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Objective: To identify factors associated with mortality and morbidity among adults admitted to intensive care units (ICUs) for pneumococcal meningitis, particularly the impact of delayed antibiotic administration. Design: We conducted a prospective, multicenter, observational study of 156 consecutive adults hospitalized for pneumococcal meningitis. We analyzed parameters associated with 3-month survival. Setting: Fifty-six medical and medical-surgical ICUs in France. Intervention: None. Results: Of the 148 strains isolated, 56 (38%) were nonsusceptible to penicillin G. At 3 months after ICU admission, the mortality rate was 33% (51/156), and 34% of survivors (36/105) had neurologic sequelae. Multivariate analysis identified three variables as independently associated with 3-month mortality: Simplified Acute Physiology Score II (odds ration [OR], 1.12; 95% confidence interval [CI], 1.072‐1.153; p .002); isolation of a nonsusceptible strain (OR, 6.83; 95% CI, 2.94‐20.8; p 3 hrs between hospital admission and administration of antibiotics (OR, 14.12; 95% CI, 3.93‐50.9; p 10 3 cells/L had a protective effect (OR, 0.30; 95% CI, 0.10‐0.944; p 0.04). Conclusions: Independent of severity at the time of ICU admission, isolation of penicillin-nonsusceptible strains and a delay in antibiotic treatment following admission were predictors of mortality among patients with pneumococcal meningitis. (Crit Care Med 2006; 34:2758‐2765)

To determine whether severity and organ failure scores over the first 3 days in an ICU predict in-hospital mortality in onco-hematological malignancy patients.Retrospective study in a 22-bed medical ICU.92 consecutive patients with onco-hematological malignancies including 20 hematopoietic stem cell transplantation (HSCT) patients (11 with allogenic HSCT).Simplified Acute Physiology Score (SAPS) II, Organ Dysfunction and/or Infection (ODIN) score, Logistic Organ Dysfunction System (LODS), and Sequential Organ Failure Assessment (SOFA) score were recorded on admission. The change in each score (Delta score) during the first 3 days in the ICU was calculated as follows: severity or organ failure score on day 3 minus severity or organ failure score on day 1, divided by severity or organ failure score on day 1.In-hospital mortality was 58%. Using multivariate analysis in-hospital mortality was predicted by all scores on day 1 and all Delta scores. Areas under the receiver operating characteristics curves were similar for SAPS II (0.78), ODIN (0.78), LODS (0.83), and SOFA (0.78) scores at day 1. They were also similar for DeltaSAPS II, DeltaODIN, DeltaLODS, and DeltaSOFA. Similar results were observed when excluding patients with allogenic HSCT.Severity and three organ failure scores on day 1 and Delta scores perform similarly in predicting in-hospital mortality in ICU onco-hematological malignancy patients but do not predict individual outcome. Decision to admit such patients to the ICU or to forgo life-sustaining therapies should not be based on these scores.

To evaluate the influence of airway humidification devices on the efficacy of ventilation in difficult to wean patients.A prospective, randomized, controlled physiologic study.A 22-bed medical intensive care unit in a university hospital.Chronic respiratory failure patients.Performances of a heated humidifier and a heat and moisture exchanger were evaluated on diaphragmatic muscle activity, breathing pattern, gas exchange, and respiratory comfort during weaning from mechanical ventilation by using pressure support ventilation. Eleven patients with chronic respiratory failure were submitted to four pressure support ventilation sequences by using the heated humidifier and the heat and moisture exchanger at two different levels of pressure support ventilation (7 and 15 cm H(2)O).Compared with the heated humidifier and regardless of the pressure support ventilation level used, the heat and moisture exchanger significantly increased all of the inspiratory effort variables (inspiratory work of breathing expressed in J/L and J/min, pressure time product, changes in esophageal pressure, and transdiaphragmatic pressure; p.05) and dynamic intrinsic positive end-expiratory pressure (p.05). Similarly, the heat and moisture exchanger produced a significant increase in Paco(2) (p.01) responsible for severe respiratory acidosis (p.05), which was insufficiently compensated for despite a significant increase in minute ventilation (p.05). This resulted in respiratory discomfort for all patients with the heat and moisture exchanger (p.01). Adverse effects were partially counterbalanced by increasing the pressure support ventilation level with the heat and moisture exchanger byor=8 cm H(2)O.The type of airway humidification device used may negatively influence the mechanical efficacy of ventilation and, unless the pressure support ventilation level is considerably increased, the use of a heat and moisture exchanger should not be recommended in difficult or potentially difficult to wean patients with chronic respiratory failure.

