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Influenza is a public health issue worldwide. Although antibiotics should not be used to treat viral infections, they are often prescribed to patients with influenza-like illness (ILI). Such misuse promotes antibiotic resistance. The role of rapid point-of-care tests (POCTs) in preventing antibiotic misuse in adults with ILI symptoms remains relatively unexplored.To evaluate whether POCT implemented in 2018-2019 to detect influenza viruses led to a decrease in antibiotic prescriptions compared with laboratory-based influenza tests.Adult patients with ILI in one emergency department (ED) were retrospectively enrolled over three epidemic seasons (from 2016-2017 to 2018-2019). The primary outcome was the rate of antibiotic prescriptions, which was compared between the three seasons in bivariate and multivariate analyses. Prescriptions for ancillary laboratory tests, chest X-rays and oseltamivir were also compared, along with hospitalizations and length of stay (LOS) at the ED.Overall, 1849 patients were included. Median age was over 70 years throughout all three seasons. The number of antibiotic prescriptions was significantly different between the three periods in bivariate analysis (48.3% in 2016/2017, 44% in 2017/2018 and 31.1% in 2018/2019; P0,0001) and in multivariate analysis (adjusted odds ratio (aOR) = 0.48, 95% confidence interval (CI) = 0.30-0.76 for 2018/2019 and aOR = 0.99, 95%CI = 0.67-1.46 for 2017/2018, compared with 2016/2017). There were significantly fewer prescriptions of ancillary laboratory tests, X-rays, hospitalizations and more oseltamivir prescriptions in 2018/2019, compared with the previous seasons. LOS was significantly lower in 2018/2019 only for influenza-positive patients.ED influenza POCT decreased antibiotic use and led to less ancillary testing, X-rays and hospitalizations among patients with ILI. However, medico-economic studies are necessary before formulating definite recommendations.

Le Groupe d’intérêt en hémostase périopératoire (GIHP) et le Groupe français d’études sur l’hémostase et la thrombose (GFHT), en collaboration avec la Société française d’anesthésie et de réanimation (SFAR) ont fait des propositions de gestion des agents antiplaquettaires (AAP) pour une procédure invasive programmée. Ces propositions ont été discutées et validées par vote ; toutes sauf une ont fait l’objet d’un accord fort. La gestion des AAP dépend de leur indication et de la procédure considérée. Le risque hémorragique lié à la procédure invasive peut être divisé en bas, intermédiaire ou élevé, selon la possibilité ou non de réaliser la procédure sous traitement (sous respectivement bithérapie antiplaquettaire, aspirine en monothérapie ou aucun AAP). Si une interruption des AAP est indiquée avant la procédure, une dernière prise d’aspirine, clopidogrel, ticagrélor et prasugrel 3, 5, 5 et 7 jours avant la procédure est proposée. Le risque thrombotique associé à l’interruption des AAP doit être évalué en fonction de l’indication des AAP. Il est plus élevé chez les patients traités par bithérapie pour un stent coronaire que chez ceux traités par monothérapie pour une prévention cardiovasculaire, un antécédent d’accident vasculaire cérébral ischémique ou une artériopathie oblitérante des membres inférieurs. Ces propositions concernent aussi le rôle potentiel des tests fonctionnels plaquettaires, la gestion des AAP pour l’anesthésie locorégionale, centrale et périphérique, et pour la chirurgie cardiaque coronaire.

The risk of venous thromboembolism (VTE) is higher in myeloma patients receiving immunomodulatory compounds. A VTE prophylaxis using low-molecular-weight heparin or aspirin is therefore proposed. Apixaban is an oral direct anti-Xa. Several studies have shown the efficacy and safety of apixaban in VTE prophylaxis compared to enoxaparin. The objective of this prospective phase 2 pilot study was to assess the risk of VTE and bleeding in patients with myeloma treated with immunomodulatory compounds lenalidomide (len) or thalidomide (thal), using apixaban in a preventive scheme. Myeloma patients requiring Melphalan-Prednisone-Thalidomide in the first line, or Lenalidomide-Dexamethasone in the relapse setting received apixaban, 2.5 mg x 2/day for 6 months. Venous (pulmonary embolism-PE, or symptomatic proximal or distal deep vein thrombosis-DVT, or all proximal asymptomatic events detected by systematic proximal bilateral compression ultrasound) or arterial thrombotic events, and bleeding events (ISTH 2005) were registered. One hundred and four patients were enrolled (mean age 69.8 ± 7.8 years), 11 in first line and 93 in relapse. Two venous thrombotic events were observed, for example, an asymptomatic proximal DVT and a symptomatic distal DVT, in the context of apixaban stopped 14 days before, due to lenalidomide-induced thrombocytopenia. No PE or arterial cardiovascular events were reported. Only one major and 11 CRNM hemorrhages were reported. These data must now be confirmed on a randomized large study.

Heparin-induced thrombocytopenia (HIT) is a rare, iatrogenic disease characterised by its potential severity, mainly related to thrombosis, and by difficulties regarding its diagnosis and management of affected patients. In 2002, a conference of experts mobilised by the French Society of Anaesthesia and Intensive Care Medicine (Société française d’anesthésie et de réanimation [SFAR]) drafted recommendations for the management of HIT [...]

The role of deferred vs immediate stenting during primary percutaneous coronary intervention (PCI) for patients with ST-segment elevation myocardial infarction (STEMI) remains controversial.We undertook a collaborative meta-analysis of study-level data by searching electronic scientific databases for investigations of primary PCI patients randomized to deferred or immediate stenting and subsequent cardiac magnetic resonance imaging. Primary angiographic and imaging outcomes were slow/no-reflow and microvascular obstruction (MVO), respectively. Main secondary outcome was recurrent ischemia.Among 4 trials, a total of 1570 patients with STEMI were assigned to primary PCI with either deferred (n = 779) or immediate stenting (n = 791). Of these, 797 participants had analyzable cardiac magnetic resonance imaging examinations. Median clinical follow-up was 9 months. Patients treated with deferred stenting showed a lower risk of developing slow/no-reflow in the culprit vessel (risk ratio [RR], 0.54 [95% confidence interval (CI), 0.41-0.72]; P0.001), a similar risk for MVO (RR, 0.93 [95% CI, 0.76-1.14]; P = 0.51), and trended higher in the risk of recurrent ischemia (RR, 2.42 [95% CI, 0.88-6.63]; P = 0.09) compared with those treated with immediate stenting. The treatment effect for slow/no-reflow and MVO correlated with a thrombus score grade3 at the baseline angiography and with the total stent length implanted in the culprit artery.A strategy of deferred stenting during primary PCI improves angiographic but not imaging or clinical outcomes compared with immediate stenting. The potential lower risk for myocardial injury by deferred stenting in primary PCI patients with STEMI and high thrombus burden requires a confirmation in adequately sized randomized trials.

Objective To describe the resources for medical condition management in mountain huts and the epidemiology of such events. Methods We conducted a 3-step study from April 2013 to August 2014 in French mountain huts. The first step consisted of collecting data regarding the first aid equipment available in mountain huts. The second step consisted of a qualitative evaluation of the mountain hut guardian's role in medical situations through semistructured interviews. Finally, a prospective observational study was conducted in the summer season to collect all medical events (MEs) that occurred during that period. Results Out of 164 hut guardians, 141 (86%) had a basic life support diploma. An automatic external defibrillator was available in 41 (26%) huts, and 148 huts (98%) were equipped with a first aid kit. According to semistructured interviews, hut guardians played a valuable role in first aid assistance. Regarding the observational study, 306 people requested the hut guardian's help for medical reasons in 87 of the 126 huts included. A total of 501 MEs for approximately 56,000 hikers (0.85%) were reported, with 280 MEs (56%) involving medical pathologies and 221 (44%) MEs involving trauma-related injuries. Conclusions MEs had low prevalence, but the hut guardian played a valuable role as a first aid responder.

Purpose We describe the impact of a multifaceted program for decreasing ventilator-associated pneumonia (VAP) after implementing nine preventive measures, including selective oropharyngeal decontamination (SOD). Methods We compared VAP rates during an 8-month pre-intervention period, a 12-month intervention period, and an 11-month post-intervention period in a cohort of patients who received mechanical ventilation (MV) for > 48 h. The primary objective was to assess the effect on first VAP occurrence, using a Cox cause-specific proportional hazards model. Secondary objectives included the impact on emergence of antimicrobial resistance, antibiotic consumption, duration of MV, and ICU mortality. Results Pre-intervention, intervention and post-intervention VAP rates were 24.0, 11.0 and 3.9 VAP episodes per 1000 ventilation-days, respectively. VAP rates decreased by 56% [hazard ratio (HR) 0.44, 95% CI 0.29–0.65; P 48 h between the pre- and post-intervention periods. Conclusions Our preventive program produced a sustained decrease in VAP incidence. SOD provides an additive value. Electronic supplementary material The online version of this article (10.1007/s00134-018-5227-4) contains supplementary material, which is available to authorized users.

