[Roles of pharmacists in multidisciplinary protocols of medical homes in 2020: A multi-methods cross-sectional descriptive study]. / Rôle des pharmaciens d'officine dans les protocoles des maisons de santé pluriprofessionnelles en 2020 : étude descriptive transversale multi-méthodes.

OBJECTIVES: To describe and analyze the roles of pharmacists in the multi-disciplinary protocols of French medical homes (MHs). METHODS: Multi-methods study combining: (i) a descriptive cross-sectional study identifying the MHs with active pharmacists in Loire-Atlantique and Vendée in 2020, (ii) an analysis of the roles of the pharmacists within the multi-disciplinary protocols of these MHs, (iii) a qualitative study by semi-directed interviews with the pharmacists participating in these protocols. RESULTS: Among the 40 MHs in Loire-Atlantique and Vendée in 2020, 22 (55%) included a pharmacist and 8 (20%) reported at least one protocol between GPs and pharmacists. Three roles of the pharmacist were identified: identification of a target population according to the inclusion criteria of the protocols, counseling and education, and new missions of the pharmacist. The interviews carried out highlighted a gap between the actions stated in the protocols and the actions carried out with the patient. CONCLUSION: There are many barriers to the involvement of pharmacists in the protocols: significant administrative difficulties, low financial profitability, lack of time, and even persistent mistrust between general practitioners and pharmacists. Despite these barriers, pharmacists experience improvements in communication between professionals and in their practice conditions.

[Introduction to debriefing for internists: how to transform real or simulated clinical situations into learning moments]. / Initiation au débriefing pour les internistes : état des connaissances et mise en pratique pour transformer des situations cliniques réelles ou simulées en moments d'apprentissage.

Debriefing is a phase of synthesis and reflection that immediately follows a real-life or simulated situation. It is an essential educational step that forces the learners to reflect upon the thought processes that underlie their actions. Debriefing encourages a personal and collective reflection in order to remodel erroneous mental schemas and rectify actions done in context. Debriefing cannot be improvised; it requires a sound structure and regular practice in order to be truly effective. The debriefer must be considerate, choose appropriate learning objectives and dedicate ample time to the learners. Debriefing is focused on learning acquired in context-in other words, on the actions that were performed within a real-life or simulated clinical practice situation-and immediately follows the situation. After an initial phase of emotional release, the debriefer will help learners analyse their actions to identify their underlying rationale (contextualization), extract the overarching principles related to the lived situation in order to modify the rationale if needed (decontextualization) and assist the transfer of learning to real life (in the case of simulation) and to similar situations (recontextualization). A final summary of learning achieved during the training session concludes the debriefing. Debriefing is useful in any learning situation, including in internal medicine. Even if simulation is still underused in internal medicine, post-event debriefing can be implanted in our clinical services. Indeed, training our students and shaping them into healthcare professionals rest in no small part on hospital rotations where the intern is confronted with real-patient situations that are suitable to learning. Some in-hospital clinical encounters can be actively transformed into learning opportunities thanks to post-event debriefing, but can also passively morph into bad daily practice if no supporting action is implemented. Debriefing can thus provide an opportunity to develop non-technical skills in critical situations, or doctor-patient communication skills, within a team or between colleagues. These competencies are the hallmark of well-trained interns and are indispensable for the proper functioning of a care team. We will not develop the emotional and psychological management of debriefing in this article. We hope we will helpfully introduce as many of our colleagues as possible to the art of debriefing in most circumstances.

[Simulation-based learning and internal medicine: Opportunities and current perspectives for a national harmonized program]. / Simulation en santé et médecine interne : quel avenir ?

