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International audience; IntroductionThe SARS-CoV-2 pandemic has impacted the care of cancer patients. This study sought to assess the pandemic’s impact on the clinical presentations and outcomes of newly referred patients with lung cancer from the Greater Paris area.MethodsWe retrospectively retrieved the electronic health records and administrative data of 11.4 million patients pertaining to Greater Paris University Hospital (AP-HP). We compared indicators for the 2018-2019 period to those of 2020 in regard to newly referred lung cancer cases. We assessed initial tumor stage, delay between first multidisciplinary tumor board (MTB) and anticancer treatment initiation, and 6-month overall survival (OS) rates depending on the anticancer treatment including surgery, palliative systemic treatment, and best supportive care (BSC).ResultAmong 6,240 patients with lung cancer, 2,179 (35%) underwent tumor resection, 2,069 (33%) systemic anticancer therapy, 775 (12%) BSC, whereas 1,217 (20%) did not receive any treatment. During the first lockdown, the rate of new diagnoses decreased by 32% compared with that recorded in 2018-2019. Initial tumor stage, repartition of patients among treatment categories, and MTB-related delays remained unchanged. The 6-month OS rates of patients diagnosed in 2018-2019 who underwent tumor resection were 98% vs. 97% (HR=1.2; 95% CI: 0.7-2.0) for those diagnosed in 2020; the respective rates for patients who underwent systemic anticancer therapy were 78% vs. 79% (HR=1.0; 95% CI: 0.8-1.2); these rates were 20% vs. 13% (HR=1.3; 95% CI: 1.1-1.6) for those who received BSC. COVID-19 was associated with poorer OS rates (HR=2.1; 95% CI: 1.6-3.0) for patients who received systemic anticancer therapy.ConclusionsThe SARS-CoV-2 pandemic has not exerted any deleterious impact on 6-month OS of new lung cancer patients that underwent active anticancer therapy in Greater Paris University hospitals.

Aims To determine the prognosis of patients treated for infective endocarditis (IE) according to their healthcare pathway. To assess how the ESC guidelines are implemented concerning the performance of transoesophageal echocardiography, the use of antibiotic therapy, and the performance of valve surgery; and to compare the epidemiological profile of IE according to the type of centres in which the patients are hospitalized. Methods and results In a prospective multicentric study including 22 hospitals in the South-East of France, 342 patients were classified into three groups according to their healthcare pathway: 119 patients diagnosed and taken care entirely in a reference centre or hospital with cardiac surgery [Referral Center (RC) group], 111 patients diagnosed and initially taken care in a non-RC (NRC), then referred in a centre including cardiac surgery [transferred to the Referral Center (TRC) group] and 112 patients totally taken care in the NRC (NRC group). One-year mortality was 26% (88 deaths) and was not significantly different between Groups 1 and 2 (20 vs. 21%, P = 0.83). Patients in the NRC group had a higher mortality (37%) compared with patients in the RC and TRC groups (P Conclusion Prognosis of patients with IE is influenced by their healthcare pathway. Patients treated exclusively in NRC have a worse prognosis than patients treated in referral or surgical centres.

Background Opioid agonist therapy (OAT) is associated with reduced injection, reduced HCV transmission, and more opportunities to initiate hepatitis C virus (HCV) treatment in people who use drugs (PWUD). We aimed to study the extent to which adherence to OAT was predictive of increased uptake of direct-acting antivirals (DAA) in PWUD with chronic HCV infection. Methods Using the French national healthcare system database, we targeted PWUD (i.e. with a history of OAT) who had chronic HCV infection and were eligible for DAA during 2014–2016. Adherence to OAT was computed as a time-varying variable expressing the proportion of days covered by OAT receipt, over any six-month interval before DAA receipt. We used a Cox proportional hazards model to estimate the association between adherence to OAT and the rate of DAA uptake after adjustment for age, sex, alcohol use disorder, socioeconomic status, and liver disease severity. Results Among the 22,615 persons included in the ANRS FANTASIO study, 3438 (15.2%) initiated DAA during the study period. After multivariable adjustment, adherence to OAT was associated with a higher rate of DAA initiation. However, this association was not linear, and only individuals on OAT for 20% or more of the time in the previous six-month period had a higher rate of DAA initiation (adjusted hazard ratio [95% confidence interval]: 1.28 [1.18–1.38]). Other variables associated with DAA initiation were male sex, older age, cirrhosis or liver cancer, and higher socioeconomic status. Conclusions Adherence to OAT is a major predictor of DAA initiation in PWUD living with chronic HCV infection in France. Our results also suggest that even moderate adherence to OAT can facilitate DAA uptake. Adequate HCV training for OAT prescribers together with interventions to ensure adherence to OAT will help improve DAA initiation rates and reach HCV elimination goals.

Background Enacted or anticipated stigma among people living with HIV (PLHIV) can negatively impact healthcare engagement. We identified factors associated with having avoided HIV health services for fear of stigma among PLHIV in Morocco. Methods The Stigma Index survey was conducted in Morocco in March-June 2016. Factors associated with avoiding HIV testing and treatment services for fear of stigma by (A) health personnel or family/neighbours and (B) health personnel and family/neighbours compared to people who did not avoid health services for fear of stigma from either of the two sources were assessed using multinomial logistic regression models. Results Among 583 respondents, 280 (48.0%) were women and median number of years living with HIV was 5[IQR:2–7]. Half of the respondents reported avoiding health services for fear of stigma by health personnel and/or family/neighbours: (A) n = 228, 39.1% and (B) n = 68, 11.7%. After adjustment on perceived health status, not having had easy access to antiretroviral treatment ((A) aRR [95% CI] = 1.76[1.16; 2.68]; (B) 2.18[1.11; 4.27]), discrimination by PLHIV ((A) 1.87[1.12; 3.13]; (B) 3.35[1.63; 6.88]) and exclusion from social activities ((A) 1.70[1.10; 2.61]; (B) 2.63[1.39; 5.00]) were associated with having avoided health services for fear of stigma by health personnel or/and family/neighbours. Being female (2.85[1.48; 5.47]), not having been referred for an HIV test for suspected symptoms 3.47[1.67; 7.22], having discussed sexual/reproductive health with a health professional (4.56[2.38; 8.71]), and not having the feeling to influence decisions on local projects for PLHIV (3.47[1.37; 7.83], were associated with having avoided health services for fear of stigma by both sources. Conclusion Results suggest a cumulative effect of fear of stigma and discrimination among PLHIV in Morocco. PLHIV who have experienced discrimination may seek to avoid similar situations at the expense of their health. These results should inform multi-level interventions and broader advocacy efforts to reduce stigma and discrimination.

