Étude des réactions des professionnels de santé prenant en charge des patients COVID non vaccinés par choix

Introduction

La pandémie à SARS-Cov2 évolue depuis début 2020. La vaccination est accessible depuis début 2021 aux patients fragiles puis a été généralisée à toute la population. Elle a montré son efficacité sur l'hospitalisation, le passage en réanimation et la mortalité. Nous avons voulu étudier les réactions des professionnels de santé prenant en charge des patients non vaccinés présentant une COVID.

Matériels et méthodes

Un questionnaire a été élaboré par un groupe de soignant du service prenant en charge les patients COVID de façon continue depuis 2 ans. Il a été distribué de façon large à tout le personnel médical et paramédical du secteur d'hospitalisation (un seul service). La participation était libre et anonyme.

Résultats

Parmi les 76 participants, 62 (82%) étaient des femmes. Il y avait 33 médecins (dont 10 internes), 20 infirmiers, 11 aides-soignants, 8 étudiants en médecine, 2 psychologues, 1 diététicienne et 1 assistante sociale. L'âge médian [IQR] était de 32 ans [26-44] et le nombre d'années de pratique médian de 5 ans [2-11]. 53 participants (70%) travaillaient en secteur COVID régulièrement depuis 2 ans (les autres de façon ponctuelle).

Concernant la COVID, 51 participants (67%) ont été infectés, dont 11 (19%) avec séquelles, et 60 participants sur 75 (80%) ont eu peur de transmettre le COVID à leur entourage du fait de leur activité professionnelle.

Soixante et un participants sur 74 (82%) se déclaraient pour la vaccination SARS-CoV-2 en général, 48 sur 75 (64%) pour l'obligation vaccinale des personnels soignants, 41 sur 75 (55%) pour le pass vaccinal dans la population générale et 36 sur 75 (48%) pour la vaccination des enfants. Trente et un participants sur 76 (41%) étaient en faveur d'une obligation vaccinale de l'ensemble de la population adulte, 45 sur 74 (61%) pour une obligation uniquement de la population à risque. L'obligation vaccinale des personnels soignants remportait l'adhésion de 88% des médecins (29/33) et de 27% des aides-soignants et infirmiers (8/30).

Lors de la prise en charge de patients non vaccinés, 55/73 participants (75%) ont eu l'occasion de parler avec eux de la non-vaccination et 46/75 (63%) déclaraient avoir essayé de les convaincre de se faire vacciner après l'épisode aigu. Le libre arbitre est souvent cité par les participants comme raison de ne pas avoir essayé de convaincre les patients.

L'agacement et l'incompréhension ont été souvent rapportés lors de la prise en charge d'un patient non vacciné en particulier si à risque mais 79% des participants (59/75) considéraient que ces patients devaient bénéficier de la même prise en charge que les autres (15% ne se prononçaient pas). Pour 31% (33/75) des participants, les patients devraient payer une partie des soins et pour 51% (38/75), la prise en charge des soins de ces patients était plus complexe.

Conclusion

La prise en charge des patients COVID non vaccinés par choix peut être source d'agacement par le personnel soignant épuisé par 2 ans de pandémie. Néanmoins la majorité des personnels considèrent que ces patients doivent bénéficier des mêmes soins que les autres et ce bien que leur prise en charge soit souvent plus complexe.

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La supervision, un élément central pour la sécurisation de la prise en charge des patients infectés par le SARS-CoV-2

Introduction

Notre hôpital a pris en charge dès janvier 2020 des patients infectés par le SARS-CoV-2 et organisé une prise en charge (PEC) des cas possibles en ambulatoire. Nous rapportons ici l’organisation paramédicale, centrée sur le principe de la supervision.