Simulation-based learning (SBL) is developing rapidly in France and the question of its use in the teaching of internal medicine (IM) is essential. While HAS encourages its integration into medical education, French Young Internists (AJI) set up a working group to reflect on the added-value of this tool in our specialty. Different sorts of SBL exist: human, synthetic and electronic. It enables student to acquire and evaluate technical skills (strengths, invasive procedures, etc.) and non-technical skills (relational, reasoning…). The debriefing that follows the simulation session is an essential time in pedagogical terms. It enables the acquisition of knowledge by encouraging the students' reflection to reshape their reasoning patterns by self-correcting. IM interns are supportive of its use. The simulation would allow young internists to acquire skills specific to our specialty such as certain gestures, complex consulting management, the synthesis of difficult clinical cases. SBL remains confronted with human and financial cost issues. The budgets allocated to the development and maintenance of simulation centres are uneven, making the supply of training unequal on the territory. Simulation sessions are time-consuming and require teacher training. Are faculties ready to train and invest their time in simulation, even though the studies do not allow us to conclude on its pedagogical validity?

Evaluation of single incision laparoscopic surgery "low-fidelity" simulation training.

GOAL: Evaluate the learning curve of SILS (Single Incision Laparoscopic Surgery) on a simulator, based on two tests of the Fundamentals of Laparoscopic Surgery certification program (FLS(®)), in a population of novice medical students, and compare their performance to those of senior surgeons practicing both "conventional" laparoscopic surgery and SILS. MATERIALS AND METHODS: Monocentric prospective study with four groups: two groups of novice medical students, and two groups of senior surgeons. The two FLS(®) tests used for evaluation were the peg transfer and the precision cutting tasks. RESULTS: No statistically significant differences were found between the novice groups, whether they started their first session directly, or immediately after watching a video presentation of the exercises. For the novice medical students, the average completion time of both tests improved significantly between the first and the sixth sessions with a short learning curve. The group of experienced seniors performed fastest in both tests. For the peg transfer task, the skills of the novice medical students were comparable to those of non-experienced seniors after the 4th session and improved after 6 sessions (P=0.017). For the precision cutting task, the average timing of the novice group became better than that of the non-experienced seniors, starting from the third session. CONCLUSIONS: FLS(®) "low fidelity" simulator training is effective for the training of novice medical students. To minimize the risk of technical errors, novice medical students should practice a minimum of six simulator-training sessions before starting their practical learning of SILS in the operating room.

If a bird flies in the forest, does an insect hear it?

Birds are major predators of many eared insects including moths, butterflies, crickets and cicadas. We provide evidence supporting the hypothesis that insect ears can function as 'bird detectors'. First, we show that birds produce flight sounds while foraging. Eastern phoebes (Sayornis phoebe) and chickadees (Poecile atricapillus) generate broadband sounds composed of distinct repetitive elements (approx. 18 and 20 Hz, respectively) that correspond to cyclic wing beating. We estimate that insects can detect an approaching bird from distances of at least 2.5 m, based on insect hearing thresholds and sound level measurements of bird flight. Second, we show that insects with both high and low frequency hearing can hear bird flight sounds. Auditory nerve cells of noctuid moths (Trichoplusia ni) and nymphalid butterflies (Morpho peleides) responded in a bursting pattern to playbacks of an attacking bird. This is the first study to demonstrate that foraging birds generate flight sound cues that are detectable by eared insects. Whether insects exploit these sound cues, and alternatively, if birds have evolved sound-reducing foraging tactics to render them acoustically 'cryptic' to their prey, are tantalizing questions worthy of further investigation.

The place of simulation in the surgical resident curriculum. The pedagogic program of the Nice Medical School Simulation Center.

INTRODUCTION: Surgical training relies on medical school lectures, practical training in patient care and in the operating room including instruction in anatomy and experimental surgery. Training with different techniques of simulators can complete this. Simulator-based training, widely used in North America, can be applied to several aspects of surgical training without any risk for patients: technical skills in both open and laparoscopic surgery, the notion of teamwork and the multidisciplinary management of acute medicosurgical situations. METHOD: We present the curriculum developed in the Simulation Center of the Medical School of Nice Sophia-Antipolis. All residents in training at the Medical School participate in this curriculum. RESULTS: Each medical student is required to pursue theoretical training (familiarization with the operating room check-list), training in patient management using a high fidelity mannequin for various medical and surgical scenarios and training in technical gestures in open and laparoscopic surgery over a 2-year period, followed by an examination to validate all technical aptitudes. This curriculum has been approved and accredited by the prestigious American College of Surgeons, making this the first of its kind in France. CONCLUSION: As such, it should be considered as a model and, in accordance to the wishes of the French Surgical Academy, the first step toward the creation of true schools of surgery.

