Approvisionnement en médicaments du service d hospitalisation à domicile du CHU de Grenoble (évaluation du double système ville - hôpital)

Dans un contexte de contrainte économique, et devant le fréquent désir des patients de rester le plus longtemps possible dans un environnement familier, l hospitalisation à domicile représente une alternative à l hospitalisation traditionnelle. Dans cet esprit, le nombre de places en HAD augmente continuellement depuis plusieurs années. Mais l organisation relativement ancienne de ces structures n est pas toujours adaptée à une telle demande, notamment en ce qui concerne l approvisionnement en médicaments. Actuellement, la gestion des médicaments du service d HAD de Grenoble repose sur une répartition entre un approvisionnement en ville et un approvisionnement hospitalier, qui pose un certain nombre de problèmes. En particulier, les équipes soignantes du service ont de plus en plus de mal à gérer les ordonnances au domicile des patients ; les préparateurs de la pharmacie de l hôpital sont de plus en plus sollicités pour des ordonnances urgentes ou non valides. Ainsi, il apparaît nécessaire de faire évoluer ce fonctionnement. Pour cela, nous avons envisagé deux hypothèses : soit une délivrance essentiellement hospitalière, soit une délivrance essentiellement officinale. L objectif de notre travail était d étudier les trois aspects de la délivrance dans ces différentes situations : la sécurité du patient, l aspect économique, et les conditions de travail du personnel impliqué. En terme de méthodologie, nous avons rassemblé pendant une période de neuf semaines toutes les délivrances concernant les patients du service. D après ces données, témoins du volume de médicaments consommés, nous avons estimé le budget mensuel de l HAD pour son approvisionnement pharmaceutique. Nous avons relevé les erreurs de délivrance, certaines pouvant remettre en cause la sécurité du patient. Enfin, nous avons interrogé le personnel concerné par ce fonctionnement, c'est-à-dire les soignants et les préparateurs, afin de recueillir leurs points de vue. Les résultats principaux sont les suivants. La majorité des médicaments étant disponible à l hôpital comme à l officine (92%), les deux hypothèses sont envisageables. Nous avons relevé 33 erreurs de délivrance pendant cette période de neuf semaines; une seule a eu une conséquence notable chez un patient car elle concernait le dosage d'un médicament à marge thérapeutique étroite. Sur le plan économique, un passage à une délivrance essentiellement officinale augmenterait le coût mensuel pour la collectivité de près de 6 700 euros (52%) par rapport à la situation actuelle. En revanche, une délivrance essentiellement hospitalière permettrait d économiser un peu plus de 400 euros par mois (soit 3,3%). Enfin, les conditions de travail dans le système actuel ne satisfont ni les préparateurs, ni les soignants. La nomination d un préparateur référent pour l HAD semble être une solution appropriée pour améliorer cette organisation. Cette étude montre que finalement l hypothèse qui respecte le mieux la sécurité du patient, le souci financier, et les conditions de travail du personnel concerné, semble être celle d une délivrance essentiellement hospitalière. Il s agirait donc de créer un poste de préparateur au sein même du service d HAD. Sa connaissance du dossier patient et des traitements habituels sécuriserait la délivrance. Grâce au contact quotidien avec les soignants, il serait informé de l évolution des patients. Cette proximité permettrait alors une délivrance de qualité, au plus près des besoins. C est donc cette solution qui nous semble la plus adaptée pour faire face à l augmentation prévue du nombre de places en HAD.GRENOBLE1-BU Médecine pharm. (385162101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Distribution of pectic epitopes in cell walls of the sugar beet root

International audienc

New data and phylogenetic placement of the enigmatic old world lupin: Lupinus mariae-josephi H. Pascual.

International audienceLupinus mariae-josephi H. Pascual is an intriguing lupin species recently discovered in the Mediterranean region. New data from seed coat micromorphology, cytology, and DNA sequences were generated in order to extend our knowledge on this species and to examine its evolutionary relationships within Lupinus. This species shows morphological similarities with the Mediterranean smooth seeded species of sections Micranthi and Lutei. It shares the same chromosome number 2n = 52 with the latter Old World taxa, but also with unifoliolate lupins from Florida. Besides, L. mariae-josephi exhibited a seed coat micromorphology ''intermediate'' between the rough and the smooth seed coat types. Phylogenetic analyses using ITS and ETS nrDNA spacers, and the LEGCYC1A locus supported L. mariae-josephi as a distinct Old World line, placed out of the Scabrispermae, but without clear placement amongst the Mediterranean smooth-seeded lineages. Unexpectedly, LEGCYC1A data revealed phylogenetic affinities between L. mariae-josephi and L. villosus, a unifoliolate North American lupin that might have experienced a reticulated evolutionary process. All together, the data underline the phylogenetic interest of L. mariae-josephi in Lupinus and the need of additional investigations in order to definitely elucidate its enigmatic status. Moreover, as L. mariaejosephi is one of the rare Old World lupins strictly restricted to poor basic soils, it opens new perspectives of ecological and agronomic interests in the wide areas of poor calcareous soils in the Mediterranean region