International audience

The French Working Group on Perioperative Haemostasis (GIHP) and the French Study Group on Haemostasis and Thrombosis (GFHT) in collaboration with the French Society for Anaesthesia and Intensive Care Medicine (SFAR) drafted up-to-date proposals for the management of antiplatelet therapy in patients undergoing elective invasive procedures. The proposals were discussed and validated by a vote; all proposals but one could be assigned with a high strength. The management of antiplatelet therapy is based on their indication and the procedure. The risk of bleeding related to the procedure can be divided into high, moderate and low categories depending on the possibility of performing the procedure in patients receiving antiplatelet agents (none, monotherapy and dual antiplatelet therapy respectively). If discontinuation of antiplatelet therapy is indicated before the procedure, a last intake of aspirin, clopidogrel, ticagrelor and prasugrel 3, 5, 5 and 7 days before surgery respectively is proposed. The thrombotic risk associated with discontinuation should be assessed according to each specific indication of antiplatelet therapy and is higher for patients receiving dual therapy for coronary artery disease (with further refinements based on a few well-accepted items) than for those receiving monotherapy for cardiovascular prevention, for secondary stroke prevention or for lower extremity arterial disease. These proposals also address the issue of the potential role of platelet functional tests and consider management of antiplatelet therapy for regional anaesthesia, including central neuraxial anaesthesia and peripheral nerve blocks, and for coronary artery surgery., SCOPUS: ar.j, info:eu-repo/semantics/published

Resume Objectif Le bilan de depistage du cancer au decours d’une maladie thromboembolique veineuse (MTEV) reste actuellement controverse. Nous avons cherche a caracteriser une population la plus a risque de developper une neoplasie au decours d’un evenement thromboembolique. Methode Nous avons realise une etude retrospective ancillaire cas-temoins, chez des patients ayant presente une MTEV authentifiee, et chez lesquels les cancers ont ete repertories. Nous avons evalue l’association de la presence d’un cancer aux caracteristiques de la MTEV et aux resultats de quatre marqueurs biologiques. Resultats Notre population etait constituee de 142 patients (53 % d’hommes, âge median de 71 ans). A deux ans de la MTEV, 24 patients (17 %) etaient porteurs d’un cancer. Les valeurs des medianes des D-dimeres, des monomeres de fibrine et de la SP-selectine sont significativement plus elevees chez les patients ayant un cancer. La regression logistique a permis d’identifier deux elements permettant de cibler les patients a haut risque de cancer : le caractere bilateral de la thrombose (OR : 4,41, 95 % IC : 1,41–13,78, p = 0,01) et un taux de D-dimeres superieur a 3,8 μg/mL (OR : 3,68, 95 % IC : 1,36–9,94, p = 0,01). Ces deux caracteristiques portent une information additive ; 58 % des patients de notre population ayant ces deux facteurs associes ont un cancer. Conclusion Le caractere bilateral de la thrombose et des D-dimeres superieurs a 3,8 μg/mL sont hautement associes a la pathologie carcinologique. Ce resultat necessite d’etre valide par une etude prospective. Cela permettrait de limiter le depistage a la population la plus a risque.

Resume Introduction L’arteriopathie obliterante des membres inferieurs (AOMI) est un marqueur de risque cardiovasculaire aux consequences medico-socioeconomiques importantes. Cependant, le depistage des sujets asymptomatiques en prevention primaire reste debattu. Objectif Determiner la prevalence, les facteurs de risque de l’AOMI au sein d’une population ambulatoire de depistage en prevention primaire mais a risque cardiovasculaire intermediaire a elever, afin d’estimer l’impact potentiel d’un tel depistage. Methode Analyse des donnees de trois campagnes de depistage multicentriques de l’AOMI realisees sur un jour (2008–2010) aupres d’une population ambulatoire âgee de plus de 50 ans diabetique ou fumeuse ou âgee de plus de 70 ans. L’AOMI a ete depistee par la mesure de l’index de pression systolique (pression systolique jambiere la plus basse/pression systolique humerale la plus elevee) (IPS) et etait consideree comme presente si IPS inferieur a 0,9. Resultats Dix mille six cent quatorze patients ont ete depistes : 16,7 % (n = 1774) presentaient une AOMI et 3,8 % (n = 407) des IPS inferieurs a 0,7 ; 7,7 % (n = 818) des patients presentaient un IPS superieur a 1,3. Un âge superieur a 70 ans, le sexe masculin, le tabagisme actif, l’HTA et le diabete traites etaient des facteurs de risque independants d’AOMI. Conclusion Le depistage ambulatoire d’une population en prevention primaire a risque cardiovasculaire intermediaire a eleve permet d’identifier de nombreux patients presentant une AOMI. L’impact en termes de morbi-mortalite cardiovasculaire d’un tel depistage reste a determiner.

Background Elevated serum blood lactate is an indicator of on-going bleeding in severe trauma patients. Point-of-care (POC) capillary lactate measurement devices may be useful to rapidly assess lactate concentration at the bedside. The aim of this study was to test the diagnostic performance of capillary lactate to predict significant transfusion in normotensive trauma patients. Methods We conducted a prospective observational study in one level-I trauma centre. From August 2011 to February 2013, 120 consecutive adult patients with systolic blood pressure (SBP) higher than 90 mmHg were included. Capillary lactate was measured on admission in the trauma bay. The primary outcome was defined as a significant transfusion within the first 48 h. Diagnostic performance was determined using receiver operating characteristic (ROC) curve analysis. We also tested the agreement between capillary lactate and blood lactate concentrations using Bland and Altman analysis. Results Of the 120 normotensive trauma patients, 30 (25 %) required at least one unit of packed red blood cells (RBC) and 12 (10 %) patients received at least four RBC within the first 48 h. All patients with significant RBC transfusion had capillary lactate higher than 3.5 mmol/l. The area under the ROC curve of capillary lactate on admission to predict transfusion of at least 4 RBC units was 0.68 [95 % CI 0.58 – 0.78]. The average bias between capillary and blood lactate measurements was 2.4 mmol/l with a standard deviation of 3.0 mmol/l (n = 60 patients). Conclusions Although a significant association was found between POC lactate concentration and transfusion requirements, the diagnostic performance of capillary lactate measurements was poor. Due to large disagreement between capillary lactate and blood lactate, capillary lactate cannot be considered in the clinical setting. Trial registration ClinicalTrials.gov, No. NCT01793428. Electronic supplementary material The online version of this article (doi:10.1186/s13049-016-0272-x) contains supplementary material, which is available to authorized users.

Background— Delayed stent implantation after restoration of normal epicardial flow by a minimalist immediate mechanical intervention aims to decrease the rate of distal embolization and impaired myocardial reperfusion after percutaneous coronary intervention. We sought to confirm whether a delayed stenting (DS) approach (24–48 hours) improves myocardial reperfusion, versus immediate stenting, in patients with acute ST-segment–elevation myocardial infarction undergoing primary percutaneous coronary intervention. Methods and Results— In the prospective, randomized, open-label minimalist immediate mechanical intervention (MIMI) trial, patients (n=140) with ST-segment–elevation myocardial infarction ≤12 hours were randomized to immediate stenting (n=73) or DS (n=67) after Thrombolysis In Myocardial Infarction 3 flow restoration by thrombus aspiration. Patients in the DS group underwent a second coronary arteriography for stent implantation a median of 36 hours (interquartile range 29–46) after randomization. The primary end point was microvascular obstruction (% left ventricular mass) on cardiac magnetic resonance imaging performed 5 days (interquartile range 4–6) after the first procedure. There was a nonsignificant trend toward lower microvascular obstruction in the immediate stenting group compared with DS group (1.88% versus 3.96%; P =0.051), which became significant after adjustment for the area at risk ( P =0.049). Median infarct weight, left ventricular ejection fraction, and infarct size did not differ between groups. No difference in 6-month outcomes was apparent for the rate of major cardiovascular and cerebral events. Conclusions— The present findings do not support a strategy of DS versus immediate stenting in patients with ST-segment–elevation infarction undergoing primary percutaneous coronary intervention and even suggested a deleterious effect of DS on microvascular obstruction size. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01360242.

