[Patient decision aids for cancer prevention Synthesis for the francophone community]. / Outils d'aide à la décision pour la prévention des cancers. Synthèse pour la francophonie.

In recent years, the relationship between patients and healthcare professionals, and more broadly between public health actors and citizens, has shifted from a paternalistic, top-down approach to one of increased patient involvement in decision-making. Primary and secondary cancer prevention involve both benefits and risks, underscoring the importance of informed decision-making aligned with each patient and citizen's unique values and preferences. Shared decision-making, supported by decision aids, offers patients and citizens clear and comprehensible information about their options, enabling informed choices. This article aims to compile and define the characteristics of tools developed or translated into French for this purpose.

Depuis plusieurs années, la relation entre les patients et les professionnels de la santé et plus largement entre les acteurs de la santé publique et les citoyens a évolué, passant d'une approche paternaliste et top-down à une implication accrue des patients dans les décisions les concernant. La prévention primaire et secondaire des cancers présente des bénéfices mais parfois également des risques, nécessitant une décision alignée avec les valeurs et les préférences des patients et des citoyens. La prise de décision partagée, via des outils d'aide à la décision, offre aux patients des informations claires et faciles à comprendre à propos des options qui leur sont offertes, afin de prendre une décision éclairée. Cet article vise à recenser les outils créés ou traduits en français et à en définir les caractéristiques.

[Scientific consensus-building to promote the link between science and public policy]. / La recherche de consensus scientifique pour promouvoir le lien entre science et politiques publiques.

Consensus, defined as the position on which most scientists specialized in a given field agree at a given time, is a key aspect in increasing the readability, credibility and, ultimately, the use of scientific knowledge in public (evidence-based health policy). This article presents several methods aiming at developing scientific consensus between experts, such as the conventional or rapid Delphi approach, the nominal group technique, the RAND-UCLA appropriateness method and the consensus development conference. These methods are used to synthesize expert judgements when uncertainties persist in the literature - each with its own specificities in terms of duration, number of steps and expert participants enlisted, as well as the ways in which they are involved.

Le consensus, défini comme la position sur laquelle la plupart des scientifiques spécialistes d'un domaine se mettent d'accord à un moment donné, est un aspect-clé pour augmenter la lisibilité, la crédibilité et in fine l'utilisation des savoirs scientifiques dans les politiques publiques (evidence-based health policy). Cet article présente plusieurs méthodes permettant le développement de consensus entre personnes expertes, telles que l'approche Delphi conventionnelle ou rapide, la technique du groupe nominal, la méthode d'adéquation RAND-UCLA et la conférence de consensus. Ces méthodes permettent la synthèse des jugements experts lorsque des incertitudes persistent dans la littérature ­ chacune avec des spécificités en termes de durée, du nombre d'étapes et de personnes expertes sollicitées, ainsi que des modalités de leur implication.

Why did Swiss citizens vote to ban tobacco advertising?

In February 2022, Swiss citizens agreed to modify the Swiss Constitution to ban tobacco advertising reaching children and adolescents. This case study analyses the arguments used by both opponents and supporters of the constitutional amendment. Opponents argued that the proposed regulation went too far, threatened the economy, restricted personal freedom, was superfluous as the current law already protected youth and that it opened the door to marketing bans of other harmful products. Proponents focused on youth protection and invoked the burden of smoking on public health and the fact that advertising bans are an effective evidence-based measure. A comparison with previous campaigns to ban tobacco advertising that had failed suggests factors accounting for the positive vote in 2022. These include the strategic framing of youth protection, the separation of tobacco from other issues (such as alcohol advertising), the deteriorating image of the tobacco industry and the ability of the proponents to mobilise a broad coalition of health and youth organisations, with improved funding and communication. The lessons may be instructive for other campaigns seeking to regulate commercial determinants of health.

[New puff-like disposable electronic cigarettes: expert consensus on their regulation]. / Nouvelles cigarettes électroniques jetables « puffs ¼ : consensus d'expert-e-s sur leur réglementation.

New disposable electronic cigarettes have arrived on the Swiss market since 2020. Our study, conducted according to the three steps of the Delphi fast-track approach developed at Unisanté, obtained a consensual agreement among French-speaking Switzerland experts on the regulation of these products. Ideally, the panel of experts recommends a sales ban of the product. If this is not possible, a number of aspects should be strictly regulated: taxation, product composition and marketing, and sales and consumption restrictions. These regulations should go further than the current European directive and the future Swiss law. The conclusions will be useful to support and guide political decision making from a public health and environmental perspective.

