Effects 4.5 years after an interactive GP educational seminar on antibiotic therapy for respiratory tract infections: a randomized controlled trial.

BACKGROUND: The few studies assessing long-term effects of educational interventions on antibiotic prescription have produced conflicting results. OBJECTIVES: Our aim was to assess the effects after 4.5 years of an interactive educational seminar designed for GPs and focused on antibiotic therapy in respiratory tract infections (RTIs). The seminar was expected to decrease antibiotic prescriptions for any diagnosis. METHODS: We conducted a randomized controlled parallel-group trial in a Paris suburb (France), with GPs as the randomization unit and prescriptions as the analysis unit. The intervention occurred in September 2004 and the final assessment in March 2009. Among 203 randomized GPs, 168 completed the study, 70 in the intervention group and 98 in the control group. Intervention GPs were randomized to attending only a 2-day interactive educational seminar on evidence-based guidelines about managing RTIs or also 1 day of problem-solving training. The primary outcome was the percentage of change in the proportion of prescriptions containing an antibiotic for any diagnosis in 2009 versus 2004. An intention-to-treat sensitivity analysis was performed using multiple imputation. RESULTS: After 4.5 years, absolute changes in the primary outcome measure were -1.1% (95% confidence interval: -2.2 to 0.0) in the intervention group and +1.4% (0.3-2.6) in the control group, yielding an adjusted between-group difference of -2.2% (-2.7 to -1.7; P < 0.001). Both intervention modalities had significant effects, and multiple imputation produced similar results. CONCLUSIONS: A single, standardized and interactive educational seminar targeting GPs significantly decreased antibiotic use for RTIs after 4.5 years.

Colorectal cancer screening: factors associated with colonoscopy after a positive faecal occult blood test.

BACKGROUND: Contextual socio-economic factors, health-care access, and general practitioner (GP) involvement may influence colonoscopy uptake and its timing after positive faecal occult blood testing (FOBT). Our objectives were to identify predictors of delayed or no colonoscopy and to assess the role for GPs in colonoscopy uptake. METHODS: We included all residents of a French district with positive FOBTs (n = 2369) during one of the two screening rounds (2007-2010). Multilevel logistic regression analysis was performed to identify individual and area-level predictors of delayed colonoscopy, no colonoscopy, and no information on colonoscopy. RESULTS: A total of 998 (45.2%) individuals underwent early, 989 (44.8%) delayed, and 102 (4.6%) no colonoscopy; no information was available for 119 (5.4%) individuals. Delayed colonoscopy was independently associated with first FOBT (odds ratio, (OR)), 1.61; 95% confidence interval ((95% CI), 1.16-2.25); and no colonoscopy and no information with first FOBT (OR, 2.01; 95% CI, 1.02-3.97), FOBT kit not received from the GP (OR, 2.29; 95% CI, 1.67-3.14), and socio-economically deprived area (OR, 3.17; 95% CI, 1.98-5.08). Colonoscopy uptake varied significantly across GPs (P=0.01). CONCLUSION: Socio-economic factors, GP-related factors, and history of previous FOBT influenced colonoscopy uptake after a positive FOBT. Interventions should target GPs and individuals performing their first screening FOBT and/or living in socio-economically deprived areas.

Glucose lowering therapeutic strategies for type 2 diabetic patients with chronic kidney disease in primary care setting in france: a cross-sectional study.

Aim. To understand glucose lowering therapeutic strategies of French general practitioners (GPs) in the management of type 2 diabetes mellitus (T2DM) patients with chronic kidney disease (CKD). Methods. A multicenter cross-sectional study was conducted from March to June 2011 among a sample of French GPs who contribute to the IMS Lifelink Disease Analyzer database. Eligible patients were those with T2DM and moderate-to-severe CKD who visited their GPs at least once during the study period. Data were collected through electronic medical records and an additional questionnaire. Results. 116 GPs included 297 patients: 86 with stage 3a (Group 1, GFR = 45-60 mL/min/1.73 m(2)) and 211 with stages 3b, 4, or 5 (Group 2, GFR < 45 mL/min/1.73 m(2)). Patients' mean age was approximately 75 years. Insulin was used in 19% of patients, and was predominant in those with severe CKD. More than two-thirds of patients were treated with glucose lowering agents which were either contraindicated or not recommended for CKD. Conclusion Physicians most commonly considered the severity of diabetes and not CKD in their therapeutic decision making, exposing patients to potential iatrogenic risks. The recent patient oriented approach and individualization of glycemic objectives according to patient profile rather than standard HbA1c would improve this situation.

Therapeutic management of orally treated type 2 diabetic patients, by French general practitioners in 2010: the DIAttitude Study.