Short-term forecasting of the COVID-19 pandemic is required to facilitate the planning of COVID-19 health care demand in hospitals. Here, we evaluate the performance of 12 individual models and 19 predictors to anticipate French COVID-19-related health care needs from September 7, 2020, to March 6, 2021. We then build an ensemble model by combining the individual forecasts and retrospectively test this model from March 7, 2021, to July 6, 2021. We find that the inclusion of early predictors (epidemiological, mobility, and meteorological predictors) can halve the rms error for 14-d–ahead forecasts, with epidemiological and mobility predictors contributing the most to the improvement. On average, the ensemble model is the best or second-best model, depending on the evaluation metric. Our approach facilitates the comparison and benchmarking of competing models through their integration in a coherent analytical framework, ensuring that avenues for future improvements can be identified.

Background Telemedicine is one of the healthcare sectors that has developed the most in recent years. Currently, telemedicine is mostly used for patients who have difficulty attending medical consultations because of where they live (teleconsultation) or for specialist referrals when no specialist of a given discipline is locally available (telexpertise). However, the use of specific equipment (with dedicated cameras, screens, and computers) and the need for institutional infrastructure made the deployment and use of these systems expensive and rigid. Although many telemedicine systems have been tested, most have not generally gone beyond local projects. Our hypothesis is that the use of smartphones will allow health care providers to overcome some of the limitations that we have exposed, thus allowing the generalization of telemedicine. Main body This paper addresses the problem of telemedicine applications, the market of which is growing fast. Their development may completely transform the organization of healthcare systems, change the way patients are managed and revolutionize prevention. This new organization should facilitate the lives of both patients and doctors. In this paper, we examine why telemedicine has failed for years to take its rightful place in many European healthcare systems although there was a real need. By developing the example of France, this article analyses the reasons most commonly put forth: the administrative and legal difficulties, and the lack of funding. We argue that the real reason telemedicine struggled to find its place was because the technology was not close enough to the patient. Conclusion Finally, we explain how the development of smartphones and their current ubiquitousness should allow the generalization of telemedicine in France and on a global scale.

International audience; Aging is the most important risk factor for the onset of several chronic diseases and functional decline. Understanding the interplays between biological aging and the biology of diseases and functional loss as well as integrating a function-centered approach to the care pathway of older adults are crucial steps towards the elaboration of preventive strategies (both pharmacological and non-pharmacological) against the onset and severity of burdensome chronic conditions during aging. In order to tackle these two crucial challenges, ie, how both the manipulation of biological aging and the implementation of a function-centered care pathway (the Integrated Care for Older People (ICOPE) model of the World Health Organization) may contribute to the trajectories of healthy aging, a new initiative on Gerosciences was built: the INSPIRE research program. The present article describes the scientific background on which the foundations of the INSPIRE program have been constructed and provides the general lines of this initiative that involves researchers from basic and translational science, clinical gerontology, geriatrics and primary care, and public health.

International audience; No abstract available

Identification of delay barriers to care is essential for an effective and efficient healthcare service delivery. In this study, we described the delay in care among parents of the patients seeking treatment for dengue. We also examined the factors affecting the severity of dengue (dengue with warning signs, severe dengue). A convergent parallel design mixed-method approach using Key Informant Interviews (KII) and a survey guided by the Three-Delay Model were conducted among 24 respondents at the National Children’s Hospital (NCH). Coding and thematic analysis using NVIVO and bivariable generalized linear models with a Poisson distribution and robust variance were utilized to analyze the KII transcripts and survey data, respectively. Results showed that financial constraints and previous dengue infection (first delay), mode of transportation, traffic density, and location (second delay), and hospital capacity (third delay) influenced the overall delay uncertainty in seeking care treatment for dengue infection. Furthermore, our bivariable analysis showed that travel time to NCH and place of residency, service given from previous health facilities, and parents’ educational background were associated and played a role in the severity of dengue infection. Interventions focused on the identified factors contributing to delayed care should be made to avoid unwanted clinical outcomes.

Objective: Documenting the perceptions and experiences of frontline healthcare workers during a sanitary crisis is key to reinforce healthcare systems. We identify the determinants of quality of working life (QWL) among night-shift healthcare workers (NSHW) in Paris public hospitals shortly after the first-wave of the COVID-19 pandemic.Methods: The ALADDIN cross-sectional online survey (15 June to 15 September 2020) collected QWL, socio-economic, behavioral, and work-related information among 1,387 NSHW in the 39 hospitals of the Assistance Publique-Hôpitaux de Paris (AP-HP). Data were weighted (margin calibration) to be representative of the entire population of 12,000 AP-HP hospitals' NSHW regarding sex, age, and professional category. Linear regression was used to identify correlates of QWL (WRQoL scale).Results: New night position during the COVID pandemic, difficulties in getting screened for COVID, and considering protective measures inadequate were associated with poorer QWL, after adjustment for socio-economic characteristics, professional category, perceived health, physical activity, and history of harassment at work. Under-estimation of night-shift work by day-shift colleagues, reporting night work as a source of tension with friends, or feeling more irritable since working at night also impaired QWL. By contrast, satisfaction regarding COVID information received from the employer, and feeling valued by the general population during the pandemic improved QWL.Conclusions: Insufficient access to screening, information, and protective measures impaired QWL of NSHW after the first wave of COVID-19 in Paris public hospitals. Social and professional recognition of night-shift work were the key determinants of QWL in this population.

ObjectiveTo characterise uncontrolled severe asthma and compare the disease burden with the general and asthmatic populations.DesignRetrospective observational study using a national sample of a French healthcare database (Echantillon Généraliste des Bénéficiaires (EGB)).SettingThe EGB, an anonymised permanent sample of health insurance databases, representing 1/97th of the French population.ParticipantsPatients (≥12 years) were selected in year 2014 and followed 2 years. A cohort of patients with uncontrolled severe asthma was defined using an algorithm based on peer-reviewed literature and Global Initiative for Asthma recommendations. Index date was the occurrence of the first marker of uncontrolled asthma. This cohort was matched with two control cohorts, general population and asthmatic controls, on baseline characteristics.Main outcomes measuresMortality, healthcare use and associated costs were studied in the 2 years of follow-up.ResultsAmong 467 716 individuals in the EGB, 16 588 patients with asthma were identified, including 739 (4.5%) with uncontrolled severe disease. The survival probability at 2 years for patients with uncontrolled severe asthma (92.0%) was lower than in the general population cohort (96.6%; relative risk of death: 2.35; 95% CI: 1.70 to 3.29; pConclusionsThis study demonstrates the huge burden of uncontrolled severe asthma in terms of mortality, morbidity and healthcare resource consumption compared with other patients with asthma and with the general population and emphasises the importance of appropriate management in this high-risk population.