First two autochthonous dengue virus infections in metropolitan France, September 2010.

In September 2010, two cases of autochthonous dengue fever were diagnosed in metropolitan France for the first time. The cases occurring in Nice, southeast France, where Aedes albopictus is established, are evidence of dengue virus circulation in this area. This local transmission of dengue calls for further enhanced surveillance, active case finding and vector control measures to reduce the spread of the virus and the risk of an epidemic.

Shared and specific susceptibility loci for schizophrenia and bipolar disorder: a dense genome scan in Eastern Quebec families.

The goal of this study was to identify susceptibility loci shared by schizophrenia (SZ) and bipolar disorder (BP), or specific to each. To this end, we performed a dense genome scan in a first sample of 21 multigenerational families of Eastern Quebec affected by SZ, BP or both (N=480 family members). This probably constitutes the first genome scan of SZ and BP that used the same ascertainment, statistical and molecular methods for the concurrent study of the two disorders. We genotyped 607 microsatellite markers of which 350 were spaced by 10 cM and 257 others were follow-up markers in positive regions at the 10 cM scan. Lander and Kruglyak thresholds were conservatively adjusted for multiple testings. We maximized the lod scores (mod score) over eight combinations (2 phenotype severity levels x 2 models of transmission x 2 analyses, affected/unaffected vs affected-only). We observed five genomewide significant linkages with mod score >4.0: three for BP (15q11.1, 16p12.3, 18q12-q21) and two for the shared phenotype, that is, the common locus (CL) phenotype (15q26,18q12-q21). Nine mod scores exceeded the suggestive threshold of 2.6: three for BP (3q21, 10p13, 12q23), three for SZ (6p22, 13q13, 18q21) and three for the CL phenotype (2q12.3, 13q14, 16p13). Mod scores >1.9 might represent confirmatory linkages of formerly reported genomewide significant findings such as our finding in 6p22.3 for SZ. Several regions appeared to be shared by SZ and BP. One linkage signal (15q26) appeared novel, whereas others overlapped formerly reported susceptibility regions. Despite the methodological limitations we raised, our data support the following trends: (i) results from several genome scans of SZ and BP in different populations tend to converge in specific genomic regions and (ii) some of these susceptibility regions may be shared by SZ and BP, whereas others may be specific to each. The present results support the relevance of investigating concurrently SZ and BP within the same study and have implications for the modelling of genetic effects.

Relevance and complications of intravenous infusion at the emergency unit at Nice university hospital.

OBJECTIVE: Insertion of peripheral venous catheters (PVCs) is current practice within the hospital environment and particularly in the emergency department (ED). This simple yet invasive technique may result in venous thrombosis, infection or mechanical complications. We conducted a prospective study at the Nice University Hospital ED in order to determine the frequency, relevance and complications of peripheral venous cannulation. PATIENTS AND METHODS: Fourteen 24 h periods were surveyed over the months of May and June 2000, during which 2515 patients over 16 years of age attended the unit. Demographic and medical data were recorded for every patient who received a PVC. These patients were followed at 12 h intervals until the catheter was removed. Reasons for PVC, time left in place, and eventual complications were recorded. Justification for PVC was evaluated upon arrival at the ED, upon exiting the ED and in some cases within the hospital ward. RESULTS: Six hundred and thirty of 2515 patients (25%) received a PVC (290 women (46%) and 340 men (54%); meanage 58 years). Indication for the PVC was considered unjustified in 24.8% of cases upon arrival at the ED, and 33.8% upon leaving the ED. Upon admission in a hospital ward after passing through the ED, out of 318 patients, the PVC was left in place for no reason in 63 (20%). Overall, 390 PVCs were followed until the time of their removal. Mean duration of IV infusion was 28 h. Among these 390 patients, 62 (15.9%) developed complications, of which 54 (13.6%) had thrombophlebitis and 9 (2.3%) developed local infection. Mean duration of PVC left in place for patients with complications was 50 h vs 25 h for patients with no complications (P<0.001). CONCLUSION: Insertion of a PVC is common practice especially in EDs. The excessive use of this procedure leads to extra cost and iatrogenic complications. A renewed definition of its indication and raised awareness among hospital staff concerning the risks involved with this standard procedure should result in less use of PVC and fewer complications.

