[Therapeutic adherence among asthma patients: Variations according to age groups. How can it be improved? The potential contributions of new technologies]

While asthma patients' treatment adherence (TA) generally leaves to be desired, few data exist on TA evolution from age group to another. During the meeting of a working group of pneumo-pediatricians and adult pulmonologists, we reviewed the literature on adherence according to age group, examined explanations for poor adherence, and explored ways of improving adherence via new technologies. Asthma is a chronic disease for which TA is particularly low, especially during adolescence, but also among adults. Inhaled medications are the least effectively taken. Several explanations have been put forward: cost and complexity of treatments, difficulties using inhalation devices, poor understanding of their benefits, erroneous beliefs and underestimation of the severity of a fluctuating disease, fear of side effects, neglect, and denial (especially among teenagers). Poor TA is associated with risks of needless treatment escalation, aggravated asthma with frequent exacerbations, increased school absenteeism, degraded quality of life, and excessive mortality. Better compliance is based on satisfactory relationships between caregivers and asthmatics, improved caregiver training, and more efficient transmission to patients of relevant information. The recent evolution of innovative digital technologies opens the way for enhanced communication, via networks and dedicated applications, and thanks to connected inhalation devices, forgetfulness can be limited. Clinical research will also help to ameliorate TA. Lastly, it bears mentioning that analysis of the existing literature is hampered by differences in terms of working definitions and means of TA measurement.

[Ramadan fasting during treatment with external beam radiotherapy]

INTRODUCTION

Many Muslim cancer patients insist on fasting during the month of Ramadan, even during treatment. The purpose of this observational study is to study the practice of fasting, in patients receiving external radiation therapy.

METHODS

Our study was conducted during the month of Ramadan 1441 (2018) in the radiotherapy department of Ibn Rochd University Hospital of Casablanca. We included all patients who received external radiotherapy during this period. We thus collected the characteristics of patients, disease and treatment modalities. After an interview, with a pre-established questionnaire, we were able to establish the observance of the fast.

RESULTS

We collected a total of 209 patients. The most frequently represented locations were breast cancer followed by gynecological cancers in 35.4% and 18.7% respectively. All our patients were fasting Ramadan before the diagnosis of cancer, however, only 39.2% were fasting during the treatment by radiotherapy, and just 40% of patients have discussed the possibility of fasting with their oncologist. In multivariate analysis, the stage of the disease was the only factor related to the fasting status of our patients.

DISCUSSION

Even under treatment, many of our patients fast during the month of Ramadan. Further studies are needed to evaluate the tolerance of fasting in order to better answer the question "can I fast?".

[Effects of Covid-19 Pandemic on the Vaccine Activities on a Reference Immunization Center in Treichville, Côte D'ivoire]

Introduction

Depuis le 11 mars 2020, la Côte d'Ivoire est touchée par l'épidémie de coronavirus, déclarée ce même jour comme pandémie par l'OMS. Au 11 mars 2021, soit un an après la pandémie, la Côte d'Ivoire a notifié 36824 cas de patients atteints de Covid-19 et parmi eux 211 sont décédés. Au 31 mai 2020, la Côte d'Ivoire avait déjà notifié 2833 cas et 33 décès. À cette période, de fausses rumeurs circulaient en Afrique sur la mise en place d'essais cliniques sur des candidats vaccins. L'impact de ces rumeurs sur l'utilisation globale des services de santé devait être mesuré et notamment sur les centres de vaccination.

Objectifs

L'objectif de cette étude était de déterminer les effets de la pandémie sur les activités des services de vaccination de l'Institut national d'hygiène publique. L'étude était basée sur les rapports d'activité de son centre de vaccination de Treichville à Abidjan, composé de quatre services: Centre des vaccinations internationales, Service de vaccination des collectivités, Centre antirabique, Unité de vaccination du Programme élargi de vaccination.

Résultats

Au Centre des vaccinations internationales, les activités ont chuté d'environ 50% en mars, de 86% en avril et de 82% en mai par rapport à 2018 et 2019. Pour les vaccinations communautaires, les activités ont diminué d'environ 26% en mars et de 99% en avril et mai. Au Centre de lutte contre la rage, ces diminutions sont estimées à 38% en avril et à 45% en mai. Les réductions les plus importantes concernent les vaccinations contre la fièvre jaune et les méningites.

Conclusion

La baisse de la fréquentation des services de vaccination pourrait augmenter le risque de survenue d'épidémies notamment de fièvre jaune qui sont déjà récurrentes à Abidjan. Des mesures de sensibilisation et de rattrapage vaccinal devraient être entreprises et d'autres études devraient être menées pour déterminer l'impact de la pandémie sur les activités de vaccination.

Therapeutic alliance is associated to treatment adherence in children with juvenile idiopathic arthritis

OBJECTIVES

Therapeutic alliance (TA) is the agreement between caregiver and patient during the care process. Therapeutic adherence is a major issue for the management of Juvenile Idiopathic Arthritis (JIA) requiring child's strong ability to follow treatments. The aim of this study was to evaluate the relationship between TA and adherence in patients with JIA.

METHODS

Observational, cross-sectional, multicenter study. Children, with JIA, aged 8-16, were included. Children, parents and physicians completed the Helping Alliance Questionnaire (HAQ-CP) for assessing TA. Adherence was measured using the Child/Parent Adherence Report Questionnaire (CARQ & PARQ). Demographic data, disease characteristics, current treatments and social environment were collected. The univariate relationship between TA and adherence, was studied by Pearson correlation coefficient. The multivariate analysis used a multiple linear regression model.

RESULTS

A total of 119 patients were included: 68.9% girls, mean age (SD) 12.4 (2.9) years, disease duration 73.1 (48.2) months. JIA was in remission (52%), in low activity (32%) and active (16%). TA scores were high (≥80/100) for children, parents and physicians. HAQCP was highly correlated with CARQ (r=0.31; P<0.001) PARQ (r=0.37; P<0.001). In univariate analysis, disease activity (P<0.05), place of residence (P<0.01) and family status (P<0.01) were associated with child's TA. In multivariate analysis, only the place of residence (P<0.001) and the family status (P<0.05) remained associated with TA.

CONCLUSION

TA strongly influences therapeutic adherence and therefore may be important for treatment effectiveness.

[Monocentric study on pharmaceuticals taken by patients to treat systemic sclerosis]

INTRODUCTION

Pharmaceutical prescription in systemic sclerosis is guided by national and international recommendations. This study's primary objective was to describe and analyze these prescriptions among patients of our cohort. We also aimed to assess drug compliance among our patients.

METHODS

This is a monocentric observational study on two cohorts of patients with systemic sclerosis; a primary cohort comprising ambulatory patients, who were prospectively included, with exhaustive prescription's data collection; and a secondary cohort included patients asked to fill in a self-questionnaire on treatment compliance.

