ObjectivesThere is little data on pregnant women with imported malaria in high-income countries, especially regarding offspring outcomes. We wanted to determine pregnancy outcomes of imported malaria in pregnant women in mainland France.Patients and MethodsWe conducted a retrospective, descriptive study of outcomes in pregnant women hospitalized with malaria from 2004 to 2014 in two regions of mainland France. An adverse outcome was defined as a miscarriage, stillbirth, preterm birth (<35 weeks of gestation), low birth weight (LBW) defined as less than 2,500 g, or congenital malaria.ResultsOf 60 pregnancies, 5 were excluded because of elective abortions; 55 were investigated, of which 11 were primigravidae and 44 multigravidae. Pregnancies were singleton (n=51) or twin (n=4). Mean age was 30.4 years (range:19-45 y). Among the 55 cases, 9 ended in a miscarriage (8 singletons and 1 twin pregnancy) and 1 had a stillbirth at 21 weeks of gestation, all immediately after the malarial episode. 45 gave birth (29 vaginal deliveries and 16 caesarean sections) to 48 (42 singletons and 6 twins) newborns. Amongst these, 30 were healthy full-term newborns, 10 had LBW, and 8 were preterm. Overall, 26 of 55 (47.3%) pregnancies, and 29 of 59 (49.2%) offsprings had adverse outcomes. Compared to singleton pregnancies, twin pregnancies were associated with adverse outcomes (p=0.0438).ConclusionsImported malaria has a severe impact on pregnancy outcomes. Prevention and management of imported malaria in pregnancy should be optimized.

The increase in worldwide travel is making imported malaria a growing health concern in non-endemic countries. Most data on the pathophysiology of malaria come from endemic areas. Little is known about cytokine profiles during imported malaria. This study aimed at deciphering the relationship between cytokine host response and malaria severity among imported cases in France. This study reports cytokine profiles in adults with Plasmodium falciparum malaria included in the PALUREA prospective study conducted between 2006 and 2010. The patients were classified as having uncomplicated malaria (UM) or severe malaria (SM), with this last further categorized as very severe malaria (VSM) or less severe malaria (LSM). At hospital admission, eight blood cytokines were assayed in duplicate using Luminex ® technology: interleukin (IL)-1α, IL-1β, IL-2, IL-4, IL-10, tumor necrosis factor (TNF)α, interferon (IFN)γ, and macrophage migration inhibitory factor (MIF). These assays were repeated on days 1 and 2 in the SM group. Of the 278 patients, 134 had UM and 144 SM. At hospital admission, over half the patients had undetectable levels of IL-1α, IL-1β, IL-2, IL-4, IFNγ, and TNFα, while IL-10 and MIF were significantly higher in the SM vs. the UM group. Higher IL-10 was significantly associated with higher parasitemia (R = 0.32 [0.16–0.46]; P = 0.0001). In the SM group, IL-10 elevation persisting from admission to day 2 was significantly associated with subsequent nosocomial infection. Of eight tested cytokines, only MIF and IL-10 were associated with disease severity in adults with imported P. falciparum malaria. At admission, many patients had undetectable cytokine levels, suggesting that circulating cytokine assays may not be helpful as part of the routine evaluation of adults with imported malaria. Persisting high IL-10 concentration was associated with subsequent nosocomial infection, suggesting its possible interest in immune monitoring of most severe patients.

Background: Studies on pediatric travelers' health rarely address expat or long-term travelers' children. Method: To investigate reasons for seeking care and adherence to pretravel preparation, we prospectively enrolled French children 0-15 years old, either expatriates or staying > 6 months in tropical areas, who attended a French health center in Africa, Central America or Southern Pacific regions from October 01, 2011 to October 31, 2012. A standardized questionnaire was completed by a general practitioner at each visit, then anonymized and included in our database. Results: 464 questionnaires were collected from 367 children (sex ratio M/F: 1:1). Median age was 6.4 years (IQR: 3.6; 10.3). Reasons for seeking care were mostly infections (n = 378), of which 12 (3.2%) were tropical. There were no deaths, but one child with tuberculosis was repatriated. Coverage was high for routine immunization, but less for travel-related vaccines. Personal antivectorial protection was significantly lower in children aged > 5 y or in non-malarial areas. Where indicated, malarial chemoprophylaxis was prescribed to only one third of the children, of whom 60% were poorly compliant. Advice regarding measures against diarrhea was followed significantly more for stays < 2 yrs. Conclusion: Mild cosmopolitan illnesses predominated but protection against tropical threats should be optimized before and during the stay.

