Comment améliorer la prise en charge ambulatoire des patients dépendants aux opiacés ? Approche pharmacoépidémiologique de l'intérêt des tests urinaires de dépistage des substances psychoactives

L'objectif de cette thèse est d'évaluer l'intérêt des tests urinaires de dépistage pour la prise en charge des patients dépendants aux opiacés en médecine ambulatoire. Dans la première partie, nous avons montré que les Médecins Généralistes (MG) prenant en charge régulièrement des patients dépendants aux opiacés ne réalisaient pas de tests par manque de connaissance. De plus, l'intérêt des tests urinaires pour la prise en charge des patients n'était pas clairement démontré dans les études incluses dans une revue systématique de la littérature. Dans la seconde partie, l'efficacité des tests sur la prise en charge des patients dépendants aux opiacés a été évaluée à partir d'études de cohorte sur les bases de données de l'Assurance Maladie. Dans une première étude, l'utilisation des tests urinaires, quoique rare, augmentait significativement le maintien sous médicament de substitution aux opiacés (MSO). Une deuxième étude n'a pu conclure sur une association entre la réalisation des tests et la mortalité. La dernière partie propose de confirmer l'impact des tests urinaires dans la vraie vie, en évaluant leur efficacité dans un essai pragmatique randomisé en cluster. Nous présentons le protocole de cette étude qui évalue l'efficacité d'une intervention (tests urinaires de dépistage au cabinet du MG) sur le maintien sous MSO de patients débutant la buprénorphine. Pour conclure, cette thèse a montré que les tests urinaires étaient peu réalisés en France chez les patients dépendants aux opiacés alors qu'ils semblent avoir un effet protecteur sur le maintien sous MSO. L'essai pragmatique randomisé en cours devrait permettre d'apporter des preuves suffisantes de leur intérêt en MGThe objective of this thesis is to assess the value of urine drug screening in opioid-addicted patients managed in ambulatory care. In the first part, we showed that many French general practitioners (GPs) treating opioid-addicted patients regularly did not perform drug tests and lacked knowledge of them. Beside, the value of urine drug screening in managing patients was not clearly indicated in studies included in a systematic review. The second part aimed to assess the effectiveness of drug tests in managing opioid-addicted patients using observational cohorts conducted from French health insurance system databases. In a first work, use of a drug, although rarely prescribed, significantly improved opioid maintenance treatment (OMT) retention. The second work could not conclude on the effectiveness of drug tests on mortality. The last part aimed to confirm the value of urine drug screening tests in real life and thus, to assess their efficacy planning a pragmatic cluster randomized controlled trial in general practice: the ESUB-MG study. We present the protocol of this study aiming to assess the impact of on-site urine drug screening tests in general practice compared to routine medical care on OMT retention at six months in patients initiating buprenorphine. To conclude, this thesis has shown that, even if urine drug screening tests were rarely done in France for managing opioid-addicted patients, drug tests seem to have a positive effect on OMT retention. The on-going pragmatic randomized trial we proposed should bring sufficient level of evidence to assess effectiveness of on-site urine drug screening in general practic

Laboratory Monitoring of Patients Treated with Antihypertensive Drugs and Newly Exposed to Non Steroidal Anti-Inflammatory Drugs: A Cohort Study

BACKGROUND: Drug-Drug Interactions between Non Steroidal Anti-Inflammatory Drugs (NSAIDs) and Angiotensin Converting Enzyme Inhibitors (ACEIs), Angiotensin Receptor Blocker (ARBs) or diuretics can lead to renal failure and hyperkalemia. Thus, monitoring of serum creatinine and potassium is recommended when a first dispensing of NSAID occur in patients treated with these drugs. METHODS: We conducted a pharmacoepidemiological retrospective cohort study using data from the French Health Insurance Reimbursement Database to evaluate the proportion of serum creatinine and potassium laboratory monitoring in patients treated with ACEI, ARB or diuretic and receiving a first dispensing of NSAID. We described the first dispensing of NSAID among 3,500 patients of a 4-year cohort (6,633 patients treated with antihypertensive drugs) and analyzed serum creatinine and potassium laboratory monitoring within the 3 weeks after the first NSAID dispensing. RESULTS: General Practitioners were the most frequent prescribers of NSAIDs (85.5%, 95% CI: 84.3-86.6). The more commonly prescribed NSAIDs were ibuprofen (20%), ketoprofen (15%), diclofenac (15%) and piroxicam (12%). Serum creatinine and potassium monitoring was 10.7% (95% CI: 9.5-11.8) in patients treated by ACEIs, ARBs or diuretics. Overall, monitoring was more frequently performed to women aged over 60, treated with digoxin or glucose lowering drugs, but not to patients treated with ACEIs, ARBs or diuretics. Monitoring was more frequent when NSAIDs' prescribers were cardiologists or anesthesiologists. CONCLUSION: Monitoring of serum creatinine and potassium of patients treated with ACEIs, ARBs or diuretics and receiving a first NSAID dispensing is insufficiently performed and needs to be reinforced through specific interventions