International audience; Benchmarking is a common and effective method for measuring and analyzing ICU performance. With the existence of national registries, objective information can now be obtained to allow benchmarking of ICU care within and between countries. The present manuscript briefly describes the current status of benchmarking in healthcare and critical care and presents the LOGIC project, an initiative to promote international benchmarking for intensive care units. Currently 13 registries have joined LOGIC. We showed large differences in the utilization of ICU as well as resources and in outcomes. Despite the need for careful interpretation of differences due to variation in definitions and limited risk adjustment, LOGIC is a growing worldwide initiative that allows access to insightful epidemiologic data from ICUs in multiple databases and registries.

International audience; The current coronavirus disease 2019 (COVID-19) pandemic is forcing healthcare systems around the word to organise care differently than before. Prompt detection and effective triage and isolation of potentially infected and infectious patients are essential to preventing unnecessary community exposure. Since there are as yet no medications to treat or vaccines to prevent COVID-19, prevention focuses on self-management strategies, creating patient education challenges for physicians doing triage and testing. This article describes a five-step process for effectively educating, at discharge, patients who are suspected of being infectious and instructed to self-isolate at home. We are proposing the CEdRIC strategy as a practical, straightforward protocol that meets patient education and health psychology science requirements. The main goal of the CEdRIC process is to give patients self-management strategies aimed at preventing complications and disease transmission. The COVID-19 pandemic is challenging clinicians to rapidly teach their patients self-management strategies while managing the inherent pressures of this emergency situation. The CEdRIC strategy is designed to deliver key information to patients and standardize the discharge process. CEdRIC is currently being tested at triage centres in Belgium. Formal assessment of its implementation is still needed.

International audience; Background: Zambia's total fertility rate (5 births per woman) and adult HIV prevalence (11.5%) are among the highest in the world, with heterosexual couples being the most affected group. Jointly counseling and testing couples for HIV has reduced up to 58% of new HIV infections in Zambian clinics. Married women using contraceptives in Zambia have a high (20%) unmet need for family planning and low (8.6%) uptake of cost-effective long-acting reversible contraceptives. We present an integrated counseling, testing, and family-planning program to prevent HIV and unplanned pregnancy in Zambia.Objective: The objective of this study was to integrate effective HIV prevention and family-planning services for Zambian couples.Study design: A 3 year program (2013-2016) progressively integrated the promotion and provision of couples' voluntary HIV counseling and testing and long-acting reversible contraceptives. The program was based in 55 urban and 215 rural government clinics across 33 districts. In the first year, a couples' family-planning counseling training program was developed and combined with existing couples HIV counseling training materials. To avoid congestion during routine clinic hours, joint counseling services were initially provided on weekends, while nurses were trained in intrauterine device and hormonal implant insertion and removal during weekday family-planning services. Demand was created through mutual referral between weekend and weekday programs and by clinic staff, community health workers, and satisfied family-planning clients. When the bulk of integrated service training was completed, the program transitioned services to routine weekday clinic hours, ensuring access to same-day services. Performance indicators included number of staff trained, clients served, integrated service referrals, HIV infections averted, and unplanned pregnancies averted.Results: A stepwise approach trained high-performing service providers to be trainers and used high-volume clinics for practicum training of the next generation. In total, 1201 (391 urban, 810 rural) counselors were trained and served 120,535 urban and 87,676 rural couples. In urban clinics, 236 nurses inserted 65,619 long-acting reversible contraceptives, while in rural clinics, 243 nurses inserted 35,703 implants and intrauterine devices. The program prevented an estimated 12,869 urban and 8279 rural adult HIV infections, and 98,626 unintended urban pregnancies. In the final year, the proportion of clients receiving joint counseling services on weekdays rose from 11% to 89%, with many referred from within clinics including HIV testing and treatment services (32%), outpatient department (31%), family planning (16%), and infant vaccination (15%). The largest group of clients requesting long-acting reversible contraceptives (45%) did so after joint fertility goal-based counseling, confirming the high impact of this couple-focused demand creation approach. Remaining family-planning clients responded to referrals from clinic nurses (34%), satisfied implant/intrauterine device users (13%), or community health workers (8%).Conclusion: Integrated HIV and unplanned pregnancy prevention can be implemented in low-resource public sector facilities. Combination services offered to couples mutually leverage HIV prevention and unplanned pregnancy prevention. The addition of long-acting reversible contraceptives is an important complement to the method mix available in government clinics. Demand creation in the clinic and in the community must be coordinated with a growing supply of well-trained providers.

L’objet de cette thèse est de comparer l’efficience du système de soins bucco-dentaire français et suédois à travers l’analyse de l’état de santé bucco-dentaire des personnes âgées. Ces dernières sont de plus en plus nombreuses : en France, les personnes âgées d'au moins 60 ans représenteront 32,1 % de la population en 2060, contre 23,5 % en 2012. Cette population est la plus représentative de l’efficience du système de soin français. Cette thèse présente d’abord une recherche sur les fondements, l’organisation et le financement du système de soin français. Nous présentons ensuite les données d’une étude menée pendant 9 mois sur l’ensemble des patients hospitalisés au sein du service de gériatrie de l’hôpital Corentin Celton (Issy-les-Moulineaux, France). Nous avons réalisé des examens cliniques de dépistage afin d’identifier les besoins de soins et collecter des données descriptives. Ce travail nous a ainsi permis de réaliser le bilan de l’état de santé bucco-dentaire de cette population. La Suède étant réputée pour la performance de son système de soin, nous avons souhaité comparer les caractéristiques de leur système de soin ainsi que l’état bucco-dentaire à travers l’étude d’une population semblable. C’est dans cette optique que nous avons mené une étude selon les mêmes critères en Suède durant 3 mois à l’hôpital de la Karolinska University (Stockholm, Suède). Enfin, l’analyse et la comparaison des données recueillies nous amèneront à proposer des réflexions sur ces systèmes de soins.