To assess gastrointestinal function in critically ill patients receiving muscle relaxant and to test clinical tolerance to enteral nutrition.Prospective study in an intensive care unit.20 critically ill patients requiring sedation with muscle relaxant to obtain adequate mechanical ventilation.Patients were randomly selected to receive infusions of opioid sedation during the first session (session 1) and the same sedation with muscle relaxation (cisatracurium) during the second session (session 2). Gastric emptying was assessed by the paracetamol absorption technique. Following the paracetamol absorption 200 ml enteral feed was given, and the residual gastric volume was measured 1 and 2 h after feeding. The maximum plasma concentration (Cmax) was 14 mg/l (range 5-26) when patients received sedation, and 12 mg/l (range 5-30) when they received muscle relaxant. The target time for reaching the maximum plasma concentration (Tmax) was 30 min (range 20-60) and 35 min (range 20-60), respectively, in sessions 1 and 2. There was no significant difference between the two session as regards Tmax, Cmax, or AUC(0-120). The residual volumes were 110+/-65 ml (H1) and 95+/-76 ml (H2) during session 1 and 125+/-85 ml (H1) and 105+/-90 ml (H2) during session 2.Enteral feeding is one of the most effective methods of supporting nutritional needs in the critically ill patient. We conclude that in critically ill patients requiring sedation gastric emptying is not improved by neuromuscular blocking agent.

Only two cases of adult-onset Still’s disease associated with shock have been previously described. We report a case of shock in a man with adult-onset Still's disease and discuss the relationship between the two processes by assessing tumor necrosis factor-alpha, procalcitonin and interleukin-6 concentrations.

Background: Methanol poisoning, potentially fatal, is generally treated with the combination of ethanol as antidote, and hemodialysis. Fomepizole, a competitive inhibitor of alcohol dehydrogenase, has more recently been used, and is capable of blocking the toxic metabolism of methanol. To our knowledge, its use has never been reported as an antidote in severe methanol poisoning requiring hemodialysis.Case Report: We report a case of fatal methanol poisoning (1.9g/L on admission) suspected due to the combined presence of coma and severe metabolic acidosis with normokalaemia. Conclusion: The fomepizole treatment protocol (10 mg/kg by IV infusion over 1 hour before dialysis, repeated 12 hours later in combination with 1.5 mg/kg/h during dialysis) was simple to use and appeared effective in eliminating methanol in combination with hemodialysis. The case is also unusual in terms of severity and the early onset of cerebral lesions demonstrated by computed tomography (CT) scan.