Innovative healthcare organization to deal with COVID-19 in primary health care in the Haute-Garonne department, France

Primary care health professionals (general practitioners, nurses) rapidly developed a collaborative approach to the management of COVID-19 with, on the one hand, hospital health professionals (emergency and infectiology services) and medical regulatory services and, on the other hand, local health, research and governmental stakeholders. GP stakeholders developed a secure digital tool shared between hospital and primary care and regularly updated according to the needs of health professionals. The authors identify key elements that guarantee the efficiency of primary care, which remains the “gatekeeper” of a care pathway adapted to the patient's needs.https://deepblue.lib.umich.edu/bitstream/2027.42/154862/1/Gimenez main article.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/154862/2/Gimenez figures.pdfDescription of Gimenez main article.pdf : Main articleDescription of Gimenez figures.pdf : Figure

Molecular diagnosis of Pseudoterranova decipiens s.s in human, France

Background: Anisakis and Pseudoterranova are the main genera involved in human infections caused by nematodes of the Anisakidae family. Species identification is complicated due to the lack of differential morphological characteristics at the larval stage, thus requiring molecular differentiation. Pseudoterranova larvae ingested through raw fish are spontaneously eliminated in most cases, but mechanical removal by means of endoscopy might be required. To date, only very few cases of Pseudoterranova infection have been reported in France. Case presentation: A 19-year-old woman from Northeastern France detected, while brushing her teeth, a larva exiting through her mouth. The patient who presented with headache, diarrhea, and abdominal cramps reported having eaten baked cod. The worm was a fourth-stage larva with a size of 22 × 0.9 mm, and molecular biology identified it as Pseudoterranova decipiens sensu stricto (s. s.). In a second P. decipiens infection case, occurring a few months later, a worm exited through the patient’s nose after she had eaten raw sea bream. Conclusion: These two cases demonstrate that Pseudoterranova infection is not uncommon among French patients. Therefore, molecular techniques should be more widely applied for a better characterization of anisakidosis epidemiology in France

Association of the PHACTR1/EDN1 genetic locus with spontaneous coronary artery dissection

Background: Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndromes (ACS) afflicting predominantly younger to middle-aged women. Observational studies have reported a high prevalence of extracoronary vascular anomalies, especially fibromuscular dysplasia (FMD) and a low prevalence of coincidental cases of atherosclerosis. PHACTR1/EDN1 is a genetic risk locus for several vascular diseases, including FMD and coronary artery disease, with the putative causal noncoding variant at the rs9349379 locus acting as a potential enhancer for the endothelin-1 (EDN1) gene. Objectives: This study sought to test the association between the rs9349379 genotype and SCAD. Methods: Results from case control studies from France, United Kingdom, United States, and Australia were analyzed to test the association with SCAD risk, including age at first event, pregnancy-associated SCAD (P-SCAD), and recurrent SCAD. Results: The previously reported risk allele for FMD (rs9349379-A) was associated with a higher risk of SCAD in all studies. In a meta-analysis of 1,055 SCAD patients and 7,190 controls, the odds ratio (OR) was 1.67 (95% confidence interval [CI]: 1.50 to 1.86) per copy of rs9349379-A. In a subset of 491 SCAD patients, the OR estimate was found to be higher for the association with SCAD in patients without FMD (OR: 1.89; 95% CI: 1.53 to 2.33) than in SCAD cases with FMD (OR: 1.60; 95% CI: 1.28 to 1.99). There was no effect of genotype on age at first event, P-SCAD, or recurrence. Conclusions: The first genetic risk factor for SCAD was identified in the largest study conducted to date for this condition. This genetic link may contribute to the clinical overlap between SCAD and FMD