Resume Objectifs Evaluer l’efficacite, la satisfaction et les modalites d’utilisation d’un labyrinthe pedagogique dans le domaine de la traumatologie grave chez des etudiants en medecine. Le labyrinthe pedagogique est constitue de posters accompagnes de commentaires delivres par des audioguides. Ce labyrinthe fait partie d’un parcours pedagogique incluant des ateliers et une seance de simulation. Type d’etude Etude prospective, interventionnelle, observationnelle monocentrique. Etudiants Les etudiants hospitaliers du CHU de Grenoble, de la troisieme a la sixieme annee de medecine, en stage dans un service du pole d’enseignement urgences-reanimation. Methode Quarante notions essentielles a la prise en charge d’un patient traumatise grave etaient presentes sur les posters et dans les commentaires des audioguides. Ces 40 notions constituaient nos objectifs pedagogiques. Une premiere evaluation a la fin du labyrinthe pedagogique a permis d’evaluer leur memorisation. Les etudiants hospitaliers devaient citer quatre notions essentielles a retenir pour chacun des dix posters soit au total 40 notions. Une deuxieme evaluation concernant leur satisfaction et les modalites d’utilisation de ce nouvel outil pedagogique a ete realisee. Resultats Cent quatre-vingt-quatre etudiants en medecine ont ete inclus dans l’etude. Soixante-quinze pour cent des notions essentielles a la prise en charge d’un patient traumatise grave etaient reconnues comme tels par plus de la moitie des etudiants en medecine. Quatre-vingt-quatorze pour cent des etudiants s’estimaient satisfaits a tres satisfaits par ce nouvel outil pedagogique. Conclusion L’association de posters et d’audioguides est un outil pedagogique novateur, apprecie et efficace pour l’acquisition par les etudiants hospitaliers de connaissances essentielles en traumatologie grave.

Background Right ventricular function predicts outcome in patients with pulmonary hypertension (PH). Therefore accurate assessment of right ventricular function is essential to graduate severity, assess follow-up, and response to therapy. Purpose To evaluate whether PH severity could be assessed using electrocardiography-gated CT (ECG-gated CT) functional parameters. A further objective was to evaluate cardiac output (CO) using two ECG-gated CT methods: the reference Simpson technique and the fully automatic technique generated by commercially available cardiac software. Material and Methods Our institutional review board approved this study; patient consent was not required. Twenty-seven patients who had undergone ECG-gated CT and right heart catheterization (RHC) were included. Two independent observers measured pulmonary artery (PA) diameter, PA distensibility, aorta diameter, right ventricular cardiac output (CT-RVCO) and right ventricular ejection fraction (CT-RVEF) with automatic and Simpson techniques on ECG-gated CT. RHC-CO and mean pulmonary arterial pressure (mPAP) were measured on RHC. Relationship between ECG-gated CT and RHC measurements was tested with linear regression analysis. Results Inter-observer agreement was good for all measurements (r > 0.7) except for CT-RVCO calculated with Simpson's technique (r = 0.63). Pulmonary artery (PA) distensibility was significantly correlated to mPAP (r = −0.426, P = 0.027). CT-RVEF was correlated with mPAP only when issued from Simpson technique (r = −0.417, P = 0.034). CT-RVEF was not significantly correlated to RHC-CO ( P > 0.2). CT-RVCO measured with Simpson technique (r = 0.487, P = 0.010) and automatic segmentation (r = 0.549, P = 0.005) correlated equally with RHC-CO. Conclusion CT-RVEF and CT-RVCO measured on ECG-gated CT are significantly correlated, respectively, to mPAP and RHC-CO in this population with severe reduction of the right ventricular ejection fraction and could be useful for evaluating and following patients with PH.

Resume Contexte La compression est maintenant consideree comme une composante essentielle et validee de la prise en charge de la thrombose veineuse. Cependant, ce traitement reste mal codifie et les habitudes tres variables d’un praticien a l’autre. Objectif Connaitre les habitudes des medecins vasculaires francais concernant le traitement compressif a la phase aigue de la thrombose veineuse. Methode Un questionnaire a ete adresse en 2009 a tous les medecins vasculaires membres de la Societe francaise de medecine vasculaire (SFMV) possedant une adresse electronique. Resultats Sept cent soixante et un medecins ont repondu au questionnaire ; 56,6 % ont un exercice liberal, 19,8 % hospitalier et 23,6 % mixte. Parmi eux, 94,3 % prescrivent toujours une compression au moment du diagnostic de la TVP. La compression initiale est preferentiellement un bas dans 57,3 % des cas (n = 426) et une bande amovible ou un bandage fixe dans 42,7 % des cas (n = 317). Lorsque le medecin prescrit initialement une bande ou un bandage, il effectue un relais par un bas dans 92,3 % des cas. Finalement, 95,8 % (n = 712) des medecins vasculaires prescrivent un bas au cours du suivi des thromboses veineuses. Il s’agit d’une classe 2 (francaise, soit 15 a 20 mmHg) dans 64,3 % des cas et d’une classe 3 (20 a 36 mmHg) dans 35,5 % des cas. La duree du traitement est influencee par les donnees de l’echo-doppler dans 85,9 % (n = 631) des cas. L’etendue de la thrombose n’influence la duree de la compression que pour un tiers des medecins. Conclusion Les medecins vasculaires francais prescrivent systematiquement une compression a la phase aigue de la thrombose veineuse. Ils sont relativement eloignes des recommandations concernant la force de compression en utilisant pour ameliorer l’observance des forces de pression inferieures qui n’ont jamais ete etudiees. Une validation scientifique de cette pratique est necessaire.

Summary. Background: The management strategies for symptomatic isolated superficial vein thrombosis (SVT) (without concomitant deep vein thrombosis [DVT] or pulmonary embolism [PE]) have yet to achieve widespread consensus. Concerns have been raised regarding the usefulness of prescribing anticoagulant treatments to all patients with isolated SVT. Determining the isolated SVT subgroups who have the highest risks of venous thromboembolism (VTE) recurrence (composite of DVT, PE, and new SVT) may facilitate the identification of patients who are likely to benefit from anticoagulant treatment. Design and methods: We performed a pooled analysis on individual data from two observational, multicenter, prospective studies, to determine predictors for VTE recurrence and their impact in an unselected population of symptomatic isolated SVT patients. Results: One thousand and seventy-four cases of symptomatic isolated SVT were followed up at 3 months. VTE recurrence was observed in 3.9% of the patients; 16.2% of the patients did not receive anticoagulants, and 0.6% experienced a VTE recurrence. Cancer, personal history of VTE and saphenofemoral/popliteal involvement significantly increased the risk of subsequent VTE or DVT/PE in univariate analyses. Only male sex significantly increased the risk of VTE or DVT/PE recurrence in multivariate analyses. Twelve per cent of the patients had cancer or saphenofemoral junction involvement, and were at higher risk of DVT/PE recurrence than patients without those characteristics (4.7% vs. 1.9%, P = 0.06). Conclusions: In patients with symptomatic SVT, only male sex significantly and independently increased the risk of VTE recurrence. Cancer or saphenofemoral junction involvement defined a population at high risk for deep VTE recurrence. Some SVTs might be safely managed without anticoagulants.

Cardiovascular disease is a major cause of mortality in end-stage renal disease patients (ESRD). The rate of elderly and polypathologic patients in ESRD is increasing. Elevated levels of C-reactive protein (CRP) have been shown to be associated with increased mortality in ESRD patients. The aim of this study was to examine whether, in elderly ESRD patients, the conventional relationship between elevated CRP and cardiovascular mortality is maintained.This prospective European cohort study included 150 ESRD patients. Data obtained at baseline included demographics, comorbidity, late referral to a nephrologist, high-sensitivity CRP, and serum albumin and hemoglobin levels. Cardiovascular events were analysed as a combined end-point.The mean age of the cohort was 61 years (22-90), with 33.3% of patients over 70 years (75 yrs, 70-83 yrs). Forty-two patients (28.2%) experienced at least one cardiovascular event. Interaction between age over 70 years and CRP exceeding 3 mg/L was a protective factor. Patients over 70 years beginning dialysis with a CRP value3 mg/L had a higher cardiovascular risk than those with a CRP value3 mg/L. Multivariate analysis showed that the independent risk factors for cardiovascular events were, in the whole cohort, age over 70 years, previous cardiovascular comorbidity, and interaction between age and CRP.This trial shows a reverse relation between cardiovascular risk in dialysis patients over 70 and CRP level. This may be a useful element in evaluating older patients before long-term dialysis.

Summary Aims To describe the clinical presentation and 3-month mortality in recognized forms of venous thromboembolism (VTE). Methods All 8256 patients referred to 359 vascular physicians for clinical suspicion of VTE were included over a 15-month period in France. Subjects without a confirmed diagnosis of VTE served as controls. Risk factors, clinical presentation and estimated 3-month survival for each form of VTE were evaluated. Results Of 5889 patients, 426 had pulmonary embolism (PE) with deep vein thrombosis (DVT), 148 had PE without DVT, and 5315 had no VTE. 2350 patients with other VTE events (DVT and superficial vein thrombosis) and 17 other patients were excluded of the analysis. PE without DVT patients presented differently for risk factors in the univariate analysis. Three-month mortality was 4.0% for controls, 12.9% for PE with DVT, and 4.6% for PE without DVT. Compared with controls, only PE with DVT patients (adjusted hazard ratio: 2.6 95% CI [1.4–4.7]) were at increased risk of mortality. Conclusions PE without DVT is not associated with a higher 3-month mortality compared to controls, in contrast to PE with DVT. When diagnosing PE in patients, the clinical significance of an associated DVT is important.