Les pathologies le plus fréquentes au retour de voyage à l’étranger sont les infections gastro-intestinales, les maladies fébriles et les problèmes dermatologiques. L’évaluation d’un enfant fébrile de retour de voyage est clinique : vérification des antécédents et des vaccinations, recherche d’autres cas au contact, signes fonctionnels et physiques, caractéristiques du voyage. Un bilan paraclinique de débrouillage complète souvent l’évaluation pour une orientation syndromique. Si les causes de fièvre sont surtout cosmopolites, la gravité des pathologies exotiques doit les faire rechercher en priorité. Le paludisme doit être évoqué devant toute fièvre en provenance d’Afrique subsaharienne. Le diagnostic repose sur l’association d’un frottis sanguin et d’un test sensible (goutte épaisse, polymerase chain reaction [PCR]) ou d’un test de diagnostic rapide (pour Plasmodium [P]. falciparum). Les critères clinicobiologiques de gravité sont essentiels pour orienter et traiter le patient. En cas d’accès non compliqué à P. falciparum, le traitement repose sur une thérapie combinée à base d’artémisinine (ACT), artéméther-luméfantrine ou arténimol-pipéraquine. Les accès graves sont traités par l’artésunate intraveineux, puis un ACT oral. Dengue, chikungunya et infection à virus Zika ont des caractéristiques cliniques communes (association fièvre-éruption-arthralgies, traitement symptomatique). En cas de dengue, il faut surveiller l’apparition de signes d’alerte qui pourraient faire craindre une évolution péjorative. Le chikungunya est grave en cas de transmission per partum, avec un risque d’encéphalite néonatale. Chez l’enfant, le Zika est a- ou peu symptomatique. Mais en cas d’infection pendant une grossesse, le risque est celui d’une embryofœtopathie. Le diagnostic de ces arboviroses repose sur la PCR à la phase aiguë et la sérologie secondairement. La symptomatologie de la typhoïde est peu spécifique, justifiant la pratique d’hémocultures systématiques devant une fièvre du retour. Son traitement repose sur les céphalosporines de troisième génération ou la ciprofloxacine, mais les résistances augmentent. Au total, la diversité des étiologies d’une fièvre de retour et la gravité potentielle des infections importées imposent une réflexion sur le parcours de soins de ces patients, en particulier vis-à-vis du risque de fièvre hémorragique.

Las enfermedades más frecuentes al regresar de un viaje al extranjero son las infecciones gastrointestinales, las enfermedades febriles y los problemas dermatológicos. La evaluación de un niño febril al regreso de un viaje es clínica: verificación de los antecedentes y las vacunaciones, búsqueda de otros casos en contacto, signos funcionales y físicos, y características del viaje. Unas pruebas complementarias de rutina completan a menudo la evaluación para una orientación sindrómica. Si bien las causas de fiebre son, sobre todo, cosmopolitas, la gravedad de la enfermedad exótica obliga a buscarlas prioritariamente. El paludismo debe sospecharse ante una fiebre procedente de África subsahariana. El diagnóstico se basa en la asociación de un frotis sanguíneo y una prueba sensible (gota gruesa, reacción en cadena de la polimerasa [PCR]) o una prueba de diagnóstico rápido (para Plasmodium falciparum). Los criterios clínico-biológicos de gravedad son esenciales para orientar y tratar al paciente. En caso de acceso no complicado por P. falciparum, el tratamiento se basa en un tratamiento combinado a base de artemisinina (ACT), arteméter-lumefantrina o artenimol-piperaquina. Los accesos graves se tratan con artesunato intravenoso, seguido de ACT oral. Dengue, chikungunya e infección por virus Zika tienen características clínicas comunes (fiebre-erupción-artralgias, tratamiento sintomático). En caso de dengue, conviene controlar la aparición de signos de alerta, que podrían hacer temer una evolución negativa. El chikungunya es grave en caso de transmisión en el parto, con un riesgo de encefalitis neonatal. En el niño, el Zika es asintomático o poco sintomático. Pero, en caso de infección durante el embarazo, el riesgo es el de una embriofetopatía. El diagnóstico de estas arbovirosis se basa en la PCR en la fase aguda y en la serología secundariamente. La sintomatología de la fiebre tifoidea es poco específica, lo cual justifica la práctica de hemocultivos sistemáticos ante una fiebre tras un viaje. Su tratamiento se basa en las cefalosporinas de tercera generación o el ciprofloxacino, pero las resistencias aumentan. En suma, la diversidad de las etiologías de una fiebre al regreso de un viaje y la potencial gravedad de las infecciones importadas imponen una reflexión sobre el proceso de tratamiento de estos pacientes, en especial en lo referente al riesgo de fiebre hemorrágica.