Matériels et méthodes

Trois patients ont été hospitalisés en maladies infectieuses (SMIT) et 1 en réanimation médicale. Un patient du SMIT a été secondairement transféré en réanimation. Au SMIT les patients sont dans l’unité de risque épidémique et biologique (REB) dans des chambres à pression négative avec sas et, en réanimation dans une partie cloisonnée, avec pression négative ou traitement d’air mobile. La supervision a été développée en 2014 avec les alertes Ebola, elle consiste à former les cadres des 3 services concernés (EOH, SMIT, réanimation) pour : anticiper l’arrivée des cas, vérifier l’habillage et le déshabillage, suivre la PEC et les examens biologiques, veiller à l’organisation logistique, transport des patients…Les alertes Ebola puis MERS-CoV, avec une vingtaine de patients admis par an, ont permis d’améliorer la supervision. L’ensemble des services de 1^re ligne (SMIT, SAU et réanimation) est régulièrement formé aux mesures de prévention. Des exercices avec le SMIT, la réanimation et le SAMU ont été organisés pour tester les circuits et les procédures.

Résultats

En situation de crise, un superviseur est mobilisable 24 h/24. Il accompagne les équipes dans la PEC des patients, de l’accueil à la sortie ou décès. Il s’assure du bon fonctionnement des circuits logistiques, de la mise à disposition du matériel et de la gestion des stocks. Il coordonne et accompagne la réalisation des examens hors du service (5 scanners pour le SARS-CoV-2) en collaboration avec les services de brancardage et de sécurité. Il encadre les visites auprès des patients infectés. Il participe aussi à l’information des services de 2^e ligne. Cette organisation est très rassurante pour les équipes soignantes, le superviseur servant de « tour de contrôle » du dispositif, et assurant la liaison opérationnelle entre tous les partenaires. Comme pour les autres acteurs impliqués dans cette épidémie, se pose la question de la pérennité de cette organisation en situation de crise prolongée, compte tenu de la charge technique et psychologique qu’il supporte.

Conclusion

Les organisations de PEC des patients REB sont variables d’un établissement à l’autre. La supervision, menée par un cadre qui maîtrise les procédures REB, semble être de nature à assurer la sécurité et la coordination entre tous les partenaires pour une prise en charge optimale des patients et la protection des personnels.

An Innovative Day Hospital Dedicated to Nursing Home Resident: A Descriptive Study of 1306 Residents Referred by their Physicians

BACKGROUND

The transfer rate of residents from nursing homes (NH) to emergency rooms is high. These transfers are often inappropriate but also potentially avoidable. Recent studies have shown that in terms of methods for training NH teams, proposals for improvement of the healthcare sector must be organized. Given this observation, Gérontopôle de Toulouse (France) opened in October 2015, a responsive day hospital dedicated to NH residents (DH NH). This day hospital is characterized by its vocation, exclusively dedicated to NH residents and its ability to provide patient care within a short period of time.

OBJECTIVES

The purpose of this day hospital is twofold: (1) decrease the rate of inappropriate transfers for NH residents by offering general practitioners and NH teams quick access to expert advice, blood tests and radiological examinations during hospitalizations and care adapted to the characteristics of NH residents; (2) potentially reduce avoidable transfers to emergency rooms and hospitalizations by taking action to prevent acute decompensation in residents, but also for the education and training of NH healthcare teams. This manuscript aims to describe the arrangements put in place and the characteristics of the residents collected after two years of activity.

DESIGN

Retrospective descriptive study.

SETTING

Gérontopôle of Toulouse, France.

PARTICIPANTS

1306 residents have been consulted at the DH NH.

MEASUREMENTS

Referring physicians (treating physicians, coordinating physician or emergency room physicians) send a standardized hospitalization request form to the day hospital by fax or email indicating the reason for the request, specialist opinion(s) desired and additional required examination(s). A gerontological assessment was conducted and anamnesis data was collected for each resident, on the very day of their coming to the DH NH.

RESULTS

In 2 years, 1306 residents from 120 NHs were sent to the DH NH. The mean age was 86.23 ± 7.05 years and the majority of patients were women (n=941, 72.22%), dependent (median ADL at 2.75, [1.25-4.5]) and malnourished (821, 63.25%). In the 3 months prior to their visit to the day hospital, 668 (57.14%) residents had been hospitalized, and one-quarter (n=336, 25.72%) had been transferred to emergency rooms. The main reasons for hospitalization included assessment of cognitive disorders (n=336, 17.52%), assistance in managing behavioral disorders (n=297, 15.48%) and bedsores and slow wound healing (n=223, 11.63%).