RESULTS

The main cohort included 157 patients, including 31 cases of diffuse systemic sclerosis. A vasodilator drug for Raynaud's phenomenon was prescribed in 75 patients (47.9%) and a specific treatment for pulmonary arterial hypertension in 10 patients (6.4%). Immuno-modulators/immunosuppressants was prescribed in 62 patients (39.5%), who received prednisone (n=37, 23.6%), mycophenolate mofetil (n=14, 8.9%), hydroxychloroquine (n=12, 7.6%) and colchicine (n=22, 14%). Treatment for "gastro-intestinal tract involvement" was prescribed for 106 patients (67.5%) and treatment of a scleroderma renal crisis with an angiotensin-converting enzyme inhibitor for 6 patients (3.8%). Among the 42 patients in the secondary cohort, 21.4% reported a good compliance, mostly older patients (P=0.045) or those who had not experienced adverse events (P=0.009).

CONCLUSION

This study provides original real-life data illustrating the heterogeneity of prescription habits in systemic sclerosis. As previously reported, treatment compliance was insufficient.

[Obesity hypoventilation syndrome and initial compliance with non-invasive ventilation]

INTRODUCTION

The obesity hypoventilation syndrome (OHS) has an increasing prevalence. Compliance with first-line non-invasive ventilation has not been evaluated, taking into account patients' initial comorbidities. This study consisted of identification of the factors associated with compliance with non-invasive ventilation during the first six months of use.

METHODS

A monocentric retrospective study, gathering patients from the pneumology department of Gabriel-Montpied hospital in Clermont-Ferrand, from April 2010 to October 2019. The analysis was carried-out through the collection of computerised medical records (age, mode of entry, patient comorbidities) and compliance reports (average daily hours of use) provided by the regional service provider for the Auvergne area (AIRRA).

RESULTS

Being hospitalized for an acute exacerbation and being older than seventy-five years were factors associated with an improved compliance to non-invasive ventilation, with an increase of 1.47h/d and 2.73h/d (P value: 0.018 and 0.02, respectively). Moreover, patients with obstructive sleep apnea hypopnea syndrome and recipients of therapeutic education may prove more compliant over time.

CONCLUSION

Age greater than seventy-five years and being hospitalized for an acute exacerbation are predictors of better use of non-invasive ventilation in OHS.

[Evaluation of the Follow-Up and State of Adolescents with Sickle-Cell Disease in Brazzaville (Congo)]

The experience of the adolescent with homozygous sickle-cell disease is influenced by several factors that differentiate it from the older child entirely dependent on his parents. The objective of this study was to describe the state of health and to assess the quality of follow-up and to identify the determinants of poor monitoring of adolescent sickle-cell followed in Brazzaville for an average of 12 ± 9.6 years, starting from a cross-sectional study carried out at the Brazzaville University Hospital from March to September 2016. It is based on a questionnaire composed of elements of assessment of the state of health and the quality of the follow-up. The vaccination coverage of adolescents was low, 81.3% for DTCP, 66.5% for Typhim Vi, 50.2% for viral hepatitis B, 76.4% for pneumococcus, and 59.1% for the ROR. In the last two years prior to the survey, 99 (48.7%) adolescents had only 2 follow-up visits instead of 4 planned per year. Therapeutic compliance was good in 132 (65%). No hospitalizations were reported during this period in 23 adolescents (11.3%); in 180 cases (88.7%), however, adolescents were hospitalized one to three times apart from regular follow-up visits. Since the discovery of the disease, 177 (87.2%) adolescents had already been transfused, more than three times in 89 cases. A history of neurovascular seizures was found in 10 cases (5.2%) and priapism in 35 cases (18.2%). Paraclinical examinations were not systematic during follow-up visits. The socioeconomic level of the family and the level of education of the father had a negative impact on monitoring and adherence (P < 0.01). On clinical examinations, stunting, undernutrition, pubertal delay, tooth decay, enuresis were found in 45.3%, 36%, 53.7%, 27.6%, 15.3%, respectively. The biological examinations carried out during the investigation showed an average inter-critical hemoglobin level between 7 and 8 g/dl, creatinine level was normal in all cases, ferritinemia was elevated in 93.6%, a negative proteinuria was found in 71.4% of the cases, and hematuria in 26.6%. Systematic abdominal ultrasound revealed vesicular lithiasis in 8 cases, hepatomegaly in 10 cases, and splenomegaly in 102 cases. Echocardiography performed in all subjects showed cardiomyopathy in 9 cases. The follow-up of the adolescent sickle-cell in Brazzaville still faces enormous difficulties. The improvement of the standard of living, the therapeutic education and the introduction of a total free of charge of the global management of sickle-cell disease would make it possible to minimize these difficulties which also would improve the future of these teenagers, adults of tomorrow.

[Assessment for antihypertensive drug intake: How, where and when?]

AIM

Hypertension is a public health problem managed according to therapeutic strategies published in France by the Hauteautoritéde santé (HAS - French Health Authorities). For patients with resistant hypertension, related or not to a non-adherence, prescribers need to be sure the exposure is high enough to achieve the tensional target. Quantitative analysis of antihypertensive drugs in different biological matrices (blood/urine) is one possible solution. However, this involves determining the concentrations observed at standard doses and knowing how to interpret the measured concentrations. It is also necessary to identify medical laboratories that can assay antihypertensive drugs. This was the aim of our work.

METHODS

The main antihypertensive drugs recommended by the HAS have been listed. For each of them, we looked for published steady-state plasma/serum concentrations and quantities excreted in the urine at usual dosages. In addition, the elimination half-life and linear pharmacokinetic profile were specified for each antihypertensive agent measured in plasma/serum. Pharmacology-Toxicology laboratories in France likely to carry out assays were identified. The time taken to report the result and the cost of the analysis were also specified.

RESULTS

All of the afore-mentioned information has been collected and presented in a table. This can then be used to compare the plasma/serum concentration or the quantity measured in a patient's urine with the values reported in the literature. In cases where the blood sampling times differ between those of the patient and the published data, the patient's measured value is compared to the estimated value based on the published concentrations and pharmacokinetics.

CONCLUSION

Interpretation of the plasma/serum/urinary value measured or estimated for an antihypertensive drug is a particularly interesting approach to determine if drug exposure is enough and a possible non-adherence. However, this activity is mostly carried out in hospital centres.

[Results and compliance of transcutaneous tibial nerve stimulation on overactive bladder syndrome in patients with Parkinson's disease. Retrospective Study.]

PURPOSE

To investigate efficiency and tolerance of transcutaneous tibial nerve stimulation (TNS) in the overactive bladder syndrome in patients with Parkinson's disease (PD), and to identify predictive factors for compliance.