De nouvelles cigarettes électroniques jetables sont arrivées sur le marché suisse depuis 2020. Notre étude, conduite selon les trois étapes de la démarche Delphi fast-track développée à Unisanté, a obtenu un accord consensuel entre expert-e-s suisses romand-e-s sur la réglementation de ces produits. Dans l'idéal, le panel d'expert-e-s recommande une interdiction de vente du produit. Si cela n'est pas possible, certains aspects doivent être strictement réglementés : taxation, composition des produits et marketing, restrictions de vente et de consommation. Ces réglementations devraient aller plus loin que l'actuelle directive européenne et la future loi suisse. Les conclusions seront utiles pour soutenir et orienter la prise de décision politique dans une perspective de santé publique et environnementale.

[Promoting physical activity in primary care practices. Review fifteen years after the launch of PAPRICA training]. / Promotion de l'activité physique au cabinet médical. Bilan quinze ans après le lancement de la formation PAPRICA.

This article reviews the PAPRICA (Physical Activity promotion in PRImary CAre) program fifteen years after the first training course in physical activity counseling for primary care physicians in French-speaking Switzerland. Subsequent developments are also presented, based on the PAPRICA experience. The article then looks at the national strategy for promoting physical activity in the medical practice, the issues involved in financing the services, and the situation in other comparable countries. The article concludes with a discussion of new challenges and future prospects for a program like PAPRICA.

Cet article dresse un bilan du programme PAPRICA (Physical Activity promotion in PRImary CAre) quinze ans après la première formation au conseil en activité physique destinée aux médecins de premier recours en Suisse romande. Sont également présentés les développements ultérieurs qui se sont appuyés sur l'expérience de PAPRICA. Cet état des lieux se penche ensuite sur la stratégie nationale en matière de promotion de l'activité physique au cabinet médical, les enjeux de financement des prestations, ainsi que la situation dans d'autres pays comparables. L'article se termine par l'évocation de nouveaux enjeux et les perspectives d'évolution pour un programme comme PAPRICA.

[REVIAC: ten years of advice for populations in vulnerable situations]. / REVIAC : dix ans de conseil pour les populations en situation de vulnérabilité.

The REVIAC device was designed ten years ago, with the aim of advising social workers in their efforts to support and reintegrate people in vulnerable situations. In this article, it will be a question of identifying the current issues and the challenges to be met for the future.

Le dispositif REVIAC a été conçu il y a dix ans dans le but de conseiller les assistants et assistantes sociales dans leurs démarches pour soutenir et réinsérer les personnes en situation de vulnérabilité. Dans cet article, il sera question de repérer les enjeux actuels et les défis à relever pour le futur.

Cigarette smoking during pregnancy and adverse perinatal outcomes: a cross-sectional study over 10 years.

BACKGROUND: It has been shown that active exposure to tobacco is associated with adverse pregnancy outcomes including, but not limited to, intrauterine fetal death, reduced fetal weight, and higher risk of preterm birth. We want to investigate these effects in a high-income country. METHODS: This cross-sectional study examined 20,843 pregnant women who delivered over 10 years at the Maternity Hospital of the Centre Hospitalier Universitaire Vaudois (CHUV) in Lausanne, Switzerland. The objective was to evaluate a dose-response relationship between daily cigarette use during pregnancy and possible adverse perinatal outcomes. The social and clinical characteristics as well as obstetric and neonatal outcomes were compared between the smoking and the non-smoking groups. Adjusted odds ratios (aOR) and trend analyses (ptrend) were calculated. RESULTS: Nineteen thousand five hundred fifty-four pregnant women met the inclusion criteria and 2,714 (13.9%) of them were smokers. Even after adjusting for confounding factors, smoking during pregnancy was associated with preterm birth, birthweight < 2500 g, intrauterine growth restriction, neonatal respiratory and gastrointestinal diseases, transfer to the neonatal intensive care unit, and neonatal intensive care unit admissions > 7 days. Intrauterine death and neonatal infection were associated with heavy smoking (≥ 20 cigarettes/day). Smoking appeared to be a protective factor for pre-eclampsia and umbilical cord arterial pH below 7.1. A significant trend (ptrend < 0.05) was identified for preterm birth, intrauterine growth restriction, birthweight < 2500 g, umbilical cord arterial pH below 7.1, transfers to our neonatal intensive care unit, and neonatal intensive care unit admissions more than 7 days. CONCLUSION: Cigarette smoking is associated with several adverse perinatal outcomes of pregnancy with a dose-dependent effect.