CONCLUSION

Our experience over a 2-year period suggests that the DH NH could be a practical response to the problem of inappropriate and avoidable transfers of NH residents to emergency rooms. This innovation could easily be utilized in other hospitals.

[PRRT2 mutation and infantile convulsions]

New genetic techniques have made it possible to better understand the implications of the PRRT2 gene (proline rich transmembrane protein 2) in various neurological disorders. Mutations within this gene are responsible for kinesigenic paroxysmal dyskinesias (PKD) as well as for benign familial infantile epilepsy (BFIE), a disease associating infantile convulsions and choreoathetosis (ICCA), a form of familial hemiplegic migraine (FHM type 4), paroxysmal benign torticollis of childhood, and episodic ataxia. We describe the case of an infant, carrying a mutation of the PRRT2 gene, with a classical presentation. Through her progression over time, we raise the question of systematic use of anti-epileptic drugs.

Patient satisfaction with psychotropic drugs: Validation of the PAtient SAtisfaction with Psychotropic (PASAP) scale in patients with bipolar disorder

PURPOSE

The PAtient SAtisfaction with Psychotropic (PASAP) scale is a self-completed questionnaire measuring satisfaction with psychotropic medication. The aim of the study was to describe its development in French and its psychometric properties.

MATERIALS AND METHODS

Scale construction was based on an extensive search of the literature. The item reduction process required semi-structured interviews of psychiatric outpatients (n=30). The final version of the PASAP is a 9-item, 5-point Likert-type scale, covering the scope of effectiveness and adherence. To assess the psychometric properties of the scale, French patients with an acute manic episode (n=314) from a large European observational cohort completed the PASAP scale 3 months after psychotropic treatment initiation/change. Internal validity and reliability were assessed using principal component analysis (PCA). Concurrent validity was assessed using comparisons to physician-rated satisfaction with life, illness severity, mood relapse, compliance and side effects.

RESULTS

Participation rate was 68.4%. PCA was in favour of uni-dimensionality. Cronbach's α coefficient was 0.85 (95%CI 0.83-0.88). All five concurrent measures were significantly associated with the PASAP score.

CONCLUSION

The PASAP scale showed good psychometric properties in a large bipolar population and thus seems adequate for evaluating treatment satisfaction. Its short length and good acceptability makes it suitable for clinical research.

Decreased intracellular GABA levels contribute to spinal cord stimulation-induced analgesia in rats suffering from painful peripheral neuropathy: the role of KCC2 and GABA(A) receptor-mediated inhibition

Elevated spinal extracellular γ-aminobutyric acid (GABA) levels have been described during spinal cord stimulation (SCS)-induced analgesia in experimental chronic peripheral neuropathy. Interestingly, these increased GABA levels strongly exceeded the time frame of SCS-induced analgesia. In line with the former, pharmacologically-enhanced extracellular GABA levels by GABA(B) receptor agonists in combination with SCS in non-responders to SCS solely could convert these non-responders into responders. However, similar treatment with GABA(A) receptor agonists and SCS is known to be less efficient. Since K⁺ Cl⁻ cotransporter 2 (KCC2) functionality strongly determines proper GABA(A) receptor-mediated inhibition, both decreased numbers of GABA(A) receptors as well as reduced KCC2 protein expression might play a pivotal role in this loss of GABA(A) receptor-mediated inhibition in non-responders. Here, we explored the mechanisms underlying both changes in extracellular GABA levels and impaired GABA(A) receptor-mediated inhibition after 30 min of SCS in rats suffering from partial sciatic nerve ligation (PSNL). Immediately after cessation of SCS, a decreased spinal intracellular dorsal horn GABA-immunoreactivity was observed in responders when compared to non-responders or sham SCS rats. One hour later however, GABA-immunoreactivity was already increased to similar levels as those observed in non-responder or sham SCS rats. These changes did not coincide with alterations in the number of GABA-immunoreactive cells. C-Fos/GABA double-fluorescence clearly confirmed a SCS-induced activation of GABA-immunoreactive cells in responders immediately after SCS. Differences in spinal dorsal horn GABA(A) receptor-immunoreactivity and KCC2 protein levels were absent between all SCS groups. However, KCC2 protein levels were significantly decreased compared to sham PSNL animals. In conclusion, reduced intracellular GABA levels are only present during the time frame of SCS in responders and strongly point to a SCS-mediated on/off GABAergic release mechanism. Furthermore, a KCC2-dependent impaired GABA(A) receptor-mediated inhibition seems to be present both in responders and non-responders to SCS due to similar KCC2 and GABA(A) receptor levels.