METHODS

We conducted a retrospective monocentric study with a cohort of 17 patients with PD who have used TNS for an overactive bladder syndrome. The efficiency of the treatment was evaluated on the clinical improvement felt (rated out of ten). Patients were classified as « adopters » if they continued using TNS for at least one year after beginning the treatment or as « non adopters » if they stopped. Patients characteristics were evaluated for their predictive value for compliance with TNS.

RESULTS

Out of 17 patients, there were 9 women and 8 men, median age 66 years (55-77), median history for Parkinson's disease 8 years (1-22) and for urinary symptoms 3 years (1-10). Subjective efficiency was seen in 10 patients (59%), on nocturia and/or urinary incontinence for 9 patients (mean efficiency 5.75/10 and median efficiency 6.5/10). Three patients found TNS not effective, and four patients didn't use it long enough to evaluate. Two patients had side effects and stopped the TNS (feeling of electricity and restless leg syndrome). 7 patients were classified as « adopters » and 10 patients as « non adopters » after one year. Most evaluated characteristics proved not to be of predictive value for compliance with TNS except nocturia and pollakiuria (P=0.03 and P=0.05).

CONCLUSION

Our study seems to reveal TNS is particularly effective on nocturia and urge. Moreover, nocturia and pollakiuria appear to be predictive factors for SNT compliance. Nocturia could be a prominent symptom in SNT's prescription. But studies with more patients should be conducted for obtain better patient selection in TNS.

LEVEL OF EVIDENCE

IV.

Factors of loss to follow-up during tuberculosis treatment in a low-incidence region

OBJECTIVE

The proportion of successfully treated tuberculosis (TB) patients remains below the WHO target in France, because of a high proportion of loss to follow-up. We aimed to identify factors associated with loss to follow-up in northern France, a low-incidence area.

METHODS

Between 1997 and 2017, all consecutive patients diagnosed with TB at the Tourcoing Hospital, except those infected with multidrug-resistant or extensively drug-resistant strains, were included in a retrospective cohort study. A logistic regression analysis was performed to determine factors associated with loss to follow-up.

RESULTS

One hundred and ninety patients were included. Previous TB treatment was reported in 32 patients (17%), extrapulmonary TB in 107 (56%), and HIV infection in 44 (23%). The proportion of loss to follow-up was 15%. In multivariate analysis, the risk of loss to follow-up decreased in case of first TB treatment (OR 0.36; 95% CI: 0.14-0.92, P=0.03) and increased in non-HIV-infected patients (OR 7.67; 95% CI: 1.00-59.0, p=0.05). Support for compliance was more frequent in HIV-infected patients (23% vs. 7%, p=0.005).

CONCLUSION

The proportion of loss to follow-up was high. HIV infection was associated with a lower risk of loss to follow-up, likely to be due to more frequent support for compliance.

[Use of the EvalObs® adherence scale in an unselected French population of treated subjects with antihypertensive, hypolipemiants or oral antidiabetics medications: The FLAHS 2017 adherence survey]

OBJECTIVE

A Visual Analog Scale (VAS) is useful for diagnosing medication nonadherence and its validity has been evaluated using electronic pillbox as the gold standard. We have developed the EvaLobs^® scale for use on paper or on smartphone and the aim of the study was to administrate the scale among FLAHS 2017 participants treated for an hypertension, a dyslipidemia or diabetes. In subjects treated with antihypertensive medications, participants completed the 6-item Girerd Scale and EvaLobs^®.

METHODS

The French League Against Hypertension Survey (FLAHS) are carried out by self-questionnaire sent by mail to individuals from the French Kantar Health sampling frame (representative panel of the population living in metropolitan France). In 2017, FLAHS was conducted in 4783 subjects aged 35 and over. The EvaLobs^® has a scale from 0 to 15 and the use instruction is "how many days have you taken the drug in the past 15 days". A score>12 indicates a "good compliance". The 6-item Girerd scale was also completed. "Good adherence" was determined for a score of 0 to 2 and "nonadherence" for a score of 3 or more. The agreement between EvaLobs^® and the 6-item Girerd scale was evaluated in treated hypertensives.

RESULTS

The survey included 4783 subjects with 1308 treated hypertensives, 942 subjects treated with lipid-lowering drugs and 405 subjects treated with anti-diabetics. EVALOBS^® indicates "Good adherence" in 96% of subjects and the 6 questions questionnaire indicates "good adherence" in 95% of subjects. An excellent agreement is noted in 93.8%. An EvaLobs^® score indicating nonadherence or an absence of response to EvaLobs^® is observed in 3.6% [CI 95, 2.5-4.7] of hypertensives, in 6.0% [CI 95, 3.9-8.1] of diabetics and in 8.2% [CI 95, 6.5-9.9] of dyslipidemic patients.

CONCLUSION

In the population living in France and in unselected patients treated for metabolic disease or hypertension, non-adherence is lowest for antihypertensive medications and highest for statins. EvaLobs^®, which shows good agreement with an adherence questionnaire, is a quick and simple tool for assessing adherence. The smartphone app EvaLobs^® is available for free on Google play and the Apple store.

Indexed plasma drug concentrations for drug adherence screening in hypertensive patients

AIM

Due to its high sensitivity, qualitative plasma drug screening by liquid chromatography/tandem mass spectrometry may not be able to distinguish same-day drug intake from drug use on preceding days and cause misclassifications of drug adherence in hypertensive patients. Analysis of plasma drug concentrations may provide more accurate results.

PATIENTS AND METHODS

We describe dose-dependent indexing of plasma drug concentrations for expected peak concentrations to define individual screening thresholds for same-day drug use. To explore its utility, plasma samples from 9 hypertensive patients without major comorbidity were prospectively analyzed on two occasions. All were on hydrochlorothiazide with either amlodipine (n=7) and/or valsartan (n=6) at different doses. Drugs were quantitated by mass spectrometry. Non-adherence was defined if an indexed drug concentration was below the expected trough level at 24-hour dosing interval.

RESULTS

All patients were adherent by qualitative plasma screening (spectrometric sensitivity). On the first visit (random sampling time), mean plasma concentrations of the drugs were 102±70, 15.4±6.7 and 2529±1608ng/mL, and mean indexes 84±57%, 85±35% and 60±38%, respectively. Using the study criterion, non-adherence was suspected in three. Intraindividual cross-checking retained two. On the second visit (fixed sampling time), amlodipine concentration was 15.6±8.5ng/mL (88±52% after indexing). Two patients were non-adherent according to the study criterion.

CONCLUSION

Indexing of plasma drug concentrations appears practicable and useful for drug adherence screening under clinical conditions. With this technique, same-day drug intake can be easily distinguished which reduces the risk of false positive results associated with qualitative drug screening.

[Persistent asthma: Chronic therapy quantitative compliance in daily practice]

INTRODUCTION

The aim of the study was to assess, compliance with maintenance treatment in patients with persistent asthma in clinical practice.

