Contraception (perception du médecin généraliste par les adolescents)

La contraception des adolescents est un paradoxe . Alors que 85 % d'entre eux déclarent utiliser une contraception, l'utilisation de la pilule du lendemain et le taux d'interruptions volontaires de grossesses ne régressent pas. Il existe donc des obstacles à une contraception efficace dans cette population. Nous nous sommes interrogés sur la perception que les adolescents avaient de leur Médecin généraliste concernant la contraception et il a été pointé, dans leurs témoignages, les obstacles , difficultés et éventuelles solutions . Pour cela ,15 adolescents de 14 à 19 ans ont participé à des entretiens semi-directifs au sein d'établissements scolaires picards. Les entretiens ont été encodées avec le logiciel N'Vivo 9 . ; 285 codes ont été réunis en thèmes permettant de dégager les idées fortes. Ayant des connaissances fragiles sur la contraception , les adolescents désignent leurs parents comme des interlocuteurs privilégiés. Ils ne souhaitent pourtant pas qu'ils soient présents lors des consultations médicales .Par ailleurs , ils font toute confiance à leur médecin généraliste qu'ils regardent comme un médecin traitant de toute la famille ce qui lui confère ainsi une légitimité non discutable. Le voyant comme un technicien de la santé , ils ont confiance en ses connaissances et espèrent trouver en lui une écoute, une aide et des conseils. Intransigeants sur le respect du secret médical ,ils ne souhaitent pas qu'il exprime de jugement de valeurs et veulent qu'il les considère d'égal à égal. La pudeur et la peur de se faire examiner sont omniprésentes. Ils mettent peu en avant les difficultés matérielles. Finalement, les adolescents donnent à leur médecin généraliste une place de choix pour parler de contraception mais identifient des difficultés spécifiques que ce dernier doit prendre en compte pour répondre au mieux à leurs besoins .Contraception for adolescents is a paradox. While 85% of them reported using contraception, the use of emergency contraception and abortion does not slow down. Do teenagers consider the general practitioner (GP) as the right person to talk to about contraception? We wanted to find out how the young ones see the GP as far as contraception is concerned and to point out, through their testimonies, what stand in their way as long as their difficulties and solutions. 15 adolescents aged 14 to 19 took part in semi-structured interviews within schools in Picardy. The interviews were encoded with software N'Vivo 9 ; 285 codes were classified into topics to identify the main issues. With an insubstancial knowledge about contraception, teenagers give their parents a very ambivalent position regarding contraception. Whereas they are the first they talk to, they don't want them to be present during medical consultations. They all trust their GP whom they consider a family doctor which gives him an undeniable legitimacy. Seeing him as a health expert, they have confidence in his knowledge and hope to find in him someone who can listen, help and give advice. Uncompromising on medical confidentiality, they do not want their GP to express any judgment of value and want him to consider them as equal. Modesty is an exacerbated feeling causing difficulties to talk about intimacy and fear to be examined. Surprisingly, they scarcely put material difficulties forward. The GP is the first person the adolescents trust to talk to about contraception but has to identify and go beyond significant difficulties to meet their needs in the best way.AMIENS-BU Santé (800212102) / SudocSudocFranceF

Informations aux patients avant un dosage sanguin de l'Antigène Prostatique Spécifique (enquête d'opinion auprès de patients de la Somme)

Introduction : Actuellement, le dosage sanguin de PSA n est pas considéré comme performant pour un dépistage organisé du cancer de la prostate. Le médecin généraliste, en tant que prescripteur dans le cadre d un dépistage individuel, se doit de délivrer à ses patients des informations claires, objectives et hiérarchisées -selon l HAS- sur les bénéfices et les limites de ce test. Notre objectif principal a été d évaluer le niveau de connaissance des hommes avant un dosage de PSA au laboratoire et l objectif secondaire, d évaluer leur satisfaction vis-à-vis de l information reçue de leur médecin traitant. Matériel et méthodes : une enquête d opinion a été réalisée auprès d hommes venant dans 5 laboratoires de la Somme, avant un dosage de PSA, à l aide d un questionnaire qui intégrait une évaluation de connaissances. Résultats : 351 patients ont répondu pendant la période du 15/01au 15/03/ 2013. 2/3 des patients estimaient savoir ce qu est le dosage sanguin de PSA ; mais la même proportion a un niveau faible de connaissances réelles (selon notre outil d évaluation). 69% des sujets sont plutôt satisfaits des informations qu ils ont reçues de la part de leur médecin et 21% ont déclaré avoir besoin d informations complémentaires. Discussion : Une certaine confusion règne autour de ce dépistage. La compréhension des enjeux et donc la qualité des informations à apporter aux patients est une tâche complexe: prendre son temps, viser l objectivité et la clarté, moduler le contenu en fonction du patient et espérons-le pour l avenir, pouvoir s aider d un support écrit type fiche patient , afin que la décision du dépistage ou non soit prise de manière la plus éclairée possible. Conclusion : Notre enquête a permis de confirmer la place cruciale de l information sur le sujet délicat du dépistage du cancer de la prostate pour respecter la notion de consentement éclairé.AMIENS-BU Santé (800212102) / SudocSudocFranceF