Descriptive study of nursing home residents from the REHPA network

INTRODUCTION

To date, very little research has been carried out in nursing homes and it is difficult to make recommendations for quality of care that are based on actual data. The Réseau de Recherche en Etablissement d'Hébergement pour Personnes Agées (REHPA) is a functional network established in collaboration between the geriatric department of Toulouse University Hospital and 240 nursing homes with the aim of compensating for the lack of evidence-based recommendations and of enhancing research.

MATERIALS AND METHODS

A cross-sectional observational study was conducted between January and March 2008. The number of residents included (randomly selected by birth date) depended on the total number of residents of the facility. Demography, medical and drug history, disabilities and care practices were assessed by geriatrician.

RESULTS

We report the findings in 4896 residents of 240 nursing homes. Residents were 73.9% women, mean age 85.7 +/- 8.8 years, mean weight 61.9 +/- 14.8 kg, with a mean ADL score of 2.8 +/- 2.1. Dementia was diagnosed in 43.5% (of whom only 50.9% were treated), 19.6% showed aggressive behaviours, 10.8% exhibited disruptive vocalization and 10.9% were wanderers, 27.4% were treated with antipsychotic medications, 54.4% had hypertension, 8.7% had diabetes, 14.8% were osteoporotic, 4.1% had fallen during the previous week, 37.9% were in pain and 19.8% had lost weight. The mean Charlson index score was 1.6 +/- 1.4. Finally, 13.5% had been admitted to hospital within the previous three months.

CONCLUSION

The survey identifies specific issues in order to target future research in the nursing home setting.

Assessment of use of microsatellite polymorphism analysis for improving spatial distribution tracking of echinococcus multilocularis

Alveolar echinococcosis (AE)--caused by the cestode Echinococcus multilocularis--is a severe zoonotic disease found in temperate and arctic regions of the northern hemisphere. Even though the transmission patterns observed in different geographical areas are heterogeneous, the nuclear and mitochondrial targets usually used for the genotyping of E. multilocularis have shown only a marked genetic homogeneity in this species. We used microsatellite sequences, because of their high typing resolution, to explore the genetic diversity of E. multilocularis. Four microsatellite targets (EmsJ, EmsK, and EmsB, which were designed in our laboratory, and NAK1, selected from the literature) were tested on a panel of 76 E. multilocularis samples (larval and adult stages) obtained from Alaska, Canada, Europe, and Asia. Genetic diversity for each target was assessed by size polymorphism analysis. With the EmsJ and EmsK targets, two alleles were found for each locus, yielding two and three genotypes, respectively, discriminating European isolates from the other groups. With NAK1, five alleles were found, yielding seven genotypes, including those specific to Tibetan and Alaskan isolates. The EmsB target, a tandem repeated multilocus microsatellite, found 17 alleles showing a complex pattern. Hierarchical clustering analyses were performed with the EmsB findings, and 29 genotypes were identified. Due to its higher genetic polymorphism, EmsB exhibited a higher discriminatory power than the other targets. The complex EmsB pattern was able to discriminate isolates on a regional and sectoral level, while avoiding overdistinction. EmsB will be used to assess the putative emergence of E. multilocularis in Europe.

