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Epidemic transition, sustained costs and health workforce shortage challenges have led numerous countries to strengthen primary care (PC) and implement new models of care. Faced with declining numbers of general practitioners (GPs), France has introduced medical assistants (MAs) in 2019 to guarantee access to care and maintain workforces in deprived areas. Trained to perform administrative and clinical tasks delegated by a physician, MAs are expected to optimize medical time and improve working conditions in practices. How does French model of MAs impact quality and productivity in GPs’ practices and articulate with other policies? We conducted a qualitative case study in 6 pilot practices to explore the effects of MAs’ work (interviews with 12 GPs, 6 MAs, collection of tasks performed by 6 MAs), complemented with views from public policy makers and health professional unions (9 interviews). MA was defined as a function centered on physicians’ needs, accessible both to administrative staff and nursing professions. MAs with a clinical profile performed a wider range of tasks, were more prone to perform clinical tasks and build developed interactions with patients, and seemed better fitted for chronic disease care management. Recruitment of MAs by physicians is supported with grants that decrease yearly while practice productivity is expected to rise. In general, a gain of efficiency in daily workload enabled GPs to slightly increase their productivity. However, for most GPs, it primarily helped them to maintain high workload without burning out. Although MAs with clinical background seem better suited for patients’ needs, recent figures have shown that more than half of MAs employed are former secretaries. If in-person secretaries could be endorsed with further administrative duties, MAs could hold a more clinical role in PC teams including physicians and allied health professionals. Other aspects than productivity must be taken into account in a support policy. Key messages • Regardless of productivity objectives to attain, hiring MAs can relieve physicians’ workload and stress, preventing them from burning out and guarantee access to care in deprived areas. • MA’s clinical profile could have a stronger impact on public health issues such as chronic disease care management.

For more than 10 years in France, multi-professional healthcare centers have been considered as innovative organizations, which offer attractive work conditions for health professionals and help to structure primary care. Their development is strongly supported by public policy (e.g. specific funding methods, a target of 2000 teams by 2022) and is seen as a mean to enhance preventive actions. From a public health perspective, when professionals define their collective project, preventive actions should be chosen according to their relevance (by considering local population needs), effectiveness (based on evidence) and realism (in terms of implementation). Our goal was to make an inventory of existing tools and recommendations but also to propose a framework that considers the actual practicing conditions of French primary care teams. Three methods were used: a bibliographic study, feedback from a consulting firm with a 10 years’ experience in supporting new teams in defining their multi-professional project, and interviews from experts and health professionals. Due to professional training and practice, preventive actions are less familiar to professionals when they are not integrated into individual and curative cares. Indeed, most existing recommendations are designed from a macroscopic point of view, dismissing the particularities of multi-professional private practice. Thus, we could identify 9 categories of factors likely to determine the relevance of a preventive action, including a specific context-population-team setting. Although this is an exploratory work, feedback from professionals confirms the potential positive or negative influence of these items on the implementation of an action. Our framework could be converted into a tool consisting of a list of questions to ask before primary care teams choose a preventive action to implement. Frequent assessments should be carried out and shared in order to develop empirical and reliable knowledge in this field. Key messages Despite a strong public policy to develop multi-professional health care centers in France, recommendations about preventive actions insufficiently consider specific conditions of practice. Mixing theoretical and practical perspectives, our framework could help to improve the relevance, effectiveness and realism of preventive actions considering a specific context-population-team setting.

