Patients' experience on pain outcomes after hip arthroplasty: insights from an information tool based on registry data.

BACKGROUND: Arthroplasty registries are rarely used to inform encounters between clinician and patient. This study is part of a larger one which aimed to develop an information tool allowing both to benefit from previous patients' experience after total hip arthroplasty (THA). This study focuses on generating the information tool specifically for pain outcomes. METHODS: Data from the Geneva Arthroplasty Registry (GAR) about patients receiving a primary elective THA between 1996 and 2019 was used. Selected outcomes were identified from patient and surgeon surveys: pain walking, climbing stairs, night pain, pain interference, and pain medication. Clusters of patients with homogeneous outcomes at 1, 5, and 10 years postoperatively were generated based on selected predictors evaluated preoperatively using conditional inference trees (CITs). RESULTS: Data from 6,836 THAs were analysed and 14 CITs generated with 17 predictors found significant (p < 0.05). Baseline WOMAC pain score, SF-12 self-rated health (SRH), number of comorbidities, SF-12 mental component score, and body mass index (BMI) were the most common predictors. Outcome levels varied markedly by clusters whilst predictors changed at different time points for the same outcome. For example, 79% of patients with good to excellent SRH and less than moderate preoperative night pain reported absence of night pain at 1 year after THA; in contrast, for those with fair/poor SHR this figure was 50%. Also, clusters of patients with homogeneous levels of night pain at 1 year were generated based on SRH, Charnley, WOMAC night and pain scores, whilst those at 10 years were based on BMI alone. CONCLUSIONS: The information tool generated under this study can provide prospective patients and clinicians with valuable and understandable information about the experiences of "patients like them" regarding their pain outcomes.

[For which patients do the latest lipid lowering treatments reduce cardiovascular events?] / Pour quels patients les nouveaux traitements hypolipémiants réduisent-ils les événements cardiovasculaires ?

Dyslipidemia is a modifiable risk factor for cardiovascular diseases. Recommendations are based on achieving LDL-C target levels, but it is essential to assess the benefits of intensifying lipid-lowering therapy in terms of absolute risk reduction of cardiovascular events across different risk groups. Current data on the absolute benefits of the latest lipid-lowering treatments are more limited in comparison with statins. A recent analysis showed that adding a second lipid-lowering treatment only reduces the absolute cardiovascular risk in patients at very high and high cardiovascular risk, without a substantial benefit in patients at moderate or low cardiovascular risk, as mentioned in the recent recommendations free of conflict of interest and published in the British Medical Journal.

La dyslipidémie est un facteur de risque modifiable des maladies cardiovasculaires. Les recommandations sont basées sur l'atteinte de valeurs cibles du LDL-C mais il est essentiel d'évaluer les avantages de l'intensification du traitement hypolipémiant en termes de réduction du risque absolu d'événements cardiovasculaires dans les différents groupes à risque. Les données actuelles sur le bénéfice des nouveaux traitements hypolipémiants sont plus limitées comparées aux statines. Une analyse récente a montré que l'addition d'un second traitement hypolipémiant réduit le risque cardiovasculaire (CV) absolu uniquement chez les patients avec un risque CV très élevé ou élevé, sans bénéfice absolu substantiel chez les patients à risque CV modéré ou faible, ce qui a été repris des recommandations internationales sans conflit d'intérêts dans le British Medical Journal.

[Selected novelties for hospital based internal medicine]. / Nouveautés en médecine interne hospitalière.

In this selective overview of articles, we describe new concepts, therapeutic measures and pharmacological agents that may modify current practice in clinical internal medicine. Novelties for the management of cardiovascular disease, such as heart failure, hypoxemic respiratory failure, nosocomial pneumonia and certain allergies are discussed.

À travers quelques articles et études choisis, cet article décrit de nouveaux concepts, mesures thérapeutiques et agents pharmacologiques pouvant modifier les pratiques courantes en médecine interne. Des notions concernant la gestion de maladies cardiovasculaires telles que l'insuffisance cardiaque, les décompensations respiratoires hypoxémiques, les pneumonies nosocomiales et la gestion d'allergies y figurent au premier plan.

Digital encounter decision aids linked to clinical practice guidelines: results from user testing SHARE-IT decision aids in primary care.

BACKGROUND: Encounter decision aids (EDAs) are tools that can support shared decision making (SDM), up to the clinical encounter. However, adoption of these tools has been limited, as they are hard to produce, to keep up-to-date, and are not available for many decisions. The MAGIC Evidence Ecosystem Foundation has created a new generation of decision aids that are generically produced along digitally structured guidelines and evidence summaries, in an electronic authoring and publication platform (MAGICapp). We explored general practitioners' (GPs) and patients' experiences with five selected decision aids linked to BMJ Rapid Recommendations in primary care. METHODS: We applied a qualitative user testing design to evaluate user experiences for both GPs and patients. We translated five EDAs relevant to primary care, and observed the clinical encounters of 11 GPs when they used the EDA with their patients. We conducted a semi-structured interview with each patient after the consultation and a think-aloud interview with each GPs after multiple consultations. We used the Qualitative Analysis Guide (QUAGOL) for data analysis. RESULTS: Direct observations and user testing analysis of 31 clinical encounters showed an overall positive experience. The EDAs created better involvement in decision making and resulted in meaningful insights for patients and clinicians. The design and its interactive, multilayered structure made the tool enjoyable and well-organized. Difficult terminology, scales and numbers hindered understanding of certain information, which was sometimes perceived as too specialized or even intimidating. GPs thought the EDA was not suitable for every patient. They perceived a learning curve was required and the need for time investment was a concern. The EDAs were considered trustworthy as they were provided by a credible source. CONCLUSIONS: This study showed that EDAs can be useful tools in primary care by supporting actual shared decision making and enhancing patient involvement. The graphical approach and clear representation help patients better understand their options. To overcome barriers such as health literacy and GPs attitudes, effort is still needed to make the EDAs as accessible, intuitive and inclusive as possible through use of plain language, uniform design, rapid access and training. TRIAL REGISTRATION: The study protocol was approved by the The Research Ethics Committee UZ/KU Leuven (Belgium) on 31-10-2019 with reference number MP011977.