Prolonged duration of endotracheal mechanical ventilation (ETMV) is associated with an increased morbidity and mortality in intensive care unit (ICU) patients. The aim of this study was to assess the usefulness of noninvasive ventilation (NIV) as a systematic extubation and weaning technique to reduce the duration of ETMV in acute-on-chronic respiratory failure (ACRF). Among 53 consecutively intubated patients admitted for ACRF, we conducted a prospective, randomized controlled trial of weaning in 33 patients who failed a 2-h T-piece weaning trial (2 h-WT) although they met simple criteria for weaning. Conventional invasive pressure support ventilation (IPSV) was used as the control weaning technique in 16 patients (IPSV group), and NIV was applied immediately after extubation in 17 patients (NIV group). The two weaning groups were similar for type of chronic respiratory failure (CRF), pulmonary function data, age, Simplified Acute Physiology Score (SAPS II), and severity of ACRF on admission. The characteristics of the two groups were also similar at randomization. In the IPSV group, 12 of 16 patients (75%) were successfully weaned and extubated, versus 13 of 17 (76.5%) in the NIV group (p = NS). NIV like IPSV significantly and similarly improved gas exchange in relation to that achieved during 2 h-WT (p < 0.05). The duration of ETMV was significantly shorter in the NIV (4.56 +/- 1.85 d) than in the IPSV group (7.69 +/- 3.79 d) (p = 0. 004). NIV also reduced the mean period of daily ventilatory support, but increased the total duration of ventilatory support related to weaning (3.46 +/- 1.42 d, versus 11.54 +/- 5.24 d with NIV; p = 0. 0001). Most patients in the IPSV group developed complications related to ETMV and/or the weaning process, but the difference was not significant (nine of 16 versus six of 17). The durations of ICU and hospital stays and the 3-mo survival were similar in the two groups. In conclusion, NIV permits earlier removal of the endotracheal tube than with conventional IPSV, and reduces the duration of daily ventilatory support without increasing the risk of weaning failures. NIV should be considered as a new and useful systematic approach to weaning in patients with ACRF who are difficult to wean.

To define patients at risk for unplanned extubation; to assess the influence of nursing workload on the incidence of unplanned extubation; and to determine predictive criteria for patients requiring reintubation.A prospective, case-control study, with 10 and 15 mos of data collection.University medical intensive care department.In the first study, which lasted 10 mos, unplanned extubation occurred in 40 (14%) of 281 ventilated and intubated patients; 36 cases were sufficiently documented to be compared with 74 intubated and ventilated controls. In the second study, which lasted 15 mos, the reintubated patients (n=23) of a series of 62 unplanned extubation patients were compared with those who were not reintubated (n=39).None.The following parameters were recorded: gender, age, main reason for admission, Simplified Acute Physiology Score II, route of intubation (oral or nasotracheal), tube diameter, ventilatory mode, FiO2, frequency and tidal volume delivered by the ventilator immediately before unplanned extubation, arterial blood gases performed 24 hrs before unplanned extubation, the presence of any sedation with, in this case, the last Ramsay score, the presence of hand restraints, the presence of weaning of ventilation, the accidental or deliberate nature of unplanned extubation, the Glasgow Coma Score at the time of unplanned extubation, the duration of ventilation before unplanned extubation, total duration of ventilation and stay in the intensive care unit, and the patient's survival or death. The nursing workload was evaluated using a score derived from the Projet de Recherche en Nursing and adapted to intensive care. Unplanned extubation patients were more frequently intubated orally than controls (33.3% vs. 14.9%, respectively; p.05). In the population of sedated patients, unplanned extubation patients were more frequently agitated than controls (60% vs. 19%, respectively; p.05). The nursing workload did not differ between days with and days without unplanned extubation. Twenty-three (37%) of the 62 cases of documented unplanned extubation were reintubated. Predictive factors of reintubation are, in decreasing order of importance: Glasgow Coma Score of11, accidental nature of unplanned extubation, and a PaO2/FiO2 ratio200 torr (26.7 kPa).Patients at risk for unplanned extubation are characterized by oral intubation and insufficient sedation. In the department studied, and with the specific score used, we did not observe a relationship between the nursing workload and the incidence of unplanned extubation. A Glasgow Coma Score of11, the accidental nature of unplanned extubation, and a PaO2/FiO2 ratio200 torr (26.7 kPa) are factors associated with a risk of reintubation.

