Comment augmenter l'observance ? Schémas thérapeutiques, mesures de l'observance, risques, améliorations proposées

Logiques divergentes et confrontations des savoirs

La prise irrégulière ou le refus d’un traitement peuvent parfois être perçus comme une déviance ou une conduite anormale et modifier la relation entre le soignant et son patient. Le rôle des soignants consiste alors à ramener vers la norme les individus ne s’y conformant pas. La non-observance thérapeutique (la conduite) est un phénomène multidimensionnel. Néanmoins, la non-observance nécessite également d’interroger le point de vue des patients, c’est-à-dire l’adhésion thérapeutique (l’attitude). L’exploration des différentes rationalités qui modulent les trajectoires thérapeutiques des patients permet de saisir la complexité du lien entre les conduites et les attitudes. En nous appuyant sur une ethnographie réalisée à la Clinique de tuberculose d’un hôpital pédiatrique à Montréal (Québec, Canada), nous présentons une étude de cas qui permet d’approfondir la compréhension de l’observance (ou non) et de l’adhésion (ou non) thérapeutique. Des familles de l’Europe de l’Est sont au coeur de la réflexion. Certaines caractéristiques de ces familles mettent en avant des profils sociodémographiques qui modifient la rencontre clinique. Plus spécifiquement, l’accent est placé sur la pluralité des rationalités et des divergences au sein de la biomédecine, qui vient teinter les dynamiques relationnelles entre les familles et l’équipe soignante tout en exposant le déplacement des frontières entre les savoirs profanes et experts.

Liquid Chromatographic Determination of Ethambutol in Serum Samples Based on Intramolecular Excimer-forming Fluorescence Derivatization

A selective liquid chromatographic method has been developed for the assay of ethambutol in serum samples. The assay involves intramolecular excimer-forming derivatization with 4-(1-pyrene)butanoyl chloride (PBC) and isocratic reversed-phase chromatography with fluorescence detection. After acetonitrile-deproteinization of the serum sample, the derivatization reaction of ethambutol with PBC was completed within 30 min at 50 degrees C. N,N'-Diethylethylenediamine was used as an internal standard. The detection limit of ethambutol was 23 ng/ml serum, corresponding to 180 fmol on column at a signal-to-noise ratio of 3. The present method was selective enough to analyze ethambutol in rabbit serum without any tedious sample clean-up procedure because biogenic monoamines gave no peak in the chromatogram. The method was applicable to drug monitoring in rabbit serum.

Determination of ethambutol in plasma by high-performance liquid chromatography after pre-column derivatization

A new HPLC assay using UV detection (200 nm) was developed to determine ethambutol (EMB) concentrations in plasma. Following extraction (0.1 ml plasma) with chloroform, EMB and octylamine (used as internal standard) were derivatized with phenylethylisocyanate. Quantitation in plasma was achieved at 200 nm. There were no interferences from endogenous compounds. Intra- and inter-day variabilities were lower than 5.2 and 7.6%, respectively. The limit of quantitation of the method was 0.2 microg/ml. In plasma, ethambutol was found to be stable for at least one month when samples were stored at -20 degrees C. This assay was applied to the therapeutic monitoring of EMB concentrations in 19 patients suffering from tuberculosis.

Tuberculose et population défavorisée en Ile de France

Tuberculosis is increasing in France, particularly in district of Paris. This resurgence is attributed, in part, to the acquired immune deficiency syndrome (AIDS) epidemic infection, but also to the worsening of the social and economic conditions of a increasingly and more and more excluded part of the population. The non compliance to the treatment is the most problem among this population and explains the high rate or the lost from follow up patients and relapses. Several solutions are proposed to improve the compliance to the treatment, which remains one of the principal measures of the fight against tuberculosis.