Context: meso level organizations are intended to link different actors to organize care for a defined population. They act between the macro level of care policies and the micro level of interaction with the patient. The establishment of Territorial Professionnal Health Communities (CPTS) in France is an opportunity for health professionals to participate in structuring primary care (PC) delivery. Objective: to query the Belgian health system to identify meso level organizations and describe them by completing data with a documentary search. Method: qualitative descriptive study conducted by semi-structured videoconference interviews with Belgian professionals considered as experts. The interview guide covered 4 clinical vignettes and 6 PC themes. Data were analyzed and discussed collectively within the research group. Results: 7 interviews were conducted. 5 main organizations illustrate the two “meso-clinical” and “meso-organizational” levels of the meso level. The Circle of General Practitioners (GPs) represent the GPs of a geographical area to organize out of hours care, health promotion, multidisciplinary collaboration, partnerships with hospitals, meeting with local politics. The reform of the Flemish front-line areas offer support to professionals and gives them a responsibility towards the population. Conclusion: the projects of CPTS could be based on some experiences led in Belgium.; Contexte : les organisations de niveau meso sont destinées à mettre en lien différents acteurs afin d’organiser les soins pour une population définie. Elles se situent entre le niveau macro des politiques de santé et le niveau micro d’interaction avec le patient. L’instauration des Communautés Professionnelles Territoriales de Santé (CPTS) en France est l’occasion pour les professionnels de santé de participer à la structuration de l’offre en soins primaires (SP). Objectif : interroger le système de santé belge pour identifier des organisations de niveau meso et les décrire en complétant les données par une recherche documentaire. Méthode : étude qualitative descriptive menée par entretiens semi-structurés en visioconférence auprès de professionnels belges, experts. Le guide d’entretien abordait 4 vignettes cliniques et 6 thèmes des SP. Les données ont été analysées puis discutées collectivement au sein du groupe de recherche. Résultats : 7 entretiens ont été réalisés, 5 organisations principales illustrent les deux strates « meso-clinique » et « meso-organisationnelle » du niveau meso. Le Cercle des médecins généralistes (MG) représente les MG d’une aire géographique pour organiser la garde et favoriser la promotion de la santé, la collaboration multidisciplinaire, les partenariats avec l’hôpital, la rencontre avec la politique locale. La réforme des zones de première ligne en Flandre offre un support aux professionnels et leur confère une responsabilité vis-à-vis de la population. Conclusion : les projets de CPTS pourraient s’appuyer sur certaines expériences menées en Belgique.

The French health care system is undergoing major changes in its organization. The needs of the population are changing. We analyzed the treatment offer in liberal general medicine as well as the territorial needs. We conducted an exhaustive census of general practitioners in strict or mixed liberal activity in the 14th arrondissement. From December 2017 to May 2018, we carried out a transversal epidemiological study with quantitative analysis. The data was collected through interviews, with hetero-assessment questionnaires, and a qualitative illustrative supplement. The official sources counted 145 practitioners, our census amounted to only 87 eligible practitioners, of which we included 47, a density of 6.2 per 10,000 inhabitants. Most practitioners are grouped, but pluriprofessional practice is met with wariness, especially regarding the operating constraints. The most common issues relate to lack of coordination between professionals of the area, lack of time, administrative overload, and insufficient earnings. The reliance on liberal specialists is perfectible, especially concerning the fees and the delays for appointments. Psychiatry faces challenges in improving coordination between somatic and psychiatric follow-up. The link between city and hospital must continue to progress, by developing direct telephone numbers, but also by perfecting communication for the hospitalization of the patients. The new systems and the creation of CPTS should encourage initiatives but should also support government intervention to simplify and enhance the work of general practitioners.; Le système de soin français connait des modifications majeures dans son organisation. Les besoins de la population évoluent. Nous avons analysé l’offre de soins en médecine générale libérale ainsi que les besoins territoriaux. Nous avons réalisé un recensement exhaustif des médecins généralistes en activité libérale stricte ou mixte du 14ème arrondissement, et mené une étude épidémiologique, transversale avec analyse quantitative de décembre 2017 à Mai 2018. Le recueil de données s’effectuait lors d’entretiens par hétéro-questionnaire, avec un complément qualitatif illustratif. Les sources officielles comptaient 145 praticiens, notre recensement réduisant à 87 éligibles, dont 47 inclus, soit une densité de 6,2 pour 10.000 habitants. L’exercice groupé est majoritaire, mais l’exercice pluriprofessionnel se heurte à une méfiance liée notamment aux contraintes de fonctionnement. Les difficultés quotidiennes principales concernent le manque de coordination entre professionnels du territoire, le manque de temps, la surcharge administrative et la rémunération insuffisante. Le recours aux spécialistes libéraux est perfectible, particulièrement pour les tarifs et délais de rendez-vous. La psychiatrie fait face à des défis d’amélioration de la coordination entre suivi somatique et psychiatrique. Le lien ville-hôpital doit continuer à progresser, en développant les numéros directs, mais aussi par une meilleure communication pour l'hospitalisation des patients. Les nouveaux dispositifs et la création d’une CPTS doivent favoriser les initiatives, mais doivent s’accompagner d’une intervention des pouvoirs publics pour une simplification et valorisation du travail des généralistes.

The organisation of ambulatory care is changing to cope with an medical demographic and an ageing population. This “ambulatory shift” is accompanied by an evolution in medical practices and exercise methods. Taking into account the general practitioner’s needs is crucial for the success of this transformation. We have analyzed the liberal care offer of general practitioners in the 14th arrondissement of Paris and their needs in terms of the organization of the medical practice. We carried out a cross-sectional observational study with quantitative analysis by hetero-questionnaire and illustrative qualitative supplement during interviews conducted between December 2017 and May 2018. Out of 145 GPs registered, 87 were eligible and 47 were included. The supply of general practitioner care was overestimated by official figures: the density of general practitioners was 6.2/10,000 inhabitants. Group exercise is the rule without any real multi-professionality. Young doctors are women, settling in groups, with a practice in gynaecology and pediatrics and are university internship supervisors. Computerization is becoming more widespread, but communication and coordination of care remains inadequate. The main needs of general practitioners are the lack of medical time with a perceived overload of work, particularly with regard to home visits. The simplification of administrative tasks, access to a trained secretary and the development of efficient digital tools are required by physicians. The success of the "ambulatory shift" must be based on simplifying and enhancing the work of general practitioners to enable them to invest in increasingly complex and transversal care.; L’organisation des soins ambulatoires se transforme pour faire face au vieillement des médecins et de la population. Ce virage ambulatoire s’accompagne d’une évolution des pratiques médicales et des modes d’exercice. La prise en compte des besoins des généralistes est déterminante pour réussir cette mutation. Nous avons analysé l’offre de soins libérale des omnipraticiens du 14e arr. de Paris et leurs besoins d’organisation du cabinet médical. Nous avons réalisé une étude observationnelle transversale quantitative par hétéro-questionnaire et complément qualitatif illustratif lors d’entretiens réalisés entre décembre 2017 et mai 2018. Sur 145 médecins généralistes recensés, 87 étaient éligibles et 47 ont été inclus. L’offre de soins était surestimée par les chiffres officiels : la densité en omnipraticiens était de 6,2/10 000 habitants. L’exercice en groupe est la règle sans réelle pluriprofessionnalité. Les jeunes médecins sont des femmes, s’installant en groupe, ayant une pratique gynécologique et pédiatrique et sont maîtres de stage universitaires. L’informatisation se généralise mais la communication et la coordination des soins reste insuffisante. Les principaux besoins des omnipraticiens concernent le manque de temps médical avec une surcharge de travail ressentie, notamment concernant les visites à domicile. La simplification administrative, l’accès à un secrétariat formé et le développement d’outils numériques performants sont demandés par les médecins. La réussite du virage ambulatoire passe par la simplification et la valorisation du travail des omnipraticiens, pour leur permettre de s’investir dans des prises en charge de plus en plus complexes et transversales.

