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This study evaluated whether quantitative measurement of collaterals by the hypoperfusion intensity ratio (HIR) on baseline computed tomography perfusion (CTP) correlated with infarct growth and clinical outcome after successful endovascular recanalization of acute ischemic stroke (AIS) caused by primary distal medium vessel occlusions (DMVO).We performed a retrospective analysis of consecutive AIS patients who underwent an initial CTP and were successfully recanalized by thrombectomy (modified thrombolysis In cerebral infarction 2b or 3) for DMVO. We evaluated the association of baseline HIR with infarct growth and clinical outcome.Between January 2018 and January 2021, 40 patients with an AIS caused by a DMVO were successfully recanalized by MT (65%, 26/40 female, median age 72 years, range 65-83 years). Baseline HIR was strongly correlated with infarct growth after successful recanalization (r = 0.501, p = 0.001). An HIR0.3 was the optimal threshold for good collaterals using ROC analysis. Patients with HIR ≥ 0.3 had higher infarct growth compared to HIR 0.3 (23.8 mL, IQR: 9.1-45.1 vs. 7.2 mL, interquartile range (IQR): 4.2-11.7, relative risk 7.9, p = 0.024 in multivariate analysis); their clinical outcome was poorer in univariate analysis (75%, 21/28 patients with a 3 months modified Rankin scale of 0-2 vs. 33%,4/12, p 0.017, odds ratio (OR) 6.0, 1.37-26.20) but it did not remain significant in multivariate analysis (p = 0.107).Good collaterals on initial CTP assessed by an HIR 0.3 are associated with less infarct growth after successful recanalization of AIS caused by a DMVO.

Purpose Wide-neck bifurcation aneurysms remain challenging for the neurointerventionist and/or neurosurgeon despite many recent advances. The pCONus (Phenox, Bochum, Germany) is an emerging device for endovascular neck protection, we report the first long-term results of this device. Methods We performed a retrospective analysis of all consecutive intracranial wide-neck bifurcation aneurysms treated with the pCONus. Patients' characteristics were reviewed, procedural complications, angiographic (Roy-Raymond scale) and clinical outcomes were documented. Results Between January 2016 and September 2019, 43 patients (74% female, median age 56 [49–66] years) with 43 wide-neck bifurcation aneurysms (mean width of 6.8 ± 2.1 mm, dome/neck ratio of 1.3 ± 0.2 and neck of 5.2 ± 1.3 mm) were included. A procedural angiographic complication was reported in five patients (12%), no patient presented a post-operative neurological deficit or long-term complication, mortality rate was 0%. At last follow-up (median of 46.5 months [38.3–51.7]), an adequate occlusion (complete and neck remnant) was observed in 37/43 patients (86%) and an aneurysm remnant in 6/43 (14%). Four patients (9%) needed retreatment. No in-stent stenosis or branch occlusion was depicted. Conclusion pCONus device provides a safe and efficient alternative for endovascular wide-neck bifurcation aneurysms management, with long-term stability.

Embolization of arteriovenous malformations (AVMs) before radiosurgery has been reported to negatively impact the obliteration rate. This study aims to assess treatment outcomes in a series of 190 patients treated by Gamma Knife radiosurgery (GKRS) for previously embolized AVMs.The institutional database of AVMs was retrospectively reviewed between January 2004 and March 2018. The clinical and radiological data of patients treated with GKRS for previously embolized AVMs were analyzed. Predicting factors of obliteration and hemorrhage following GKRS were assessed with univariate and multivariate regression analyses.The mean AVM size was significantly reduced after embolization (p 0.001). The obliteration rate was 78.4%. Multivariate analyses showed that a lower Spetzler-Martin grade (p = 0.035) and a higher marginal dose (p = 0.007) were associated with obliteration. Post-GKRS hemorrhages occurred in 14 patients (7.4%). A longer time between diagnosis and GKRS was the only factor associated with post-GKRS hemorrhages in multivariate analysis (p = 0.022). Complications related to the combined treatment were responsible for a new permanent neurological disability in 20 patients (10.5%), and a case of death (0.5%).This study shows that the embolization of AVMs does not have a negative impact on the obliteration rate after radiosurgery. Embolization reduces the AVM size to a treatable volume by GKRS. However, the combined treatment results in an increased complication rate related to the addition of the risks of each treatment modality.