METHODS

This observational, cross-sectional, prospective, multicenter study was conducted in metropolitan France on patients with persistent asthma under the care of a representative sample of general practitioners and pneumologists. Compliance was determined via access to the Health Insurance database allowing comparison between the actual consumption of medications and the corresponding theoretical consumption related to prescription. Additional compliance data were obtained using the validated Morisky questionnaire.

RESULTS

Eighty one physicians included 488 patients, mean age of 51 years, 55% women. The statement of consumption (SC) was available for 35% of patients however the Morisky questionnaire (present for 85% of patients) showed a similar compliance between patients with or without SC. The good compliance rate (compliance ≥80%) was observed in 51% based on the SC and in 38% based on the Morisky questionnaire. Among possible predictive factors, only obesity was associated with a bad compliance (19% vs 7%, P<0.05). Patients with poor compliances displayed more severe symptoms and a higher rate of non-control (21.7% vs 5.7%, P<0.01).

CONCLUSIONS

The statement of consumption is a useful tool to provide quantitative measurement of compliance in daily practice.

[Asthma: Adapting the therapeutic follow-up according to the medical and psychosocial profiles]

INTRODUCTION

This work is based on the data of REALISE™, a survey conducted among 8000 European patients to identify the profiles of adult asthma patients and how these are linked with treatment adherence behaviors.

METHODS

A cluster analysis was performed by combining data in three ways: control of asthma, attitude towards the disease, compliance with treatment. A multidisciplinary group analyzed the results for the 1024 French survey respondents.

RESULTS

Four patient profiles were identified: "rather confident" (28% of patients), rather young patients with a low level of concern about their asthma. "Rather committed" (23%) patients considering themselves to be mostly healthy, reporting better therapeutic declared. "Rather questing" (26%), patients poorly controlled, seeking to manage their asthma themselves. "Rather concerned" profile (23%), a bit older, with poor clinical control, considering their asthma to be severe.

CONCLUSIONS

Cluster analysis provides a multidimensional approach to understand the therapeutic behavior of the different patient profiles better and so adjust communication by and education of healthcare professionals.

Use of telemedicine in the management of infectious diseases

Communication technologies have invaded our daily lives. Several studies have assessed these technologies in the management of infectious diseases (mainly HIV). Weekly short text messages and real-time compliance monitoring assessed in HIV patients are both associated with higher compliance in low-income countries. Virtual consultations to monitor stable chronic HIV patients or tuberculosis treatment in high-income countries appear to be acceptable and efficient. Although assessed in small studies, virtual monitoring seems to reinforce the doctor-patient relationship and the relation between primary care settings and hospitals in various infectious diseases (endocarditis, urinary tract infection, skin and soft tissue infection, HIV, tuberculosis, hepatitis C). A better prevention of infectious diseases (mainly sexually transmitted infections) seems to be observed with telemedicine tools. As fees for teleconsultation or telemonitoring have yet to be defined, the development and evaluation (cost effectiveness) of these tools are difficult. The regulatory framework will need to be improved to encourage such developments, all the while ensuring the confidentiality of data. The development of new tools will require the collaboration of physicians, users, and healthcare systems.

[Adherence to treatment with continuous positive airways pressure]

INTRODUCTION

Continuous positive airways pressure (CPAP) is the standard treatment for obstructive sleep apnea syndrome (OSAS). It produces substantial benefits if used for the appropriate indication and if patients adhere to treatment.

METHODS

We conducted a prospective study of 103 patients treated with CPAP over four years follow-up.

RESULTS

Our population had a mean age of 52 years with a sex ratio of 0.63. Face to face, individual education was provided in all cases. CPAP titration was performed by an unattended domiciliary autoadjusted CPAP device in 83.5% of patients for 15 days to one month. Twenty patients refused CPAP treatment after the period of titration. Eighty two patients (98.8%) were treated by constant CPAP. Seventy five percent of the patients complained of at least one side effect. The more common were nasal (56.6%) and mask related problems (40%). Seventy six percent of patients used CPAP for more than 4hours per day. Eleven patients stopped CPAP therapy because of intolerance (10 cases) and reluctance to instrumental therapy (one case). Adherence to CPAP therapy was associated with the severity of OSAS, the level of daytime sleepiness, higher pressures, repeated education during the course of follow up, clinical efficacy and the presence of fewer side-effects.

CONCLUSIONS

We obtained satisfactory rates of adherence and tolerance of CPAP assisted by regular medical and technical follow-up of patients.

[Cohort of patients initiated to home ventilation. Observational and prospective study]

Cohort of patients initiated to home ventilation. Observational and prospective study. The effectiveness of home noninvasive ventilation (NIV) for chronic respiratory failure (CRF) is well established. However, few data are available about home NIV prescription and utilization according to the different etiologies of respiratory failure. The ANTADIR Federation, in partnership with the Ventilatory Support Group of the French Speaking Pulmonary Society, has set up a national, observational and multicenter cohort study. The main goal of this study is to analyze the clinical data justifying home NIV prescription in patients with chronic respiratory insufficiency. The secondary objectives will be to assess: the evolution of comorbidities or their occurrence, hospitalizations, NIV compliance, dropout and survival. The population includes patients with chronic respiratory failure newly initiated onto NIV, both in a stable state and following an acute exacerbation who qualify for long-term NIV. Data collected include: diagnosis and comorbidities, age, sex, BMI, biomarkers (hematocrit, arterial blood gases, total CO₂) and functional data (FEV1, VC, TLC), nocturnal results (SaO₂, PtcCO₂), type of ventilator used, ventilator parameters and mask type. Follow-up data will be collected at 4 months, 1 year and 2 years and will include: hospitalizations, changes in prescription, adherence, dropouts and deaths. This work will make it possible to obtain new scientific information on long-term NIV use in France.

[Compliance with treatment in Wilson's disease: On the interest of a multidisciplinary closer follow-up]

BACKGROUND

Compliance with treatment is very important for patients who suffer from Wilson's disease, a rare genetic disorder. They can benefit a long-life and effective treatment. The purpose of our study is to identify the level of compliance in Wilson's disease patients and features associated with compliance as well.

METHODS

This is a prospective study carried out in the National Reference Center for Wilson Disease (based in Paris and Lyon) over a 8 months period. Patients were evaluated on the first (M0) and last month (M8) with a questionnaire evaluating the number of missed treatment doses, a self-questionnaire collecting the reasons for non-compliance, and analogic scales analyzing the doctor-patient relationship and their behavior towards the treatment. The severity of depression symptoms was investigated by the Beck Depression Inventory (BDI). A detailed phone call interview was conducted by a psychologist every two months to evaluate their compliance and feeling.

