Evaluation des outils d'aide au maintien de l'INR en zone cible et perspectives d'amélioration de la sécurité des patients sous AVK d'après l'observatoire OPTIPLEX sur l'usage de concentré de complexes prothrombiniques au cours des accidents hémorragiques graves sous AVK

Les antivitamine K constituent encore le traitement anticoagulant de référence par voie orale en France. Leur importante iatrogénie, s'illustre au travers de l'étude observationnelle multicentrique OPTIPLEX qui s'est intéressée à 686 patients d'âge moyen 77,8 ans, ayant bénéficié de concentré de complexes prothrombiniques au cours d'un accident hémorragique sous AVK. Au sein de cette population, les syndromes hémorragiques étaient essentiellement représentés par les hémorragies intracrâniennes (43,73 %) et les hémorragies digestives aigues (24,34 %). La valeur initiale de l'INR était connue chez 87 % des patients, elle était supérieure à 3 chez plus de 68 % des patients. Au terme du suivi, le taux de mortalité s'élève à plus de 25 %, atteignant même 35,5 % au sein du sous-groupe hémorragie intracrânienne (n = 300). Les résultats de cette étude permettent de dégager certains facteurs de risque d'accident hémorragique parmi lesquels : l'âge (plus de 75 ans), l'existence de comorbidités et le surdosage en AVK. Au regard de leur marge thérapeutique étroite, et ainsi que le montre l'ensemble des études, le plus sûr moyen d'éviter les accidents iatrogènes repose sur le maintien durable de l'INR en zone cible. Afin d'y parvenir, plusieurs outils sont utilisés et leur intérêt a été évalué au cours d'essais cliniques. Parmi ceux-ci, nous citerons : l'éducation thérapeutique, l'usage du carnet de suivi, d'appareils d'automesure, de logiciels médicaux d'aide à la gestion de l'INR, les cliniques des anticoagulants. Nous évoquerons quelques propositions de "bon usage des AVK", s'adressant à l'ensemble des professionnels de santé impliqués. Nous exposerons le projet régional aquitain : FAREMBOL de réduction du risque thromboembolique chez les patients de plus de 75 ans en fibrillation auriculaire. Enfin, nous proposerons une présentation et une évaluation des nouveaux anticoagulants oraux dans l'optique d'une éventuelle alternative aux AVK.BORDEAUX2-BU Santé (330632101) / SudocSudocFranceF

Traitement ambulatoire de l'embolie pulmonaire (mythe ou réalité?)

L'embolie pulmonaire est une maladie potentiellement grave, qui n'a pas encore de traitement ambulatoire validé. Notre but, était d'étudier l'utilité du score Pulmonary Embolism Severity Index (PESI) comme un outil possible pour sélectionner des patients atteints d'une embolie pulmonaire afin qu'ils bénéficient d'un traitement ambulatoire. Nous avons comparé, à trois mois, l'utilisation de ce score avec le jugement intuitif des soignants pour traiter les patients en ambulatoire ou non. Parmi les données du registre Registro Informatizado de la Enfermedad TromboEmbolica venosa (RIETE), entre mars 2001 et fevrier 2008, 6727 patients avec une embolie pulmonaire (avec ou sans thrombophlébite) ont été enregistrés de manière consécutive. 85 (1,26 %) ont été traités à domicile et les autres ont été hospitalisés. L'application du score PESI souligne une augmentation graduelle des complications avec le niveau de la classe : 8 % de complications dont 3,3 % de décès dans les classes à faible risque et 25,77 % dont 19,66 % de décès dans les classes à haut risque. Ainsi, 30 à 40 % des patients avec une EP pourraient être traités, sans risque, à domicile.BORDEAUX2-BU Santé (330632101) / SudocSudocFranceF

Carbon footprint of general practice: Retrospective case study of GP offices in a rural department of France