We report a case of cerebral aneurysm rerupture 24 months after initial bleeding and complete occlusion using a WEB device. A middle-aged patient was transferred at our institution because of a recurrent aneurysmal bleeding. The patient was graded WFNS2 and unenhanced CT showed a modified Fisher grade 3 SAH. DSA showed an increased compaction and an evolutive “proximal recess” of the WEB device associated with a small unprotected part of the aneurysm wall and a bleb pointing towards the haemorrhage. Balloon- and stent-assisted coiling was performed, allowing to completely occlude the recurrence. The patient suffered no neurological deficit neither delayed complication and was discharged at day 16.

Endovascular treatment of unruptured intracranial aneurysms with stent-assisted coiling or flow diverter stents requires a prophylactic antiplatelet premedication to avoid thrombo-embolic complications. Guidelines for optimal antiplatelet regimens are poorly defined. The aim of this study is to report our experience using a high dosage antiplatelet premedication regimen for patients with unruptured intracranial aneurysms undergoing endovascular treatment by stent-assisted coiling or flow diverter stents. From a retrospective analysis of a prospectively maintained database, we collected clinical and angiographic data of 400 procedures in 362 patients treated by stent-assisted coiling or flow diverter stents for 419 unruptured intracranial aneurysms. Descriptive and analytic statistics were performed to report morbidity, mortality, and complication rates and to demonstrate associations between variables and outcomes. Logistic multivariable regression was performed to rule out confounding factors between subgroups. Thrombo-embolic complications occurred in 23/400 procedures (5.75%) and hemorrhagic complications in 19/400 procedures (4.75%). The majority of complications were minor and transient with overall procedure-related morbidity and mortality rates of 1.75% (n = 7/400) and 1.25% (n = 5/400) respectively. The co-existence of multiple cardiovascular risk factors among smoking, hypertension, dyslipidemia, and age > 65 years old was significantly associated with permanent procedure-related morbidity (p = 0.006) and thrombo-embolic complications occurrence (p = 0.034). Age alone was associated with higher permanent morbidity (p = 0.029) and was the only variable associated with higher hemorrhagic complication (p = 0.024). In this study, the use of a high dosage antiplatelet premedication was safe and effective for the treatment of unruptured intracranial aneurysms with stent-assisted coiling or flow diverter stents. Mortality and morbidity rates compare favorably with the current literature. The thrombo-embolic complications rate is low and most of them were clinically silent. However, the hemorrhagic complications rate was substantial and a significant proportion of them were associated with mortality.

International audience; Drawing upon a study carried out at a funeral home, a hospital, and a police station, this article explores the sociological study of emotions at work and their political dimension. First, it emphasizes the methodological contributions of comparative ethnography, arguing in favor of this combined methodology by seeking to highlight its refined use of observation and interviews by mobilizing various professional circles. Second, the article aims to understand the political handling of emotions in the workplace (especially what we term “emotional risk”). Emotional risk is often an invisible risk because it is normalized. It is an important issue for working conditions and their negotiation, but it is difficult to bring to the fore. It is often explained and legitimized by professional culture, more or less ignored by management, and relatively forgotten by trade union action. As a result, it rarely or never detaches itself from the local sphere and therefore does not acquire a broader political dimension, although public policies are showing a growing interest in matters of well-being at work.; En s’appuyant sur une enquête menée dans les pompes funèbres, à l’hôpital et dans la police, l’article propose de traiter de l’étude sociologique des émotions au travail et de leur dimension politique. D’un côté, il souligne donc les apports méthodologiques de l’ethnographie comparée. L’article plaide en faveur de cette méthodologie combinée en cherchant à montrer la finesse qu’elle permet par l’usage de l’observation et des entretiens en mobilisant divers milieux professionnels. D’un autre côté, l’article vise à comprendre comment les émotions au travail (surtout ce que nous avons appelé le « risque émotionnel ») sont traitées politiquement. Le risque émotionnel peut apparaître souvent comme un risque invisibilisé, car normalisé. Il constitue un enjeu important pour les conditions de travail et leur négociation, mais il est délicat à mettre en avant. Il est souvent expliqué et légitimé par la culture professionnelle, plus ou moins nié par les logiques gestionnaires et relativement oublié de l’action syndicale. Par conséquent, il s’extrait peu ou pas du champ local et n’acquiert donc pas une dimension politique plus large, alors même que l’on observe un intérêt croissant des politiques publiques pour les questions de bien-être au travail.