RESULTS

Thirty-nine patients were included. The mean age of patients was 34 years (±9.9). At M0, 84.6% had a poor compliance with treatment. They were diagnosed more recently (P=0.049) with a higher proportion involving neurological disorders (P=0.007). Age, the type of treatment and the quality of the doctor-patient relationship were not associated with the outcome; 38.5% suffered from depressive symptoms. At M8, 56.8% of patients were poor compliants and 21.6% presented depressive symptoms.

CONCLUSION

Wilsons's disease patients have important problems with compliance, without necessary being depressed. A close follow-up may help them become compliant, particularly those with neurological symptoms.

[Usefulness of patient education in antihypertensive treatment compliance in black Africans]

AIM OF THE STUDY

To evaluate the compliance for antihypertensive treatment and to assess the effects of patient education as tool to improve the compliance in hypertensive patients.

METHODS

We include prospectively all hypertensive patients followed in consultation in the cardiology department of the national police hospital in Ivory Coast. Compliance evaluation was made with the Girerd scale. After evaluation, all the patients benefit from an individual and/or collective education sessions. All the patients were followed and reevaluated after 1 year.

RESULTS

We included consecutive 1000 hypertensive patients (mean age 40±20 years, 80 % male). Among these, 50 % have been treated by a single therapy, 30 % by a fixed double therapy and 25 % by a fixed triple combined therapy. At the start of the study, a low compliance is observed in 60 % of patients, 25 % have minimal problems of observance and 15 % are compliant. In 70 %, the low compliance may be explained by misconceptions and is associated with a persistent hypertension. One year after the education program, the compliance is improved: non-compliant patients represent 5 % of the population, 10 % having slight problems on compliance and 85 % have a good compliance.

CONCLUSION

In hypertension, the therapeutic compliance is poor, and associated with various factors. However, patient education improves the therapeutic compliance and this should be systematically proposed in antihypertensive management in Africa.

[A "fast track" to improve management of neovascular age related macular degeneration]

OBJECTIVE

To evaluate the role of a fast track for management of patients with neovascular age- related macular degeneration (nARMD) treated by intravitreal injection of anti-VEGF.

PATIENTS

The records of 100 patients in the chronic maintenance phase of intravitreal anti-VEGF followed in the fast track and 63 patients followed in the standard protocol for at least 12 months were retrospectively analyzed.

METHOD

Patients in the fast track underwent visual acuity (VA) testing by ETDRS, optical coherence tomography (OCT) and a physician assessment. The injection was performed the same day whenever possible. The primary endpoint to evaluate patient adherence was the time between the ideal date of visit or injection prescribed by the physician and the actual date of administration.

RESULTS

The mean time between the ideal date of visit or injection prescribed by the physician and the actual date of administration was 4.1±7.5 days for the patients followed in the fast track and 5.6±18.7 days for the patients followed in the standard protocol. Mean VA remained stable for the patients followed in the fast track: 20/50 (20/800 to 20/20) at baseline vs. 20/50 (20/800 to 20/16) at the conclusion of follow-up. It dropped from 40/50 at baseline to 20/63 at the conclusion of follow-up for the patients followed in the standard protocol.

CONCLUSION

In the context of a fast track, it was possible to improve the adherence of nARMD patients and maintain their VA gain or stabilization achieved after the induction phase.

[Factors of compliance with the wearing of elastic compression stockings in a Sub-Saharan population]

INTRODUCTION

Elastic venous compression is the basic treatment of chronic venous insufficiency (CVI) and deep vein thrombosis (DVT). Very little data exist in sub-Saharan Africa concerning the wearing of compression stockings.

AIM

To determine the factors of compliance with wearing elastic compression stockings.

MATERIALS AND METHODS

This retrospective cross-sectional descriptive and analytical study involved 200 consecutive patients (93 cases of DVT, 94 cases of CVI, 13 cases of DVT and CVI). Data on compliance with wearing compression stockings and the factors influencing this compliance were collected.

RESULTS

The average age was 51±15 years old (range 17 and 91 years old). The sex ratio was 1. The majority of patients (78.5%) performed their occupation in a standing position, for more than 8hours per day for 80.5%. DVT were preferentially on the left side (52.9%) and proximal (44.4%). Concerning the CVI, the predominant symptoms were class C3 (52.3%), C4 and C5 (43.9%) of the CEAP classification. Bilateral involvement was dominant (53.3%) and the large saphenous vein was the most affected (66.9%) compared with 33.1% for the small saphenous vein exclusively. The most common type of stockings prescribed was the lower mid-thighs (57%), followed by the pantyhose (30%), in classes 3 (63%) and 2 (36.5%). The majority of patients (75%) agreed to wear their stockings after prescription with a good compliance rate of 58.5% at the beginning of the prescription. At the time of the study, this rate was 11%. The optimal duration of compliance with wearing compression stockings was 6 months (64%). Over 12 months this rate fell to 7.5%. The main causes were stocking-related compression discomfort (36.7%), patient neglect (21.5%), threading difficulties (16.9%), and an unfavorable working environment (8.7%). The determining factors of compliance with wearing of stockings were living in a couple (68.4% vs 54.2, P=0.04), CVI (53% vs 38.2%, P=0.04) and C3 (39% vs 80%), C4 (37.5% vs 17%), C5 (18% vs 3%) CVI (P=0.0005).

CONCLUSION

Compliance with wearing elastic compression stockings is mediocre. The main factors of non-compliance are discomfort, threading difficulties and patient neglect.

[Sucroferric oxyhydroxide, a novel iron-based phosphate binder. Which current use in dialysis patients?]

International guidelines suggest lowering elevated phosphorus level to the normal range in patients on dialysis. Among the phosphate-lowering strategies, phosphate binder is frequently used in addition to dietary phosphate restriction and an adequate dialysis strategy. However, serum phosphate concentration higher than 1.78mmol/L is observed in more than 40% of patients justifying the quest for new drugs. Sucroferric oxyhydroxide is one of the new iron-based agents and is available in France since May 2016. A recent international multicentre study showed this new drug to be as efficacious and non-inferior to sevelamer carbonate in magnitude of serum phosphate control. The serum phosphorus-lowering effect was maintained over 1year. When compared to carbonate sevelamer, the pill-burden was half with sucroferric oxyhydroxide because of its high phosphate binding capacity. As previously shown by experimental studies, no risk of iron accumulation was observed since iron absorption is negligible. Discolored feces and diarrhea were fairly frequent side effects. When diarrhea subsides, the tolerability of this new phosphate binder is excellent on a long-term basis.

[Development of a risk calculator for drug compliance in treated hypertensives: The FLAHS Compliance Calculator]

OBJECTIVE

To investigate the determinants of non-compliance with antihypertensive treatments among participants in the FLAHS 2015 survey and to develop a risk calculator for drug compliance in a hypertensive population.

