacist. The main obstacles for engaging in these activities were the lack of time, lack of knowledge about these missions and the lack of remuneration. We identified differences in pharmacists' involvement in collaborative activities depending on selected characteristics of the pharmacies.The findings of this survey underlined pharmacists' acceptance of these missions and suggest that better information and appropriate remuneration could enhance commitment. Recent changes in the legal framework (establishment of "pharmaceutical fees", extension of the scope of pharmaceutical interviews) enable funding for collaborative practices between medical practitioners and pharmacists, thus encouraging better coordination in the patient care pathway.

Nurses are on the frontline with regard to the administering of medicines. While medication errors are more frequent than professionals think, caregivers are the last line of defence before the adverse event. A form for reporting adverse events, including medication errors, is made available to users by the Risk Management Committee of each health institution. This declaration is the main way to improve the management of medication risks.

In addition to antiretroviral therapy, non-antiretroviral drugs are necessary for the appropriate care of people living with HIV. The costs of such drugs are totally or partially supported by the people living with HIV. We aimed to evaluate the overall costs, the costs supported by the people living with HIV and factors associated with the prescription of non-antiretroviral drugs in people living with HIV on antiretroviral therapy in Senegal.We conducted a retrospective cohort study on 331 people living with HIV who initiated antiretroviral therapy between 2009 and 2011 and followed until March 2012. The costs of non-antiretroviral drugs were those of the national pharmacy for essential drugs; otherwise they were the lowest costs in the private pharmacies. Associated factors were identified through a logistic regression model.The study population was 61 % female. At baseline, 39 % of patients were classified at WHO clinical stage 3 and 40 % at WHO clinical stage 4. Median age, body mass index and CD4 cells count were 41 years, 18kg/mNon-antiretroviral drugs are frequently prescribed to people living with HIV in developing countries; mainly those infected with HIV-1 and those at an advanced clinical stage. Their costs can be a barrier to appropriate care and necessary efforts must made to make them available. However, early initiation of antiretroviral therapy and the registration of some non-antiretroviral drugs on the list of essential drugs, as well as social protection systems, should reduce their use and costs.

Free access to medicines is an important element in the implementation of health care access policies. Paradoxically, this aspect is rarely addressed in the literature on this subject. The Ville-Evrard psychiatric hospital introduced so-called "poverty prescriptions" allowing free drug dispensing, independently of specific PASS (Permanent Access to Health_ Care) systems. This paper presents the results of a study of all poverty prescriptions issued by the facility in 2011./t provides an analytical description of this system and shows that, despite the absence of strict controls, it was used relatively rarely.

Comparisons outpatient drug prescriptions: France, Denmark, Norway, Sweden.Project compares quantitatively outpatient drug prescriptions in France, Denmark, Norway and Sweden.Data were obtained from national databases; the unit of measurement was defined daily dose per 1000 inhabitants. The five most prescribed drug classes were compared in each country in 2009, then benzodiazepines and antibiotics from 2006 to 2012. A literature review was focused on the context of prescriptions for each country.In 2009, the five most prescribed drug classes in the four countries represented seven classes in total. France was not the biggest prescriber of drugs, but from 2006 to 2012 benzodiazepines and antibiotics were prescribed much more in France than in the other countries. The evolution of prescriptions was different for each country, and very stable in France.In 2009, France was not the biggest drugs consumer of all classes, but was characterized by high prescriptions in some classes.