Declines in stroke admission, IV thrombolysis (IVT), and mechanical thrombectomy volumes were reported during the first wave of the COVID-19 pandemic. There is a paucity of data on the longer-term effect of the pandemic on stroke volumes over the course of a year and through the second wave of the pandemic. We sought to measure the effect of the COVID-19 pandemic on the volumes of stroke admissions, intracranial hemorrhage (ICH), IVT, and mechanical thrombectomy over a 1-year period at the onset of the pandemic (March 1, 2020, to February 28, 2021) compared with the immediately preceding year (March 1, 2019, to February 29, 2020).

Introduction Stent-assisted coiling has widened indications and improved stability of endovascular treatment of intracranial aneurysms. However, stent-assisted coiling is usually not used to treat acutely ruptured intracranial aneurysms to avoid antiplatelet therapy. The objective of this study is to evaluate a strategy of staged endovascular treatment of ruptured intracranial aneurysms including coiling at the acute phase with complementary stenting with or without coiling at the subacute phase. Material and methods Between 2012 and 2017, we retrospectively identified, in our prospectively maintained database, all patients treated for a ruptured intracranial aneurysm based on this staged stenting strategy. Clinical charts and imaging follow-up were analyzed to assess the procedural safety and feasibility as well as clinical and anatomical outcome. Results We identified 23 patients with 23 intracranial aneurysms including 15 (65.2%) women with a mean age of 50 years (range 24–69 years). No rebleeding occurred during the mean delay of 24.3 days between initial coiling and stenting. All procedures were successful and additional coiling was performed in 5/23 procedures (21.7%). Clinical status was unchanged in all patients. At follow-up, the modified Rankin scale was graded 0 in 19/23 (82.6%), 1 in 2/23 (8.7%), and 2 in 2/23 (8.7%) patients, respectively. The rate of complete occlusion rose from 30.4% before the stenting procedure to 52.2% immediately after and 72.7% at follow-up. Conclusion This strategy of early staged stenting in selected patients is safe and improves immediate intracranial aneurysm occlusion and long-term stability in this population at high risk of intracranial aneurysm recurrence with coiling alone.

Background and PurposeGood clinical outcome predictors have been established in mechanical thrombectomy (MT) for acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). An early neurological improvement (ENI), defined as a reduction of ≥8 on the National Institutes of Health Stroke Scale (NIHSS), compared with the baseline score or an NIHSS of 0 or 1 at 24 h after MT, is a strong predictor of favorable outcome. We aimed to study the impact of ENI after MT for distal medium vessel occlusions (DMVO).MethodsWe retrospectively analyzed the data of consecutive patients who underwent MT for a primary DMVO in one large academic center. We compared clinical outcomes between patients with DMVO stratified by ENI. Multivariate analyses were performed to determine the impact of ENI on good 90-day outcome (modified Rankin scale of 0–2) and identify factors contributing to ENI.ResultsBetween January 2018 and January 2021, 61 patients underwent an MT for an AIS with a primary DMVO. An ENI was seen in 24 (39%) patients (ENI+). Outcomes were significantly better in ENI+ patients, with 83% achieving a good outcome at 3 months vs. 43% for patients without ENI (ENI–; p = 0.019). ENI was an independent predictive factor of good clinical outcome even after adjusting for potential confounding factors [odds ratio 12.49 (1.49–105.01), p = 0.020]. The use of intravenous tissue plasminogen activator [IVtPA; Odds-ratio 6.59 (1.82–23.89), p = 0.004] was a positive predictor of ENI.ConclusionENI at day 1 following MT for DMVO stroke is a strong independent predictor of good to excellent 3-month clinical outcome.

