A propos des céphalées et de la migraine (quelles actions développer en pharmacie d'officine ?)

LYON1-BU Santé (693882101) / SudocRENNES1-BU Santé (352382103) / SudocSudocFranceF

Accidents vasculaires cérébraux en hôpital général (évaluation de la prise en charge locale et relations avec l'hôpital de référence)

RENNES1-BU Santé (352382103) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Sténose carotidienne du sujet âgé et très âgé (enquête sur les attitudes chirurgicales)

RENNES1-BU Hôpital Sud (352382126) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Prise en charge des urgences de fin de vie en EHPAD : quelles pistes d’amélioration ?

International audiencePrès d’un quart des résidents d’établissement pour personnes âgées dépendantes (EHPAD) décèdent à l’hôpital, certains étant identifiés en situation de fin de vie en amont du transfert hospitalier. Certaines de ces hospitalisations seraient évitables. Le projet PUFPAE (Prise en charge des urgences de fin de vie chez les personnes âgées en EHPAD) visait à décrire les situations de fin de vie dans un échantillon d’EHPAD bretons et à identifier les éléments pratiques et organisationnels conditionnant la prise en charge d’une aggravation de l’état de santé de ces résidents au sein de l’EHPAD ou un éventuel recours à l’hôpital. L’objectif de cette dernière phase du projet était d’identifier des actions d’amélioration concernant la prise en charge des « urgences de fin de vie » en EHPAD et d’en évaluer la faisabilité dans les territoires de santé bretons. Les principaux axes d’améioration identifiés concernaient la connaissance par les professionnels d’EHPAD et les médecins libéraux des structures extérieures participant à la prise en charge des résidents en fin de vie, la formation des professionnels de santé en soins palliatifs, la diffusion des fiches SAMU-Pallia et la mise en oeuvre d’astreintes infirmières mutualisées nuits et week-ends. Ces résultats fourniront aux acteurs locaux des politiques de soins palliatifs, en s’appuyant sur le Plan national pour le développement des soins palliatifs et l’accompagnement en fin de vie 2015-2018 et les récentes recommandations de l’ANESM, des éléments d’orientation sur les mesures prioritaires à mettre en oeuvre afin d’améliorer les pratiques en soins palliatifs en région Bretagne

Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care: a meta-analysis of individual patient data

Background: General anaesthesia (GA) during endovascular thrombectomy has been associated with worse patient outcomes in observational studies compared with patients treated without GA. We assessed functional outcome in ischaemic stroke patients with large vessel anterior circulation occlusion undergoing endovascular thrombectomy under GA, versus thrombectomy not under GA (with or without sedation) versus standard care (ie, no thrombectomy), stratified by the use of GA versus standard care. Methods: For this meta-analysis, patient-level data were pooled from all patients included in randomised trials in PuMed published between Jan 1, 2010, and May 31, 2017, that compared endovascular thrombectomy predominantly done with stent retrievers with standard care in anterior circulation ischaemic stroke patients (HERMES Collaboration). The primary outcome was functional outcome assessed by ordinal analysis of the modified Rankin scale (mRS) at 90 days in the GA and non-GA subgroups of patients treated with endovascular therapy versus those patients treated with standard care, adjusted for baseline prognostic variables. To account for between-trial variance we used mixed-effects modelling with a random effect for trials incorporated in all models. Bias was assessed using the Cochrane method. The meta-analysis was prospectively designed, but not registered. Findings: Seven trials were identified by our search; of 1764 patients included in these trials, 871 were allocated to endovascular thrombectomy and 893 were assigned standard care. After exclusion of 74 patients (72 did not undergo the procedure and two had missing data on anaesthetic strategy), 236 (30%) of 797 patients who had endovascular procedures were treated under GA. At baseline, patients receiving GA were younger and had a shorter delay between stroke onset and randomisation but they had similar pre-treatment clinical severity compared with patients who did not have GA. Endovascular thrombectomy improved functional outcome at 3 months both in patients who had GA (adjusted common odds ratio (cOR) 1·52, 95% CI 1·09–2·11, p=0·014) and in those who did not have GA (adjusted cOR 2·33, 95% CI 1·75–3·10, p<0·0001) versus standard care. However, outcomes were significantly better for patients who did not receive GA versus those who received GA (covariate-adjusted cOR 1·53, 95% CI 1·14–2·04, p=0·0044). The risk of bias and variability between studies was assessed to be low. Interpretation: Worse outcomes after endovascular thrombectomy were associated with GA, after adjustment for baseline prognostic variables. These data support avoidance of GA whenever possible. The procedure did, however, remain effective versus standard care in patients treated under GA, indicating that treatment should not be withheld in those who require anaesthesia for medical reasons