Background Critically ill patients frequently experience pain, but assessment rates remain below 40% in mechanically ventilated patients. Whether pain assessment affects patient outcomes is largely unknown. Methods As part of a prospective cohort study of mechanically ventilated patients who received analgesia on day 2 of their stay in the intensive care unit (ICU), the investigators performed propensity-adjusted score analysis to compare the duration of ventilator support and duration of ICU stay between 513 patients who were assessed for pain and 631 patients who were not assessed for pain. Results Patients assessed for pain on day 2 were more likely to receive sedation level assessment, nonopioids, and dedicated analgesia during painful procedures than patients whose pain was not assessed. They also received fewer hypnotics and lower daily doses of midazolam. Patients with pain assessment had a shorter duration of mechanical ventilation (8 vs. 11 days; P < 0.01) and a reduced duration of stay in the ICU (13 vs. 18 days; P < 0.01). In propensity-adjusted score analysis, pain assessment was associated with increased odds of weaning from the ventilator (odds ratio, 1.40; 95% confidence interval, 1.00-1.98) and of discharge from the ICU (odds ratio, 1.43; 95% confidence interval, 1.02-2.00). Conclusions Pain assessment in mechanically ventilated patients is independently associated with a reduction in the duration of ventilator support and of duration of ICU stay. This might be related to higher concomitant rates of sedation assessments and a restricted use of hypnotic drugs when pain is assessed.

Resume Introduction L’âge et l’hospitalisation sont deux facteurs de risque independants de maladie thromboembolique veineuse (MTEV). Il existe une reticence a utiliser une prevention pharmacologique au long cours chez les patients âges par crainte des complications hemorragiques et du fait de l’absence de recommandations en dehors d’un contexte postchirurgical. Methode Un programme d’amelioration de la qualite de la prevention de la MTEV impliquant au total 50 services de soins de suite et readaptation fonctionnelle a ete conduit et evalue entre 2001 et 2003. Les donnees ont ete recueillies au cours de deux etudes epidemiologiques transversales qui ont inclus 1664 patients âges de 65 ans ou plus avec realisation systematique d’un echo-doppler veineux des membres inferieurs. Resultats Malgre l’utilisation d’une prevention pharmacologique prolongee chez 56 % des patients, la prevalence des thromboses veineuses profondes (TVP) etait de 15 %. Des facteurs de risque de MTEV specifiques ont pu etre identifies : un score ADL superieur a 3, une valeur elevee du up and go test, et la presence d’escarres. L’implantation d’une intervention multifacettes s’est accompagnee d’une reduction de la prevalence des TVP (OR = 0,58, IC 95 %, 0,40–0,83). L’implication des soignants augmentait la proportion de patients mobilises (62 % versus 37 %, p Conclusion Ce projet souligne la prevalence elevee de la MTEV en soins de suite et l’importance d’une prise en charge multidisciplinaire dans la prevention de cette pathologie.

Resume Introduction Des recommandations de pratiques cliniques ont ete diffusees par l’Agence francaise de securite sanitaire des produits de sante (Afssaps) et la Haute Autorite de sante (HAS) vers les professionnels de sante visant a ameliorer la gestion des antivitamines K (AVK), responsables d’une iatrogenie importante. Elles rappellent notamment la necessite d’une education therapeutique. GRANTED est le reseau de sante Ville-Hopital des pathologies vasculaires du secteur Sud-Isere. Une de ses actions est de prendre en charge l’education therapeutique des patients sous AVK avec une demarche educative precise et standardisee. Objectif L’objectif de l’etude est d’evaluer qualitativement l’education therapeutique realisee au sein de ce reseau chez des patients sous AVK, quel que soit leur facteur de risque. Patients et methodes Une etude retrospective a ete realisee chez 100 patients tires au sort, sous traitement AVK depuis au moins trois mois et eduques par GRANTED en 2007. Le critere evalue etait le nombre d’evenements hemorragiques et/ou thromboemboliques. Resultats Sur 97 patients contactes, 3,1 % presentaient une hemorragie grave et 1,03 % une recidive d’un evenement thromboembolique. Conclusion La qualite d’une etude scientifique repose sur une qualite methodologique preferant des etudes prospectives. Il semble neanmoins pertinent de s’assurer que les recommandations officielles de prise en charge des patients appliquees sur le terrain aient un benefice pour les patients. Nous rapportons la premiere evaluation d’un programme d’education therapeutique des patients sous AVK d’un reseau de sante. L’education au sein de cette structure permet de limiter la iatrogenie des AVK et ce, malgre les biais de selection de la population de GRANTED probablement a plus haut risque.

BACKGROUND: After stopping a 3 to 6 months course of oral anticoagulation for a first episode of idiopathic venous thromboembolism (VTE), the risk of recurrent VTE is high (10% per year). In this setting, international guidelines recommend at least 6 months treatment. However, this recommendation is not satisfactory for the following reasons: (1) no randomized trial has compared 6 months to extended duration (2 years) anticoagulation; and (2), even though the frequency of recurrent VTE is similar after pulmonary embolism (PE) and deep vein thrombosis (DVT), the fatality rate of recurrent VTE after PE is higher than that after DVT. METHODS: A French multicentre double blind randomized trial. The main objective is to demonstrate, after a first episode of symptomatic idiopathic PE treated for 6 months using a vitamin K antagonist, that extended anticoagulation for 18 months (INR between 2 and 3) is associated with an increased benefit / risk ratio (recurrent VTE and severe anticoagulant-related bleeding) compared to placebo. The double blind evaluation is ensured using by active warfarin and placebo, and blinded INR. The protocol was approved by the ethics board of the Brest Hospital on the 7th of March 2006. For an alpha risk of 5% and a beta risk of 20%, the estimated sample size is 374 patients. EXPECTED RESULTS: This study has the potential to: (1) demonstrate that the benefit / risk ratio of extended anticoagulation for 18 months is higher than that observed with placebo in patients with a first episode of idiopathic PE initially treated for 6 months, during and after the treatment period; and (2) to validate or invalidate the contribution of isotope lung scans, lower limb Doppler ultrasound and D-Dimer at 6 months of treatment as predictors of recurrent VTE (medico-economic analysis included).

Bleeding is the main complication on vitamin K antagonist treatment (VKA), particularly in elderly patients. However, the bleeding risk prediction in geriatric patients remains difficult. We evaluated the predictive value of the HAS-BLED and ATRIA bleeding scores in VKA-treated patients aged 75 and over. Various clinical bleeding risk factors in elderly were also studied. 208 patients were included in a case-control study: 52 hemorrhages cases were compared to 156 hemorrhage-free cases (controls), mean age 83.1 years in cases and 82.6 in controls. This elderly subgroup was provided from the prospective SCORE cohort study (study designed to validate the use of bleeding scores in an ambulatory population). The patients were included during a VKA-therapeutic education between May 2009 and May 2010 in 4 French hospitals, and followed for 1 year. The primary endpoint, collected prospectively, was the occurrence of severe and clinically relevant bleeding events. According to the Receiver operating characteristics (ROC), the ATRIA score was as effective as HAS- BLED to predict all bleeding (c-statistic: 0.59 [95% CI 0.50-0.68] vs 0.56 [0.48-0.65]) including severe bleeding (c-statistic: 0.64 [95% CI 0.49-0.79] vs 0.62 [0.49-0.75]). Multivariate Cox regression analysis showed increasing bleeding risk with anemia (OR = 2.6 [95% CI 1.34-5.23], p = 0.005), serotonin reuptake inhibitors (2.8 [1.08-7.47], 0.034), and family-management of VKA-treatment (2.8 [1.28-6.15], 0.01). ATRIA hemorrhage predictive value can be improved by adding such parameters as family-management of VKA-treatment and serotonin reuptake inhibitors treatment. ATRIA appears as relevant as HAS-BLED in predicting all bleeding including major hemorrhages in elderly patients educated VKA-management. The ATRIA bleeding score is improved by including items of serotonin reuptake inhibitors treatment and family-management of VKA-treatment.

International audience; PURPOSE:There has been a growing interest in continuous local anaesthetic wound infiltration as a non-opioid technique for postoperative pain relief. The impact of this modality on baseline analgesia after spinal fusion surgery has however been inconclusive. We tested whether continuous wound infiltration with ropivacaine can enhance postoperative analgesia compared to a baseline intravenous multimodal analgesia protocol after spinal fusion surgery.METHODS:In this randomized, double-blinded, placebo-controlled study, a multiholed 19-gauge catheter was placed at the end of the surgical procedure through the wound to permit the continuous administration (8 ml/h) of ropivacaine 0.2 % (ropivacaine group; n = 19 patients) or saline (control group; n = 20 patients) during the first 48 postoperative hours (H48). Both groups received intraoperative low-dose ketamine, a combination of acetaminophen, non-steroidal anti-inflammatory drug, and nefopam over the same postoperative period, and morphine delivered by a patient-controlled analgesia (PCA) device.RESULTS:Morphine consumption was comparable between the two groups both at H48, 38 mg (26:52) (median, 25th:75th percentile) (control group) versus 43 mg (19:74) (ropivacaine group), and at H24, 18 mg (16:22) versus 22 mg (9:35) respectively. Pain scores at rest and during mobilization, quality of postoperative sleep, and morphine-related side effects were comparable between the two groups at H24 and H48.CONCLUSION:Our findings indicate that no additional analgesia was provided with continuous wound infiltration of ropivacaine compared to a baseline intravenous multimodal analgesia protocol after spinal fusion surgery.TRIAL REGISTRATION:Clinicaltrials.gov #NCT01743794.