Investigating acceptability of a training programme in precision medicine for frontline healthcare professionals: a mixed methods study.

BACKGROUND: Precision Medicine offers tailored prevention, diagnosis, treatment and management to patients that considers genomics, lifestyle and environmental factors. If implementation of Precision Medicine is to advance, effective, focused upskilling of frontline healthcare professionals through quality continuing professional development is needed. This study reports on an evidence-based approach to needs assessment to investigate the current level of knowledge of Precision Medicine, acceptable content for training, the perceived potential of a more precision approach to patient care and motivation to participate in a training programme among pharmacists, advanced practice nurses and general practitioners. Investigating perceived needs can avoid a top-down approach and support a design that is fit for purpose to targeted professions. METHODS: This study reports on 2 focus groups (n = 12) delivered in French and German with equal professional participation of the targeted professions. The research objectives were investigated in two phases. During the first phase, a literature review and expert consultations were conducted to develop a definition of PM, patient cases and content for training. In a second phase, these investigations were further explored using focus groups to investigate acceptable learning objectives, the potential of PM to relevant professions and motivation of participants. Quantitative investigations using rating scales and visual analogues were incorporated. The focus groups were audio recorded, transcribed by intelligent verbatim and translated to English. NVivo was used for data analysis and interpretation following a hybrid approach using the Framework Method and thematic analysis. The analytical framework, Implementation Science, was applied to organise and present research data. RESULTS: Precision Medicine is considered a new topic area, largely unfamiliar to frontline healthcare professionals.. There was acceptance of a more precision approach to care among all participants with perceived positive implications for patients. Valuable insight was gathered on acceptable content and form for training. All participants expressed concerns on readiness within their professions which included an insufficient system infrastructure, a lack of time to attend needed training, a lack of clarity for use in practice and the time needed to build a support network. CONCLUSIONS: A precision approach to patient care is on the horizon for health care professionals not only in hospital settings but also at the community level. Our results conclude that an adaptable and flexible training programme in PM is timely, contextually relevant and conducive to the needs of targeted health professions for successful implementation. A training programme in PM will require support across sectors and stakeholders, supporting insurance models, educated patients and integrated care supported by innovative technology. Implementation Science outcomes are a useful strategy towards design of an effective training programme that can have measurable impact in practice.

[Risk assessment and management: between epidemiology and social acceptability]. / Évaluation et gestion des risques : entre épidémiologie et acceptabilité sociale.

Risk is a well-known concept in medicine and in epidemiology and its approach intend to be rational and measurable. Risk measurement makes it possible to communicate with a patient or a population the risk of occurrence of an event. However, it is often difficult to estimate accurately the probability of occurrence of an adverse event and there is therefore uncertainty. In addition, the notion of risk is not easy to grasp for most people. The same risk can be perceived very differently from one individual to another and this perception and understanding depends on psychological, social, cultural, historical and political factors. Understanding this social dimension of risk in clinical practice or in public health is essential to implement efficient risk management.

La notion de risque est bien connue en médecine et en épidémiologie et son approche se veut rationnelle et mesurable. Cette mesure du risque permet de communiquer à un patient ou à une population le risque de survenue d'un événement. Mais il est souvent difficile d'estimer avec précision la probabilité de survenue d'un événement et il existe donc de l'incertitude. De plus, la notion de risque n'est pas facile à appréhender pour la plupart des personnes. Un même risque pourra être perçu très différemment d'un individu à l'autre et ces perception et compréhension des risques dépendent de facteurs psychologiques, sociaux, culturels, historiques et politiques. Bien comprendre cette dimension sociale du risque est essentiel pour appréhender une gestion des risques, que ce soit en clinique ou en santé publique.

May direct-to-consumer genetic testing have an impact on general practitioners' daily practice? a cross-sectional study of patients' intentions towards this approach.