International audience; Acute respiratory distress syndrome (ARDS) is heterogeneous by definition and patient response varies depending on underlying biology and their severity of illness. Although ARDS subtypes have been identified with different prognoses in past studies, the concept of phenotypes or endotypes does not extend to the clinical definition of ARDS. This has possibly hampered the development of therapeutic interventions that target select biological mechanisms of ARDS. Recently, a major advance may have been achieved as it may now be possible to identify ARDS subtypes that may confer different responses to therapy. The aim of personalised medicine is to identify, select, and test therapies that are most likely to be associated with a favourable outcome in a specific patient. Several promising approaches to ARDS subtypes capable of predicting therapeutic response, and not just prognosis, are highlighted in this perspective paper. An overview is also provided of current and future directions regarding the provision of personalised ARDS medicine. The importance of delivering the right care, at the right time, to the right patient, is emphasised.

Background Many doctors fail to practice Evidence-Based Medicine (EBM) effectively, in part due to insufficient training. We report on the design, fate and impact of a short learner-centered EBM train-the-trainer program aimed at all 2400 doctors at the Karolinska University Hospital in Sweden on the heels of a tumultuous merger, focusing particularly on whether it affected the doctors’ knowledge, attitudes and skills regarding EBM. Methods We used a validated EBM instrument in a before-and-after design to assess the impact of the training. Changes in responses were analyzed at the individual level using the Wilcoxon matched pairs test. We also reviewed documentation from the program – including the modular EBM training schedule and the template for participants’ Critically Appraised Topic reports – to describe the training’s content, design, conduct, and fate. Results The training, designed to be delivered in modules of 45 min totaling 1.5 days, failed to reach most doctors at the hospital, due to cost cutting pressures and competing demands. Among study participants (n = 174), many reported suboptimal EBM knowledge and skills before the training. Respondents’ strategies for solving clinical problems changed after the training: the proportion of respondents reporting to use (or intend to use) secondary sources “Often/very often” changed from 5 % before the training to 76 % after the training; in parallel, reliance on textbooks and on colleagues fell (48 to 23 % and 79 to 65 %, respectively). Participants’ confidence in assessing scientific articles increased and their attitudes toward EBM became more positive. The proportion of correct answers in the EBM knowledge test increased from 52 to 71 %. All these changes were statistically significant at p

International audience; OBJECTIVE: The aim of this study was to provide a definition of big data in healthcare.METHODS: A systematic search of PubMed literature published until May 9, 2014, was conducted. We noted the number of statistical individuals (n) and the number of variables (p) for all papers describing a dataset. These papers were classified into fields of study. Characteristics attributed to big data by authors were also considered. Based on this analysis, a definition of big data was proposed.RESULTS: A total of 196 papers were included. Big data can be defined as datasets with Log(n∗p) ≥ 7. Properties of big data are its great variety and high velocity. Big data raises challenges on veracity, on all aspects of the workflow, on extracting meaningful information, and on sharing information. Big data requires new computational methods that optimize data management. Related concepts are data reuse, false knowledge discovery, and privacy issues.CONCLUSIONS: Big data is defined by volume. Big data should not be confused with data reuse: data can be big without being reused for another purpose, for example, in omics. Inversely, data can be reused without being necessarily big, for example, secondary use of Electronic Medical Records (EMR) data.

International audience; Even in most egalitarian societies, disparities in care exist to the disadvantage of some people with chronic musculoskeletal (MSK) disorders and related disability. These situations translate into inequality in health and health outcomes. The goal of this chapter is to review concepts and determinants associated with health inequity, and the effect of interventions to minimize their impact. Health inequities are avoidable, unnecessary, unfair and unjust. Inequities can occur across the health care continuum, from primary and secondary prevention to diagnosis and treatment. There are many ways to define and identify inequities, according for instance to ethical, philosophical, epidemiological, sociological, economic, or public health points of view. These complementary views can be applied to set a framework of analysis, identify determinants and suggest targets of action against inequity. Most determinants of inequity in MSK disorders are similar to those in the general population and other chronic diseases. People may be exposed to inequity as a result of policies and rules set by the health care system, individuals' demographic characteristics (e.g., education level), or some behavior of health professionals and of patients. Osteoarthritis (OA) represents a typical chronic MSK condition. The PROGRESS-Plus framework is useful for identifying the important role that place of residence, race and ethnicity, occupation, gender, education, socioeconomic status, social capital and networks, age, disability and sexual orientation may have in creating or maintaining inequities in this disease. In rheumatoid arthritis (RA), a consideration of international data led to the conclusion that not all RA patients who needed biologic therapy had access to it. The disparity in care was due partly to policies of a country and a health care system, or economic conditions. We conclude this chapter by discussing examples of interventions designed for reducing health inequity.

Around 90% of antibiotics used in human medicine are prescribed in primary care. At least half of these prescriptions are either unnecessary or inappropriate. Multifaceted interventions have proved useful in improving antibiotic prescribing, but they should be adapted to the context (‘One size does not fit all’ and ‘No magic bullet’ concepts). Behavior change theories are helpful for designing interventions that target healthcare professionals. Recent evidence related to various interventions targeting healthcare professionals are described here (Table 1): education, guidelines, clinical decision support systems, delayed prescribing, patient materials, public commitment, POC diagnostic tests, selective susceptibility reporting, quality indicators, audit and feedback, and restrictive prescribing measures. Interventions targeting the healthcare system have been overlooked so far, even though their impact can be large and sustained. Some examples are given here, including dispensing of antibiotics, financial incentives, and public reporting. Most published studies come from Europe or North America. We need studies from a much greater range of settings. Most interventions have focussed on GPs. In the future, all healthcare professionals should be targeted. Most studies have focussed on RTIs ; we need to develop a better understanding of how much improvement is possible for other conditions and how well suited our current interventions are to achieving this. Patient-centered outcomes remain largely underdeveloped and underreported. Innovative strategies, including those targeting the system organization, should be tested.