Background. Caregivers' suffering has been highlighted, and medical residents are no exception. In France, around 40 % of them suffer from burnout syndrome. Aim. To explore the constraints leading to medical residents' sufferance. Methods. Qualitative study using semi-structured interviews of 12 general practice residents in Grenoble. A interpretative phenomenological approach was used for the analysis. Results. Three categories emerged from the analysis: Education proposal, Relation - communication and Professionnalism. For the first, requirements of the medical studies in practice and out of practice. For the second, the construction of an identity, concessions undergone on personal life ( family life and friendship, leisure, health), psychological and emotional fatigue and relationship dimension. For the third: the responsibility in medical decisions, the constraints on their practice and the lack of recognition. Conclusion. The phenomenon appeared more complex than the frontal research of sufferance and burn out syndrome origins. Sociological approach would be necessary to complete these explorative data in the context of status suppression of medical resident in favor of postgraduate medical student.

Background. Non-pharmacologic home remedies (NPHR) are often used by patients. They offer advantages of being cheap, easy to access, they could avoid the risks associated with polypharmacy and could complete drug-based therapies in the treatment of minor health complaints. Aim. To evaluate attitude and practice of general practitioners (GPs) on these NPHR. Methods. A cross-sectional study was conducted in 2017 among all GPs in the Grenoble urban area. They were interviewed through anonymous questionnaire about NPHR prescription frequency in the previous week. The frequency of prescription of 40 NPHR (often, sometimes, never) and their presumed effectiveness (not; moderately; very effective) were asked. Results. 177 of 500 GPs answered (35.4% response rate). An average of 10.7% of patients received NPHR prescription. The most often used NPHR were saline water into the nasal passages to treat colds (74.6%), then doing mobility and/ or stretching exercises for lower back pains (69.4%) and bicarbonate mouthwash for oral candidiasis (61.1%). Those perceived as the most effective remedies were squatting during defecation to treat constipation (89.9%), running cold on burns (86.2%) and strengthening of the quadriceps for patellofemoral syndrome (78%). Only young age was associated with increased NPHR prescription, female sex with wide range of NPHR suggested. Conclusion. These results suggest that GPs knew and used a few home remedies. Others studies should be conducted in order to use them in a better way, to provide appropriate information to patients on their efficacity-security profil and to participate to reduce polymedication.

Background: Collaboration between general practitioners (GP) and community pharmacists (CP) is a priority to respond to the demand for primary health care, to improve the supply of care in the territories and to secure patient care. However, their respective curriculum are isolated and monoprofessional. There isn't any legal obligation encouraging universities to implement interprofessional education (IPE) programs. Objective: To carry out an inventory of GP-CP interprofessional education curriculums in France during the academic year 2016-2017. Methods: An observational transversal study was conducted in the 36 medicine universities and the 24 pharmacy universities in France. Data regarding existing pedagogical methods for interprofessional GP-CP education were collected by digital exchanges from September 2016 to February 2017. Results: Thirteen universities were invested in IPE programs. Ten universities provided initial GP-CP trainings, 2 provided continuing GP-CP trainings, and 1 provided both types of training. Different pedagogical methods were used. Five universities used role plays and 5 groups discussion worked on the representation of the profession. Three worked on clinical cases, 2 set up a practical clerkship, 2 used the classical lecture and one the educational speed dating. Conclusion: IPE is gradually merging in the curriculum of medical and pharmacy students in France. This inventory is a declarative database inviting the various UFRs to initiate or pursue their reflections on interprofessional education.