L'information des médecins généralistes sur les médicaments

Introduction : Les accidents liés au MEDIATOR® posent le problème de l information du médecin en général et plus particulièrement du médecin généraliste sur les médicaments. Objectif : Notre enquête a consisté à évaluer les principales sources d information thérapeutique utilisées par les médecins généralistes, le crédit qu ils leurs accordent et leurs besoins ressentis. Méthode : Il s agit d une enquête par voie postale auprès de 600 médecins généralistes de Picardie entre le mois de juillet et le mois d août 2011. Résultats : Le taux de réponse de notre enquête a été de 25,6%. Les principales sources d information utilisées par les médecins interrogés sont les revues médicales (98%) notamment la revue Prescrire , suivies par les recommandations AFSSAPS (96,7%), les FMC (86,2%) qui bénéficient de la meilleure crédibilité et les banques de données médicamenteuses (84,3%). Les DAM (81%) et les visiteurs médicaux (79,7%) s ils sont utilisés n ont qu une crédibilité médiocre auprès des médecins généralistes. Les critères de qualités suivants sont reconnus par une majorité des médecins interrogés : données de pharmacovigilance (92,8%), Service Médical Rendu (84,2%) et Amélioration du Service Médical Rendu (80,3%). Bien que les médecins de l étude considèrent leur information comme étant bonne en qualité et en quantité, la plupart sont demandeurs d une amélioration de leur information thérapeutique (72%) et choisissent parmi les différentes propositions, la création d un site internet de pharmacovigilance adapté aux médecins généralistes et l organisation d une visite médicale indépendante des laboratoires pharmaceutiques. Conclusion : Le nouveau projet de loi proposé par le ministre de la santé en réponse à l affaire Médiator®, permettra-t-elle de répondre aux difficultés liées à l information thérapeutique ?Introduction: Adverse events related to MEDIATOR® rise the question of medical information in medicine especially in GP practice. Objective: Our study ant sought to assess the main sources of information used by general practitioners, the credit they attributed to these sources and their needs. Method: This is a postal survey among 600 general practitioners in Picardy between July and August 2011. Results: The participating rate to our survey was 25.6%. Main sources of information used by doctors considered in medical journals (98%) including the journal "Prescrire", followed by recommendations of AFSSAPS French Agency of Sanitary Security) (96.7%), the CME credits (Continuing Medical Education) (86.2%) which benefits from the greater credibility and drug databases (84.3%). The DAM (81%) and health visitors (79.7%) had a low credibility among general practitioners. Control quality criteria are recognized by a majority of physicians surveyed: data pharmacovigilance (92.8%), medical service (84.2%) and improvement of medical service (80.3%). Although the study participants view ad their information of good quality and of reasonable ????; most are seeking an improvement in their therapeutic information (72%) and plebiscite the creation of a website dedicated to pharmacovigilance and adapted to general practitioners and the organization of an independent medical pharmaceutical companies. Conclusion: The new bill proposed by the Minister of Health in response to the case MEDIATOR®, be able to meet the difficulties of therapeutic information.AMIENS-BU Santé (800212102) / SudocSudocFranceF

Trois ans de pratique du test de diagnostic rapide de l'angine dans un cabinet de médecine générale à Amiens (à propos de 484 cas)