AIM: To describe the behaviour of French general practitioners (GP) regarding intensification of hypoglycaemic agents in orally treated type 2 diabetic (T2D) patients, according to their HbA(1c) level. METHODS: General practitioners were recruited from a panel of office-based general practitioners. T2D patients who had been orally treated for at least 6 months were included in the study; their characteristics were recorded, and their HbA(1c) values and hypoglycaemic treatments over the previous 24 months extracted from electronic records The major reasons for intensification (or no intensification) of hypoglycaemic agents were recorded at the inclusion visit. RESULTS: A total of 236 general practitioners recruited 2109 T2D patients: 1732 had at least one HbA(1c) value recorded in the previous 6 months, and 52%, 33% and 14% had been treated, with oral hypoglycaemic agents in monotherapy, bitherapy or tri-or quadritherapy, respectively. Of these patients, 702 (41%) remained uncontrolled (47%, 39% and 20% respectively) and according to the current French guidelines needed treatment intensification. Only 46 (7%) had their treatment intensified at inclusion. Of those without intensified treatment, 60% were treated with monotherapy; the main reason given by the general practitioners for not intensifying treatment was a satisfactory HbA(1c) level (53%), although 32% had an HbA(1c)>7%. Other reasons were: lifestyle advice had greater priority (20%); decision was postponed until the next visit (11%); HbA(1c) had decreased since last visit (7%; not confirmed by available data in 58% of cases); a medical priority other than diabetes (6%) and other reasons related to the patient (3%). CONCLUSION: For T2D patients managed by French general practitioners, guidelines are not consistently followed: HbA(1c) should be monitored more frequently and treatment adjusted according to HbA(1c) levels.

Clinical inertia: viewpoints of general practitioners and diabetologists.

Large clinical studies have enabled best practice guidelines to be issued. Intended to serve practitioners in their daily practice, the guidelines are also excellent tools for assessing physician performance. It was therefore demonstrated that despite the observation of insufficient glycaemic control, physicians did not systematically increase drug treatments. As a result, they have been accused of clinical inertia! In this journal, we first try to reveal what is behind this concept and to differentiate true inertia from pseudo inertia. Secondly, we consider how general practitioners and diabetologists, through their respective positions, can develop a synergy that is able to fight against inertia but that can especially, improve the glycaemic control of our patients.

Chronic kidney disease in type 2 diabetes patients in France: prevalence, influence of glycaemic control and implications for the pharmacological management of diabetes.

AIM: Type 2 diabetes mellitus (T2DM) is often associated with chronic kidney disease. For this reason, this article reviews the relationship between treatment of T2DM and renal disease. METHOD: The review presents the recent French data on the management of diabetes in patients with renal impairment, and discusses the implications of renal disease for the treatment of such patients. Prescribing data are presented for various antidiabetic treatments, and the use of the more commonly prescribed medications is discussed with reference to T2DM patients with renal disease. RESULTS: In France, it is estimated that 4-5% of the general population has T2DM and that almost 40% of patients with end-stage renal failure have diabetes. Diabetes and renal disease are both risk factors for cardiovascular morbidity and mortality. Glycaemic control is pivotal in T2DM patients for minimizing the risk of vascular complications and hypoglycaemic episodes, particularly in patients with renal disease who also have a higher risk of hypoglycaemia. Whereas poorly controlled glycaemia increases the risk of renal disease and its progression, the risk is diminished in patients treated intensively for diabetes and in those who achieve stable glycaemic control. Intensive multitargeted treatment can also help to decrease cardiovascular morbidity and mortality, especially if started early in patients who have not yet developed macrovascular complications. CONCLUSION: In recent years, considerable improvement has been observed in France regarding the follow-up of diabetic patients. Less extensive, but nonetheless significant, improvement has also been observed in glycaemic control. However, even though treatment decisions generally take renal function into account, some at-risk treatments are often still being used in patients with renal insufficiency.

Improving glycaemic control of patients with Type 2 diabetes in a primary care setting: a French application of the Staged Diabetes Management programme.

AIMS: To assess the impact of a French adaptation of the Staged Diabetes Management (SDM) programme on glycaemic control of people with Type 2 diabetes in primary care. Secondary endpoints were blood pressure, blood lipids, healthcare costs and quality of life. METHODS: Prospective, randomized controlled study, of 1 years' duration. General practitioners (GPs) were recruited in four separate districts of a French region. They enrolled consecutive patients with Type 2 diabetes. GPs in the intervention group were educated in the SDM programme. GPs in the control group were asked to provide usual care. Healthcare costs were collected by medical departments of the Health Insurance systems. Quality of life was assessed with the Duke Health Profile. RESULTS: Three hundred and forty patients enrolled by 57 GPs completed the study, 192 in the intervention group and 148 in the control group. Patients in the intervention group were managed more adequately in accordance with the guidelines (P < 0.05 for nine out of 10 items). HbA(1c) decreased by 0.31% in the intervention group and increased by 0.56% in the control group, resulting in a difference of 0.87% by the end of the study (P = 0.001). Blood pressure and blood lipids did not differ between groups. Occurrence of major complications was low and identical in both groups. Incremental costs during the study in the intervention group were 35 euros per patient per month, and this was not significantly different in comparison with the control group. Quality of life was not affected by the intervention. CONCLUSIONS: Educating GPs in the French adaptation of the SDM programme improves glycaemic control in a primary care setting, without significantly increasing healthcare costs.