Good clinical outcome predictors have been emphasized in mechanical thrombectomy (MT) for acute ischemic stroke (AIS) with large vessel occlusion. MT for distal, medium vessel occlusions (DMVO) is still debated. We sought to assess the factors associated with clinical outcome after MT for DMVO.We retrospectively analyzed the data of consecutive patients who underwent MT for a primary DMVO in 1 large academic center and aimed to identify the baseline clinical, imaging, and MT factors associated with good clinical outcome (defined as modified Rankin scale score of 0-2) at 3 months.Between January 2018 and January 2021, 61 patients underwent a MT for an AIS with a primary DMVO. Overall, good clinical outcome was achieved in 56% (34 of 61) of our patients. In multivariate analysis, an older age (odds ratio [OR] 0.89 [95% confidence interval 0.83-0.96], P = 0.003), longer puncture to recanalization time (OR 0.97 [0.93-0.99], P = 0.033), and higher baseline core volume (OR 0.84 [0.75-0.94], P = 0.003) decreased the probability of good clinical outcomes, while a final complete (or near-) recanalization (modified Thrombolysis In Cerebral Infarction [mTICI] score 2c-3) increased the probability of good outcome (OR 14.19 [1.99-101.4], P = 0.008).An older age, a longer puncture to recanalization time, and a higher baseline core volume decreased the probability of good clinical outcomes, while successful recanalization (mTICI 2c-3) was associated with better outcomes after MT for DMVO.

Purpose To evaluate the safety and efficacy of the Tigertriever 13 (Rapid Medical, Yoqneam, Israel) stent retriever in acute ischemic stroke (AIS) patients with primary or secondary distal, medium vessel occlusions (DMVO). Methods We performed a retrospective analysis of all consecutive AIS patients who underwent thrombectomy with the Tigertriever13 for DMVO. Patients’ characteristics were reviewed, procedural complications, angiographic (modified thrombolysis in cerebral infarction score [mTICI]) and clinical (modified Rankin Scale [mRS]) outcomes were documented. Results Between November 2019 and November 2020, 16 patients with 17 DMVO were included (40% female, median age 60 [50–65] years). The Tigertriever13 was used in 11/17 (65%, median NIHSS of 8 [6–15]) primary DMVO and in 6/17 (35%, median NIHSS of 20 [13–24]) cases of secondary DMVO after a proximal thrombectomy. The successful reperfusion rate (mTICI 2b, 2c, 3) was 94% (16/17) for the dedicated vessel. At day 1, CT imaging showed a subarachnoid hemorrhage in 29% of the cases and a parenchymal hematoma in 12%. At 3 months, 65% of the patients (11/17) had a favorable outcome (mRS 0–2). Conclusion Mechanical thrombectomy using the Tigertriever13 appears to be safe and effective for DMVO. Clinical and anatomical results are in line with those of patients with proximal occlusions.

Paratuberculosis (PTB) is a disease caused by Mycobacterium avium subspecies paratuberculosis (MAP), which affects a broad range of hosts, including domestic and wild animals. PTB is a chronic granulomatous enteritis and lymphadenitis that compromises animal welfare and causes economic losses. The objective of this study was to evaluate the effect of a commercial heat-inactivated MAP vaccine on lesions and immunopathology developed in the target tissues of goats naturally infected with MAP. Lesions compatible with PTB in the intestine and regional lymph nodes (LNs), as well as local immune response to MAP, were evaluated and compared in Gudair®-vaccinated (n = 14) and unvaccinated (n = 11) goats from a MAP-infected farm. The percentage of animals with multifocal granulomatous lesions in the jejunal (p = 0.05) and ileocecal (p = 0.02) LNs was higher in unvaccinated animals, while a lesion score reduction of 50% was found in the LNs of vaccinated animals. Unvaccinated animals showed increased numbers and wider distribution of macrophages (MΦs, CD68 +) in histiocytic infiltrate (p = 0.0003), associated with increased numbers of mycobacteria. Increased inducible nitric oxide synthase (iNOS) expression was also reported in these animals, while M2 MΦs (CD163 +) were scarce in both groups. Vaccinated animals showed an increase in CD3 + lymphocytes, although differences in interferon gamma (IFNγ) were negligible. These results support the hypothesis that heat-inactivated MAP vaccination could reduce the severity of PTB lesions and mycobacterial load in target tissues in vaccinated adult goats.