Prescribe in the elderly has specifcities, with age-related pharmacologica modifications, polypharmacy, and risk of drug toxicity. At time of the prescription renewal, each drug must be re-evaluated. The objective of this study was to identify the nature and reasons of drugs modifications during a hospitalization in a geriatric ward, in order to optimize drug prescriptions in elderly and to limit iatrogenic diseases. A descriptive study was carried out with 221 patients hospitalized in 4 geriatrics wards of Lyon region, over a period of 2 months. Prescriptions modifications between admission and exit were studied. Among drugs the most often stopped, we found proton pump inhibitors and serotonin uptake inhibitors. All non steroidal anti inflammatory agents and anti-arthritis drugs, as neary al cerebra vasodilators which were prescribed, were stopped. The reasons for stop were no indication (37 % of cases), adverse effects (13.2 %), inappropriate medication (7.7 %), non demonstrated effectiveness (5.9 %). Drugs overuse concerned above all proton pump inhibitors and antihypertensive agents. Among drugs the most often started, we found paracetamol, morphine, benzodiazepines with short half-life, cholinesterase inhibitors, the most often for an acute pathology (61.7 % of cases). Drugs overuse is therefore predominant, more than inappropriate medication and drugs underuse. To stop needless drugs and drugs which didn't prove their effectiveness would already allow to improve drugs prescription in elderly.

During a hospitalization in an internal medicine department, drug prescriptions are frequently modified. We studied the course of these therapeutic changes after patients' discharge.Eighty-four patients with a long-term drug prescription and a registered general practitioner were included on the day of their discharge from an internal medicine department in Paris. Their medications before and after the hospitalization were established according to the discharge letter, and patients were contacted two months after discharge in order to assess the modifications that could have occurred during these two months after discharge.Medications prescribed before the admission were often preserved, 17.7% were withdrawn, and 7% were switched to another medication. Two months after discharge, 85% of the modifications were maintained, the discharge drug prescription was renewed without a change for 77% of the patients. The drug classes that were the more frequently modified during the hospital stay were the antihypertensive therapies, with 65% of sustained modifications at two months, and analgesics, with 75% of sustained modifications. Therapeutic changes that were explained in the discharge letter were more frequently preserved at two months than those that were not explained (100% versus 79%, 95%CI of the difference [0.09-0.27]; P0.0001).Therapeutic changes decided during a hospitalization in an internal medicine unit and prescribed at discharge are mostly preserved in outpatients two months after discharge, especially when the modifications are explained in the discharge letter.

The present article describes the first French database of drugs prescribed and dispensed during pregnancy and the outcome of these pregnancies, named EFEMERIS (Évaluation chez la Femme Enceinte des MÉdicaments et de leurs RISques). At the present time, EFEMERIS contains anonymous data concerning around 78,000 pregnant women who gave birth to a baby between 1 July 2004 to 31 December 2012 in Haute-Garonne (South West France) and who are registered in the French health insurance service. Data sources include 1- the French health insurance database (drugs prescribed during pregnancy), 2- the mother and child protection centre database (newborn health) 3- the antenatal diagnostic centre database (medical pregnancy interruptions) and 4- medical data from the hospital (PMSI). EFEMERIS provides exact data on period of exposure to drugs, pregnancy terminations, and follow up of the babies 9 months and 2 years after birth. It is incremented each year with around 10 000 new pregnancies. Analysis of data until December 2011 shows a prevalence rate of congenital anomalies of 2.4%. Pregnant women were prescribed around 10 different reimbursed drugs during their pregnancy, the potential risk of a lot of these medications having not been evaluated during pregnancy. EFEMERIS can be used to monitor the prescription of reimbursed drugs to French pregnant women as well as to identify adverse pregnancy outcomes such as congenital malformation or effects on psychomotor development of the child. Examples of some studies already performed are given.

Analyze prescriptions in public hospital psychiatric practice.Psychiatric and somatic prescriptions were analyzed a given day regarding their indication, dosage, treatment duration, and prescription scheme. Consultants were individually asked for the reasons of off-label prescriptions.Five thousand eighty-six lines of prescription were recorded for 495 patients, showing a total of 34% off-label prescriptions, including 43.5% for psychiatric medications and 22.7% for somatic medications. Psychiatric medications: 22.3% were off-label for indication, 13.1% for dosage, 4.5% for treatment duration, and 6.2% for prescription scheme. (off-label prescriptions for indication: 12.1% without clonazepam - which delivery have been restricted by the end of 2011). Somatic medications: respectively 4.5%, 14.9%, 4.8% and 12.5%.Percentage of off-label prescriptions for indication of psychiatric medications was clearly less than percentages published in the literature (other percentages are new). While most of off-label prescriptions were made in accordance with clinical reports in the literature, some others were not.