Introduction. Collaboration between general practitioners (GP) and community pharmacists (CP) help to secure patient care, to reduce health costs, and to improve comfort for professional's practice. However, difficulties to communicate between professionals, lack of interest in cooperative practice and ignorance of each other's skills limit the development of this beneficial practice. The discovery of the professional practice of his senior correspondent, by students in authentic learning situations, could be one of the answers. Objectives. Design a pharmacy clerkship for general practice residents (GPR) to discover CP practice and a medical training period for students in the 6th year of community pharmacy (S6CP) to discover clinical practice in Grenoble. Methods. A formalized consensus of experts by rounds Delphi was conducted between December 2016 and February 2017. The educational objectives for those ambulatory training proposed were based on the pedagogical models existing in the French universities and the proposals of the investigators. Experts could also propose new pedagogical objectives. The set was submitted to consensus validation using the RAND corporation rating. Results. A three. round Delphi approach was conducted including 18 experts. Among the 53 proposed objectives (35 by investigators, 18 by experts), 23 out of 30 reached a consensus for the GPR, 20 out of 23 for the S6CP. A pedagogical reference system was created based on these objectives. Conclusion. Following this work, a pilot study to assess feasibility, acceptance and clinical relevance should take place in Grenoble Alpes University.

Kuperman et al. found that patients with anemia had a higher risk of major bleeding (RR 2.84; 95% CI 2.52–3.39) in RIETE database. Anemia appeared to be an independent predictive factor for major bleeding [hazard ratio (HR) 1.95; 95% CI 1.72–2.20] in this registry. Unfortunately, selection bias due to enrolled patients does not allowed us to use these major results in ambulatory care. The aim of SCORE study was to refine bleeding risk estimation in French vitamin K antagonist (VKA) treated patients and to identifying one or several parameters of prognostic significance. We conducted a prospective, multi-center cohort study of 962 consecutive outpatients from private angiologic offices, clinics and hospitals enrolled in grenoble angiologic network for thromboembolic diseases between May 2009 and December 2010, followed during 1 year by their general practitioner. Main outcome was the occurrence of major bleeding or clinically non major relevant bleeding (CNMRB). Incidence rates major bleeding and CNMRB were 2.86 (95% CI 1.95–4.2) events per 100 patient-years and 12% (95% CI 9.89–14.11) respectively. Cox multivariate analyses showed that only anemia was strongly associated with a risk of major bleeding (HR 6.1; 95% CI 2.7–13.8; p = 0.001). Logistic regression analyses performed in CNMRB showed that anemia, prior gastro-intestinal bleeding and antiplatelet drug use were strongly associated with a risk of CNMRB at 1 year, respectively OR 2.53, 95% CI (1.4–4.56); p = 0.002, OR 3.32, 95% CI (1.51–7.31); p = 0.003 and OR 1.77, 95% CI (1.1–2.83); p = 0.017. These new data were consistent between major and CRNM bleeding in VKA treated patients. The key role of anemia should be confirmed in other prospective cohort studies, with different anticoagulants use such as direct oral anticoagulant in ambulatory care settings.

Background. Facing a demanding environment, the practitioner considers he is like any other patient. However, most of the time, he denies his fatigue and symptoms of illness because of indifference or because of fear of the truth. Aim. To gather community-based general practitioners' (GPs) point of view in the northern French Alps regarding the management of their own health through a structure project of specific treatments, its expected characteristics and its critics. Methods. An epidemiological analytic cross-sectional survey has been led with the help of an anonymous questionnaire with follow ups sent to 1076 community-based GPs from the counties of Isere, Savoie and Haute-Savoie between May and July 2012. Results. The high rate of answers obtained (59.4%) revealed an interest for this subject. Almost 69% of GPs who were asked were in favor of a dedicated health care system. They asked for preventive consultations and also for medical care (therapeutic prescriptions and medical treatments) within a reinforced confidential frame. They opted strongly for a free choice of practitioner as well as place of consultation. Self-surveillance (68.5%), the follow up already done by other colleagues (30.2%) together with the lack of time one has to consult (22.1%) seem to be the main causes of reluctance to the creation of a specific structure. Conclusion. The creation of a structure dedicated to the management of community-based GPs' health care is approved by a large majority. Requirements are numerous and obstacles are powerful. Its aim would be to improve practitioners' health, and through this, to ensure an optimal health care to patients.