Summary What is known and objectives The French Society of Clinical Pharmacy has developed a website, named Act-IP©, enabling hospital pharmacists to document and analyse pharmacists' interventions (PIs) proposed during medication order review when a drug-related problem is detected. This study analyses PIs documented in Act-IP© and assesses factors associated with physicians' acceptance of PIs. Methods PIs documented into Act-IP© over a 30-month period were analysed. Independent predictors of physicians' acceptance were assessed using multiple logistic regression. Results and discussion A total of 34 522 PIs were registered by 201 pharmacists working in 59 hospitals. PIs were mostly related to ‘dose adjustment’ (25%), ‘drug discontinuation’ (20%) and ‘drug switch’ (19%). Of the 43 343 medications involved, 28% targeted drugs acting on the central nervous system, 17% anti-infective drugs and 16% cardiovascular drugs. Sixty-eight per cent of PIs were accepted by physicians (15% refusals and 17% non-assessable). Physicians' acceptance was significantly associated with 1/ drug group: antineoplastics and immunomodulators (OR = 2·29, CI 95[1·94–2·69]), anti-infectives (OR = 1·19, CI 95 [1·11–1·28]); 2/ type of intervention: drug switch (OR = 1·54, CI 95 [1·43–1·65]), drug discontinuation (OR = 1·38, CI 95 [1·29–1·48]), administration modality optimization (OR = 1·19, CI 95 [1·11–1·29]), addition of a new drug (OR = 1·12, CI 95 [1·00–1·24]); 3/ ward specialty: paediatrics (OR = 1·83, CI 95 [1·24–2·70]) and intensive care (OR = 1·34, CI 95 [1·10–1·64]); 4/ level of pharmacist integration in the ward: higher when the pharmacist is regularly in the ward compared with occasionally (OR = 0·74, CI 95 [0·70–0·79]) or never (OR = 0·68, CI 95 [0·60–0·75]) present. What is new and conclusion This study highlights the role of routine pharmacist review of medication orders to prevent drug-related problems and gives new insights for a successful collaboration between physicians and pharmacists.

Resume Les objectifs d'un Centre d'innovation technologique (CIT) sont de valoriser la recherche medicale par transfert de technologie, de mettre au service des industriels un environnement hospitalier de haute technologie et de favoriser la creation de petites entreprises de produits innovants. Apres avoir precise l'environnement grenoblois particulierement bien adapte a l'emergence d'un CIT ayant pour thematique l'ingenierie medicale et en particulier la modelisation, la robotique et la domotique, cet article precise la collaboration tripartite centree sur l'information et necessaire a la realisation des objectifs de ce CIT. La synthese des premiers resultats obtenus illustre les apports d'une telle structure dans le cadre de la valorisation de l'innovation technologique appliquee au domaine de la sante.

Resume La maladie thrombo-embolique veineuse est une affection repandue. Bien que les formes cliniques, les methodes diagnostiques, et les traitements de cette pathologie aient recemment evolue, la plupart des etudes concernant ses facteurs de risque sont anciennes, conduites en milieu hospitalier et souvent non adaptees aux formes actuelles de la maladie. Dans cet article, nous decrivons le rationnel, les objectifs et la methodologie de l’etude OPTIMEV (OPTimisation de l’Interrogatoire pour la Maladie thromboEmbolique Veineuse). Rationnel Les facteurs de risque de la maladie thromboembolique veineuse (MTEV) sont multiples, complexes, associes entre eux, la question de leur signification clinique se pose. Nous avons effectue une analyse bibliographique systematique entre 1972 et 2005 des articles originaux, essais, description de cohortes ou meta-analyses decrivant les facteurs de risque et avons choisi les themes de travail suivants : l’antecedent de MTEV, la chirurgie, le cancer, l’immobilisation, l’âge, les facteurs biologiques ainsi que d’autres facteurs moins valides ou des facteurs protecteurs. Quatre-vingt-quatre articles ont ete retenus et analyses. Pour chacun de ces themes, une evaluation du risque a ete presentee (odds ratio) et les questions non resolues ont ete posees. Objectifs L’objectif principal de l’etude OPTIMEV est de redefinir et preciser la place actuelle des differents facteurs de risque de MTEV accessibles a l’interrogatoire pour prendre en compte les changements survenus depuis leur identification. Les objectifs secondaires sont 1) de determiner si les memes facteurs de risque doivent etre recherches a l’interrogatoire pour l’evaluation du risque de MTEV quelle que soit sa topographie (thrombose veineuse profonde TVP. distale, proximale, musculaire, ou embolie pulmonaire) ; 2) si les facteurs de risque different entre les patients vus en ville et ceux vus a l’hopital. Une des hypotheses de l’etude est que les facteurs de risque communement admis ne s’appliquent pas aux TVP distales. Methodes L’etude OPTIMEV est une etude prospective multicentrique avec suivi longitudinal de 10 000 patients inclus par les medecins vasculaires francais liberaux et hospitaliers. Sont eligibles tous les patients avec une suspicion de MTEV adresses dans les centres participants sur une periode donnee. Les caracteristiques, facteurs de risque, et les resultats des examens paracliniques sont recueillis a l’inclusion par l’investigateur a l’aide d’un cahier d’observation electronique. Le 1 er juin 2005, 4 173 patients ont ete inclus. Un suivi longitudinal avec recueil de criteres de jugement cliniques (deces, recidive de MTEV, accident hemorragique, cancer) est effectue a 3 mois et un an par telephone. Le promoteur de l’etude est la Societe Francaise de Medecine Vasculaire. L’organisation a ete confiee au Centre d’Investigation Clinique du CHU de Grenoble. Cette etude a recu un soutien financier du Programme Hospitalier de Recherche Clinique et du Laboratoire Sanofi Aventis France qui fournit egalement un soutien logistique. Un comite scientifique independant a ete mis en place pour veiller au bon deroulement de l’etude et pour decider de l’utilisation des donnees obtenues. Discussion Les resultats de l’etude OPTIMEV montreront comment apprehender le risque thrombo-embolique veineux en consultation. De nouveaux outils seront developpes pour evaluer la probabilite clinique de MTEV en tenant compte de sa topographie. Les resultats finaux seront presentes courant 2006. (J Mal Vasc 2005 ; 30 : 217-227).

EBV viral load (EBV-VL) in PBMC was prospectively determined by semi-quantitative PCR in 85 stem cell transplants (40 genoidentical, 45 non-genoidentical) in order to characterize the kinetics of EBV-VL and to assess the ability of this measure to predict the development of EBV-induced lymphoproliferative disease (EBV-LPD). PCR was performed prior to and after transplantation. An EBV-VL >300 copies/μg DNA was chosen as the threshold for risk of developing an EBV-LPD. Two hundred and fifty-eight EBV-VL measures were evaluable. Five patients (5.9%) developed an EBV-LPD. All had an elevated EBV DNA peak level before EBV-LPD. Fifteen out of 80 recipients (18.7%) without EBV-LPD had EBV levels over 300 copies/μg DNA at least once during the follow-up. Overall, the manifestation of at least one EBV-VL over 300 copies/μg DNA during the entire follow-up demonstrated a sensitivity, specificity, positive and negative predictive value for the diagnosis of EBV-LPD of 100%, 81%, 25% and 100%, respectively. In patients without EBV-LPD, HLA incompatibility, grade ⩾II acute GVHD and use of an unmanipulated graft were significantly associated with an EBV-VL >300 copies/μg DNA. This strategy appears sensitive for the diagnosis of EBV-LPD but its positive predictive value has to be improved in order to guide pre-emptive therapy. Bone Marrow Transplantation (2002) 29, 21–28. doi:10.1038/sj.bmt.1703331