Cooperation between general practitioners and diabetologists and clinical audit improve the management of type 2 diabetic patients.

A programme was set up in the Essonne (France) between 1994 and 1998 to improve the quality of care for Type 2 diabetic patients. A consensus panel of general practitioners and diabetes specialists established guidelines based on the French St. Vincent recommendations. An audit involving 73 volunteer general practitioners (out of 965 in the Essonne) then evaluated compliance with these guidelines. Care and outcome were assessed in 505 (1995) and 604 (1996) Type 2 diabetic patients. The first audit cycle showed that defined standards were not met for several criteria and also revealed a lack of standardisation of HbA1c measurements and delayed intervention when blood glucose control was inadequate. Corrective measures were adopted: cooperative protocols for foot care, prevention of nephropathy and retinopathy, standardisation of HbA1c, and an educational programme at the primary health care level. The second audit cycle showed improvement in foot care (+33.6%), quality (+39.9%), prescription of HbA1c (+11.9%), and control of blood pressure (+11.9%) and blood lipids (+12.8%). The proportion of early interventions in case of inadequate glucose control increased significantly (+10.5%). However, some gaps persisted, mainly regarding screening for complications, diet counselling and patient education. This study shows that cooperation between general practitioners and diabetes specialists is feasible and effective in the context of a district-wide approach, and that it facilitates the adoption of international guidelines by local physicians. A project has been developed to provide structured diabetes care in general practice and better access to specialist services in order to improve the outcome of Type 2 diabetic patients.

[Right ventricular function: physiological and physiopathological features]. / Fonction ventriculaire droite: bases physiologiques et physiopathologiques.

Sinus and conus constitute the two cavities of the right ventricle. They are anatomically and functionally different. The sinus is a flow-generator and the conus a pressure-regulator. The coronary circulation of the right ventricle is provided by the right coronary artery and the left anterior descending artery. The right ventricle is perfused during systole and diastole. When oxygen demand increases, coronary arteries dilate and oxygen extraction rises. As for the left ventricle, right ventricular performance depends upon heart rate, rhythm, contractility and loading conditions. Ventricular interactions are very important for right ventricular function. Loading conditions and contractility of the left ventricle are of major significance for right ventricular performance. For the right ventricle, the end of the ejection is different from the end of the active contraction. The time between them allows to achieve ventricular emptying. This duration is linked to afterload. Presently, it is impossible to accurately and simply assess these conditions. Pressure and volume overloadings result in right ventricular failure. They are responsible for ventricular dilation and ischaemia with a decrease in cardiac output, generating a vicious circle. Treatment includes the removal of the cause, and the maintenance of systemic arterial pressure and biventricular contractility. It is difficult to assess the effects of intravenous vasodilators on right ventricular afterload.

Mycoplasma pneumoniae pneumonia following assisted ventilation.

BACKGROUND: Mycoplasma pneumoniae pneumonia is regarded as a community-acquired pneumonia, rarely requiring hospitalization, with sporadic cases or limited outbreaks occurring after close contacts with an infected patient. Few reports mention M pneumoniae pneumonia acquired during hospitalization. PATIENTS AND METHODS: M pneumoniae was diagnosed in patients who developed pneumonia following perioperative and postoperative assisted ventilation by the isolation of M pneumoniae from bronchial washing, the detection of M pneumoniae DNA from bronchial washing, and serologic testing for the presence of specific immunoglobulin M (IgM) antibodies. RESULTS: Four patients were diagnosed as having M pneumoniae pneumonia following mechanical ventilation over a 1 1/2-year period. They were men, older than 50 years, and were hospitalized for vascular surgery. They developed febrile hypoxemia and intersticial pneumonia. Isolation of M pneumoniae and detection of M pneumoniae DNA were positive in 1 case; specific IgM antibodies were present in 4 cases. CONCLUSIONS: These observations allow the description of a new clinical entity and highlight the role of M pneumoniae as an agent of nosocomial infections. This diagnosis should be considered in any patient with precocious post-assisted ventilation febrile hypoxemia and diffuse interstitial pneumonia, and empiric treatment protocols may include M pneumoniae in their spectrum.