Background and Purpose: Previous studies have noted the angiographic appearance of early venous filling (EVF) following recanalisation in acute ischemic stroke. However, the prognostic implications of EVF as a novel imaging biomarker remain unclear. We aimed to evaluate the correlation between EVF with (i) the risk of subsequent reperfusion hemorrhage (RPH) and (ii) the association of EVF on both the NIHSS score at 24 h and functional outcome as assessed with the Modified Rankin Scale (mRS) score at 90 days. Methods: We conducted a retrospective cohort study of patients presenting with an acute ischemic stroke due to a proximal large-vessel occlusion of the anterior circulation treated by thrombectomy. Post-reperfusion digital subtraction angiography was reviewed to look for EVF as evidenced by the contrast opacification of any cerebral vein before the late arterial phase. Results: EVF occurred in 22.4% of the 147 cases included. The presence of EVF significantly increased the risk of RPH (p = 0.0048), including the risk of symptomatic hemorrhage (p = 0.0052). The presence of EVF (p = 0.0016) and the absence of RPH (p = 0.0021) were independently associated with a better outcome as defined by the NIHSS difference at 24 h, most significantly in the EVF+RPH- group. No significant relationship was however found between either EVF or RPH and a mRS score ≤ 2 at 90 days. Conclusion: Early venous filling on angiographic imaging is a potential predictor of reperfusion hemorrhage. The absence of subsequent RPH in this sub-group is associated with better outcomes at 24 h post-thrombectomy than in those with RPH., info:eu-repo/semantics/published

Cet article, appuye sur une enquete ethnographique, rend compte du travail d’encadrement dans le secteur marchand de l’aide a domicile. Interrogeant le travail d’articulation des managers de proximite, il montre comment ce personnel œuvre pour repondre aux differentes tensions qui traversent un milieu caracterise par une forte demande economique, un haut taux de rotation du personnel et une sinistralite importante. Pris dans certaines logiques contradictoires et injonctions paradoxales, ce personnel encadrant sort regulierement du cadre. Le cas du systeme de reconnaissance et de remuneration variable permet d’illustrer cette activite et ses tensions.

International audience

Au milieu des annees 1990, plusieurs reformes ont profondement transforme l’organisation de la Police nationale francaise, en particulier en ce qui concerne les differentes categories de personnels. L’une de ces reformes a conduit a conferer, sous certaines conditions, aux agents de police des pouvoirs d’enquete et de coercition auparavant reserves a des enqueteurs specialises ou aux niveaux superieurs de la hierarchie. Le present article examine les consequences de ces reformes sur les pratiques des agents et le fonctionnement de l’institution, a partir d’une enquete aupres d’un service judiciaire de premiere ligne, dans un service de police d’une grande ville.

Large vessel occlusion (LVO) leads to debilitating stroke and responds modestly to recombinant tissue plasminogen activator (rt-TPA). Early thrombectomy improves functional outcomes in selected patients with proximal occlusion but it is not available in all medical facilities. The best imaging modality for triage in an acute stroke setting in drip-and-ship models is still the subject of debate., info:eu-repo/semantics/published

Stent-assisted coiling (SAC) has widened indications of endovascular treatment of intracranial aneurysms (wide-neck, fusiform aneurysms); moreover, it is associated with more stable anatomical results. Besides the development of other techniques such as flow diverter stents, bifurcation stents, or intrasaccular flow disruptors, SAC remains one of the most used endovascular techniques because it provides good clinical and anatomical results for most aneurysms. Several devices based on the same principle are available and have undergone many adaptations and developments over 20 years of intracranial stenting.The purpose of this article is to review and compare intrinsic properties of available devices and their anatomical and clinical performance.Based on this review and our experience of SAC, we will discuss the behavior and performance of those devices in different anatomic and clinical situations.