[Motives for the prescription of antibiotics in the emergency department of the University Hospital Center in Nice. A prospective study]. / Motifs de prescriptions des antibiotiques dans le service des urgences du centre hospitalier universitaire de Nice. Enquête prospective.

OBJECTIVES: Since April 1999, we have set-up an infectious disease consultation in the emergency unit of the University Hospital in Nice. Unjustified antiobiotherapy is often initiated. We therefore conducted a survey to study the motives and validity of antibiotic prescriptions. METHOD: This prospective study was conducted in two phases. The first consisted in asking the emergency physicians prescribing antibiotics to fill-in a questionnaire giving information on the diagnosis established and the antiobiotherapy proposed. In the second phase, the diagnoses and corresponding treatments were submitted to 4 experts who assessed the acceptability of the diagnoses and the antibiotics prescribed. The experts only had access to the clinical and para-clinical data available. Moreover, their therapeutic judgement was based on previously published consensuses. RESULTS: The 6-month survey collected 117 questionnaires that could be analysed. The rate of error in diagnosis was of 33% (39/117). Thoracic x-rays could not be interpreted in 11% of cases. In single variant analysis, factors of erroneous diagnosis were due to its interpretation by an internist, the diagnostic category of "broncho-pulmonary infections" and the lack of documentation. In multi variant analysis, only the lack of documentation was related to erroneous diagnosis (OR = 5.5; IC 95% (2.03; 15.30), p < 0.0002). The rate of antibiotherapy not adapted to the diagnosis made by the physician was of 32% (37/117). In 24 cases the modalities of the prescription were incorrect and in 13 cases the prescription was unjustified. Only the status of the prescriber (internist) was statistically associated with an antibiotherapy not adapted to the diagnosis (OR = 2.2; IC 95% (0.93; 5.26), p < 0.05). CONCLUSION: Unjustified antibiotherapy in an emergency unit is generally due to erroneous diagnosis of infection. The lack of documentation and inexperience of the prescribers appear to be the two elements contributing to unjustified antibiotherapy.

A search for specific and common susceptibility loci for schizophrenia and bipolar disorder: a linkage study in 13 target chromosomes.

We report the first stage of a genome scan of schizophrenia (SZ) and bipolar disorder (BP) covering 18 candidate chromosomal areas. In addition to testing susceptibility loci that are specific to each disorder, we tested the hypothesis that some susceptibility loci might be common to both disorders. A total of 480 individuals from 21 multigenerational pedigrees of Eastern Québec were evaluated by means of a consensus best-estimate diagnosis made blind to diagnoses in relatives and were genotyped with 220 microsatellite markers. Two-point and multipoint model-based linkage analyses were performed and mod scores (Z, for max Z(max)) are reported. The strongest linkage signals were detected at D18S1145 (in 18q12; Z = 4.03) for BP, and at D6S334 (in 6p 22-24; Z(het) = 3.47; alpha = 0.66) for SZ. Three other chromosomal areas (3q, 10p, and 21q) yielded linkage signals. Chromosomes 3p, 4p, 5p, 5q, 6q, 8p, 9q, 11q, 11p, 12q, 13q, 18p and 22q showed no evidence of linkage. The 18q12 results met the Lander and Kruglyak (1995) criterion for a genome-wide significant linkage and suggested that this susceptibility region may be shared by SZ and BP. The 6p finding provided confirmatory evidence of linkage for SZ. Our results suggest that both specific and common susceptibility loci must be searched for SZ and BP.

[Evaluation of a hospitalization unit opened during the winter influenza epidemic of 1999-2000]. / Bilan médical d'une unité d'hospitalisation ouverte pendant l'épidémie de grippe de l'hiver 1999-2000.