METHODS

The FLAHS surveys are carried out by self-questionnaire sent by mail to individuals from the TNS SOFRES (representative panel of the population living in metropolitan France) sampling frame. In 2015, FLAHS was performed in subjects aged 55years and older. Using the Girerd questionnaire, the "perfect observance" was determined for a score of 0 and "nonobservance" for a score of 1 or higher. A Poisson regression was conducted in univariate and multivariate to estimate risk ratios for each determinant. A non-compliance risk calculator is constructed from multivariate analysis. A Poisson regression was performed in univariate and multivariate to estimate risk ratios. For each sex, a probability table is produced from the equation of the multivariate analysis and then the calculation of a nonobservance probability ratio (PR) using the profile with the best probability as a reference. Each subject is then classified into one of the three classes of risk of non-compliance: low (PR <1.5), high (PR>=2) and intermediate (PR>=1.5 and <2).

RESULTS

The survey included 6379 subjects and analysis based on 2370 treated hypertensives. The onset of treatment was less than 2years in 7% of subjects and the median follow-up duration of treatment was 10years. Perfect compliance was observed in 64% of subjects. Independent determinants of non-compliance are: male sex, young age, number of antihypertensive tablet, treatment for a metabolic disease (diabetes, dyslipidemia), presence of other chronic illness, secondary prevention of cardiovascular disease. To get the risk class of nonobservance a web page is available at http://www.comitehta.org/flahs-observance-hta/.

CONCLUSION

The development of the FLAHS Compliance Test is a tool whose use is possible during an office visit. Its free availability for French doctor will be one of the actions undertaken as part of the "call for action for adherence in hypertension" proposed by the French League Against Hypertension in 2017.

[Oral anticoagulants adherence in elderly patients treated for atrial fibrillation in the era of direct oral anticoagulants]

BACKGROUND

The aim of this study was to determine the level of adherence to oral anticoagulants in the population of elderly patients treated for a non-valvular atrial fibrillation (AF) in the era of direct oral anticoagulants.

PATIENTS AND METHOD

This transversal study used Morisky scale to assess adherence to oral anticoagulants. We also collected patients' reviews about the treatment and factors explaining a poor adherence.

RESULTS

Between January and June 2015, 64 patients were included in Loire Atlantique. Average age was 77.8 years, CHA₂DS₂-VASc score was 4.06 and treatment (vitamin K antagonists [VKAs] in 78% patients) was prescribed since 4.3 years. According to Morisky scale, 84.4% of patients had a good adherence. There was 88% of good adherence with AVK versus 71% with direct oral anticoagulant, there was no statistically significant difference. The prescriber and the knowledge of anticoagulant treatment role seemed to be determinant factors.

CONCLUSIONS

The level of adherence for oral anticoagulant appears higher than in most published studies. Diversification of therapeutic options could constitute an aid to personalize the prescription in order to improve it.

[Compliance and leaflet's reading, which link and which media? Results from a French population with chronic kidney disease]

Leaflets inside drug boxes are complex and often poorly understood. Patients consulting in nephrology are mostly old and often suffer from multiple comorbidities. As so, they are often subject to various contra-indications and drug interactions. This paper aims to evaluate if patients actually read leaflets or other medical information on others medias such as Internet and whether this could, potentially, interfere with their observance. Results showed that leaflets were read by 65.1% of patients, leading to 12% of withdrawal or not taking drugs. Furthermore, compliance to medical guidance was deemed e-read by 65.1% of patients, leading to 12% of withdrawal or not taken drugs. Furthermore, this study showed no clear profile for non-compliant patients. Even the youngest patients (under 50 years old) have had a good compliance, with not more withdrawal or not taking pills. Nonetheless, youngest patients used more often to consult alternative medias and did not read much of the leaflets' information. Patients who were reading leaflets however, tended to search further information on other medias. This situation would create new challenges in health care, as it seems that data available on new medias are not systematically validated or adapted to the needs of the patients.

[Is there a need for a therapeutic education with patients suffering with open-angle glaucoma? Preliminary inquiry regarding knowledge and patient adherence]

PURPOSE

To evaluate the knowledge and compliance of patients with open-angle glaucoma in order to propose an approach by therapeutic education, validated for other chronic pathologies.

METHODS

A questionnaire-based interview of all patients in the waiting room of the glaucoma center is performed by the same health care professional.

RESULTS

Out of 200 patients, 73% know they will need to be treated throughout their lives and 95% are aware of the risk of blindness in the absence of appropriate treatment. However, 16% respond that they can be cured, and 54% believe that treatment can save their eyesight. Knowledge increases with the length of follow-up of patients at the glaucoma center beyond one year, but the progress is still insufficient in their confidence that treatment can save their eyesight (36% to 57%), and in the decrease in the number of patients who forget their treatment (56% to 30%).

CONCLUSION

Cognitive knowledge is insufficient to encourage the patient to comply with treatment. It is necessary to consider therapeutic patient education (TPE) techniques, such as described by WHO, in group and/or individual sessions, aimed at building the patient's confidence that treatment can delay the progression of the disease and blindness, strengthening his/her capacity to properly administer the eye drops, managing his/her treatment and coping with frequent side effects. Within this framework, our knowledge of the patients' representations of their glaucoma and its treatment must improve.

Results of the French REALISE™ survey]

INTRODUCTION

Poor adherence to treatment is a cause of inadequate asthma control and increased exacerbations. Better understanding of the factors associated with adherence could lead to recognition of appropriate solutions.

METHOD

An online, quantitative, self-completed questionnaire-based survey was conducted among 1024 French adults with asthma (aged 18-50years). Data were collected on socio-demographic characteristics, asthma control, patient perception of the disease and adherence.

RESULTS

Only 11% of asthma patients considered that their asthma is uncontrolled while 48% were uncontrolled according to the GINA criteria. More than half (56%) of respondents admitted not taking their maintenance therapy every day. The perception that asthma was well controlled and lack of impact of the disease on daily activities were the most common reasons cited (46% of respondents) for not taking maintenance therapy. The other main reasons cited were forgetting and use only during symptomatic periods (21% and 14% of respondents, respectively).

CONCLUSION

Adult asthma patients tend to overestimate their level of asthma control. Improving the management of asthma requires systematic detection of respiratory symptoms, awareness of the patient that asthma is a chronic disease and improved physician assessment of patients' expectations and perception of their disease.