HER-2 expression is a prognostic factor in patients with metastatic breast cancer treated with a combination of high-dose cyclophosphamide, mitoxantrone, paclitaxel and autologous blood stem cell support

The expression levels of a circulating extracellular domain of HER-2 can be detected in the plasma and serum of patients with metastatic breast cancer using an enzyme immunoassay (ELISA) method. In this study, we evaluated the clinical significance of high and low levels of HER-2 in the plasma of 46 patients with metastatic breast cancer enrolled in a clinical trial of high-dose chemotherapy (HDCT) using cyclophosphamide, mitoxantrone, and paclitaxel with autologous stem cell transplantation (ASCT). Using 2500 U/ml as the cut-point, 20 patients (46%) had elevated HER-2 levels (HER-2 positive). Our results suggest that patients with metastatic breast cancer and high soluble plasma HER-2 have a significantly poorer overall (OS) and progression-free survival (PFS) following high-dose chemotherapy with paclitaxel and ASCT. The median OS of patients with low levels of HER-2 was significantly longer (P < 0.01) than the median OS of patients with high levels of HER-2 (29.8 months vs 15.9 months). PFS was also significantly longer (P < 0.01) for patients who were HER-2-negative, than for patients who were HER-2-positive (13.0 vs 8.6 months). Univariate analysis showed that patients with liver or lung metastases had significantly reduced OS and PFS. Patients with metastases to two or more sites also had a significantly reduced time to disease progression, but not OS. In multivariable analysis, lung metastases contributed along with HER-2-positive status to determine a group of patients with significantly poorer OS. However, HER-2-positive status remained the only independent predictor of PFS.

Detecting hydrogen bonding by NMR relaxation of the acceptor nuclei

The formation of hydrogen bonds (HB) between phenol or N-methyltrifluoroacetamide and several acceptors (pyridine, carbonyl compounds, nitriles, amides) in CCl4 or CHCl3 been investigated through the analysis of NMR relaxation times (T1) of the heteronuclei (14N and 17O) directly involved in the HB interaction. Thus, a comparison is made between such T1 values (corrected for changes in molecular dynamics and motional anisotropy) and electric field gradients calculated by ab initio methods for the acceptor molecules, both isolated and in 1:1 or 2:1 hydrogen-bonded complexes. When other effects are properly accounted for, there is a good agreement between theoretical and experimental electric field gradient (efg) changes. The noticeable difference found between CCl4 or CHCl3 as solvents is discussed in relation to the presence of phenol oligomers, and the non-negligible HB donor power of CHCl3.

Consensus Conference on the Treatment of Aplastic Anemia

This article presents guidelines for the diagnosis and treatment of aplastic anemia (AA) established by a consensus panel of investigators from various countries. The panel used the scientific evidence presented during the Consensus Conference forum and found in the scientific literature to prepare guidelines categorized as immunosuppressive therapy, unrelated bone marrow transplantation in patients with AA, and myelodysplasia/acute myeloid leukemia after immunosuppressive therapy.

Physical and chemical properties of human type III procollagen

Type III procollagen was isolated from the serum-free culture media of human foreskin fibroblasts by adsorption to controlled-pore glass beads and chromatography of the eluted procollagen pool on diethylaminoethylcellulose [Gerard, S., & Mitchell, W. M. (1979) Anal. Biochem. 96, 433-447]. Sodium dodecyl sulfate (NaDodSO4) electrophoresis in 1% agarose-2% acrylamide gels with or without prior sample reduction revealed the predominance of a band with retarded mobility as compared to human procollagen I [hupro(I)]. Digestion of hupro(III) with pepsin yielded a product whose electrophoretic mobility was retarded for both the intact trimer and its reduced monomeric subunit as compared to that for the respective bands of rat skin (type I) collagen. NaDodSO4-polyacrylamide gel electrophoresis of bacterial collagenase-digested hupro(III) demonstrated disulfide-bonded propeptides which upon reduction were replaced by two distinct monomeric propeptide bands. The amino acid composition of hupro(III) was similar to that of hupro(I) but contained increased amounts of HO-Pro and Cys and less Thr, Ala, Val, and Arg. Sedimentation equilibrium analysis in 1 M CaCl2 yielded at extrapolated zero concentration a Mr of 505 +/- 25K. A [hupro(III) - collagen(III)] circular dichroic difference spectrum suggests approximately 10% alpha helix. The zero-order mutarotation rate of hupro(III) (vo = 55.0 X 10(-5) s-1) was twice that of hucol(III) (vo = 25.4 X 10(-5) s-1) at 20 degrees C, which may reflect the influence of the interchain disulfide-bonded carboxyl propeptides on the process of collagen fold formation.