BACKGROUND: Direct-to-consumer genetic testing (DTCGT) offers individuals access to information on their probable risks of suffering from a wide range of chronic diseases. General practitioners (GPs) will probably play a major role in supporting its use, but patients' perception of DTCGT remain unclear. This study aimed to describe those attitudes and expectations and how they might affect GPs' daily practices. METHODS: In 2018-2019, a study related to the use of DTCGT for preventive care in general medicine was conducted among patients in Switzerland's French-speaking areas. Data were collected in the waiting room using a self-administrated questionnaire about patients' interest in DTCGT and what their attitudes might be if testing revealed an elevated risk of diabetes, colorectal cancer, or Alzheimer's disease. RESULTS: About 40% of the 929 participating (participation rate about 80%) patients had heard about DTCGT and, once the test had been explained, 43% reported that they would be interested in being tested. If that testing suggested an elevated risk of disease, the majority of patients reported that they would change their lifestyle (65%-81%, depending on the disease), request more examinations (63%-77%), and expect changes in their GP's follow-up (48%-59%). Personal characteristics such as sex, age, urbanity, marital status, and perceived health were factors predictive of patients' attitudes. CONCLUSION: Findings indicated that the generalization of DTCGT might affect GPs' daily practices in terms of workload and knowledge about this approach. However, this result must be qualified by the fact that it is based on hypothetical situations.

Médecine personnalisée et prévention des maladies chroniques : l'attitude des médecins généralistes.

OBJECTIVES: In a context of future generalization of access to genetic risk profiles, general practitioners (GP) will have a major role to play. The objective of this study was to understand their attitude towards this approach and the potential consequences on their practice. METHODS: In 2018, the University Center of General Medicine and Public Health of Lausanne, the Department of Primary Care Medicine of the University Hospitals of Geneva, and the Institute of Social Sciences of the University of Lausanne set up a study with patients and general practitioners concerning the access to genetic risk profiles. The GPs attitude, the subject of this study, was explored using the two-round Delphi consensus method. 120 interns and senior clinicians responded to 24 statements. RESULTS: A consensus was reached for 80% of the statements. The GP’s significant role in terms of access to genetic profiles became evident, even if their position seems conditioned by their position as front-line health workers, and doubts remain as to the impact of this process in guiding their practice. The need for training was widely emphasized as well as the possibility multidisciplinary support and management. There was also a consensus for the need of a legislative framework for these practices. CONCLUSION: This study has underlined the importance of anticipating the needs in developing an advanced and evolving training and information program for GPs in the domain of genomic medicine in light of the prevention activities that could result.

[Community-based medical practice. New academic teaching through a mass COVID-19 screening]. / Pratique médicale communautaire - Un nouvel enseignement universitaire à l'occasion d'un dépistage de masse de Covid-19.

Clusters of COVID-19 cases emerged during the months of December 2020 and January 2021 in the Vaud Alps. This epidemiological situation was worrying, as it appeared before a winter holiday period. In view of this epidemiological risk, the cantonal authorities decided to carry out mass screening in three communes from 5 to 13 February 2021 in addition to the standard measures in place. Seeing an opportunity to create innovative university teaching, Unisanté set up a new course for medical students of the University of Lausanne called Community Medical Practice. This immersion in the practice of public health enabled some thirty students to carry out several activities (clinical, research and epidemiological) in a unique pandemic context.

L'émergence de clusters de cas de Covid-19 a été constatée de décembre 2020 à janvier 2021 dans les Alpes vaudoises. Cette situation épidémiologique est devenue préoccupante, puisqu'elle est apparue avant une période de vacances hivernales. Face à ce risque épidémiologique, les autorités cantonales ont décidé d'effectuer un dépistage de masse, du 5 au 13 février 2021, dans trois communes en complément des mesures en vigueur. Voyant l'occasion de créer un exercice pédagogique novateur, Unisanté a mis en place un nouvel enseignement destiné aux étudiant·e·s de médecine de l'université de Lausanne, nommé Pratique médicale communautaire. Cette immersion dans la pratique de santé publique a permis à une trentaine d'étudiant·e·s d'exercer plusieurs activités (cliniques, de recherche et épidémiologiques) dans un contexte unique de pandémie.