The French public health medical residency was created in 1984 to train medical public health specialists. Knowledge was lacking on the career of the trained practitioners, with the sole study dating from 1995. In this study, the French national association of medical public health residents aimed to describe the training and career of all medical public health specialists since the inception of the residency.An online survey took place during the first semester of 2012 to collect information on all medical public health specialists graduated from the French public health medical residency. Descriptive analysis of the collected information was performed.Replies from 563 graduated medical public health residents were collected from all over the country and years since the inception of the training. Ninety-eight percent of the informants were in activity. They mostly worked in public healthcare facilities (56%) and public administration (16%). Their main areas of practice were: epidemiology, clinical research, biostatistics (37%); health management information system (19%); health policy (14%). Eighty-eight percent of the respondents held a master degree, 29% a PhD. Practical training during the medical residency was deemed as very useful or needed by 73% of the informants, theoretical training by 43%. Sixty-eight percent of informants were very or fully satisfied by their carrier, 29% rather satisfied.This is the first study to achieve coverage of more than 45% of all medical public health specialists graduated since the inception of the public health medical residency. Full employment, wide-range activities, evolving carriers can explain the high satisfaction rates. The public health medical residency being the main access point to the public health medical specialty, the impact of the initial training on the career should lead to rethink the design of the public health medical residency to fulfil the needs in the public health sector.

Summary Introduction: Observation of schistocytes on the peripheral blood following haematopoietic stem cell transplantation (SCT) is a common finding. As their presence is not specific to the onset of SCT-related thrombotic microangiopathy, we evaluated the interest of schistocyte measurement twice a week during the entire follow-up of 195 patients undergoing SCT, particularly focussing on the 125 allogeneic SCT. Methods: Schistocytes were strickly defined as triangular-, crescent- or helmet-shaped red blood cells according to consensus standards and were checked blindly under the microscope and with computer image analysis. Results: Mean schistocyte percentage was 0.7% (±0.5%, reference value ≤0.5). High schistocyte percentage was observed after allografts (0.79%) when compared to autologous SCT (0.47, P 1.2%. SCT-TM grade ≥2 occurred in nine patients. A marked rise in schistocyte >4.5% was observed, which was not reached during the other SCT-related complications. Children with ALL, undergoing unrelated allogeneic SCT, with early acute graft-versus-host disease refractory to steroids were prone to present SCT-TM, associated with VOD, interstitial pneumopathy and HC, resulting in a high mortality rate (six of seven patients). Our data confirmed that schistocytosis was common after SCT. Mild percentages were likely concomitant with extensive endothelial damage but higher percentage should have prompted to a close monitoring with SCT-TM investigation. Conclusion: In our experience, systematic schistocyte count after HSCT proved to be useful: the occurrence of an increased percentage was a surrogate marker for complications even if unspecific for TM.

Resume Objectif Notre objectif etait d’ameliorer l’organisation et la gestion de la prise en charge des enfants atteints de cancer ou de leucemie et de repondre a la legislation en vigueur en France. Methodes Nous rapportons les etapes successives de la mise en place d’un systeme d’assurance qualite, les methodes utilisees, les motivations, le cout, les difficultes rencontrees ainsi que les avantages obtenus. Nous avons entrepris dans le centre regional de cancerologie pediatrique (CRCP) du CHU de Clermont-Ferrand une demarche qualite basee sur la norme ISO 9001/2000. La mise en place du systeme d’assurance qualite a ete conduite comme un projet de recherche et un projet medical d’etablissement avec le soutien de sa direction. La mission de notre CRCP est « la prise en charge de l’enfant et de sa famille ». Cette mission a ete eclatee en plusieurs « processus », approche qui consiste a considerer le service clinique en terme de flux et de successions de transformations (accueil, soins, soutien, accompagnement, etc.) qui produisent de la valeur ajoutee (des services et des produits adaptes aux besoins des « clients » : enfants, familles, correspondants, etc.). Resultats Nous avons individualise 10 processus « realisation » ou « metier » tels « diagnostic », « soins de support » ou « projet de l’enfant ». La cartographie qui est la representation systemique des processus et des interactions entre eux a permis d’avoir une vision globale de l’activite « soins » de notre CRCP. Conclusion La norme ISO 9001/2000 etant un outil d’aide a l’organisation et a la gestion, le benefice obtenu grâce a son implantation dans un service clinique a ete avant tout percu en terme organisationnel aboutissant a un veritable esprit d’equipe, une uniformisation des pratiques professionnelles et une valorisation du role de chacun. Les avantages apparaissent a 3 niveaux : l’enfant et sa famille, les equipes medicale et paramedicale et les tutelles.