Introduction Le syndrome post-thrombotique (SPT) correspond aux manifestations chroniques d’insuffisance veineuse secondaires a une thrombose veineuse profonde (TVP). L’epidemiologie du SPT (incidence, facteurs de risque, impact medico-economique) reste incertaine car il y a de nombreuses difficultes methodologiques. Quelle definition du SPT utiliser ? Le score de Villalta est actuellement le plus utilise. Un score de Villalta > 4 definit la presence d’un SPT. L’echelle de Villalta permet une evaluation qualitative et quantitative du SPT (leger, modere, severe). Focaliser la recherche sur les formes graves de SPT avec des criteres diagnostiques plus fiables et reproductibles comme les ulceres cutanes est egalement possible (CEAP). Il faut aussi des cohortes de qualite, de grande taille car les formes graves sont rares, et avec un suivi a long terme ce qui est exceptionnel au-dela de deux ou trois ans. Malgre ces difficultes methodologiques, on dispose de donnees sur le SPT. Incidence du SPT post-TVP proximale Deux ans apres une TVP proximale, 20–50 % des patients presentent un SPT et 5–10 % presentent un SPT severe. A plus long terme, les donnees sont contradictoires avec pour certains une augmentation de l’incidence du SPT et pour d’autres une stabilite de l’incidence et une simple evolution vers des formes plus graves. L’incidence des ulceres post-TVP varie de 1 a 4 % de 2 a 5 ans apres la TVP, pouvant atteindre jusqu’a 10 % a 10 ans dans certaines etudes. Principaux facteurs de risque de SPT Les seuls facteurs predictifs incontestables de SPT sont une recidive de TVP ispsilaterale (RR = 10) et le caractere tres proximal de la TVP, c’est-a-dire femoro-iliaque. Le role de nombreux autres facteurs de risque (âge, sexe, extension de la thrombose, taille du thrombus, persistance des signes cliniques de TVP ou d’anomalies biologiques comme une elevation des d-dimeres…) est beaucoup moins evident. Impact medico-economique du SPT Le SPT est responsable d’une alteration importante de la qualite de vie des patients, proportionnelle a sa severite. Ainsi, si l’impact sur la qualite de vie du SPT en general est comparable a celui de l’arthrose ou du diabete, le SPT severe aurait un impact negatif sur la qualite de vie comparable a un cancer ou a une insuffisance cardiaque. Apres une TVP, la survenue d’un SPT est le principal facteur predictif d’alteration de la qualite de vie. A contrario, les patients presentant une TVP n’ayant pas developpe de SPT avaient une qualite de vie globale a 2 ans comparable a celle de temoins sans TVP, c’est donc bien l’apparition d’un SPT qui impacte la qualite de vie post-TVP. Risque attribuable Le SPT a les memes expressions cliniques que l’insuffisance veineuse. De ce fait il est difficile de faire la part des symptomes reellement dus a la TVP. On dispose de tres peu de donnees sur ce point important car cela necessite des cohortes de grande taille avec un groupe de patients sans TVP. Neanmoins on estime qu’une insuffisance veineuse primaire preexistante pourrait expliquer jusqu’a 40 % des SPT diagnostiques. Conclusion Le SPT est incontestablement la plus frequente des complications post-TVP proximale avec un impact important sur la qualite de vie des patients. La diminution d’incidence des TVP demontree recemment dans le grand Ouest de la France est la meilleure approche dans la prevention du SPT. Il reste malgre tout tres important de mieux connaitre l’epidemiologie du SPT pour mieux affiner les strategies therapeutiques. Le suivi a plus de 10 ans de la cohorte Optimev et l’etude Celest sur la compression veineuse vont apporter d’ici fin 2017 des elements de reponses a plusieurs de ces questions en suspens.

1 Departement thoracique, institut mutualiste Montsouris, 42, boulevard Jourdan, 75674 Paris cedex 14, France ; 2 comite de gestion de la MTE, centre hospitalier universitaire de Grenoble, 38700 La Tronche, France ; 3 service de reanimation medicale, hopital Bichat, 75877 Paris cedex 18, France ; 4 unite de reanimation neonatale, centre hospitalier universitaire de Rennes, 35033 Rennes cedex 9, France

The quality of discharge letters has been evaluated in order to initiate a process of improved communications between the hospital and general practitioners. From each of 37 volunteer clinical departments of a French university hospital, a random sample of 30 stays was selected among the hospitalisations for one year. The quality of discharge letters was assessed according to recipients’ needs and to French legislation. In total, 1,024 medical records were relevant and were analysed. This study showed deficiencies in management of discharge letters in the hospital. It constitutes the first step of a quality improvement process based on the awareness of concerned actors through information feedback and the follow‐up of specific indicators.

In this study we present data on cytomegalovirus (CMV) seroprevalence in pregnant women in France. One thousand and eighteen women were enrolled in a prospective study carried out in Grenoble. The overall rate of seropositivity, using a specific IgG ELISA test, was 51.5 % (95 % CI: 48.5-54.5). Among a homogeneous population of 873 women born in France with high or middle socioeconomic status, CMV seropositivity increased with age and parity. The seroprevalence according to age was found to depend on parity. It increased with age in women with no children or with only one; it was higher but no more age-dependent in women with two children or more. In addition, CMV seroprevalence was significantly higher in women born in southern France (51.6%) than in those born in northern France (37.4%), these findings being consistent with the existence, within France, of a gradient in seroprevalence rate, increasing from the North to the South. A logistic regression analysis reveals the place of birth in France as a major predictive factor of CMV antibody status (OR: 3.5) followed by age (OR: 2) and parity (OR: 1.7). In this study, we show an independent effect of parity on CMV seroprevalence, arguing for the importance of child-to-mother transmission; nevertheless, the latitude of the place of birth, even within a size-limited country such as France, appears to be a major predictive factor of CMV seroprevalence.

Objective To determine whether the addition of spa therapy to home exercises provides any benefit over exercises and the usual treatment alone in the management of generalised osteoarthritis associated with knee osteoarthritis. Methods This study was a post-hoc subgroup analysis of our randomised multicentre trial ( www.clinicaltrial.gov : NCT00348777 ). Participants who met the inclusion criteria of generalized osteoarthritis (Kellgren, American College of Rheumatology, or Dougados criteria) were extracted from the original randomised controlled trial. They had been randomised using Zelen randomisation. The treatment group received 18 days of spa treatment in addition to a home exercise programme. Main outcome was number of patients achieving minimal clinically important improvement at six months (MCII) (≥ −19.9 mm on the VAS pain scale and/or ≥ −9.1 points in a WOMAC function subscale), and no knee surgery. Secondary outcomes included the “patient acceptable symptom state” (PASS) defined as VAS pain ≤ 32.3 mm and/or WOMAC function subscale ≤ 31 points. Results From the original 462 participants, 214 patients could be categorized as having generalised osteoarthritis. At sixth month, 182 (88 in control and 94 in SA group) patients, were analysed for the main criteria. MCII was observed more often in the spa group ( n = 52/94 vs. 38/88, P = 0.010). There was no difference for the PASS ( n = 19/88 vs. 26/94, P = 0.343). Conclusions This study indicates that spa therapy with home exercises may be superior to home exercise alone in the management of patients with GOA associated with knee OA.

Purpose We searched for factors independently associated with the prescription of multimodal (balanced) analgesia in mechanically ventilated critically ill patients. Methods In this post hoc analysis of a cohort study, 172 patients who received a combination of 1 opioid with nonopioids, that is, paracetamol and/or nefopam, (multimodal analgesia), were compared with 302 patients who received opioid only on day 2 of their stay in the intensive care unit. Results Patients given multimodal analgesia were more likely to have fewer organ failures and received fewer hypnotics compared with patients who received opioid only. They self-reported more frequently their pain level. There were no differences in the daily dose of opioids between the 2 groups. A low illness severity score, no more than 1 organ failure on day 2, the ability to self-rate pain, and a moderate-to-severe pain rated on day 2 were factors independently associated with the prescription of multimodal analgesia on day 2 (all P Conclusions In mechanically ventilated patients, the addition of nonopioids to opioids is mostly prescribed for patients with lower illness severity scores and who are able to self-rate their pain intensity. These findings suggest that the concept of multimodal analgesia must be promoted in the intensive care unit.

Assessment of cancer screening in the context of venous thromboembolic disease (VTE) remains controversial. We tried to characterize a population at high risk of developing cancer among patients suffering from VTE.We conducted a retrospective ancillary case-control study among patients with VTE who later had a positive diagnosis of cancer. We assessed the association of cancer with characteristic features of VTE and with the results for four biological markers.Our population included 142 patients (53% men, median age 71 years). Two years after VTE, 24 patients (17%) had cancer. Median values for D-dimers, fibrin monomers and SP-selectin were significantly higher among patients who developed cancer. Logistic regression enabled us to identify two parameters targeting patients with a high risk of cancer: bilateral venous thrombosis (OR: 4.41, 95%CI: 1.41-13.78, P=0.01) and D-dimers superior to 3.8 μg/mL (OR: 3.68, 95%CI: 1.36-9.94, P=0.01). The information provided by these two characteristics was additive; 58% of patients in our population who had both factors developed cancer.Bilateral venous thrombosis and D-dimers superior to 3.8 μg/mL are highly associated with carcinoma. This result requires a prospective validation. It could be useful in limiting the screening process to the population most at risk.