[Personalized medicine and chronic disease prevention: Needs, attitudes and expectations regarding in general practice]. / Médecine personnalisée et prévention des maladies chroniques - Besoins, perceptions et attentes des patients et des médecins généralistes.

The ambition of personalized medicine now also concerns the prevention of chronic diseases, based on genetic risk profiles. The objective of this project was to describe the perception and attitudes of patients and general practitioners (GP) on this issue, in order to consider the consequences on the health system. The study included two axes, patients (questionnaire survey) and GPs (consensus study using the Delphi method), preceded by a qualitative exploratory phase. The study showed that genetic screening for disease risk factors was not a priority, either for patients or for GPs. On the other hand, the role of the GP in the use of these tests will probably be predominant. This implies the need for training and availability of up-to-date information.

L'ambition de la médecine personnalisée (MP) concerne désormais aussi la prévention des maladies chroniques en se basant sur les profils génétiques de risque. L'objectif de ce projet était de connaître la perception et les attentes des patients et des médecins généralistes (MG) sur cette question, pour envisager les conséquences sur le système de santé. L'étude comprenait deux axes, patients (enquête par questionnaire) et MG (étude de consensus par méthode Delphi), précédés d'une phase exploratoire qualitative. Elle a montré que le dépistage génétique des facteurs de risque aux maladies ne constituait pas une priorité, ni pour les patients, ni pour les MG. En revanche, la place du MG autour de l'utilisation de ces tests sera probablement prépondérante. Cela implique la nécessité de formations et la disponibilité d'informations à jour.

[Practical management of long Covid disease in outpatients: illustration by clinical cases]. / Prise en charge des patients avec Covid long : illustration par des cas cliniques.

The SARS-CoV-2 pandemic has caused an unprecedented global public health crisis. The term long Covid is used to describe diverse and heterogeneous symptoms that persist more than 4 weeks after infection with an estimated incidence of 10-40%, which varies between studies. The principal characteristics of long Covid are fluctuating symptoms of prolonged duration affecting multiple organs, such as fatigue, dyspnea, cough, anosmia, dysgeusia, chest pain, palpitations, headache, myalgia, cognitive and gastrointestinal disorders. Contributing factors, possible pathophysiological explanations and international recommendations can help in the management of the disease in the outpatient setting. Biopsychosocial and multidisciplinary management in primary care medicine is essential.

La pandémie due au virus SARS-CoV-2 a provoqué une crise de santé publique sans précédent. Le terme Covid long est utilisé pour décrire les divers symptômes hétérogènes et persistant plus de 4 semaines après l'infection, avec une incidence de 10 à 40 %, qui varie selon les études. Les caractéristiques principales du Covid long sont une atteinte multisystémique et des symptômes fluctuants et prolongés comme la fatigue, la dyspnée, la toux, l'anosmie, la dysgueusie, les douleurs thoraciques, les palpitations, des céphalées, des myalgies, des troubles cognitifs et des troubles gastro-intestinaux. Les facteurs favorisants, les explications physiopathologiques possibles et les recommandations internationales rendent indispensable une prise en charge biopsychosociale et pluridisciplinaire en médecine de premiers recours.

[Mass testing for Covid-19 : what can we learn from real-world implementation ?] / Dépistage de masse du Covid-19 : quelles leçons tirer des récentes expériences ?

While several modelling studies suggest mass testing for SARS-CoV-2 could be effective, real-world attempts at implementation have not been sufficient to evaluate its contribution to controlling the pandemic. To slow the spread of the virus, a mass-testing campaign would need frequent testing over a prolonged period with high rates of participation, all while maintaining public health measures. Screening seems more useful for targeted populations or high-risk events (businesses, teaching facilities, public or private institutions, sporting or cultural events). With their low cost and rapid results, rapid tests should be favored for these interventions.

Bien que des modélisations de dépistage de masse pour le SARS-CoV-2 suggèrent une certaine efficacité, leur réalisation en pratique n'a, à ce jour, pas été confirmée et leur potentiel impact en termes de contrôle sur la pandémie reste à démontrer. Pour espérer endiguer la propagation du virus, il faut réaliser un dépistage fréquent, sur une période prolongée, et atteindre un taux de participation très élevé, cela tout en maintenant les mesures sanitaires. Le dépistage semble toutefois envisageable s'il est ciblé sur une population ou un événement à risque (entreprises, lieux de formation, établissements publics ou privés, manifestations sportives ou culturelles). De par leur faible coût et leur rendu rapide du résultat, les tests rapides sont à favoriser pour de telles stratégies interventionnelles de dépistage.