La prescription d'antibiotique dans l'angine est une question de santé publique; trop massivement prescrite, elle a un coût et expose aux pressions de sélection bactérienne. Les médecins français disposent depuis fin 2002, à leur cabinet et à leur demande, d'une nouvelle stratégie, le TDR, qui permet une orientation et un choix thérapeutique. Dans les pays anglo-saxons, le recours à un score clinique méthodique (de Mac Isaac), est proposé pour orienter le diagnostic et limiter la réalisation de la culture du prélèvement de gorge, seul examen para-clinique de certitude mis à la disposition des praticiens. A partir de 484 TDR pratiqués par 2 médecins généralistes, j'ai voulu confronter le TDR au score de Mac Isaac, et, m'interroger sur les recommandations de l'AFSSAPS. Pour des scores inférieurs à 2, il est peu probable que le patient présente une angine bactérienne : le score et le TDR sont convergents. Pour les scores supérieurs ou égaux à 3, le TDR reste indispensable : convergence insuffisante entre le score et le TDR. Pour un score de 2, le TDR s'impose. Cela revient finalement aux recommandations françaises. Par contre, le TDR doit être réalisé dès 18 mois, et non dès 3 ans. Il faut réellement se méfier de l'impression clinique de l'examen de l'oropharynx qui ne permet pas d'orienter vers l'étiologie bactérienne d'une angine. Le TDR permet surtout d'argumenter sur l'absence d'antibiothérapie, mais chez les tout-petits et les patients non-dysphagiques, le TDR peut devenir un outil de prescription d'antibiotique.AMIENS-BU Santé (800212102) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Absence of Rotation Perception during Warm Water Caloric Irrigation in Some Seniors with Postural Instability

Falls in seniors are a major public health problem. Falls lead to fear of falling, reduced mobility and decreased quality of life. Vestibular dysfunction is one of the fall risk factors. The relationship between objective measures of vestibular responses and age has been studied. However, the effects of age on vestibular perception during caloric stimulation have not been studied.Twenty senior subjects were included in the study separated in two groups: 10 seniors reporting postural instability (PI) and exhibiting absence of vestibular perception when they tested with caloric stimulation and 10 sex and age-matched seniors with no such problems (controls). We assessed vestibular perception on a binary rating scale during the warm irrigation of the caloric test. The function of the various vestibular receptors was assessed using video-head impulse test (vHIT), caloric tests, and cervical and ocular VEMPs. The Equitest was used to evaluate balance. No horizontal canal dysfunction assessed using both caloric test and vHIT was detected in either group. No significant difference was detected between PI and control groups for the peak SPV of caloric induced ocular nystagmus or for the HVOR gain. All of the controls perceived rotation when the maximal SPV during warm irrigation was equal to or greater than 15°/s. None of the subjects in the PI group perceived rotation even while the peak SPV exceeded 15°/s, providing objective evidence of normal peripheral horizontal canal function. All of the PI group had abnormal Equitest results, particularly in the two last conditions.These investigations show for the first time that vestibular perception can be absent during a caloric test despite normal horizontal canal function. We call this dissociation vestibular neglect. Patients with poor vestibular perception may not be aware of postural perturbations and so will not correct for them. Thus, falls in the elderly may result, amongst other factors, from a vestibular neglect due to an inappropriate central processing of normal vestibular peripheral inputs. That is, failure to perceive rotation during caloric testing when the SPV is greater than 15°/s, should prompt the clinician to envisage preventive actions to avoid future falls such as rehabilitation

Distinct Transcriptomic Features are Associated with Transitional and Mature B-Cell Populations in the Mouse Spleen.

Splenic transitional B-cells (T1 and T2) are selected to avoid self-reactivity and to safeguard against autoimmunity, then differentiate into mature follicular (FO-I and FO-II) and marginal zone (MZ) subsets. Transcriptomic analysis by RNA-seq of the five B-cell subsets revealed T1 cell signature genes included RAG suggesting a potential for receptor revision. T1 to T2 B-cell differentiation was marked by a switch from Myb to Myc, increased expression of the PI3K adapter DAP10 and MHC class II. FO-II may be an intermediate in FO-I differentiation and may also become MZ B-cells as suggested by principle component analysis. MZ B-cells possessed the most distinct transcriptome including down-regulation of CD45 phosphatase-associated protein (CD45-AP/PTPRC-AP), as well as upregulation of IL-9R and innate molecules TLR3, TLR7, and bactericidal Perforin-2 (MPEG1). Among the endosomal TLRs, stimulation via TLR3 further enhanced Perforin-2 expression exclusively in MZ B-cells. Using gene-deleted and overexpressing transgenic mice we show that IL-9/IL-9R interaction resulted in rapid activation of STAT1, 3, and 5, primarily in MZ B-cells. Importantly, CD45-AP mutant mice had reduced transitional and increased mature MZ and FO B-cells, suggesting that it prevents premature entry of transitional B-cells to the mature B-cell pool or their survival and proliferation. Together, these findings suggest, developmental plasticity among splenic B-cell subsets, potential for receptor revision in peripheral tolerance whereas enhanced metabolism coincides with T2 to mature B-cell differentiation. Further, unique core transcriptional signatures in MZ B-cells may control their innate features

Fluoroquinolone Resistance Mechanisms and population structure of Enterobacter cloacae non-susceptible to Ertapenem in North-Eastern France.