Context: The medical sector has a significant impact on greenhouse gas emissions which, in turn, impacts global health. In the context of the climate emergency, measures should be adopted to reduce greenhouse gas emissions from the health care sector. So far, few regulations have been implemented for general practice facilities, despite the fact that the potential impact of general practice is large, due to the size of this sector. This study seeks to establish the carbon footprint of general practices in a rural French department, and to identify the main vectors of CO2 emissions. Materials and Methods: Three general practitioners’ offices located in Lot-et-Garonne agreed to participate in this study. This retrospective study extrapolated the carbon footprint of the practices during 2020 using the ADEME BEGES method and Life Cycle Assessment. We collected data and accounting reports directly from practices regarding different potential CO2 emission sources (electricity, water, transport, waste, digital activities, stationery, and medical equipment). Results: Medical practices emitted an average of 39.8t of CO2 equivalent in 2020, i.e. 1.5 kg of CO2eq per consultation. Transportation was the main vector of emissions with 95 % of the total (83 % via patient transportation and 12 % via physician transportation), followed by medical equipment (3 %), electricity consumption (1.1 %), office supplies (0.7 %), digital activities (0.1 %), then water and waste (both, < 0.1 %). Conclusion: General Practice generates a significant amount of CO2 and, therefore, requires specific actions to be implemented to reduce its impact on the environment

Admissions des sujets âgés aux Services d'Accueil des Urgences pour effets indésirables médicamenteux

Objectif. Étudier les caractéristiques des effets indésirables médicamenteux (EIM) ayant motivé l'entrée des sujets âgés dans des Services d'Accueil des Urgences (SAU) français. Méthodes. Les données de deux études prospectives menées en 1999 et 2003 selon un protocole identique ont été regroupées. La part des EIM dans les motifs d'admission, leur gravité et leur degré d'évitabilité ont été évalués chez les patients $\geq$ 70 ans (groupe A) et comparés à ceux observés chez des patients < 70 ans (groupe B). Résultats. Sur les 2907 patients inclus, 1158 (39,8 %) avaient $\geq$ 70 ans. Dans ce groupe, l'incidence des EIM atteignait 17,1 % vs. 13,2 % dans le groupe B (p = 0,004). Les EIM apparaissaient plus sévères dans le groupe A que dans le groupe B. La proportion d'EIM évitables ne différait pas significativement entre le groupe A (48,9 %) et le groupe B (43,7 %). Conclusion. Les EIM sont une cause fréquente – souvent évitable – d'admission aux SAU, en particulier dans la population âgée

Interpretation of idarucizumab clinical trial data based on spontaneous reports of dabigatran adverse effects in the French pharmacovigilance database

International audienc

Comparison of the Wells score and the revised Geneva score as a tool to predict pulmonary embolism in outpatients over age 65.

INTRODUCTION: The incidence and mortality of pulmonary embolism (PE) is high in the elderly. The Wells score (SW) and the revised Geneva score (RGS) have been validated in patient populations with a large age range. The aim of this study was to compare the predictive accuracy of these two scores in diagnosis of PE in patients over 65 years of age. METHOD: A prospective multicentre study (nine French and three Belgian centres) was conducted at the same time as the PERCEPIC study. A total of 1757 patients admitted with suspected PE were included and divided into two groups according to age (≥65 years or <65 years). The pre-test probability of PE was assessed prospectively for the RGS. The SW was calculated retrospectively. The predictive accuracy of the two scores was compared by the area under the curve (AUC) of the ROC curves. RESULTS: The overall prevalence of PE was 11.3%. The prevalence among patients aged ≥65 in the low, moderate and high pre-test probability groups, evaluated using the WS and was respectively 13.5% (CI 95%: CI 9.9-17.3), 28.2% (CI 22.1-34.3), 50% (CI 26-74) and 8.1% (CI 3.2-12.9), 22.3% (CI 18.2-26.3), 43.7% (CI 25.6-61.9) using the RGS. The AUC for the WS and RGS for patients aged ≥65 was 0.632 (CI 0.574-0.691) and 0.610 (CI 0.555-0.666). The difference between the AUCs was not statistically significant (p = .441). CONCLUSION: In the population for this study, the WS and RGS have the same PE diagnostic accuracy in patients over age 65. This result should be validated in a prospective study that directly compares these scores

Major ischaemic and bleeding risks following current drug-eluting stent implantation: Are there differences across current drug-eluting stent types in real life?