International audience; Cost-effectiveness estimates can help optimize use of available financial resources and this is especially relevant for implementation of cardiac resynchronization therapy (CRT), given the high upfront costs and the timescale of expected benefits. All available cost-effectiveness estimates for devices with (CRT-P) or without (CRT-D) a defibrillator are based on results of randomized trials of selected patients, with a relatively brief follow-up. Extrapolation suggests that the cost effectiveness of CRT may become more favourable as time horizons increase. Using a lifetime time horizon and comparison with optimal medical therapy, the cost effectiveness of both CRT-P and CRT-D appears to meet the $50 000/QALY benchmark commonly used for health-care interventions in the USA, as well as similar thresholds used in Europe. The absence of direct comparisons of the efficacy/effectiveness of CRT-P and CRT-D hampers cost-effectiveness comparisons, and so clinical judgment in the context of current evidence supporting the benefits of cardioverter-defibrillators may provide a rational basis for choosing between CRT-P and CRT-D. Efforts are currently being dedicated to improve CRT response rates by improved patient selection and, reasonably, any improvement in this field will translate into improved effectiveness, and therefore into improved cost effectiveness. The extended longevity of CRT devices will also positively impact cost-effectiveness estimates.

International audience; Although most of the people in good health questioned about the subject said they would like to die at home, in the western world between 60 and 80% of deaths occur in hospital. Most authors consider that the indispensable conditions for a return home are the patient's desire and presence of the family and caregivers with the appropriate skills. The assessment of other factors predictive of a return home is inadequate. The aim of this study is to clarify how the return home is influenced by the vulnerability of the patient at the end of life, and by that of the family and caregivers. We carried out a multicentric, observational, prospective, exhaustive and longitudinal epidemiological study (three months follow-up), including 146 patients hospitalized at the end of their life and desiring to return home. For these patients the caregivers respected their freedom to choose to die at home in over half the cases (56%). Their overall vulnerability (personal, family context and caregivers) had a significant influence on the return home. This overall vulnerability was in fact identified as applying in 40% of the clinical situations, and made the possibility of a return home 50% less likely.

International audience; BACKGROUND: Delayed diagnoses of pulmonary tuberculosis contribute to the spread of the epidemic. METHODS: This study aims to identify risk factors associated with patient delay (from symptoms onset to the first visit), health system delay (from the first visit to the tuberculosis treatment initiation) and total delay (sum of the patient and the health system delay) in low income and high tuberculosis burden countries. A systematic literature review has been performed using the keywords: "tuberculosis"; "delay", care seeking"; "health care seeking behavior"; "diagnosis" and "treatment". Only quantitative studies showing delays for pulmonary tuberculosis adult cases were included in this review. RESULTS: Low income, gender, rural life, unemployment, ageing and misunderstanding the microbial cause of tuberculosis are associated with delayed diagnoses. Systemic factors including low health care coverage, patient expenditures and entry into the health system by consulting a traditional healer or a non-skilled professional delay the beginning of tuberculosis treatment. CONCLUSION: Delays can be used as indicators to evaluate tuberculosis control programs. Active case finding in the households of contagious patients can help to diminish diagnostic delays in low-income countries with high endemicity.

Based on a statistical analysis of 111 facilities in Africa, Asia, and Latin America, Benjamin Chi and colleagues develop a standard loss-to-follow-up (LTFU) definition that can be used by HIV antiretroviral programs worldwide., Background Although patient attrition is recognized as a threat to the long-term success of antiretroviral therapy programs worldwide, there is no universal definition for classifying patients as lost to follow-up (LTFU). We analyzed data from health facilities across Africa, Asia, and Latin America to empirically determine a standard LTFU definition. Methods and Findings At a set “status classification” date, patients were categorized as either “active” or “LTFU” according to different intervals from time of last clinic encounter. For each threshold, we looked forward 365 d to assess the performance and accuracy of this initial classification. The best-performing definition for LTFU had the lowest proportion of patients misclassified as active or LTFU. Observational data from 111 health facilities—representing 180,718 patients from 19 countries—were included in this study. In the primary analysis, for which data from all facilities were pooled, an interval of 180 d (95% confidence interval [CI]: 173–181 d) since last patient encounter resulted in the fewest misclassifications (7.7%, 95% CI: 7.6%–7.8%). A secondary analysis that gave equal weight to cohorts and to regions generated a similar result (175 d); however, an alternate approach that used inverse weighting for cohorts based on variance and equal weighting for regions produced a slightly lower summary measure (150 d). When examined at the facility level, the best-performing definition varied from 58 to 383 d (mean = 150 d), but when a standard definition of 180 d was applied to each facility, only slight increases in misclassification (mean = 1.2%, 95% CI: 1.0%–1.5%) were observed. Using this definition, the proportion of patients classified as LTFU by facility ranged from 3.1% to 45.1% (mean = 19.9%, 95% CI: 19.1%–21.7%). Conclusions Based on this evaluation, we recommend the adoption of ≥180 d since the last clinic visit as a standard LTFU definition. Such standardization is an important step to understanding the reasons that underlie patient attrition and establishing more reliable and comparable program evaluation worldwide. Please see later in the article for the Editors' Summary, Editors' Summary Background Since 1981, AIDS has killed more than 25 million people, and about 33 million people (mostly in low- and middle-income countries) are now infected with HIV, the virus that causes AIDS. Because HIV destroys immune system cells, HIV-positive individuals are very susceptible to other infections, and, early in the AIDS epidemic, most HIV-infected people died within ten years of contracting the virus. Then, in 1996, antiretroviral therapy (ART)—a cocktail of drugs that keeps HIV in check—became available. For people living in developed countries, HIV infection became a chronic condition. However, for people living in developing countries, ART was prohibitively expensive, and HIV/AIDS remained a fatal illness. In 2003, this situation was declared a global emergency, and governments, international agencies, and funding bodies began to implement plans to increase ART coverage in resource-limited countries. By the end of 2009, more than a third of people living in these countries who needed ART were receiving it. Why Was This Study Done? Because ART does not cure HIV infection, patients have to take antiretroviral drugs regularly for the rest of their lives. But in some ART programs, more than a third of patients are lost to follow-up (LTFU), that is, they stop coming for treatment, within three years of starting treatment. Patient attrition threatens the success of ART programs, but to understand why it occurs, a standardized method for classifying patients as LTFU is essential. Classification of patients as LTFU relies on an interval-based definition of LTFU. That is, a patient who fails to attend a clinic within a specified interval after a previous visit is classified as LTFU. If this interval is too short, although many patients will be accurately identified as LTFU, there will be a high false-positive rate—some patients classified as LTFU will actually return to the clinic later. Conversely, if the interval is too long, some patients who are truly LTFU will be misclassified as active (a false-negative classification). In this study, the researchers analyzed data from health facilities across Africa, Asia, and Latin America to determine a standard definition for LTFU that minimizes patient misclassification. What Did the Researchers Do and Find? Using data collected from 111 health facilities by the International Epidemiologic Databases to Evaluate AIDS (IeDEA) Collaboration, the researchers categorized patients receiving ART at each facility at a “status classification” date (12 months before the facility's last data export to IeDEA) as active or LTFU using a range of intervals (thresholds) since their last clinic visit. For example, for a test interval of 200 days, patients who had not revisited the clinic within 200 days of their previous visit at the status classification date were classified as LTFU; patients who had revisited the clinic were classified as active. The researchers then looked forward 365 days from the status classification date to assess the performance and accuracy of these classifications. So, a “LTFU” patient who visited the clinic anytime during the year after the status classification date represented a false-positive classification, and an “active” patient who did not return within the ensuing year represented a false-negative classification. When data from all the facilities were pooled, a threshold of 180 days produced the fewest misclassifications. At the facility level, the best-performing threshold for patient classification ranged from 58 to 383 days (with an average of 150 days), but application of a 180-day threshold to individual facilities only slightly increased misclassifications. Finally, using the 180-day threshold, average LTFU at individual facilities was 19.9%. What Do These Findings Mean? Based on these findings, the researchers recommend that the standard definition for LTFU should be when it has been 180 days or more since the patient's last clinic visit. Given the wide range of best-performing definitions among facilities, however, they recognize that local, national, or regional definitions of LTFU may be more appropriate in certain contexts. Adoption of a standard definition for LTFU, the researchers note, should facilitate harmonization of monitoring and evaluation of ART programs across the world and should help to identify “best practices” associated with low LTFU rates. Importantly, it should also provide the necessary framework for research designed to improve patient retention in ART programs, thereby helping to maximize and sustain the health gains from HIV treatment programs. Additional Information Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001111. Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS NAM/aidsmap provides basic information about HIV/AIDS and summaries of recent research findings on HIV care and treatment Information is available from Avert, an international AIDS charity on many aspects of HIV/AIDS, including information on HIV/AIDS treatment and care and on universal access to AIDS treatment (in English and Spanish) The World Health Organization provides information about universal access to AIDS treatment (in several languages) Information about the IeDEA Collaboration available Patient stories about living with HIV/AIDS are available through Avert and through the charity website Healthtalkonline