To compare the effects of noninvasive assist-control ventilation (ACV) and pressure support ventilation (PSV) by nasal mask on respiratory physiologic parameters and comfort in acute hypercapnic respiratory failure (AHRF).A prospective randomized study.A medical ICU.Fifteen patients with COPD and AHRF were consecutively and randomly assigned to two noninvasive ventilation (NIV) sequences with ACV and PSV mode, spontaneous breathing (SB) via nasal mask being used as control. ACV and PSV settings were always subsequently adjusted according to patient's tolerance and air leaks. Fraction of inspired oxygen did not change between the sequences.ACV and PSV mode strongly decreased the inspiratory effort in comparison with SB. The total inspiratory work of breathing (WOBinsp) expressed as WOBinsp/tidal volume (VT) and WOBinsp/respiratory rate (RR), the pressure time product (PTP), and esophageal pressure variations (deltaPes) were the most discriminant parameters (p0.001). ACV most reduced WOBinsp/VT (p0.05), deltaPes (p0.05), and PTP (0.01) compared with PSV mode. The surface diaphragmatic electromyogram activity was also decreased32% as compared with control values (p0.01), with no difference between the two modes. Simultaneously, NIV significantly improved breathing pattern (p0.01) with no difference between ACV and PSV for VT, RR, minute ventilation, and total cycle duration. As compared to SB, respiratory acidosis was similarly improved by both modes. The respiratory comfort assessed by visual analog scale was less with ACV (57.23+/-30.12 mm) than with SB (75.15+/-18.25 mm) (p0.05) and PSV mode (81.62+/-25.2 mm) (p0.01) in our patients.During NIV for AHRF using settings adapted to patient's clinical tolerance and mask air leaks, both ACV and PSV mode provide respiratory muscle rest and similarly improve breathing pattern and gas exchange. However, these physiologic effects are achieved with a lower inspiratory workload but at the expense of a higher respiratory discomfort with ACV than with PSV mode.

Objective: Fluoxetine is widely prescribed for depressed patients. Hyponatrenia secondary to inappropriate secretion of antidiuretic hormone has been reported in a few cases associated with routine use of fluoxetine, especially in elderly patients. The mechanism has been postulated to be linked to the inappropriate secretion of antidiuretic hormone. Serum concentrations of antidiuretic hormone and fluoxetine have not been reported in previously published reports. Case Report: We report two new cases of severe and reversible hyponatremia associated with routine use of fluoxetine therapy in two elderly women. Fluoxetine-induced inappropriate secretion of antidiuretic hormone was confirmed by elevated serum concentrations of antidiuretic hormone and fluoxetine

Bordetella bronchoseptica is a rarely reported cause of human infection, but is a common respiratory tract commensal of mammals. Human infection with B. bronchoseptica is almost always associated with severe underlying disease and contact with an appropriate animal reservoir. We report a case of pneumonia with shock caused by B. bronchoseptica in an immunocompetent patient.

During sepsis the endocrine, immune and nervous systems elaborate a multitude of biological responses. Little is known regarding the mechanisms responsible for the final circulating erythropoietin (EPO) and renin levels in septic shock. The aim of the present study was to assess the role of EPO and renin as biological markers in patients with septic shock. A total of 44 critically ill patients with septic shock were evaluated. Nonsurvivors had significantly higher serum EPO levels than did survivors on admission (median [minimum–maximum]; 61 [10–602] versus 20 [5–369]). A negative relationship between serum EPO and blood haemoglobin concentrations was observed in the survivor group (r = -0.61; P < 0.001). In contrast, in the nonsurvivors the serum EPO concentration was independent of the blood haemoglobin concentration. Furthermore, we observed significant relationships between EPO concentration and lactate (r = 0.5; P < 0.001), arterial oxygen tension/fractional inspired oxygen ratio (r = -0.41; P < 0.005), arterial pH (r = -0.58; P < 0.001) and renin concentration (r = 0.42; P < 0.005). With regard to renin concentration, significant correlations with lactate (r = 0.52; P < 0.001) and arterial pH (r = -0.33; P < 0.05) were observed. Our findings show that EPO and renin concentrations increased in patients admitted to the intensive care unit with septic shock. Renin may be a significant mediator of EPO upregulation in patients with septic shock. Further studies regarding the regulation of EPO expression are clearly warranted.