Cet article propose d’aborder la question des émotions dans la relation socio-éducative en prenant l’exemple d’un service pédiatrique hospitalier et de deux brigades de police. Il soutient l’idée que le travail sur les émotions réalisé par les professionnels est fondamental dans la relation de service ; en d’autres termes, qu’il s’agit d’une compétence professionnelle. Il montre alors la forme que peut prendre cette intelligence émotionnelle. En outre, l’article interroge l’origine de cette intelligence en soulignant qu’elle est à la fois le fruit d’une organisation collective et d’un parcours individuel. Based on a comparative study of hospital pediatric services and two police departments, the article studies the emotions in socio-educational relation. He supports the idea that the work on the feelings realized by the professionals is fundamental in this relationship ; in other words, it is a professional skill. This article shows the shape that this emotional intelligence can set. Besides, he questions the origin of this intelligence by underlining that it is at the same time the result of a collective organization and an individual caree. Este artículo aborda la cuestión de las emociones en la relación socioeducativa tomando como ejemplo un servicio pediátrico hospitalario y dos brigadas de policía. Apoya la idea de que el trabajo sobre las emociones que realizan los profesionales es fundamental en la relación de servicio ; en otras palabras, se trata de una competencia profesional. El artículo muestra así la forma que puede tomar esta inteligencia emocional. Además, cuestiona el origen de esta inteligencia haciendo hincapié en que es, a la vez, fruto de una organización colectiva y de una trayectoria individual.

Cet article presente quelques resultats d’une etude comparative interrogeant la construction de l’ethos professionnel a travers l’usage memoriel. En s’interessant a la facon dont les souvenirs sont mobilises dans trois collectifs de travail, les auteurs montrent comment les identites s’elaborent dans l’appel a differents regimes discursifs. Trois types de recits sont degages : l’anecdote, le recit experientiel et l’« histoire illustre ». S’ils s’appuient sur des souvenirs individuels et sont partages au sein des groupes, ils contribuent cependant chacun specifiquement a la construction du sens du travail.

International audience; A new prompt fission neutron spectra (PFNS) measurement in the 238U(n,f) reaction was performed at LANSCE/WNR facility. Evaluated data show discrepancies on the low (below 1 MeV) and high (above 5 MeV) energy parts in the PFNS for different major and minor actinides. The goal is to improve these measurements in a wide range of incident energy. The energy of the incoming neutron, inducing the fission, and the prompt neutron energies, are measured by time-of-flight method. A dedicated fission chamber was developed, in order to improve alpha-fission discrimination, timing resolution, actinide mass, and to reduce the amount of neutron scattering. To detect prompt neutrons, the 54 Chi-Nu scintillator cells array were surrounding the fission chamber. High statistics were recorded during this experiment, allowing a precise study of PFNS behavior as a function of incident neutron energy, from 1 MeV to 200 MeV. This experiment also showed that all the new tools developed to improve PFNS measurements are performing. Therefore, measurements of PFNS with others actinides such as 239Pu are planned.

Ce chapitre d'ouvrage traite de la requisition de police d'une entreprise des pompes funebres par un officier de police judiciaire. Il montre que si la requisition de police revet toutes les caracteristiques du sale boulot dans les pompes funebres (risque emotionnel, activite stigmatisante, etc.), elle est aussi envisagee par les agents funeraires comme un challenge, une epreuve pour temoigner de son professionnalisme aupres des pairs. Des lors, plus la requisition de police est insolite, plus elle permet a l'individu de se valoriser aupres de son collectif.

A new 238U(n,f) prompt fission neutron spectra (PFNS) measurement has been recently performed at the WNR facility of the Los Alamos National Laboratory. The measurement allows one to explore the dependence of the prompt fission neutron energy spectra on the incident neutron energy. The experimental setup couples the Chi-Nu scintillator array to a newly developed fission chamber, characterized by an improved alphafission discrimination and time resolution, a reduced amount of matter in the neutron beam and a higher actinide mass. The dedicated setup and the high statistics collected allow us to obtain a good precision on the measured fission neutron energy, as well as to explore the low energy region, down to 650keV, and the high energy region, above 5 MeV, of the emitted neutron spectrum. These are indeed the regions where discrepancies in the evaluated PFNS data are found. We present here the first preliminary results of the experiment.