International audience; The sustainability of successful public health programmes remains a challenge in low and middle income settings. These programmes are often subjected to mobilization-demobilization cycle. Indeed, political and organizational factors are of major importance to ensure this sustainability. The cooperation between the World Bank and the Brazilian AIDS programme highlights the role of international institutions and global health initiatives (GHI), not only to scale up programmes but also to guarantee their stability and sustainability, at a time when advocacy is diminishing and vertical programmes are integrated within health systems. This role is critical at the local level, particularly when economic crisis may hamper the future of public health programmes. Political and organizational evolution should be monitored and warnings should trigger interventions of GHI before the decline of these programmes.

High rates of misdiagnosis, delayed diagnosis, and lack of recognition and treatment of comorbid conditions often lead patients with bipolar illness to have a chronic course with high disability, unemployment rates, and mortality. Despite the recognition that long-term outcome of bipolar disorder depends on systematic assessment of both interepisodic dysfunctional domains and comorbid psychiatric and medical conditions, treatment of bipolar disorder still focuses primarily on alleviation of acute symptoms and prevention of future recurrences. We propose here to review the evidence offering a modern view of bipolar disorder defined as a chronic and progressive multisystem disorder, taking into account characteristics of each patient as well as biosignatures in order to help design personalized treatments.We conducted a systematic PubMed search of all English-language articles, published between 2000 and 2010, focusing on the English and French literature with bipolar disorder cross-referenced with the following search terms: emotional dysregulation, sleep and circadian rhythm disturbances, cognitive impairment, age at onset, comorbid medical and psychiatric conditions, psychosocial and medical interventions, outcome, remission, and personalized medicine. The search was conducted between July 2009 and July 2010. The literature on bipolar disorder was reviewed to provide supporting evidence that the assessment of various symptom domains that are dysfunctional between episodes should all be considered as core dimensions of the disorder.Forty-one articles were identified through the PubMed search described above and selected on the basis of addressing any combination of the search terms in conjunction with bipolar disorder.Current guidelines advocate the use of more or less similar treatment algorithms for all patients, ignoring the clinical, pathophysiological, and lifetime heterogeneity of bipolar disorder. Systematic assessment of interepisodic dimensions, along with comorbid medical and psychiatric risk factors, should be performed along the life cycle in order to plan specific and personalized pharmacologic, medical, and psychosocial interventions tailored to the needs of each patient and ready-to-test biosignatures to serve as risk factors or diagnostic or prognostic tools.Medical and research findings, along with health economic data, support a more modern view of bipolar disorder as a chronic, progressive, multisystem disorder. This new comprehensive framework should guide the search to identify biomarkers and etiologic factors and should help design a new policy for health care, including prevention, diagnosis, treatment, and training.

International audience; OBJECTIVE: Because a centre effect can sometimes exist in HIV treatment, we sought to measure the heterogeneity of French hospital departments delivering HIV care and to test the presence of such an effect on adherence and response to highly active antiretroviral therapy. METHODS: The ANRS-EN12-VESPA study is a nationally representative 2-stage cross-sectional survey conducted in France in 2003 and covering 102 hospital departments providing HIV care. Each department described its HIV care activities and care provision. Analyses of adherence and 4 indicators of treatment outcome were restricted to the 699 patients diagnosed from 1996 onwards and treated with highly active antiretroviral therapy for at least 6 months. The variability between departments was assessed with random-effect models for binary outcomes. RESULTS: The departments delivering HIV care proved to be somewhat heterogeneous in numerous respects, including their size and their onsite provision of consultancies and other services, and the characteristics of their patient population. Mean observed adherence was 63.3%, and the means of the different treatment failure indicators ranged from 6.1% to 59.8%. The departments showed some variability for these outcomes, but no significant centre effect was detected. CONCLUSIONS: Despite the heterogeneity of the specific types of medical services offered by the hospitals providing HIV care, the nationwide treatment results seem homogeneous. This homogeneity could be attributed to the widespread and consistent application of therapeutic guidelines, which are regularly updated by consensus.