Can Biomarkers Correctly Predict Ventilator-associated Pneumonia in Patients Treated With Targeted Temperature Management After Cardiac Arrest? An Exploratory Study of the Multicenter Randomized Antibiotic (ANTHARTIC) Study

IMPORTANCE:. Ventilator-associated pneumonia (VAP) frequently occurs in patients with cardiac arrest. Diagnosis of VAP after cardiac arrest remains challenging, while the use of current biomarkers such as C-reactive protein (CRP) or procalcitonin (PCT) is debated. OBJECTIVES:. To evaluate biomarkers’ impact in helping VAP diagnosis after cardiac arrest. DESIGN, SETTING, AND PARTICIPANTS:. This is a prospective ancillary study of the randomized, multicenter, double-blind placebo-controlled ANtibiotherapy during Therapeutic HypothermiA to pRevenT Infectious Complications (ANTHARTIC) trial evaluating the impact of antibiotic prophylaxis to prevent VAP in out-of-hospital patients with cardiac arrest secondary to shockable rhythm and treated with therapeutic hypothermia. An adjudication committee blindly evaluated VAP according to predefined clinical, radiologic, and microbiological criteria. All patients with available biomarker(s), sample(s), and consent approval were included. MAIN OUTCOMES AND MEASURES:. The main endpoint was to evaluate the ability of biomarkers to correctly diagnose and predict VAP within 48 hours after sampling. The secondary endpoint was to study the combination of two biomarkers in discriminating VAP. Blood samples were collected at baseline on day 3. Routine and exploratory panel of inflammatory biomarkers measurements were blindly performed. Analyses were adjusted on the randomization group. RESULTS:. Among 161 patients of the ANTHARTIC trial with available biological sample(s), patients with VAP (n = 33) had higher body mass index and Acute Physiology and Chronic Health Evaluation II score, more unwitnessed cardiac arrest, more catecholamines, and experienced more prolonged therapeutic hypothermia duration than patients without VAP (n = 121). In univariate analyses, biomarkers significantly associated with VAP and showing an area under the curve (AUC) greater than 0.70 were CRP (AUC = 0.76), interleukin (IL) 17A and 17C (IL17C) (0.74), macrophage colony-stimulating factor 1 (0.73), PCT (0.72), and vascular endothelial growth factor A (VEGF-A) (0.71). Multivariate analysis combining novel biomarkers revealed several pairs with p value of less than 0.001 and odds ratio greater than 1: VEGF-A + IL12 subunit beta (IL12B), Fms-related tyrosine kinase 3 ligands (Flt3L) + C–C chemokine 20 (CCL20), Flt3L + IL17A, Flt3L + IL6, STAM-binding protein (STAMBP) + CCL20, STAMBP + IL6, CCL20 + 4EBP1, CCL20 + caspase-8 (CASP8), IL6 + 4EBP1, and IL6 + CASP8. Best AUCs were observed for CRP + IL6 (0.79), CRP + CCL20 (0.78), CRP + IL17A, and CRP + IL17C. CONCLUSIONS AND RELEVANCE:. Our exploratory study shows that specific biomarkers, especially CRP combined with IL6, could help to better diagnose or predict early VAP occurrence in cardiac arrest patients

Women and health professionals’ perspectives on a conditional cash transfer programme to improve pregnancy follow-up: a qualitative analysis of the NAITRE randomised controlled study

Objectives Women of low socioeconomic status have been described as having suboptimal prenatal care, which in turn has been associated with poor pregnancy outcomes. Many types of conditional cash transfer (CCT) programmes have been developed, including programmes to improve prenatal care or smoking cessation during pregnancy, and their effects demonstrated. However, ethical critiques have included paternalism and lack of informed choice. Our objective was to determine if women and healthcare professionals (HPs) shared these concerns.Design Prospective qualitative research.Setting We included economically disadvantaged women, as defined by health insurance data, who participated in the French NAITRE randomised trial assessing a CCT programme during prenatal follow-up to improve pregnancy outcomes. The HP worked in some maternities participating in this trial.Participants 26 women, 14 who received CCT and 12 who did not, mostly unemployed (20/26), and - 7 HPs.Interventions We conducted a multicentre cross-sectional qualitative study among women and HPs who participated in the NAITRE Study to assess their views on CCT. The women were interviewed after childbirth.Results Women did not perceive CCT negatively. They did not mention feeling stigmatised. They described CCT as a significant source of aid for women with limited financial resources. HP described the CCT in less positive terms, for example, expressing concern about discussing cash transfer at their first medical consultation with women. Though they emphasised ethical concerns about the basis of the trial, they recognised the importance of evaluating CCT.Conclusions In France, a high-income country where prenatal follow-up is free, HPs were concerned that the CCT programme would change their relationship with patients and wondered if it was the best use of funding. However, women who received a cash incentive said they did not feel stigmatised and indicated that these payments helped them prepare for their baby’s birth.Trial registration number NCT0240285