Nasal mask ventilation (NMV) has been used successfully in chronic restrictive respiratory failure and more recently in acute exacerbations of chronic obstructive pulmonary disease (COPD). This study aimed to evaluate the possible role of NMV in acute respiratory failure (ARF) episodes when mechanical ventilation with endotracheal intubation is questionable. Thirty patients (age, 76 ± 8.1 years) were treated by NMV during ARF episodes (COPD, 20; other chronic respiratory failure [CRF], 5; chronic heart failure [CHF], 4). All patients were hypoxemic (PaO 2 , 5.85 ± 1.62 kPa) and hypercapnic (PaCO 2 , 8.63 ± 1.89 kPa) with respiratory acidosis (pH, 7.29 ± 0.08). In all cases, clinical or physiologic parameters indicated the need for mechanical ventilation, but endotracheal intubation was either not applied because of the age and the physiologic condition of the patients (17 cases) or was postponed (13 cases). NMV was performed using a volume-cycled ventilator and a customized nasal mask. Ventilation was continuous during the first 12 hours and the following nights and was then intermittent during the day. Twenty-one patients improved clinically, within a few hours. Progressive correction of arterial blood gases was observed: PaO 2 increased during the first hour, but PaCO 2 decreased more slowly. Eighteen patients were able to be successfully weaned from NMV. Twelve patients foiled to improve despite NMV: eight of them died and four required endotracheal intubation. There was no difference in the success rate between patients in whom endotracheal ventilation was contraindicated or postponed. Clinical tolerance was satisfactory in 23 patients and poor in seven patients. A return to the respiratory condition was observed in the surviving patients with subsequent discharge from hospital. NMV therefore successfully treated respiratory distress initially in 60 percent of the 30 patients. These results suggest that NMV could be a possible alternative in the treatment of ARF, even in very ill patients, when endotracheal ventilation is controversial or not immediately required.

Ventilator-associated pneumonia (VAP) is the most common infection in intubated critically ill patients. Microaspiration of the contaminated gastric and oropharyngeal secretions is the main mechanism involved in the pathophysiology of VAP. Tracheal cuff plays an important role in stopping the progression of contaminated secretions into the lower respiratory tract. Previous in vitro studies suggested that conical cuff shape might be helpful in improving tracheal sealing. However, clinical studies found conflicting results. The aim of this study is to determine the impact of conical tracheal cuff shape on the microaspiration of gastric contents in critically ill patients. This prospective cluster randomized controlled crossover open-label trial is currently being conducted in ten French intensive care units (ICUs). Patients are allocated to intubation with a polyvinyl chloride (PVC) standard (barrel)-shaped or a PVC conical-shaped tracheal tube. The primary objective is to determine the impact of the conical shaped tracheal cuff on abundant microaspiration of gastric contents. Secondary outcomes include the incidence of microaspiration of oropharyngeal secretions, tracheobronchial colonization, VAP and ventilator-associated events. Abundant microaspiration is defined as the presence of pepsin at significant level (>200 ng/ml) in at least 30 % of the tracheal aspirates. Pepsin and amylase are quantitatively measured in all tracheal aspirates during the 48 h following inclusion. Quantitative tracheal aspirate culture is performed at inclusion and twice weekly. We plan to recruit 312 patients in the participating ICUs. BEST Cuff is the first randomized controlled study evaluating the impact of PVC tracheal-cuff shape on gastric microaspirations in patients receiving invasive mechanical ventilation. Enrollment began in June 2014 and is expected to end in October 2015. ClinicalTrials.gov Identifier: NCT01948635 (registered 31 August 2013).