Self-reported screening practices of family physicians participating in the colorectal cancer screening program of the canton of Vaud: a cross-sectional study.

BACKGROUND: The organized colorectal cancer (CRC) screening program in the canton of Vaud, Switzerland offers citizens the choice of the faecal immunochemical test (FIT) or colonoscopy via a visit with a family physician (FP). Given the central role of FPs in the program, this study aimed to compare their self-reported preventive practices with the objectives of the program, namely to inform patients about CRC screening and present the choice of colonoscopy and FIT, and to identify factors associated with presenting a choice of tests. METHODS: Mixed-methods study using an online survey and semi-structured interviews. Participants were FPs from the canton of Vaud who had included ≥1 patient in the screening program. We used multivariate logistic regression to compare FPs offering only colonoscopy to those who offered a choice of tests or FIT. RESULTS: The participation rate was 40% (177 respondents / 443 eligible). Most FPs (68%) reported informing more than 75% of eligible patients about the program. Lack of time (n = 86, 33%) was the principal reason cited for not informing patients. Regarding the screening methods, 20% (n = 36) of FPs prescribed only colonoscopy, 13% (n = 23) only FIT and 65% (n = 115) both screening methods. Predictors of offering only colonoscopy rather than a choice of screening tests included: first, FP reporting that they chose/would choose colonoscopy for themselves (OR 8.54 [95% CI 1.83-39.79, P < 0.01]); second, being > 20 years in practice (OR 4.8 [95% CI 1.3-0.17.66, P = 0.02]); and third, seeing 300 or more patients per month (OR 3.05 [95% CI 1.23-7.57, P = 0.02]). When asked what could improve the program, 17% (n = 31) wrote that patients should be informed in advance about the program by postal mail and a large-scale communication campaign. CONCLUSION: The majority of FPs reported CRC screening practices consistent with the objectives of the program. However, to ensure that patients are well informed and to save time, all patients need to be systematically informed about the program. Further, FPs should be encouraged to offer a choice of tests.

[Principles of prevention and precaution†: some guidelines for understanding them]. / Principes de prévention et de précaution†: quelques repères pour leur compréhension.

The COVID-19 pandemic highlighted, sometimes painfully, the stakes of decision-making in a context of significant uncertainty. Social distance, wearing a mask, confinement… difficult choices with significant health, social and economic impacts. To guide and justify our decisions, the principles of precaution and prevention have been used. Invoked like mantras to protect us from bad luck, are these two principles really a panacea for these situations ? Not sure… Beyond their intrinsic moral value and the rationality they bring to the decision-making process, their implementation suffers from serious limitations. Doesn't their use make us forget the essential ? The need to tackle the roots of the problem before ending up in an uncomfortable toss-up.

La pandémie de Covid-19 a mis en exergue, parfois douloureusement, les enjeux de la prise de décision dans un contexte d'incertitude importante. Distance sociale, port du masque, confinement… des choix difficiles dont les effets sanitaires, mais aussi sociaux et économiques sont conséquents. Pour guider et justifier nos décisions, les principes de précaution et de prévention ont été mis à contribution. Invoqués tels des mantras pour se protéger du mauvais sort, ces deux principes sont-ils réellement la panacée à ces situations ? Pas sûr… Au-delà de leur valeur morale intrinsèque et de la rationalité qu'ils apportent au processus décisionnel, leur mise en œuvre souffre de sérieuses limites. Leur usage ne nous fait-il pas oublier l'essentiel ? La nécessité de s'attaquer aux racines du problème avant de se retrouver dans un inconfortable pile ou face.

[Convergence of primary care and public health†: international examples and current issues]. / Convergence de la médecine générale et de la santé publique†: exemplesinternationaux et enjeux actuels.