Efficacité d'un outil d'évaluation des consommations de substances pour la prise en charge des patients sous buprénorphine en médecine générale (étude ESUB-MG)

TOULOUSE3-BU Santé-Centrale (315552105) / SudocSudocFranceF

Soutien aux aidants de patients atteints de maladie d'Alzheimer ou de maladies apparentées (contribution d'un groupe de parole au sein de l'hôpital de jour de psycho-gériatrie)

Les aidants familiaux de patients atteints de Maladies d'Alzheimer ou de maladies apparentées (MAMA) tiennent un rôle primordial dans la prise en charge de ces malades mais subissent souvent les effets néfastes de cette relation d'aide sur leur santé et leur bien être, correspondant au fardeau. Notre étude s'intéresse à une intervention de soutien, un groupe de parole (GP) proposé aux aidants de patients atteints de MAMA suivis à l'hôpital de jour de psychogériatrie du centre hospitalier de Dax. OBJECTIFS : Description de la population des aidants ayant participé au GP et de leur ressenti face à la maladie. Etude du fardeau en comparant les aidants ayant assisté au GP à ceux qui n'y ont pas assisté. METHODE : Enquête par auto-questionnaire auprès des aidants participant au GP. Etude rétrospective du fardeau des aidants mesurée par l'échelle de Zarit. RESULTATS : Les aidants sont majoritairement des femmes et des conjoints. Ils déclarent un manque de disponibilité, une anxiété (60 %), un épuisement (38 %) et avoir retardé ou annulé un soin pour eux-mêmes dans 46 % des cas. Le GP leur apporte un accompagnement (66 %) et un soutien (41 %) et sa contribution majeure est le soutien à l'accompagnement du malade pour 48 % d'entre eux devant la compréhension de la maladie et le partage des expériences. Ils estiment recevoir un soutien de la part de leur médecin traitant dans 74 % des cas. Nous décrivons une diminution significative du fardeau lors de la première année de participation au GP. Hypothèses : nous suggérons que le GP est utilisé par une population d'aidants vulnérables et que le GP a un impact positif sur leur santé et leur bien être durant la première année de patrticipation.Family caregivers of people suffering from Alzheimer's Disease or related syndromes (AD-RS) play an essential role in the day to day care of these patients. However, they often suffer themselves from the negative effects of this situation as a result of the burden which undermines their own health and well-being. This study investigated the impact of a Support Group (SG) offered to caregivers of patients with AD-RS at the psychogeriatrics day hospital of Dax. OBJECTIVES : 1) To describe the population of caregivers who participated with the SG and to relate their feelings concerning the illness, 2) To evaluate the relative burdens endured by the caregivers by comparing the experience of caregivers who attended the SG with those who did not. METHODS : A questionnaire completed by the caregivers who participated at the SG and a retrospective study of the burden endured by caregivers as measured by the Zarit Scale. RESULTS : The majority of caregivers were women and spouses. They complained of a lack of availability, anxiety (60 %), exhaustion (38 %), and even declared having put off or cancelled a consultation or healthcare for themselves (46 %. They declared that the SG gave them moral assistance and support. They declared that the major contribution of the SG, for 48 % of them, was its support in helping the caregiver to assist the patient, front of the understanding of the illness, and the sharing of experience. They also declared that their general practitioner gave them support in 74 % of cases. This study reveals a significant decrease of the caregiver's burden during the first of intervention. DISCUSSION : We suggest that the SG is useful to a vulnerable population of caregivers and that it has a positive impact on their health and well-bing, during the first year of intervention.BORDEAUX2-BU Santé (330632101) / SudocSudocFranceF

L'assistance médicale à la procréation en France en 2012 (techniques cliniques et biologiques et encadrement juridique)

BORDEAUX2-BU Santé (330632101) / SudocSudocFranceF

Guide de la première prescription des benzodiazépines dans les troubles anxieux et l'insomnie (une revue systématique de la littérature)

TOULOUSE3-BU Santé-Centrale (315552105) / SudocSudocFranceF