The aim of this paper is to emphasize the studies carried out for the new generation of hydrazine pump s, in terms of modeling, control and experiments in order to optimize the use of gas. It consists of an actuator conception for which it is possible to move the hydrazine pump leading to very short required displacements. It may be shown that the main advantage in using these new devices is the volume gain with respect to the existing satellites systems besides this will allow the system operates even if the gas reservoir pressure level is low, thus bringing great benefits.

Observation of schistocytes on the peripheral blood following haematopoietic stem cell transplantation (SCT) is a common finding. As their presence is not specific to the onset of SCT-related thrombotic microangiopathy, we evaluated the interest of schistocyte measurement twice a week during the entire follow-up of 195 patients undergoing SCT, particularly focussing on the 125 allogeneic SCT.Schistocytes were strickly defined as triangular-, crescent- or helmet-shaped red blood cells according to consensus standards and were checked blindly under the microscope and with computer image analysis.Mean schistocyte percentage was 0.7% (±0.5%, reference value ≤0.5). High schistocyte percentage was observed after allografts (0.79%) when compared to autologous SCT (0.47, P0.001). All but one patients undergoing allogenic SCT had schistocytes ≥0.6%. Conversely, significant schistocytosis was observed in 20% of the autologous SCT. Initial diagnosis [chronic myelocytic leukaemia, acute lymphoblastic leukaemia (ALL)], high-risk status, unrelated transplant and conditioning regimen including total body irradiation influenced higher schistocyte percentage (≈0.9%). Significant rise in the schistocyte percentage was observed during acute/chronic graft-versus-host disease, veno-occlusive disease (VOD), cholestatic hepatitis, haemorrhagic cystitis (HC) and pulmonary complications. Multivariate analysis showed a significant association between thrombotic microangiopathy (TM), renal impairment and delayed thrombopaenia after day 50, and schistocyte1.2%. SCT-TM grade ≥2 occurred in nine patients. A marked rise in schistocyte4.5% was observed, which was not reached during the other SCT-related complications. Children with ALL, undergoing unrelated allogeneic SCT, with early acute graft-versus-host disease refractory to steroids were prone to present SCT-TM, associated with VOD, interstitial pneumopathy and HC, resulting in a high mortality rate (six of seven patients). Our data confirmed that schistocytosis was common after SCT. Mild percentages were likely concomitant with extensive endothelial damage but higher percentage should have prompted to a close monitoring with SCT-TM investigation.In our experience, systematic schistocyte count after HSCT proved to be useful: the occurrence of an increased percentage was a surrogate marker for complications even if unspecific for TM.

Our objective was to improve the organization and management of care facilities for children suffering from cancer or leukaemia and to be aligned with the legislation in force in France.Our report is on the successive steps for the implementation of a quality assurance system, methods used, motivations, cost, difficulties encountered as well as the advantages obtained. In the Regional Centre for Paediatric Oncology (CRCP) at the CHU in Clermont-Ferrand, we launched a quality programme based on ISO9001/2000 standards. The implementation of the quality assurance system was conducted as a research project and an established medical project with the support of the Management Team. The mission was divided into several "processes", an approach consisting of considering the clinical service in terms of flow and successions of transformations (reception, care, support, accompaniment, etc.) which produce added-value (services and products adapted to the needs of the "customers": children, families, correspondents).We singled out ten physical processes or "job specializations" such as "diagnosis", "care" or "project for the child". The cartography which is the systematic representation of the processes and the interactions between them made it possible to draw up a global vision of the CRCP "care" activity.The ISO9001/2000 standard is a tool designed to help organization and management. The benefit obtained in implementing it in a clinic was perceived in organisational terms and lead to a true team spirit, a standardization of the professional practices and the enhancement of the role of each person. The advantages appear at three levels: the child and his/her family, the medical and paramedical teams, and the administrative supervisory bodies.