International audience; Background: Spontaneous-breathing trials can be performed with the use of either pressure-support ventilation (PSV) or a T-piece. Whether PSV trials may result in a shorter time to tracheal extubation than T-piece trials, without resulting in a higher risk of reintubation, among patients who have a high risk of extubation failure is unknown.Methods: In this multicenter, open-label trial, we randomly assigned patients who had a high risk of extubation failure (i.e., were >65 years of age or had an underlying chronic cardiac or respiratory disease) to undergo spontaneous-breathing trials performed with the use of either PSV (with a pressure-support level of 8 cm of water and no positive end-expiratory pressure) or a T-piece. The primary outcome was the total time without exposure to invasive ventilation (reported as the number of ventilator-free days) at day 28 after the initial spontaneous-breathing trial. Secondary outcomes included extubation within 24 hours and extubation within 7 days after the initial spontaneous-breathing trial, as well as reintubation within 7 days after extubation.Results: A total of 969 patients (484 in the PSV group and 485 in the T-piece group) were included in the analysis. At day 28, the median number of ventilator-free days was 27 (interquartile range, 24 to 27) in the PSV group and 27 (interquartile range, 23 to 27) in the T-piece group (difference, 0 days; 95% confidence interval [CI], -0.5 to 1; P = 0.31). Extubation was performed within 24 hours in 376 patients (77.7%) in the PSV group and in 350 patients (72.2%) in the T-piece group (difference, 5.5 percentage points; 95% CI, 0.01 to 10.9), and extubation was performed within 7 days in 473 patients (97.7%) and 458 patients (94.4%), respectively (difference, 3.3 percentage points; 95% CI, 0.8 to 5.9). Reintubation was performed in 72 of 481 patients (14.9%) in the PSV group and in 65 of 477 patients (13.6%) in the T-piece group (difference, 1.3 percentage points; 95% CI, -3.1 to 5.8). Cardiac or respiratory arrest was a reason for reintubation in 9 patients (3 in the PSV group and 6 in the T-piece group).Conclusions: Among patients who had a high risk of extubation failure, spontaneous-breathing trials performed with PSV did not result in significantly more ventilator-free days at day 28 than spontaneous-breathing trials performed with a T-piece. (Supported by the French Ministry of Health; TIP-EX ClinicalTrials.gov number, NCT04227639.).

We studied COVID-19 associated mucormycosis based on 17 cases reported nationwide and assessed the differences with India. They differed by frequencies of diabetes mellitus (47% in France versus up to 95% in India), hematological malignancies (35% versus 1%), anatomical sites (12% versus >80% rhino-orbito-cerebral) and prognosis (88% mortality versus, We reported 17 cases of COVID-19 associated mucormycosis in France. Compared to India, they differed by frequencies of diabetes mellitus (47% versus up to 95% in India), hematological malignancies (35% versus 1%), anatomical sites and mortality (88% versus

La volonté d'une acculturation de la sécurité des soins primaires au sein du pôle de santé d'Évreux nous a amené à effectuer une première démarche de description des perceptions des dimensions de la culture de sécurité auprès des médecins généralistes adhérents. La dynamique créée lors de l'élaboration du projet professionnel du pôle nous incitait à faire l'hypothèse d'un taux de réponse satisfaisant pour en interpréter les résultats comme le reflet de leurs perceptions de la sécurité des soins. Méthode : Il a été proposé à 49 médecins généralistes de l'agglomération d'Évreux, dont les 18 médecins du pôle de santé, une traduction en français du questionnaire Medical Office Survey on Patient Security Culture (MOSPSC) diffusé par l'Agency for Healthcare Research and Quality (AHRQ). Les participants étaient interrogés sur la sécurité des soins à travers 10 dimensions de la culture de sécurité. Un taux de participation supérieur à 80% était défini comme satisfaisant. Résultats : Le taux de participation des médecins généralistes du pôle de santé était de 100%. Les dimensions ayant obtenues les meilleurs scores étaient la capacité à diriger (87,5%), le travail d'équipe (84,4%), la communication libre (76,2%) et la communication sur les erreurs (76,15%). Les dimensions ayant obtenu les plus faibles scores étaient les procédures standardisées (23%) et le rythme et la charge de travail (11,8%). La sécurité des soins était jugée "assez bonne" (44,4%), et la qualité "bonne" sur les critères "soins centrés sur le patient" (66,67%), "soins efficaces" (66,67%) et "soins équitables" (55,56%). Le taux de participation des médecins hors pôle était de 46,1%. 16,7% d'entre eux envisageaient de faire partie du pôle à l'avenir. Discussion : Le taux de participation de 100% des médecins du pôle nous a permis d'interpréter ces résultats. Le score des dimensions de travail d'équipe et de capacité à diriger pourrait montrer une capacité des médecins à travailler et fonctionner ensemble au sein de l'organisation afin d'améliorer la sécurité et la qualité des soins. Les dimensions à développer telles que les procédures standardisées et le rythme et la charge de travail pourraient être améliorées. C'est sur ces dimensions de la sécurité que devront probablement se pencher en priorité les médecins du pole de santé d'Évreux. Le taux de participation des médecins hors pôle ne permettait pas d'interpréter leurs résultats comme le reflet des perceptions des médecins d'Évreux (46,1%). Conclusion : L'excellent taux de participation des médecins du pôle de santé pourrait témoigner très probablement de l'acceptabilité de l'outil comme support d'évaluation de l'acculturation de la sécurité et de la qualité des soins. Il semble par ailleurs être un bon outil d’identification des voies d'amélioration de la culture de sécurité des soins comme en témoigne la cohérence entre les scores des dimensions à développer et le ressenti exprimé par certains médecins répondants.