PURPOSE: Last winter, a great many patients with influenza-like infection were admitted to our hospital, leading us to open a specific unit for 6 weeks. We report the evaluation of medical care given to these patients. METHODS: Useful data for evaluating care to patients presenting respiratory infections were determined beforehand by the retrospective analysis of patients' charts. RESULTS: Fifty-seven out of 185 admitted patients (31%) had infectious respiratory symptoms. The mean age was 81 years. Six cases of influenza virus infection, 43 cases of viral bronchitis, six cases of bacterial pneumonia, one superinfected asthma and one septic shock were diagnosed. All patients presented with cardiac and/or chronic pulmonary diseases. Influenza vaccination had been performed in 28 patients (49%). Before hospitalisation, 30 patients (52%) had received antibiotics, and 17 (30%) a steroid therapy. In contrast, only 12 patients (21%) have received anti-infective agents during the hospitalisation. Twenty-five patients were able to go back home and a nursing home was required for 27 patients (47%); five patients died. Tools for improving this specific department in a public hospital are discussed. CONCLUSION: Vaccinations in the elderly appear to be poorly utilized; meanwhile, antibiotic treatments, as well as steroid therapy, are overused. Managing epidemic infections requires attention from the public hospital system.

Early (99m)Tc-ethylcysteinate dimer brain SPECT patterns in the acute phase of stroke as predictors of neurological recovery.

OBJECTIVES: Accurate prediction of outcome in acute stroke would help in identifying subgroups of patients for therapeutic trials and intravenous thrombolysis. The purpose of this study was to prospectively test the hypothesis that brain SPECT, with (99m)Tc-L, L-ethylcysteinate dimer (ECD), a tracer sensitive to cell function, performed in the first hours after stroke onset, adds predictive power to concomitant neurological evaluation. METHODS: Twenty-four patients with a first-ever middle cerebral artery stroke were prospectively studied with ECD-SPECT within 12 h after stroke onset. Neurological evaluation was performed using Orgogozo's scale at admission and 3 months later in order to calculate the percent Martinez-Vila evolution indices (EI%). Semiquantitative visual analysis of SPECT images was performed in 6 cortical regions relevant for carotid artery territory. Both the extent and the intensity of cortical reduced ECD uptake were calculated, leading to an 'ischemia' score, corresponding to the sum of regions of interest (ROI) where ECD uptake was between 40 and 80% of the contralateral healthy hemisphere, and an 'irreversibly damaged tissue' (IDT) score, corresponding to an uptake below 40%, and a total score (ischemia + IDT). Each patient was assigned to one of three patterns: (1) pattern I with severe ECD cortical uptake reduction defined by at least one ROI with uptake under 40%, (2) pattern II with moderate ECD cortical uptake reduction (40-80%) only and (3) pattern III with normal ECD uptake. RESULTS: There were 11 patients (46%) with pattern I ECD-SPECT. This group had almost invariably (10/11 patients) a poor outcome. The 12 patients (50%) classified in pattern II had a variable clinical outcome, ranging from improvement to deterioration. The single patient with a normal SPECT (pattern III) had a full clinical recovery. Both total score and IDT score were strongly significantly correlated with neurological recovery EI% (respectively p = 0.006 and 0.004). Their predictive value was significantly higher than, and independent of, day 0 neurological evaluation. No patient had an increased ECD uptake. CONCLUSION: Our results show that the degree of ECD cortical uptake reduction, measured on early brain SPECT, is a strong predictor of neurological recovery. ECD-SPECT data have a higher predictive value than day 0 neurological evaluation. The apparently better predictive value of ECD over hexamethylpropyleneamine oxime may reflect this tracer's brain retention mechanisms which are weighted more towards cell function than towards perfusion. ECD-SPECT is easily obtainable and may help in selecting out from therapy those patients who are likely to have either very good or very poor spontaneous outcome, and thus improve the assessment of acute stroke and the choice of therapeutic strategy.

Instruments measuring behavioral disturbance in relatives with schizophrenia.

This article presents a review of 16 instruments measuring behavioral disturbance of persons with schizophrenia as perceived by their family members. Information about the domain, the types of rating scales, and the psychometric properties of these instruments are provided. Future directions in the study of behavioral disturbance are proposed.