International audience; BACKGROUND: The accuracy of combined clinical examination (CE) and chest radiography (CXR) (CE + CXR) vs thoracic ultrasonography in the acute assessment of pneumothorax, hemothorax, and lung contusion in chest trauma patients is unknown. METHODS: We conducted a prospective, observational cohort study involving 119 adult patients admitted to the ED with thoracic trauma. Each patient, secured onto a vacuum mattress, underwent a subsequent thoracic CT scan after first receiving CE, CXR, and thoracic ultrasonography. The diagnostic performance of each method was also evaluated in a subgroup of 35 patients with hemodynamic and/or respiratory instability. RESULTS: Of the 237 lung fields included in the study, we observed 53 pneumothoraces, 35 hemothoraces, and 147 lung contusions, according to either thoracic CT scan or thoracic decompression if placed before the CT scan. The diagnostic performance of ultrasonography was higher than that of CE + CXR, as shown by their respective areas under the receiver operating characteristic curves (AUC-ROC): mean 0.75 (95% CI, 0.67-0.83) vs 0.62 (0.54-0.70) in pneumothorax cases and 0.73 (0.67-0.80) vs 0.66 (0.61-0.72) for lung contusions, respectively (all P < .05). In addition, the diagnostic performance of ultrasonography to detect pneumothorax was enhanced in the most severely injured patients: 0.86 (0.73-0.98) vs 0.70 (0.61-0.80) with CE + CXR. No difference between modalities was found for hemothorax. CONCLUSIONS: Thoracic ultrasonography as a bedside diagnostic modality is a better diagnostic test than CE and CXR in comparison with CT scanning when evaluating supine chest trauma patients in the emergency setting, particularly for diagnosing pneumothoraces and lung contusions.

Assess efficacy, satisfaction and usefulness of an educational maze based on posters and audioguide for major trauma care teaching to medical students. The educational maze consists of posters with audio comments recorded in an audioguide. This tool was part of a larger educational program including medical simulation.Prospective, interventional, observational, monocentric study. STUDENT: Medical student of Grenoble University Hospital, in the four last years of medical school, following a training course in anesthesia, emergency medical services and intensive care units.Forty essentials key messages for major trauma management were included in 10 posters and audioguides. A first assessment with short opened answers was handed to the students at the end of the educational maze to assess their memorization. A second assessment with simple choice answers regarding satisfaction and usefulness of this new educational tool was realized at the end of the entire program.One hundred and eighty-four medical students attending the major trauma program were included in this study. On the first test, 75% of essential knowledge on major trauma management was memorized by more than 50% of the medical students. On the second test, 94% of medical students had a high satisfaction level of this educational maze.An educational maze based on posters and audioguides seems to be an efficient, useful tool for teaching essential knowledge on major trauma management to medical students.

Compression therapy constitutes the cornerstone of prevention of post-thrombotic syndrome in patients with deep-vein thrombosis (DVT). However, no consensus has been reached regarding the optimal timing for initiation, duration, and strength of compression therapy.To document prescribing practices of compression therapy in case of DVT by French Vascular Medicine physicians.E-mail survey sent in 2009 to all physicians members of the French Society of Vascular Medicine.Seven hundred and sixty-one vascular medicine physicians (56.6% private practice, 19.8% hospital-based and 23.6% both private practice and hospital-based physicians) responded. At diagnosis, 94.3% (n=707) systematically prescribed compression therapy. The initial compression consisted in elastic compression stockings (ECS) for 57.3% of patients (n=426) and in bandages for 42.7% (n=317). When physicians initially prescribed bandages, in 92.3% of cases they later switched to elastic compression stockings (ECS). Finally, 95.8% (n=712) of vascular medicine physicians reported prescribing ECS during DVT follow-up. The ECS ankle pressure gradient was 15-20 mmHg in 64.3% of cases and 20-36 mmHg in 35.5%. Most physicians (85.9%, n=631) modulated the duration of compression therapy according to the results of follow-up compression ultrasonographic explorations. Only a limited proportion of physicians took into account thrombus localization or its initial extention.In case of DVT, French vascular medicine physicians systematically prescribed compression therapy. However, the strength of compression was lower than recommended by international guidelines. Efficacy and benefits (potential better compliance) of this common practice should be assessed with a randomized controlled trial.

International audience; OBJECTIVES: The main objective was to estimate the nature, severity and medical care of severe trauma injuries following mountain activities as compared to severe trauma following traffic accident in a mountain area. STUDY DESIGN: We conducted a prospective comparative monocentric observational study at a University Hospital located in the northern Alps area, using the First national study database (French intensive care recorded in severe trauma). PATIENTS AND METHODS: Three hundred and thirty-seven patients were included during a 2-year-period from January 2005 to December 2006. Three hundred and thirty-seven patients, including 223 traffic accidents and 114 mountain accidents were included. The survey data was achieved with a standardized method on a period of 30 days after the accident, and recorded in a computerized file for optimal completeness. RESULTS: The study did not show higher severity or mortality rates in patients with mountain accidents. In both groups, we found a peak of mortality for young adults and similar causes of death. However, spinal cord injuries were statistically more frequent in mountain accidents. CONCLUSION: So, it seems important to continuously warn population about dangers of this playground.

International audience; OBJECTIVE:: To investigate the effects of moderate-dose hydrocortisone on hemodynamic status in critically ill patients throughout the period of etomidate-related adrenal insufficiency. DESIGN:: Randomized, controlled, double-blind trial (NCT00862381). SETTING:: University hospital emergency department and three intensive care units. INTERVENTIONS:: After single-dose etomidate (H0) for facilitating endotracheal intubation, patients without septic shock were randomly allocated at H6 to receive a 42-hr continuous infusion of either hydrocortisone at 200 mg/day (HC group; n = 49) or saline serum (control group; n = 50). MEASUREMENTS AND MAIN RESULTS:: After completion of a corticotrophin stimulation test, serum cortisol and 11β-deoxycortisol concentrations were subsequently assayed at H6, H12, H24, and H48. Forty-eight patients were analyzed in the HC group and 49 patients in the control group. Before treatment, the diagnostic criteria for etomidate-related adrenal insufficiency were fulfilled in 41 of 45 (91%) and 38 of 45 (84%) patients in the HC and control groups, respectively. The proportion of patients with a cardiovascular Sequential Organ Failure Assessment score of 3 or 4 declined comparably over time in both HC and control groups: 65% vs. 67% at H6, 65% vs. 69% at H12, 44% vs. 54% at H24, and 34% vs. 45% at H48, respectively. Required doses of norepinephrine decreased at a significantly higher rate in the HC group compared with the control group in patients treated with norepinephrine at H6. No intergroup differences were found regarding the duration of mechanical ventilation, intensive care unit length of stay, or 28-day mortality. CONCLUSION:: These findings suggest that critically ill patients without septic shock do not benefit from moderate-dose hydrocortisone administered to overcome etomidate-related adrenal insufficiency.

Introduction Les erreurs medicamenteuses (EM) en anesthesie sont frequentes et evitables [1] . La moitie de ces EM se produisent lors de la preparation ou de l’injection d’un medicament [2] . La simulation permet, en complement des connaissances theoriques, l’acquisition de competences techniques et non techniques indispensables a la securite des soins. Cette etude a pour but d’evaluer un outil de simulation integrant des conditions techniques, environnementales et contextuelles pour realiser une EM au bloc operatoire (BO). Ce scenario a pour objectif de sensibiliser aux risques d’EM. Materiel et methodes Nous avons cree un scenario de simulation dans un environnement de BO, incluant 20 opportunites d’EM classiquement decrites dans la litterature : 12 dans le chariot d’anesthesie (« Le chariot piege ») et 8 environnementales et contextuelles. Apres un briefing classique, un medecin anesthesiste reanimateur (facilitateur) annonce l’arrivee d’un patient presentant une fissuration d’anevrisme de l’aorte abdominale. L’etudiant doit preparer un plateau de medicaments. Le scenario prend fin a l’arrivee du patient. Lors du debriefing, un questionnaire demande a l’etudiant les opportunites d’EM detectees au cours de la seance. Quarante-six volontaires (22 internes en anesthesie reanimation et 24 etudiants infirmiers anesthesistes) ont ete inclus (janvier–fevrier 2014). Le critere de jugement principal etait l’existence d’une variabilite interindividuelle dans le nombre de sources d’EM detectees (Test du X2 d’adequation avec la loi normale). Resultats La repartition du nombre d’opportunites d’EM detectees suivait une loi normale (10 ± 2) confirmant, par une diversite interindividuelle forte, l’interet de notre outil. Les opportunites d’EM les plus souvent detectees sont decrites dans la Fig. 1 . Dans le questionnaire sur l’experience professionnelle ces memes opportunites d’EM ont ete citees avec une frequence inferieure : « calcul de dose » (15/46), « temperature de conservation non adaptee » (1/46), « interruption de tâche » (2/46) et « seringue non etiquetee » (8/46). Les seances ont ete jugees « tout a fait » ou « plutot » realistes par 45 participants et « tout a fait » ou « plutot » enrichissantes pour leur pratique professionnelle par l’integralite des participants. Discussion Le « chariot piege » apparait comme un outil favorisant la detection des opportunites d’EM en anesthesie au bloc operatoire. En complement des recommandations publiees par la SFAR en 2006 [3] , il pourrait etre integre dans divers programmes pedagogiques bases sur la simulation et la gestion des risques.