Contexte : Le carnet lombalgie CORAIL (Coordination, Recherche, Autogestion et Information des Lombalgiques) regroupe des outils validés scientifiquement ou recommandés pour soigner les patients souffrant de lombalgie commune subaigüe (PSLCS) en prévention de lombalgie chronique. Son usage en pratique n’avait pas encore été expérimenté. Objectifs: Démontrer la faisabilité de l’utilisation du carnet lombalgie CORAIL par la majorité des PSLCS sur prescription médicale de façon ordonnée et complète selon le mode d’emploi du carnet. Les objectifs secondaires étaient d’identifier et de décrire les déterminants qu’on classera comme facilitant ou freinant l’utilisation ordonnée et complète du carnet, appréhender son coût réel afin de préciser le modèle économique envisageable. Matériels et Méthode : Étude de faisabilité précoce expérimentale, non interventionnelle, sans comparaison de groupes. Durant 4 mois en 2016, 26 médecins généralistes (MG) libéraux volontaires du département de l’Eure ont prescrit le carnet lombalgie CORAIL à chacun des 29 patients inclus. Les pharmaciens (PHA) titulaires d’officines étaient chargés de délivrer et de récupérer les carnets des patients au cours de 2 entretiens pharmaceutiques distincts à 2 mois d’intervalle. Chaque MG et PHA volontaire recevait le protocole d’étude incluant le mode d’emploi du carnet. Le critère principal de jugement de la faisabilité était le taux de 50% de carnets récupérés en pharmacie parmi les carnets prescrits. Résultats : Au total 5 carnets ont été récupérés parmi les 29 carnets prescrits (17%). Ces 5 carnets ont été prescrits par 4 MG différents et délivrés par 4 PHA différents. La faisabilité sur les plans technique, éthique, ordinal était incontestée par les participants. 41% des PHA n’ont pas reçu les carnets commandés à l’éditeur, 40% n’ont pas rendu leur fiche de suivi et 50% des MG n’ont pas rendu leur fiche de suivi. Discussion : Le point commun des parcours de soin qui ont permis la récupération des 5 carnets est la formation orale informelle avant le début de l’étude des MG et des PHA qui ont prescrit et délivré ces carnets. Conclusion : Cette étude test n'est pas parvenue à démontrer la faisabilité de l'utilisation du carnet CORAIL. Toutefois la réalisation de cette étude nous a permis d'observer de potentiels déterminants facilitateurs et freinateurs dans ce type d'approche coordonnée autour d'un patient. En particulier, une diffusion d'informations orales pourrait probablement notamment améliorer l’implémentation du dispositif.