Blending public health and primary care together means building bridges between professionals - those who deal with the health and care of individuals and those who deal with the health of a population. At the organizational level, many factors facilitate the integration of these two areas among which : a clear mandate with a vision, identified goals, and the development of a collaborative culture. In French-speaking Switzerland, the integration of public health and general medicine into a common university dynamic was one of the driving forces behind the Alliance santé project that led to the creation of Unisanté in 2019. Elsewhere in the world, similar institutions already exist and sometimes take different forms. In this article, we will briefly present four of them in Wales, Scotland, Canada and the Netherlands.

Faire converger la santé publique et la médecine générale, c'est créer des ponts entre les professionnel·le·s qui s'occupent de la santé et des soins d'une personne d'une part et celles et ceux qui ont pour sujet la santé d'une population. Plusieurs facteurs facilitent l'intégration de ces deux domaines parmi lesquels : un mandat clair avec une vision et des objectifs identifiés et le développement d'une culture collaborative. En Suisse romande, l'intégration de la santé publique et de la médecine générale dans une dynamique universitaire commune fut l'un des moteurs du projet Alliance santé qui a permis la création d'Unisanté en 2019. Ailleurs dans le monde, des institutions similaires existent déjà et prennent des formes parfois différentes. Nous allons dans cet article en présenter brièvement quatre au pays de Galles, en Écosse, au Canada et aux Pays-Bas.

[To screen or not to screen after age 75 ?] / Dépistages : que faire au-delà de 75 ans ?

The older population is heterogenous: at the same age, elderly patients can be robust, frail or dependent. Screening decisions must be individualized, taking into account the remaining life expectancy, the Time to Benefit (TTB: delay until preventive care gives a benefit), and patient preferences. Thus, robust patients, who have a longer life expectancy, can still benefit from some screening tests over age 75 that are inappropriate in vulnerable or dependent patients whose life expectancy is shorter than the TTB. Discussing life expectancy issues remains difficult outside of crises but medical encounters are unique opportunities to inquire about individual preferences and expectations, in order to define care objectives and discuss advanced care planning.

La population âgée est hétérogène : à âge identique, les patients peuvent être robustes, vulnérables ou dépendants. Le dépistage doit être individualisé en mettant en relation l'espérance de vie résiduelle estimée (EVR), le Time To Benefit (TTB : délai jusqu'à l'apparition de bénéfices après intervention) et les préférences du patient. Ainsi, les patients robustes, dont l'EVR est supérieure au TTB, peuvent encore bénéficier de certains examens de dépistage après 75 ans alors qu'ils seront inappropriés chez ceux dont l'EVR est inférieure au TTB (vulnérables, dépendants). Bien que discuter de l'EVR puisse être ardu, chaque consultation est une opportunité pour l'aborder, s'enquérir des préférences et attentes du patient quant à sa santé afin de définir ensemble les modalités de sa prise en charge et de son projet de soins anticipés.

[Covid-19 diagnosis†: clinical recommendations and performance of nasopharyngeal swab-PCR]. / Performance du frottis nasopharyngé-PCR pour le diagnostic du Covid-19 - Recommandations pratiques sur la base des premières données scientifiques.

The Covid-19 pandemic imposes new diagnostic strategies in order to optimize the medical care of our patients. The current biblio-graphy, although of low quality, shows a sensitivity of 56 to 83 % for the Covid-19 PCR. Even though one negative test can exclude a Covid-19 in the majority of cases, the NPV (Negative Predictive Value) decreases with increasing prevalence (pre-test probability). This finding suggests the need for strict auto-isolation of patients until the resolution of their symptoms. For patients that present with typical symptoms, who have a presumed Covid-19 prevalence of -40-50 %, a negative test should be interpreted with caution and a repeat test may be needed.

La pandémie actuelle du Covid-19 impose une stratégie diagnostique pour la prise en charge des patients. La performance du frottis nasopharyngé avec analyse par PCR peut être estimée sur la base des premières données bibliographiques. Celles-ci, certes de qualité faible, montrent une sensibilité de 56 à 83 % pour la PCR Covid-19. Un seul test négatif permet d'infirmer un Covid-19 dans la majorité des situations. Cependant, comme la valeur ­prédictive négative du test se situe entre 88 et 95 % en cas de ­probabilité prétest de 30 %, il est indispensable d'assurer le suivi de ces patients. Pour ceux qui présentent des symptômes typiques, qui auraient une probabilité prétest présumée à 40-50 %, un test négatif doit être interprété avec précaution et un deuxième test peut être indiqué.