[Blood exposure accidents: knowledge and practices of hospital health workers in Mali]

This is a prospective study conducted in December 2012 among 128 at the Nianankoro Fomba Hospital in Segou in order to assess their knowledge and practices on Blood Exposure Accidents (BEA). The average age of caregivers was 35.4 ± 9 years (range: 22-59 years). The nurses were predominant with 37.5%. The definition of BEA was mastered by 43.8%. The main transmissible infectious agents (HIV, HBV and HCV) were ignored by 76.6%. Questioning revealed that during the treatment, 78.9% wore gloves and 36.0% recapped needles after use. The concept of washing and disinfection after BEA was known by 68.8%. The disinfectant applied was correct for 21.9% of the cases, the time of application for 69.5%. Consulting a referring physician after BEA was mandatory for 32% of them. The time limit of 48 hours delay for the declaration of BEA was experienced by 51.3%. Among staff interviewed 82 caregivers (64.1%) experienced at least one BEA. Students and nursing students were most at risk. Needle pricks were the most frequent (73.2%). BEA is a major problem in the Segou Nianankoro Fomba Hospital. Compliance with standard precautions is not of common practice. Post-exposure care is not widely known. The experienced cases show poor management of BEA in the structure.

[Compression care for venous leg ulcers: Assessment of medical practices in 100 patients]

INTRODUCTION

The etiologic treatment of venous ulcers is based on compression therapy in compliance with the new guidelines promulgated by the French National Authority for Health (HAS) in 2010. Prescriptions often originate from a request by the nurse delivering care in the patient's home. A recent French study demonstrated the positive impact of compression therapy on venous ulcer healing. The objective of this study was to evaluate medical practices in order to target corrective actions.

MATERIALS AND METHODS

We conducted a single-center prospective observational study, using a standardized questionnaire from January to May 2014. Patients with venous ulcers who had an indication for compression therapy were included consecutively. The questionnaire collected demographic and clinical data and also recorded the results of complementary tests and the characteristics of the compression therapy.

RESULTS

One hundred patients were included (61 women and 39 men). The average age was 76 years. Patients were recruited during consultations (n = 69), with a majority of patients living at home (n = 80) and receiving home care delivered by a nurse (n = 81). Thirteen patients were seen for the first time and 87 patients were receiving long-term care. The ulcers evolved for 5.7 years on average. Patients presented peri-lesional edema (n = 58), ankle ankylosis (n = 49), autonomous mobilization (n = 40) and walking problems (n = 60). Physical therapy was prescribed for 39 patients and was effectively carried out for 24. The two main causes were venous varices (n = 66) and post-phlebitis disease (n = 18). Compression therapy was prescribed for 97 patients and the products delivered by the pharmacy were consistent with the prescription for 74 patients. Compliance with compression therapy was faulty for 28 patients because of poor tolerance, misunderstanding, manipulation problems, or inappropriate footwear. At assessment, 66 patients were wearing the bands, but not always correctly (starting at the base of the toes [n = 61], heel included [n = 43], proper stretching [n = 43] up to below the knee [n = 57]). Proper footwear was noted in 70 patients.

CONCLUSION

Data are scarce on compliance with compression banding. This study shows that further efforts are needed to ensure proper patient education and professional training for physicians and allied profession concerning the installation of compression therapy. Total compliance was observed in only 35% of patients. In addition, the products delivered by the pharmacy were not consistent with the prescription in 26% of cases. Many discrepancies were observed between what was prescribed and what the patients achieved. Patient adherence is a crucial issue for compression therapy.

[Acceptability and compliance to long-term continuous positive pressure treatment]

INTRODUCTION

Compliance with continuous positive pressure treatment (CPAP) is a determining factor in the management of the obstructive sleep apnea syndrome (OSAS). Long-term compliance has been poorly studied.

METHODS

The probability of long-term continuation of CPAP was evaluated retrospectively by an analysis of survival in 252 patients treated by CPAP after a screening of 472 patients during the years 2002 and 2003.

RESULTS

Twenty-eight patients fulfilling the criteria for CPAP immediately refused the treatment. The mean follow-up for the 252 treated patients was 76.9±46.4 months, with 38 patients having died and 75 having discontinued treatment during the period. The 136 patients who continued treatment used CPAP for a mean of 7.4±1.6hours daily. The probability of continuing treatment was 71% at 5 years and 68% at 10 years. The severity of OSAS was a predictive factor for long-term CPAP compliance, with a 10-year compliance of 82% in patients having an apnoea/hypopnoea index >60, versus 68% with an index between 30-60 and 44% with an index <30.

CONCLUSION

Long-term CPAP treatment is globally well accepted, with a 68% probability of continuing treatment for 10 years, particularly in the most severely affected patients. Long-term daily compliance is very satisfactory.

Hospital and ambulatory management, and compliance to treatment in HIV infection: regional health insurance agency analysis

OBJECTIVE

We had for objective to study HIV management (hospital, ambulatory, and mixed) and assess compliance with health insurance database.

METHOD

We conducted a retrospective study using the French Social Security (CPAM) database. The inclusion criteria were: age>18years of age, at least 2 prescriptions of antiretroviral therapy.

RESULTS

Five hundred and seventy-five patients were included: extra-hospital (12), hospital (162), mixed (401). The prescriptions were exclusively hospital issued for 76.2% of the patients. Among the mixed group patients, 91% of treatments were delivered at least once in the community, and 45.6% of biological tests were performed in private laboratories at least once. The sex ratio (2.1 vs. 1.3), the number of patients having switched antiretroviral therapy (36.7% vs. 27.8%), and the frequency of biological tests (3.1 vs. 2.6) were significantly higher in the mixed group compared to the hospital group. The mean compliance was 90% in the hospital group and 91.8% in the mixed group. The compliance was<80% for 104 patients (21.8%). Patients with≥80% compliance were older (46.1years of age vs. 42.7years of age), with more frequent biological tests (3 per year vs. 2.5 per year), and more frequent switches in treatment (35.4% vs. 26.0%).

CONCLUSION

Prescriptions of ARV were almost exclusively hospital issued. Their dispensation and biological tests were split between hospital and extra-hospital settings. Most patients demonstrated an optimal compliance. The CPAM database allows describing HIV management and assessing compliance.

Assessment of patient adherence to anti-infective treatment after returning home

OBJECTIVE

The lack of patient adherence to medical treatment has become a major concern for healthcare professionals. The World Health Organization estimated patient adherence to treatment at 50% only. The inadequate use of antibiotics can cause bacterial resistance the progression of which reduces therapeutic alternatives. The objective of this pilot study was to assess the patient's adherence to anti-infective agents prescribed for acute infection, after returning home.

METHOD

Thirty-seven patients hospitalized in the Infectious and Tropical Diseases unit were included. Their adherence to anti-infective drugs was assessed indirectly through data collected by calling the pharmacy and the patient in the week following discontinuation of anti-infective treatment.

RESULTS

Sixteen patients were identified as non-adherent (43.2%). A single patient could have several behaviors: extension of treatment (50%), dose modification (6.3%), voluntary omission (12.5%), and involuntary (6.3%). One patient (6.3%) did not take his anti-infective treatment. There was no major cause of non-adherence; every patient had his own reasons. The comparison of several criteria between adherent and non-adherent patients did not reveal any predictive risk factors.