International audience

Dans un contexte actuel de pénurie médicale, une multitude de demandes formulées par les patients ne se traitent plus systématiquement en consultation de médecine générale. Le secrétariat est un pivot central clans la relation entre le médecin et ses patients et il est en première ligne face aux requêtes des patients. Le métier de secrétaire évolue et les médecins généralistes ont dorénavant le choix de systèmes de secrétariat très différents, Le but de ce travail est d'étudier les méthode de gestion par les secrétaires médicaux des demandes des patients hors prise de rendez-vous, les moyens dont ils disposent et leurs conséquences ressenties. Une étude qualitative a été réalisée par entretiens semi -dirigés auprès de dix secrétaires médicaux entre septembre 2016 et juin 2017, lesquels travaillaient dans huit cabinets de médecins généralistes libéraux en Seine-Maritime. Des secrétariats sur place ainsi que des secrétariats à distance sous forme de plateforme ont été interrogés. Les principales demandes formulées par les patients concernent des ordonnances de soins sans consultation, des résultats des examens, des problèmes administratifs ou des avis médicaux. Les secrétaires doivent souvent rechercher des précisions qui peuvent entraîner des réactions différentes de la part des patients. Ils disposent de plusieurs moyens pour répondre à ces requêtes leur avis base sur leur expérience, les consignes reçues du médecin, l'accès aux dossiers médicaux, le recours aux collègues ainsi que l'avis auprès du médecin. Ces moyens sont variables selon les types de secrétariat. La gestion de ses demandes a des conséquences sur le reste de leurs tâches et peut générer une tension personnelle ou vis-a-vis des patients voir du médecin. Des aides techniques et théoriques pourraient les aider. Cette étude a permis de mieux comprendre la gestion de ces demandes par les secrétaires et suggère une amélioration des conditions matérielles et d'encadrement médical. Par ailleurs la prise en charge de ses demandes par les secrétaires semble avoir des conséquences directes sur l'activité du médecin en évitant son implication dans beaucoup de ces situations. En plus des nombreuses tâches exécutées par les secrétaires ce rôle tend à prouver l'importance de leur situation dans la relation médecin-patient. Les nouvelles formes de secrétariats dématérialisés ne semblent pas en mesure d'effectuer ce type de prise en charge.

Le médecin généraliste est un acteur essentiel de la lutte contre l'émergence des entérobactéries productrices de bêta-lactamases à spectre étendu (EBLSE). Les recommandations de la Société de Pathologie Infectieuse de Langue Française (SPILF) de mai 2014 encadrent pour la première fois la prise en charge des infections urinaires à EBLSE. L'objectif de cette étude était d'évaluer la prise en charge de ces infections par les médecins généralistes à la lumière de ces nouvelles recommandations. Méthode : Nous avons réalisé une étude épidémiologique observationnelle descriptive en colligeant tous les examens cytobactériologiques des urines (ECBU) ayant isolé une EBLSE prescrits entre le 01/07/2014 et le 30/06/2015 par des médecins généralistes, provenant d'un seul laboratoire d'analyse médicale. Nous avons recueilli de manière rétrospective à travers un questionnaire entre autres : les antécédents du patient, la situation clinique dans laquelle a été réalisé l'ECBU, l'antibiothérapie prescrite de manière probabiliste ou documentée. Le critère de jugement principal était la prescription d'une antibiothérapie permettant un succès thérapeutique théorique avec pour référentiel les recommandations de la SPILF 2014. Résultat : Nous avons recueilli les informations concernant 48 patients pris en charge par 31 médecins généralistes. 25% des patients ne présentaient aucun facteur de risque d'infection à EBLSE. Dans 63% des cas, l'antibiothérapie prescrite en dernière intention était conforme avec une association statistiquement significative entre l'appel à un spécialiste et une prescription respectant les recommandations (p=0,018). Dans 56% des cas (n=9) la cause de non-conformité de la prise en charge était la prescription d'une antibiothérapie dans un contexte de bactériurie asymptomatique. Des mesures d'hygiène n'ont été mises en place que dans 25% des cas et le patient informé de son infection par une EBLSE dans 44% des cas. Conclusion : La sensibilisation des médecins à la problématique des infections à EBLSE doit être accentuée. Plus de moyens doivent être mis en oeuvre pour aider les médecins. Une collaboration entre médecins généralistes, biologistes et infectiologues semble essentielle pour améliorer la prise en charge de ces infections afin de développer le concept de mésusage des antibiotiques. Le but étant de diminuer la pression de sélection à l'origine de nombreuses résistances bactériennes.