Fluoroquinolone (FQ) agents are a potential resort to treat infection due to Enterobacteriaceae producing extended spectrum β-lactamase and susceptible to FQ. In a context of increase of non-susceptibility to carbapenems among Enterobacteriaceae, we characterized FQ resistance mechanisms in 75 Enterobacter cloacae isolates non-susceptible to ertapenem in North-Eastern France in 2012 and describe the population structure by pulsed field gel electrophoresis (PFGE) and multilocus sequence typing (MLST).Among them, 14.7% (12/75) carried a carbapenemase-encoding gene. Except one isolate producing VIM-1, the carbapenemase-producing isolates carried the well-known IncL/M pOXA48a plasmid. Most of the isolates (59/75) harbored at least a FQ-R determinant. qnr genes were predominant (40%, 30/75). The MLST study revealed that E. cloacae isolates’ clonality was wide (24 different STs). The more widespread STs were ST74, ST101, ST110, ST114 and ST133. Carbapenem MICs were higher for E. cloacae ST74 than for other E. cloacae isolates. PMQR determinants were more often observed in E. cloacae ST74 isolates. These findings showed that (i) pOXA-48a is spreading in North-Eastern France, (ii) qnr is preponderant in E. cloacae, (iii) E. cloacae comprised a large amount of lineages spreading in North-Eastern France and (iv) FQ as an alternative to β-lactams to treat ertapenem non-susceptible Enterobacteriaceae are compromised

Selection of IgG variants with increased FcRn binding using random and directed mutagenesis: impact on effector functions

Despite the reasonably long half-life of IgGs, market pressure for higher patient convenience while conserving efficacy continues to drive IgG half-life improvement. IgG half-life is dependent on the neonatal Fc receptor FcRn, which amongst other functions, protects IgG from catabolism. FcRn binds the Fc domain of IgG at an acidic pH ensuring that endocytosed IgG will not be degraded in lysosomal compartments and will then be released into the bloodstream. Consistent with this mechanism of action, several Fc engineered IgG with increased FcRn affinity and conserved pH-dependency were designed and resulted in longer half-life in vivo in human FcRn transgenic mice (hFcRn), cynomolgus monkeys and recently in healthy humans. These IgG variants were usually obtained by in silico approaches or directed mutagenesis in the FcRn binding site. Using random mutagenesis, combined with a pH-dependent phage display selection process, we isolated IgG variants with improved FcRn-binding which exhibited longer in vivo half-life in hFcRn mice. Interestingly, many mutations enhancing Fc/FcRn interaction were located at a distance from the FcRn binding site validating our random molecular approach. Directed mutagenesis was then applied to generate new variants to further characterize our IgG variants and the effect of the mutations selected. Since these mutations are distributed over the whole Fc sequence, binding to other Fc effectors, such as complement C1q and FcgRs, was dramatically modified, even by mutations distant from these effectors’ binding sites. Hence, we obtained numerous IgG variants with increased FcRn binding and different binding patterns to other Fc effectors, including variants without any effector function, providing distinct fit-for-purpose Fc molecules. We therefore provide evidence that half-life and effector functions should be optimized simultaneously as mutations can have unexpected effects on all Fc receptors that are critical for IgG therapeutic efficacy

How CAGE, RAPS4-QF, and AUDIT Can Help Practitioners for Patients Admitted with Acute Alcohol Intoxication in Emergency Departments?

International audienceAims: To help clinicians to identify the severity of alcohol use disorders (AUDs) from optimal thresholds found for recommended scales. Especially, taking account of the high prevalence of alcohol dependence among patients admitted to the emergency department (ED) for acute alcohol intoxication (AAI), we propose to define thresholds of severity of dependence based on the AUDIT score.Methods: All patients admitted to the ED with AAI (blood alcohol level >0.8 g/L), in a 2-month period, were assessed using the CAGE, RAPS-QF, and AUDIT, with the alcohol dependence/abuse section of the mini international neuropsychiatric interview (MINI) used as the gold standard. To explore the relation between the AUDIT and the MINI the sum of the positive items on the MINI (dependence) as a quantitative variable and as an ordinal parameter were analyzed. From the threshold score found for each scale we proposed intervals of severity of AUDs.Results: The mean age of the sample (122 males, 42 females) was 46 years. Approximately 12% of the patients were identified with alcohol abuse and 78% with dependence (DSM-IV). Cut points were determined for the AUDIT in order to distinguish mild and moderate dependence from severe dependence. A strategy of intervention based on levels of severity of AUD was proposed.Conclusion: Different thresholds proposed for the CAGE, RAPS4-QF, and AUDIT could be used to guide the choice of intervention for a patient: brief intervention, brief negotiation interviewing, or longer more intensive motivational intervention