To compare mood disorder (MD) prevalence in Quebec in 2006, and compare health services and medication use, mortality and morbidity in patients with MD based on sex and the dwelling sector level of material and social deprivation. The objective was also to identify subgroups of individuals using health services in a larger proportion and having a higher risk of morbidity and mortality.We conducted a secondary analysis of the Régie de l’assurance maladie du Québec medico-administrative data. The cohort is composed of adults diagnosed with MD and living in Quebec in 2006. Variables include: physician consultation, medication demand, consultation for substance or alcohol abuse, emergency visit, hospitalization for a mental disorder, and death. Dwelling sector types are defined by crossing Pampalon material and social deprivation quintiles.MD prevalence in 2006 was 3.06% (177 850 patients), with prevalence in women 1.7-fold with respect to men. Findings show a higher MD prevalence as well as a higher mortality and morbidity rate in materially and socially deprived dwelling sectors. Young men also represent a specifically vulnerable subgroup for many study variables.Public policies aimed at improving material conditions (income, education, employment) and breaking out social isolation would have an important impact on the population mental health. Public health program development should pay close attention to young men population.

In 2007, the use of a new therapeutic association that included two expensive drugs (bevacizumab and irinotecan), used in second line treatment for progressive glioblastoma, led to the increase of the monitoring and self-evaluation of the medical prescriptions. Methodological tools have been designed by neuro-oncologists together with pharmacists of the Pitié-Salpêtrière Hospital in order to be consistent with the "good use economic contract". Those drugs have not been approved by European authorities in this indication and, moreover, this combination presents adverse effects and contraindications that need to be known by the professionals, the patient and his family. Some documents have been created in order to facilitate prescriptions for neuro-oncologists and others provide monitoring tools for the physicians and nurses. A letter of information targets the patient and his family, another one targets the general practitioner. This is useful for a better coordination between these ones and the hospital. The patient receives a document and a monitoring book in order to inform him about his treatment and help him to prevent and react in time in case of side effects occurrence. Those measures have been designed to put a frame around the prescriptions and to decrease iatrogenic events as well as the economic costs.

Clinicians must be aware that aging can lead to changes in the pharmacokinetics and pharmacodynamics of many drugs. Drug distribution may be modified with aging secondarily to the decrease of serum albumin and to modifications of body composition (increase in the proportion of fat mass and decrease of lean mass). Hepatic metabolism of several drugs is reduced with age, especially drugs which depend of hepatic blood flow or P450 cytochroms. The incidence of renal failure increase largely with age. Glomerular filtration rate should be systematically estimated in older patients and, when needed, the doses of those drugs having significant renal elimination should be adjusted. In older patients, changes in the response to drugs can also develop, concerning specially the central nervous system (increased sensibility to any neurological effect of drugs), the cardiovascular system and the renal management of water and electrolytes. In many cases, the pharmacological changes associated to age are mild and requires no dose adjustment. However, many drugs should be adapted depending on the individual situation of each patient, particularly his renal function and nutritional state. Finally, some drugs should be avoided in older patients because of a bad effectiveness/tolerance ratio compared to alternatives.