Lorsque une personne doit recevoir plusieurs vaccins vivants atténués, il est recommandé de les administrer soit simultanément, soit en respectant un délai minimal de 28 jours entre les deux injections, en raison d’une possible interférence négative sur la réponse immune à chacun de ces vaccins. L’objectif principal de cette étude était de comparer la réponse humorale au vaccin amaril et au vaccin rougeole-oreillons-rubéole chez des enfants âgés de 6 à 24 mois, vaccinés avant un voyage en zone d’endémie amarile. Une étude rétrospective cas-témoins multicentrique a été menée dans 7 centres de vaccinations internationales de la région parisienne. Le statut immunologique d’enfants ayant reçu le vaccin amaril et le vaccin rougeoleux, seul ou combiné aux vaccins rubéole et oreillons, à un intervalle compris entre 1 et 27 jours (cas) a été comparé à celui d’enfants vaccinés simultanément (témoins no 1) ou à plus de 27 jours d’intervalle (témoins no 2) contre la fièvre jaune et la rougeole (la rubéole et les oreillons). Le critère d’évaluation principal était le pourcentage d’enfants présentant une immunité protectrice vis-à-vis de la fièvre jaune (titre neutralisant ≥ 10). Cent trente et un enfants ont été inclus, 62 cas, 50 témoins no 1 et 19 témoins no 2. Parmi eux, 127 (96 %) avaient un titre protecteur d’anticorps antiamarils ; les quatre enfants non immunisés vis-à-vis de la fièvre jaune appartenaient tous au groupe témoins no 1. Des études complémentaires seraient nécessaires pour confirmer ou infirmer ces résultats et modifier les recommandations actuelles, en supprimant l’intervalle minimum de 27 jours à respecter entre les vaccins rougeole-oreillons-rubéole et amaril. Nous pensons cependant qu’il est dès à présent possible de conseiller aux centres de vaccinations internationales de ne pas administrer ces deux vaccins le même jour.

Background. In France, one in five persons suffers from primary chronic insomnia with major implications in terms of morbidity, mortality and quality of life. Primary care management of insomnia could be improved by understanding the main actors' relation and representations.Objective. To high light common points and discrepancies of the representations of insomnia in general practitioners (GP) and patients.Methods. Qualitative study conducted in French North exploring the expectations and support difficulties experienced by both populations. A thematic analysis of codes was performed by independent researchers. A matrix analysis was then conducted.Results. 13 GP and 31 patients were interviewed, five common themes were identified. The multiplicity of reasons and late approach of this pattern during the same visit, iterative failures of self-therapy, delayed the care process. Insomnia was seen as minor by all interviewed persons and did not require any systematic individual screening. GPs felt stressed to prescribe drugs. Patients were afraid of drugs, and expected more listening and dialogue. The doctors had difficulties facing drugs withdrawal, while patients felt ready for it. Patients did not regard their GP as able to support them and many GPs did not feel equipped enough.Conclusion. Cross-analysis showed perspectives for enhancing insomnia care, patient-doctor relationship and communication and health education.

Backgrounds Malaria is a leading cause of imported febrile illnesses in pediatric travelers, but few studies have addressed severe imported pediatric malaria. We aimed to determine the risk factors and the features of imported pediatric severe malaria. Methods We conducted a retrospective, descriptive study using the French National Reference Center for Imported Malaria database, in children aged 0–15 years who were hospitalized with a falciparum malaria from January 1st 1996 to December 31th 2005. Uncomplicated and severe cases of falciparum malaria were compared to identify risk factors for severe cases. In the hospitals that reported more than five severe cases during the study period, we evaluated severe cases for prognostic factors and assessed the accuracy WHO criteria for predicting severity. Given the rarity of deaths, adverse outcomes were defined as requiring major therapeutic procedures (MTPs)—e.g., sedation, mechanical ventilation, nasal oxygen therapy, blood transfusions, hemodialysis, fluid resuscitation—or pediatric intensive care unit (PICU) admission. Results Of 4150 pediatric malaria cases included in the study, 3299 were uncomplicated and 851 (20.5%) were severe. Only one death was recorded during this period. Predictors for severe falciparum malaria were: age <2 years (OR = 3.2, 95% CI = 2.5–4.0, p <0.0001) and a travel in the Sahelian region (OR = 1.7, 95% CI = 1.3–2.0, p = 0.0001). Of 422 severe malaria cases, a stay in a Sahelian region, lack of chemoprophylaxis, age <2 years or thrombocytopenia <100 x 10^3/mm^3 predicted adverse outcomes. Except for the hyperparasitemia threshold of 4%, the main WHO 2000 criteria for severe malaria reliably predicted adverse outcomes. In our study, the threshold of parasitemia most predictive of a poor outcome was 8%. Conclusion In imported pediatric malaria, children younger than 2 years deserve particular attention. The main WHO 2000 criteria for severity are accurate, except for the threshold of hyperparasitemia, which should be revised.