Contexte L’amélioration de l’observance thérapeutique est un enjeu majeur de santé publique et serait selon l’OMS « la plus grande avancée médicale du XXIème siècle ». Elle estime que près de 50% des traitements prescrits sont peu ou mal suivis. L’hypertension artérielle est la première maladie chronique dans le monde, et environ 50% des patients traités ne sont pas contrôlés. Une mauvaise observance thérapeutique serait l’une des principales causes de ce mauvais contrôle. Les interventions visant à améliorer cette observance ont été évaluées dans de nombreux essais randomisés, mais il n’en ressort pas de recommandations claires. Objectif Rassembler et évaluer les interventions visant à améliorer l’observance thérapeutique dans l’HTA de l’adulte en médecine ambulatoire. Méthode Revue de la littérature des essais cliniques randomisés publiés de 2000 à 2015 et référencés dans MEDLINE. Les articles inclus portaient sur les interventions visant à améliorer l’observance thérapeutique des adultes souffrant d’HTA essentielle en médecine ambulatoire. Résultats principaux 32 articles ont été inclus regroupant 47 interventions dont 17 ont eu un effet statistiquement significatif sur l’observance thérapeutique. 43% des interventions centrées sur des entretiens dirigés, éducatifs ou motivationnels ont eu un impact significatif sur l’observance (amélioration de 6 à 42,5%). La mise en place de matériels éducatifs a eu un effet limité (2 études sur 8). 60% des interventions proposant une simplification des schémas thérapeutiques (combinaison médicamenteuse à dose fixe, réduction du nombre de prise quotidienne, packaging adapté) ont amélioré l’observance thérapeutique (de 9 à 35%). Conclusion : L’entretien motivationnel et la simplification des schémas posologiques semblent prometteurs afin d’améliorer l’observance thérapeutique. Ces résultats doivent être cependant interprétés avec prudence en raison de l’hétérogénéité de la qualité méthodologique des études et des outils de mesure de l’observance utilisés.

Contexte. À l'image de nombreux pays, la répartition des professionnels de santé sur le territoire français ainsi que l’organisation globale des soins de premiers recours posent de réelles difficultés. L’installation des jeunes générations de médecins généralistes est souvent mise en avant pour expliquer en partie ce problème. Mais assez peu de travaux ont cherché à étudier comment ces nouveaux médecins exerçaient. Objectifs. Dans ce contexte nous avons voulu comparer les conditions d’exercice en Haute Normandie des jeunes médecins généralistes installés et collaborateurs de moins de 5 ans à celles des remplaçants. Dans un deuxième temps nous avons comparé les conditions d’exercice entre hommes et femmes. Méthode. Nous avons réalisé une étude épidémiologique transversale comparative dans ces 3 groupes entre février 2014 et juin 2014. Résultats. 158 médecins ont été inclus : 80 installés, 15 collaborateurs et 61 remplaçants. Les 3 groupes réalisent le même nombre de consultations par jour, soit entre 20 et 30. Les installés travaillent 4,16 jours/semaine et les collaborateurs 3,4 jours/semaine. Ils délèguent au maximum les tâches non médicales. Les installés et les collaborateurs sont à une quinzaine de kilomètres de leurs lieux d'exercice contre une quarantaine de kilomètres pour les remplaçants. Les remplaçants prennent 8,7 semaines de vacances par an alors que les installés 6,7 semaines/an et les collaborateurs 5,7 semaines/an. Ils sont satisfaits de leur exercice. Les hommes installés réalisent plus de consultations par jour et travaillent un nombre de jours plus important par semaine que leurs homologues féminins. Discussion /Conclusion. Cette étude nous a permis d'avoir une idée sur l'exercice des jeunes médecins généralistes travaillant en libéral et sur l'impact de la féminisation. Dans les années à venir il y aura nécessairement des modifications dans l'organisation du système de santé, les entrants n'exerçant pas tout à fait de la même façon que les sortants.