International audienceBackground. - Current drug-eluting stents (c-DESs) reduce the occurrence of ischaemic events, but expose recipients to stent thrombosis and bleeding secondary to preventive antiplatelet therapy. To date, comparative data on the relative effectiveness and safety of the various c-DESs in real life are limited. Aim. - To compare ischaemic and bleeding risks across the major c-DESs used in France. Methods. - French national health insurance reimbursement and hospitalization databases were used. Patients implanted with a c-DES in 2014 were followed for 1 year. The risks of ischaemic events (revascularization, myocardial infarction and/or stroke), major bleeding events and death were compared across six c-DESs (XIENCE (R), PROMUS (R), RESOLUTE (R), BIOMATRIX (R), NOBORI (R) and ORSIRO (R)), using multilevel Cox models adjusted for baseline individual and hospital characteristics. Results. - A total of 52,891 subjects were included: 34.4% with XIENCE (R); 27.6% with PROMUS (R); 24.0% with RESOLUTE (R); 8.0% with BIOMATRIX (R); 5.0% with NOBORI (R); and 1.0% with ORSIRO (R). Among them, 9378 had at least one event (ischaemic, 6064; major bleeding, 1968; death, 2411), resulting in an overall incidence rate of 19 per 100 person-years. In the multivariable analysis, the risk of ischaemic events, major bleeding events or death did not differ between the c-DESs overall (adjusted hazard ratios between 0.85 [95% confidence interval 0.68-1.07] and 1.04 [95% confidence interval 0.98-1.10] compared with XIENCE (R) used as the reference) and when each outcome was considered separately. Conclusions. - In real life, major ischaemic and bleeding risks do not differ across the various cDESs over the first year following implantation. Future studies are needed to assess comparative c-DES effectiveness and safety longer term. (C) 2019 Elsevier Masson SAS. All rights reserved

Pulmonary embolism rule-out criteria (PERC) rule in European patients with low implicit clinical probability (PERCEPIC): a multicentre, prospective, observational study

International audienc

Risk for Recurrent Venous Thromboembolism in Patients With Subsegmental Pulmonary Embolism Managed Without Anticoagulation : A Multicenter Prospective Cohort Study

Background: The incidence of pulmonary embolism has been increasing, but its case-fatality rate is decreasing, suggesting a lesser severity of illness. The clinical importance of patients with pulmonary embolism isolated to the subsegmental vessels is unknown. Objective: To determine the rate of recurrent venous thromboembolism in patients with subsegmental pulmonary embolism managed without anticoagulation. Design: Multicenter prospective cohort study. (ClinicalTrials.gov: NCT01455818). Setting: Eighteen sites between February 2011 and February 2021. Patients: Patients with isolated subsegmental pulmonary embolism. Intervention: At diagnosis, patients underwent bilateral lower-extremity venous ultrasonography, which was repeated 1 week later if results were negative. Patients without deep venous thrombosis did not receive anticoagulant therapy. Measurements: The primary outcome was recurrent venous thromboembolism during the 90-day follow-up period. Results: Recruitment was stopped prematurely because the predefined stopping rule was met after 292 of a projected 300 patients were enrolled. Of the 266 patients included in the primary analysis, the primary outcome occurred in 8 patients, for a cumulative incidence of 3.1% (95% CI, 1.6% to 6.1%) over the 90-day follow-up. The incidence of recurrent venous thromboembolism was 2.1% (CI, 0.8% to 5.5%) and 5.7% (CI, 2.2% to 14.4%) over the 90-day follow-up in patients with single and multiple isolated subsegmental pulmonary embolism, respectively. No patients had a fatal recurrent pulmonary embolism. Limitation: The study was restricted to patients with low-risk subsegmental pulmonary embolism. Conclusion: Overall, patients with subsegmental pulmonary embolism who did not have proximal deep venous thrombosis had a higher-than-expected rate of recurrent venous thromboembolism.</p

Sotrovimab to Prevent Severe COVID-19 in High-Risk Patients Infected with Omicron BA.2

International audienceBefore the Omicron era, the neutralizing antibody targeting the SARS-CoV2 Spike protein Sotrovimab has been shown to reduce the risk of COVID-19-related hospitalization in patients who are at high risk for progression (1, 2). We recently showed that early administration of Sotrovimab in Omicron-infected patients with very high-risk for progression was associated with a low rate of COVID-19-related hospitalization within one month after treatment administration (3%), and with no death (1). However, the dominance of the Omicron sublineage BA.2 led health agencies to suspend Sotrovimab emergency use authorizations because of its lower neutralizing ability in vitro compared to BA.1 sublineage (3, 4). Clinical efficiency of Sotrovimab to prevent COVID-19 related complications in high-risk patients with mild-to-moderate COVID-19 Omicron BA.2 remains unknown. Our aim was to compare the clinical and virological outcomes of Omicron BA.1 and BA.2-infected patients with mild-to-moderate COVID-19 who received 500 mg of Sotrovimab IV to prevent COVID-19-related complications