[A cause of difficult weaning from artificial respiration: polyneuropathy of intensive care]. / Une cause de difficulté de sevrage de la ventilation artificielle: la polyneuropathie de réanimation.

Three cases of Critically Illness Polyneuropathy (CIP) are reported. The difficulty of weaning the patients from the ventilator, whereas sepsis and MOF had been successfully treated, was the main feature in the three cases. The diagnosis was established by eletromyogram, showing a primary axonal denervation of peripheral nerve fibres, which was confirmed by a pathological study in one patient.

[Diprivan: evaluation of the depth of anesthesia]. / Diprivan: évaluation de la profondeur de l'anesthésie.

In daily practice, assessing the exact depth of anaesthesia relies even today on clinical signs such as movements elicited by painful stimuli and/or changes in blood pressure and heart rate. Neurophysiological indicators, such as EEG and evoked potentials, are most probably techniques of the future. They are not yet in routine medical practice, because of the complexity of the information supplied, unresolved technical problems and the high cost of equipment. Nevertheless, these techniques are gradually entering the operating theatre and contribute to the monitoring of the anaesthetized patient. EEG, in particular, regardless of the method of analysis used, seems effective and reliable during the induction phase of anaesthesia, However, the most adequate method of monitoring the maintenance phase or detecting awareness during anaesthesia remains to be produced.

[Computer-assisted intravenous anesthesia: value, method and use]. / Anesthésie intraveineuse assistée par ordinateur: intérêt, méthode et application.

Total intravenous anaesthesia (TIVA) is becoming increasingly popular among anaesthetists. It has several advantages, namely each component of the anaesthetic protocol can be independently controlled, and the operating room remains unpolluted with nitrous oxide or volatile anaesthetic agents. TIVA aims to maintain a constant blood concentration of each anaesthetic agent. This means that infusion rates need to be repeatedly altered. A computer calculates theoretical blood concentrations of agent according to a pharmacokinetic model, and drives an infusion device. Only a few programmes have been developed by research teams. No commercial device is available as yet. However, there are several syringe pumps and volumetric pumps which are accurate enough for use in TIVA and which may be controlled by computer. Clinical studies have shown the benefits of TIVA: greater haemodynamic stability, decreased drug consumption, more rapid recovery, and a lesser need for postoperative ventilatory support. The most appropriate agents are propofol and etomidate as hypnotics, alfentanil and sufentanil for opioids, vecuronium and atracurium as muscle relaxants. Etomidate is not recommended for prolonged infusions, because of the risk of adrenocortical suppression. TIVA seems to be attractive for neurosurgery, thoracic surgery, day case surgery, endoscopic procedures, and anaesthesia in remote locations. Unfortunately, it is an expensive technique. Moreover, there is considerable interpatient variability of the drug concentration required for a same clinical effect. Two methods are proposed to decrease this variability: population pharmacokinetic models and Bayesian forecasting. Closed loop systems are still research tools. It is concluded that computer-driven anaesthesia is the equivalent to the vaporizer for volatile agents. However, further clinical studies are needed to determine whether the advantages of this technique outweigh its disadvantages.

Pharmacodynamic properties of propofol during recovery from anaesthesia.

Propofol was used to induce and maintain anaesthesia in 20 healthy adult ASA physical status 1 patients undergoing dental surgery. Recovery was studied using psychometric tests and clinical assessment while propofol blood levels were obtained at the same study times. Recovery was rapid and there were no significant differences 60 min after anaesthesia (t60) for the tracing test and 90 min for the choice reaction time. All patients were orientated in time at t30 and in space at t45; Stewart's score was maximal in all patients at t60; recovery of normal walking was slower, i.e. t120. Return to baseline for psychometric function was linked to a decrease in propofol blood level, for both the tracing test (P less than 10(-6)) and the choice reaction time (P less than 10(-3)). We conclude that propofol is a suitable anaesthetic agent for induction and maintenance of short duration dental anaesthesia.

Propofol as the main anaesthetic agent in dental surgery.

Propofol was used as the main anaesthetic agent for induction and maintenance of anaesthesia in 30 patients undergoing dental surgery requiring tracheal intubation. Anaesthesia was successfully induced and intubation performed in all patients, with a propofol induction dose of 3.5 mg/kg and without muscle relaxants or opioids. Intubating conditions were good for 77% of the patients. No haemodynamic changes occurred. Maintenance with propofol 9 mg/kg/h and 70% nitrous oxide provided suitable conditions for surgery. Awakening and recovery times were short and few side effects were recorded. However, post-operative dental pain was systematically recorded and was present in 60% of the patients.