Drug prescription in general practice is present in 78 to 83% of consultations; practitioners must give to their patient clear loyal and appropriate information about the undesirable side effects of the medicines prescribed. The object of the EICLAT study was to give some light on the feasibility to respect this obligation. To that effect the study evaluates, for a normal prescription activity, the average number of potential undesirable side effects (USE) in relation with the number of lines of different medicines prescribed in each doctor's prescription. A total of 8,382 doctor's prescriptions, generating 34,427 lines of prescriptions given by 175 general practitioners, were analysed. Amongst these prescriptions, 11% included only one line, 55% from 2 to 4 lines and 34% 5 lines or more. The average doctor's prescription was of 4 lines of medicines generating 407 potential USE, of which 194 were different (the same undesirable effect may be present twice or more in the same doctor's prescription), and 293 frequent or serious potential USE, of which 166 were different. The patent medicines with a major or important added medical value (AMV), present in 7,840 doctor's prescriptions for a total of 24,127 lines exposed the patient, in the average, to 151 frequent or serious USE different. The patent medicines with an insufficient AMV, present in 2,292 prescriptions for a total of 3,887 lines, exposed the patient to 37 frequent and/or serious potential USE. Supposing that the information provided by the legal authority is sufficiently adequate, precise and exhaustive, the volume of information that must be given to the patient is not compatible with the present conditions of exercise of the profession.

An inaccurate medication history may prevent the discovery of a pre-admission iatrogenic event or lead to interrupted drug therapy during hospitalization. Medication reconciliation is a process that ensures the transfer of medication information at admission to the hospital. The aims of this prospective study were to evaluate the interest in clinical practice of this concept and the resources needed for its implementation.We chose to include patients aged 65 years or over admitted in the internal medicine unit between June and October 2010. We obtained an accurate list of each patient's home medications. This list was then compared with medication orders. All medication variances were classified as intended or unintended. An internist and a pharmacist classified the clinical importance of each unintended variance.Sixty-one patients (mean age: 78 ± 7.4 years) were included in our study. We identified 38 unintended discrepancies. The average number of unintended discrepancies was 0.62 per patient. Twenty-five patients (41%) had one or more unintended discrepancies at admission. The contact with the community pharmacist permitted us to identify 21 (55%) unintended discrepancies. The most common errors were the omission of a regularly used medication (76%) and an incorrect dosage (16%). Our intervention resulted in order changes by the physician for 30 (79%) unintended discrepancies. Fifty percent of the unintended variances were judged by the internist and 76% by the pharmacist to be clinically significant.The admission to the hospital is a critical transition point for the continuity of care in medication management. Medication reconciliation can identify and resolve errors due to inaccurate medication histories.

After having noted that 25% of prescriptions were not respected by nurses, the Henri-Mondor university hospital in Creteil (AP-HP, 94), carried out an investigation to understand the causes. The results were then circulated to doctors and nurses in order to establish best practice recommendations.

Inability to identify clinically group A streptococcal (GAS) tonsillitis has resulted for a long time in treating all tonsillitis with antibiotics in France. The use of the rapid detection tests (RDT) for GAS is currently recommended, in order to keep antibiotics only for GAS tonsillitis. Our objective was to carry out a cost-effectiveness analysis, comparing various strategies for the management of acute tonsillitis in France.We used a decision analysis model, including seven strategies (S) for tonsillitis management, specifically in children and in adults: S1: observation only (reference strategy); S2: clinical scoring; S3: RDT testing; S4: throat culture; S5: clinical scoring combined with RDT testing; S6: RDT testing combined with throat culture; S7: systematic antibiotic therapy. The criterion for effectiveness was the absence of locoregional suppurative complications.The use of the RDT alone had the best cost-effectiveness ratio in both adults and children. For this strategy, we estimated the cost per suppurative complication avoided at 970€ in children and at 903€ in adults. For the strategy associating a confirmative throat culture to the RDT, the extra cost per suppurative complication avoided was estimated at 106,666€ in children and at 228,000€ in adults. Sensitivity analysis showed the stability of the model while making the main parameters vary.In acute tonsillitis, in both adults and children, RDT testing by practitioners is the more efficient strategy to identify and treat patients with GAS tonsillitis. Combining RDT testing with throat culture can provide additional effectiveness, but at the cost of a significant extra charge for the community.