International audience; OBJECTIVE: Because a centre effect can sometimes exist in HIV treatment, we sought to measure the heterogeneity of French hospital departments delivering HIV care and to test the presence of such an effect on adherence and response to highly active antiretroviral therapy. METHODS: The ANRS-EN12-VESPA study is a nationally representative 2-stage cross-sectional survey conducted in France in 2003 and covering 102 hospital departments providing HIV care. Each department described its HIV care activities and care provision. Analyses of adherence and 4 indicators of treatment outcome were restricted to the 699 patients diagnosed from 1996 onwards and treated with highly active antiretroviral therapy for at least 6 months. The variability between departments was assessed with random-effect models for binary outcomes. RESULTS: The departments delivering HIV care proved to be somewhat heterogeneous in numerous respects, including their size and their onsite provision of consultancies and other services, and the characteristics of their patient population. Mean observed adherence was 63.3%, and the means of the different treatment failure indicators ranged from 6.1% to 59.8%. The departments showed some variability for these outcomes, but no significant centre effect was detected. CONCLUSIONS: Despite the heterogeneity of the specific types of medical services offered by the hospitals providing HIV care, the nationwide treatment results seem homogeneous. This homogeneity could be attributed to the widespread and consistent application of therapeutic guidelines, which are regularly updated by consensus.

Objectives. We investigated involvement and cooperation patterns of local Brazilian AIDS program actors and the consequences of these patterns for program implementation and sustainability.Methods. We performed a public policy analysis (documentary analysis, direct observation, semistructured interviews of health service and nongovernmental organization [NGO] actors) in 5 towns in 2 states, São Paulo and Pará.Results. Patterns suggested 3 models. In model 1, local government, NGOs, and primary health care services were involved in AIDS programs with satisfactory response to new epidemiological trends but a risk that HIV/AIDS would become low priority. In model 2, mainly because of NGO activism, HIV/AIDS remained an exceptional issue, with limited responses to new epidemiological trends and program sustainability undermined by political instability. In model 3, involvement of public agencies and NGOs was limited, with inadequate response to epidemiological trends and poor mobilization threatening program sustainability.Conclusions. Within a common national AIDS policy framework, the degree of involvement and cooperation between public and NGO actors deeply impacts population coverage and program sustainability. Specific processes are required to maintain actor mobilization without isolating AIDS programs.

International audience; Since 2000, the emergence of several large disease-specific global health initiatives (GHIs) has changed the way in which international donors provide assistance for public health. Some critics have claimed that these initiatives burden health systems that are already fragile in countries with few resources, whereas others have asserted that weak health systems prevent progress in meeting disease-specific targets. So far, most of the evidence for this debate has been provided by speculation and anecdotes. We use a review and analysis of existing data, and 15 new studies that were submitted to WHO for the purpose of writing this Report to describe the complex nature of the interplay between country health systems and GHIs. We suggest that this Report provides the most detailed compilation of published and emerging evidence so far, and provides a basis for identification of the ways in which GHIs and health systems can interact to mutually reinforce their effects. On the basis of the findings, we make some general recommendations and identify a series of action points for international partners, governments, and other stakeholders that will help ensure that investments in GHIs and country health systems can fulfil their potential to produce comprehensive and lasting results in disease-specific work, and advance the general public health agenda. The target date for achievement of the health-related Millennium Development Goals is drawing close, and the economic downturn threatens to undermine the improvements in health outcomes that have been achieved in the past few years. If adjustments to the interactions between GHIs and country health systems will improve efficiency, equity, value for money, and outcomes in global public health, then these opportunities should not be missed.

International audience; The continuous improvement policy for healthcare quality requires practice evaluation. The principle of a clinical audit is to compare practice to guidelines. Prescription guidelines on antifungal agent use has been available in our hospital since 2003. It was updated in 2005 and 2006. OBJECTIVE: The aim of this study was to assess compliance to guidelines, with an audit of prescriptions: amphotericin B lipid formulation, voriconazole and caspofungin, expensive antifungals concerned by the budget allowance correlated to activity, subject to supplementary reimbursement to the coded Homogeneous Group of Diseases. METHOD: The assessment criteria were: relevance of the indication, absence of a better alternative, complying to recommended dosage, loading dose and timing. This retrospective study dealt with all prescriptions of all departments, from January to May 2007. RESULTS: Hundred and eighteen prescriptions were retrospectively analyzed for 81 patients. The rate of overall conformity was 54%. Antifungal therapy was justified for 113 prescriptions (96%). In 30% of the cases, a more efficient alternative was advised, cheaper or less toxic. The dosage and the charge dosing were right in 92% and 80% of the cases respectively. CONCLUSION: This audit allowed assessing good-use of antifungals. We showed an over-prescription of caspofungin and sometimes insufficient regimen of voriconazole dosages for children. Reporting these audit results and development of new international guidelines stress the need to update local recommendations regularly.

International audience

International audience; In developing countries, prisons do not have adequate healthcare systems. The problem is particularly acute for tuberculosis (TB) and is exacerbated by crowding and HIV infection. Improved passive TB detection is a priority for control, but in highly endemic prisons mass screening may be needed to obtain a more rapid decrease in incidence. The provision of health care in prisons is made more difficult by social conditions within prisons and the political climate in which they operate. International guidelines seem to be largely ignored.

International audience

‘‘Chronic respiratory diseases (CRD) which include asthma and chronic obstructive pulmonary diseases (COPD) comprise a major cause of death and disability for all age groups and regions in the world. In the absence of effective interventions, risk factors such as smoking, air pollution, allergen exposure, severe childhood respiratory infection and TB are expected to cause a further rise in the magnitude of these health problems in the coming years, particularly in developing countries. Evidence also indicates that in many countries people with common CRDhave no access to acceptable standards of health care; health systems may also provide inappropriate care due to misdiagnosis arising from respiratory symptoms which are often common for acute and chronic illnesses.’’ (1) In low and middle-income countries, the capacity of health professionals should be expanded to address CRD. Sub-Saharan Africa appears to be an important region of the world that could be used to assess how the CRD program can be modeled and implemented. In these countries, CRD (including allergic diseases) represent only one type of major disease, and in many instances are not the main disease burden. Thus, it is important to propose an integrated management of disease that covers communicable and noncommunicable diseases.

International audience; Using an indirect assessment technique we assessed the epilepsy treatment gap (ETG) in Madagascar. We estimate the ETG in Madagascar to be 92%. However, given the sociological, economic and sanitary conditions of the country, it is likely that the true ETG is even higher than our estimate. Our study also documents the lack of access to treatment for patients in this developing country. The indirect method could be used to assess the treatment gaps of other chronic medical conditions.