Introduction Les ponctions realisees selon les reperes anatomiques pour la pose de voies veineuses centrales sont associees a des complications [1] type ponction arterielle, pneumothorax. L’echoguidage les diminue [2] mais necessite une ponction strictement dans le plan de la sonde d’echographie. Grâce aux echographes munis d’un systeme GPS (Guidance Positioning System) affichant une projection de la progression de l’aiguille et le point d’intersection avec le plan de la sonde, la ponction hors plan est possible. L’habilete et la dexterite pour la realisation de ponctions est variable, dependant de l’apprentissage, de l’experience mais aussi d’autres facteurs [3] comme la lateralite, la pratique de musique ou de jeux video. Le but de cette etude est de comparer l’habilete de trois groupes de professionnels pour atteindre des cibles sur un fantome en utilisant soit l’echoguidage dans le plan sans GPS soit l’echoguidage hors du plan avec GPS. Materiel et methodes Quarante-et-un MAR (Medecin Anesthesiste-Reanimateur), 41 DESAR (Interne DES Anesthesie-Reanimation) et 39 IADE (Infirmiere Anesthesiste) ont realise trois tâches sans GPS et avec GPS : ponction dans le vaisseau, ponction a droite et a gauche du nerf. Ces ponctions etaient realisees sur un fantome en silicone integrant deux elements representant un vaisseau et un nerf. L’appareil d’echographie SonixGPS (Ultrasonix) a ete utilise. L’experience et l’apprentissage a la ponction sous echographie, la lateralite, la pratique de la musique et des jeux video ont ete notes. Le critere de jugement principal etait le temps pour atteindre les differentes cibles. Le nombre de ponction et la coordination mains-yeux etaient egalement evalues. Resultats Sans GPS, le personnel experimente (MAR, DESAR) met significativement moins de temps et commet moins d’erreurs que le personnel non experimente (IADE). Les temps pour realiser les trois tâches etaient significativement diminues avec GPS (Ponctions dans le vaisseau 79 ± 95 s sans GPS vs 30 ± 24 s avec GPS ; a droite et a gauche du nerf, respectivement 39 ± 27 s et 162 ± 168 s sans GPS, 26 ± 17 s et 25 ± 16 s avec GPS). Avec GPS, les differences significatives entre professionnels experimentes ou non ne sont plus retrouvees ( Fig. 1 ). En analyse multivariee, les facteurs expliquant un court delai pour atteindre les cibles sans GPS etaient, pour les trois groupes, l’experience et la pratique de jeux video. Ces facteurs n’etaient pas retrouves lors des ponctions avec GPS. Discussion Dans cette etude, il existe une grande variabilite dans la realisation des ponctions sous echographie. Cette variabilite est en grande partie expliquee par l’experience des differentes categories de professionnels. La pratique des jeux video est egalement un des facteurs retrouve. La technique GPS appliquee sur ce modele de simulation a permis d’ameliorer les performances lors de la realisation des tâches : gain de temps, suppression de la variabilite individuelle, augmentation du taux de succes ; et ce quelle que soit la categorie professionnelle : personnel forme ou non a ce type de geste.

En 2011, 1,1 million de francais ont ete traites par AVK avec un âge moyen de 72,5 ans. Les AVK sont en France la premiere cause d'hospitalisation pour accidents iatrogenes (17000/an) et la premiere cause de mortalite par iatrogenie directe (5000 a 6000/an). L'evaluation de la balance benefices-risques du traitement AVK est delicate. Malgre les indications posees, il y a beaucoup de sous-prescriptions ou non prescriptions du fait d'une perception subjective d'un risque eleve de saignements graves. Il existe, dans la litterature, des scores predictifs individuels du risque hemorragique grave mais avec chacun leurs limites, et etablis pour la plupart, uniquement sur une population hospitaliere. Pourtant, les AVK sont prescrits majoritairement par les generalistes. Nous avons mene une etude epidemiologique descriptive longitudinale multicentrique par suivi d'une cohorte de mai 2009 a decembre 2010. Les patients ont beneficie d'un programme d'education therapeutique par un reseau ville-hopital iserois. L'analyse a porte sur 949 patients, d'âge median 70 ans (54-81), suivis en medecine generale. L'etude a montre qu'aucun score existant dans la litterature ne peut etre utilise en medecine ambulatoire apres education therapeutique pour predire le risque de survenue d'hemorragie grave a 1 an. L'etude nous a permis de mettre en evidence trois facteurs de risque d'hemorragie grave a 1 an : l'anemie severe (Hgb 65ans, l'antecedent de chute dans l'annee ayant necessite un recours a un medecin. Le risque eleve d'hemorragie grave a 1 an est determine uniquement par la presence d'une anemie severe. Nous avions une population rendue plus homogene dans ses comportements vis-a-vis des AVK car eduquee. Lorsque ce nouveau score fera l'objet d'une validation prospective sur une autre serie de patients, cela augmentera la possibilite d'extrapoler les resultats aux nouveaux anticoagulants oraux. Ces nouveaux anticoagulants oraux sont caracterises par un meilleur profil d'utilisation : posologie standard pour tous les patients, pas de surveillance biologique. Mais ils ont les memes risques hemorragiques independamment du comportement du patient et de son medecin. La problematique de la caracterisation des populations a risque reste donc entiere.

Objective To determine whether spa therapy, plus home exercises and usual medical treatment provides any benefit over exercises and usual treatment, in the management of knee osteoarthritis. Methods Large multicentre randomised prospective clinical trial of patients with knee osteoarthritis according to the American College of Rheumatology criteria, attending French spa resorts as outpatients between June 2006 and April 2007. Zelen randomisation was used so patients were ignorant of the other group and spa personnel were not told which patients were participating. The main endpoint criteria were patient self-assessed. All patients continued usual treatments and performed daily standardised home exercises. The spa therapy group also received 18 days of spa therapy (massages, showers, mud and pool sessions). Main Endpoint The number of patients achieving minimal clinically important improvement (MCII) at 6 months, defined as ≥19.9 mm on the visual analogue pain scale and/or ≥9.1 points in a normalised Western Ontario and McMaster Universities osteoarthritis index function score and no knee surgery. Results The intention to treat analysis included 187 controls and 195 spa therapy patients. At 6 months, 99/195 (50.8%) spa group patients had MCII and 68/187 (36.4%) controls (χ 2 =8.05; df=1; p=0.005). However, no improvement in quality of life (Short Form 36) or patient acceptable symptom state was observed at 6 months. Conclusion For patients with knee osteoarthritis a 3-week course of spa therapy together with home exercises and usual pharmacological treatments offers benefit after 6 months compared with exercises and usual treatment alone, and is well tolerated. Trial registration number NCT00348777.

Hemorrhagic events constitute a major risk for patients on oral anticoagulant therapy.We conducted a prospective survey of all patients taking oral anticoagulants and admitted to the emergency room of Grenoble University Hospital over a period of 10 months. The objective was to identify the causes of drug-induced adverse hemorrhagic events, and whether they were related to health care practices or patient behavior concerning their treatment.Two hundred and sixteen patients treated with oral anticoagulants were identified and 68 of them had a hemorrhagic adverse drug event. Not taking into account prior medial history before prescribing an anticoagulant was noted for 21 of the patients who experienced a hemorrhagic event (p = 0.0003). In addition, compared with patients who had not had a hemorrhagic event, inadequate prescribing with regard to doses and administration frequency there were also more common in the hemorrhagic event group (p0.0001). Pharmacists delivering the drugs had not intervened to correct drug interactions, contraindications and inadequate doses in 72% of patients with hemorrhage (p0.0001). Other factors associated with increased the risk of hemorrhage were self-medication, not taking the prescribed drug at a predefined time of the day, insufficient INR monitoring and poor compliance (p0.0001).To achieve the beneficial effects expected with anticoagulants, physicians must carefully comply with prescription recommendations, especially for elderly patients. Pharmacists delivering the drugs should also intervene more readily when required.

The guidelines for good clinical practices issued by the French Agency for Health and Drug Safety and the Superior Health Authority are designed to improve management of oral anticoagulants which can be an important source of iatrogenic morbidity. These guidelines have focused on the need for special education. The GRANTED network in Isère developed an education program for patients taking oral anticoagulants.The purpose of this study was to evaluate quantitatively the therapeutic education of these patients taking oral anticoagulation, irrespective of their risk factor(s).This was a retrospective analysis of 100 randomly selected patients taking oral anticoagulants for at least three months who participated in the GRANTED education program in 2007. The evaluation criterion was the number of hemorrhagic and/or thromboembolic events.Among the 97 patients contacted, 3.1% had a serious hemorrhagic event and 1.03% a recurrent thromboembolic event.The quality of a scientific study depends on the quality of the methodology, leading to a preference for prospective studies. It would nevertheless be pertinent to determine whether or not official management recommendations are applied correctly in real life conditions. We report a first evaluation of a therapeutic education program designed for patients taking oral anticoagulants. The education program within the GRANTED network has enabled a reduction in the iatrogenic morbidity related to oral anticoagulation despite the selection bias of the probably high-risk population enrolled in the GRANTED network.