CONCLUSION

Our study results revealed for the first time that 50% of patients were adherent to anti-infective agents, after returning home. They confirm the need to implement preventive actions such as a discharge pharmaceutical consultation.

[Deliberate interruptions and changes of dose of inhaled corticosteroids by asthma patients: "a community pharmacy study"]

BACKGROUND

Adherence to inhaled corticosteroids (ICS) remains a major issue for asthma management, even among patients receiving a regular prescription from their doctor. The frequency of deliberate interruption of ICS, and of spontaneous changes of dose, were studied in a population of asthma patients recruited in community pharmacies.

METHODS

Asthma patients (aged 18-50) recruited in community pharmacies reported in self-administered questionnaires their spontaneous interruptions and changes of doses of ICS during the past 3 months. The characteristics of patients who interrupted their therapy or who modified the dose were compared with other patients.

RESULTS

The studied population included 252 patients (mean age 35 year-old, females: 59%), of whom 62% had inadequately controlled asthma. Among these patients, 25% had interrupted ICS therapy during the past 3 months, while 21% spontaneously changed the dose. The most reported reason for interrupting ICS was the cessation of symptoms (50%). In multivariate analysis, interrupting ICS was mainly associated with inadequate asthma control (OR=3.1, 95% CI 1.5-6.4), while the strongest association with changing ICS doses was the patients' perception of asthma as a concern in their lives (OR=3.2, 95% CI 1.2-8.4).

CONCLUSION

These results underline a poor understanding of the purpose of ICS therapy by patients. They also highlight the need of therapeutic education to improve the management of the disease.

[Reluctance of patients with chronic kidney disease stage 3 to join education programs offered by a health network]

INTRODUCTION

Therapeutic education helps patients to acquire the knowledge and ability to live with their disease. However, some patients are not willing to take part in a health education program. Identifying the barriers of their non-adherence would help us to determine accurately their effective educational needs and to adapt the program to deliver a better education for less-motivated patients.

PATIENTS AND METHODS

An education program for chronic kidney disease stage 3 patients was implemented across a health network. The study is based on patient's participation during each step of the program. The reasons for non-participation were collected, via direct survey and cross-referencing with available medical records.

RESULTS

From 80 eligible patients, and after medical approval, 66 patients received information about the program. Thirty-six patients elected to participate in program and 21 of them joined a therapeutic education group. We did not find any significant differences in the medical or social profile to determine the characteristics of non-participating patients. We found less program involvement however, with patients complying with biomedical follow-up but who do not benefit from complementary paramedical care.

CONCLUSION

Nearly half of patients did not take part in the therapeutic education program, primarily those who did not benefit from a multidisciplinary team to manage their chronic disease. Therapeutic education remains a less known concept by patients, and requires an informative and encouraging exhortation from practitioners during casual medical care.

[Is a patient's knowledge of cardiovascular risk factors better after the occurrence of a major ischemic event? Survey of 135 cases and 260 controls]

AIM

We hypothezised that patients (cases) who are hospitalized for a major ischemic event--myocardial infarction, stroke, decompensation of peripheral arterial disease--acquire better knowledge than a control population--atheromatous patients without a major ischemic event, patients consulting for a vein disease or a diabetes evaluation, and accompanists--about cardiovascular risk factors (smoking, hypertension, diabetes, dyslipidemia, obesity) and have a better understanding of the usefulness of making changes in their lifestyle (quit smoking, regular exercise, Mediterranean diet, low salt diet, weight control, diabetes care).

METHODS

A questionnaire was proposed at vascular surgery consultations and vascular and cardiac functional explorations, at the M Pavillon of the Édouard-Herriot hospital, Lyon, France. In five months, 395 questionnaires (135 cases and 260 controls) were analyzed.

RESULTS

The global knowledge score was statistically higher for cases than for controls (cases 3.23±1.81; controls 2.77±2.03; P=0.037). Cases did not abide by monitoring and dietary rules better, except as regards the management of diabetes. Regular physical activity was statistically more prevalent among controls than among cases. Cases mainly received their information from their doctors (general practitioner for 59% of controls and 78% of cases, cardiologist for 25% of controls and 57% of cases) while controls got their information more through magazines or advertising.

CONCLUSION

Our results show that after a major ischemic event, cases' knowledge of risk factors is better than the rest of the population without improved rules lifestyle changes. This suggests the usefulness of evaluating a therapeutic education program for atheromatous disease.

[Toward a conditional price for medicine?]

For the first time, and as an exceptional option, the 2012 LEEM-CEPS framework agreement introduces the notion of conditional prices in conventional practice. The contractualization of drug price according to changes in its value that could occur in "real world" enables the Payer and the Company to settle, in a predictable manner, the "bet" represented by first registration price setting. Its systematization is based on the ability to standardize the implementation and assessment of observational studies, whereas the analysis and sharing of the risk of value changes (depreciation, appreciation) are structuring elements of the contractualization. Ethical from both the payer's and patient's point of view, drug price conditionality on its value is impeded by compliance with legal and economic constraints for the company, that should be taken into account by legalising this latter's ability to influence it through observance or therapeutic education and by guaranteeing a sufficiently long period of revenues for the company.

[Manipulation in the exercise of psychiatric interviews]

INTRODUCTION

The term "manipulation" is defined as "getting someone to behave otherwise than he spontaneously would". Unlike cognitive therapies, it does not involve cognitive functioning and may increase psychotherapies' efficiency.

METHOD

In the absence of data in the scientific literature (Medline and Web of Science), we propose a synthesis of theoretical data from social psychology with a reflection on its applications in the daily practice of psychiatry.

RESULTS

Firstly we present auto-manipulation: the "chilling effect" is the fact that people tend to keep to a decision and to duplicate it, even if it does not work. The commitment of the patient, i.e., the degree to which he/she identifies with his/her act, will be even stronger if the patient's sense of freedom is high. The rationalization process is the ability for individuals to revisit their beliefs after being forced to issue a behavior (that he/she did not adhere to) to justify it a posteriori. In the second part, we present techniques for hetero-manipulation. Priming is to ask about a low effort to "initiate" the behavior. The lure technique is to hide convenience or invent fictitious benefits of a product, but is not ethical. The labeling technique is to assign an individual to a positive value regardless of his or her behavior, which increases the probability of emission of positive behaviors. The touch technique, whatever the cultural context, encourages a patient to have more confidence in his/her therapist and to make them friendly towards the person involved by creating a positive mood, reduces stress in patients before surgery, and improve the academic performance of students.

DISCUSSION AND CONCLUSION

We propose reflections on the application of these concepts in daily practice in the psychiatric interview. These techniques seem fundamental in improving therapeutic alliance and the likelihood of good compliance in our patients, and should be known to all practitioners.