The caregiver's perception of behavioral disturbance in relatives with schizophrenia: a stress-coping approach.

This article suggests some theoretical orientations in studying behavioral disturbance from a stress-coping perspective. First, an overview of Lazarus and Folkman's cognitive theory of stress is presented. Secondly, some linkages are proposed between the rating scales used to measure behavioral disturbance and the concepts of this theory. Future research directions are then suggested to further explore the affective, cognitive and behavioral responses related to the management of disturbing behaviors.

Clinical and methodological factors related to reliability of the best-estimate diagnostic procedure.

OBJECTIVE: The reliability and accuracy of the best-estimate diagnostic procedure were examined, and factors associated with reliability were determined. METHOD: The subjects were 134 members of large multigenerational pedigrees densely affected by bipolar disorders or schizophrenia. Three best-estimate diagnoses were derived: first, by a research psychiatrist and research assistant unblind to the relatives' diagnoses; second, by two blind independent psychiatrists; third, by a panel of four blind psychiatrists. The subjects were characterized on several clinical and methodological variables, which were used to compare the agreements of two types of best-estimate diagnoses with the disagreements. RESULTS: There was satisfactory agreement between the unblind and blind consensus best-estimate diagnoses and between the two blind independent psychiatrists. Latent class analyses revealed that limited sensitivity was the main source of imperfect reliability. Confusability analyses revealed that the most problematic diagnostic distinctions involved schizoaffective disorder, which was confused with schizophrenia, bipolar I disorder, and schizophreniform disorder. Blindness significantly affected diagnostic outcome in latent class analyses. Moreover, for diagnostic disagreements, unblind diagnoses had greater continuity with the most predominant diagnosis in the pedigree than did blind diagnoses. Diagnostic disagreements were associated with the presence of mixed affective and psychotic symptoms, less diagnostic certainty, and shorter duration of illness. CONCLUSIONS: These results suggest that it is possible to identify cases that are more likely to lead to diagnostic disagreements in family and epidemiological studies and that blind diagnoses may help to prevent false positive diagnoses, which may be particularly detrimental to genetic linkage analyses.

[Malaria attacks after returning from endemic areas. Failure or inadequate chemoprophylaxis?]. / Accès palustre au retour de zone d'endémie. Echec ou inadéquation de la chimioprophylaxie?

OBJECTIVE: Determine the causes of malaria attacks in subjects who have returned from endemic areas by assessing prescriptions for chemical prophylaxis and compliance. PATIENTS AND METHODS: All patients who developed a paroxysmal episode of malaria diagnosed at the University of Nice hospital in 1995 answered specific questions concerning their anti-malaria prophylaxis. RESULTS: Thirty-three patients were hospitalized for paroxysmal episodes of malaria in 1995. In 32 cases (97%) the attack resulted from either the lack of any prophylaxis (17 cases, 52%), inadequate prescription (11 cases, 12%) or poor compliance (4 cases, 12%). The prescribed chemical prophylaxis was not adapted to the chloroquinone-resistant area in 8 cases (24%) and medical recommendations concerning administration rules were inadequate in 3 cases (9%). Only one patient developed a paroxysmal episode despite correct compliance to a chloroquine-resistant zone-adapted well-conducted prescription. The cost of poor prophylaxis in terms of human suffering and financial cost was high for this preventable disease. Four patients had to be hospitalized in the intensive care unit and one died during hospitalization. The cumulative cost of hospitalization for these 33 cases was evaluated at 660,000 FF. CONCLUSION: Preventive measures for malaria must include better information for physicians on changing recommendations for chemical prophylaxis as well as better information for travelers provided by all those involved in organizing travel to endemic areas.

Schizophrenia: revisited.

Schizophrenia is a devastating illness for the affected individuals and their families. Health care providers and researchers are also challenged by the clinical heterogeneity of this disorder. The goal of the present paper is to offer an updated overview of the aetiology, definition, clinical manifestations and pharmacological and psychosocial treatments of schizophrenia. Finally, some future directions for psychiatric nursing will be suggested in light of the existing knowledge of schizophrenia.