[Less is more, Choosing wisely, Smarter medicine : perspectives and issues]. / Less is more, Choosing wisely, Smarter medicine : enjeux et perspectives.

The « Choosing Wisely ¼ initiative aims to reduce overtreatment by issuing specific lists of recommendations. These campaigns have spread around the world over the last ten years, including in Switzerland, under the brand « Smarter Medicine ¼. The methodology used by different medical societies to issue these recommendations remains heterogeneous and heavily consensus-based and could benefit from a better synergy with the recent development of Evidence-Based Medicine and GRADE. Patient partnership, and reflections regarding economic and sustainability issues represent future avenues to enhance the potential impacts of such campaigns.

Le mouvement « Choosing Wisely ¼ a comme objectif de lutter contre la surmédicalisation via le développement de listes de recommandations. La dernière décennie a vu ce mouvement se diffuser à travers le monde, y compris en Suisse sous le nom de « Smarter Medicine ¼. La méthodologie avec laquelle ces recommandations sont élaborées par les sociétés savantes reste hétérogène et fortement basée sur le consensus, et pourrait bénéficier d'une meilleure synergie avec les développements de l'« Evidence-Based Medicine ¼ et de GRADE. Le partenariat avec les patients et les réflexions quant aux enjeux économiques et de durabilité sont autant de perspectives d'évolution de ces mouvements, afin de renforcer leurs impacts.

[Management of gout in the inpatient setting]. / Prise en charge hospitalière de la goutte.

Gout is a common complication occurring among inpatients, as factors affecting urate levels in blood and tissues are often modified by acute conditions. The control of chronic uricemia within recommended target values helps reduce the risk of flares. Joint aspiration is the gold standard for diagnosis, but ultrasound and dual-energy CT scan are reasonable alternatives. Acute and chronic treatments do not differ from those provided in outpatient care, although the increased prevalence of organ failures often require treatment adjustments. Active patient engagement, including therapeutic education during hospitalization, is essential for long-term disease control.

Lors d'un séjour hospitalier, les facteurs impactant la concentration sanguine et tissulaire d'urate sont souvent modifiés, augmentant le risque d'une crise de goutte. Le maintien de l'uricémie dans les cibles reconnues grâce à la poursuite des traitements contribue à réduire ce risque. La ponction articulaire est la méthode de référence pour établir le diagnostic, mais l'ultrason et le scanner à double énergie sont des alternatives fiables pour diagnostiquer une goutte. Les traitements aigu et chronique ne diffèrent pas de ceux pratiqués en ambulatoire, mais la fréquence augmentée d'insuffisances d'organes peut nécessiter l'adaptation des traitements. Pour assurer un contrôle de la maladie sur le long terme, il est essentiel d'impliquer le patient dans sa prise en charge, notamment par l'éducation thérapeutique dispensée pendant l'hospitalisation.

[Advances in hospital based internal medicine]. / Nouveautés en médecine interne hospitalière.

Hospital based internal medicine has been strongly solicited for over two years with the SARS-CoV-2 epidemic. This epidemic continues to evolve and represents a strain for public health. Numerous studies have addressed issues concerning this epidemic, and multiple novelties concerning other frequent pathologies have also been published. Management strategies of cardiovascular, pulmonary, gastro-intestinal and metabolic diseases are discussed.

La médecine interne hospitalière a été fortement sollicitée depuis 2 ans avec l'épidémie de SARS-CoV-2. Celle-ci continue d'évoluer et reste une épreuve pour la santé publique. Une pléthore d'études a tenté de résoudre les multiples défis que représente cette épidémie, mais de multiples nouveautés concernant d'autres pathologies fréquentes sont également apparues. La prise en charge des maladies cardiovasculaires, pulmonaires, gastro-intestinales et métaboliques est évoquée.

[Can we increase the availability of decision aids in French-speaking Switzerland?] / Comment augmenter l'accès aux outils d'aide à la décision en Suisse romande ?

Models of shared decision making recommend the use of patient decision aids. Hundreds of such aids exist worldwide but scaling up of their use in French-speaking Switzerland requires their translation to French and their adaptation to the clinical context. We review seven sources of tools that we assume relevant for French-speaking Switzerland. A short survey on a selection of three decision aids of general practitioners in the canton of Vaud confirmed their general interest in using such tools. They preferred a limited amount and a simple presentation of information in the decision aids to facilitate integration in clinical practice. Given the complexity of the required translations and adaptations, the medical community should develop a collaborative approach to lift this important task.

Les modèles de décision partagée recommandent, autant que possible, l'utilisation d'outils d'aide à la décision. La mise à l'échelle de la décision partagée en Suisse romande nécessite l'accès à un grand nombre d'outils de qualité disponibles en français et adaptés à notre pratique. Des centaines d'outils existent dans le monde entier. Nous passons en revue 7 types d'outils que nous supposons pertinents pour leur utilisation en Suisse romande. Nous présentons également l'avis d'un échantillon de convenance de 10 médecins généralistes vaudois sur une sélection de 3 outils. Les médecins étaient intéressés par l'utilisation de ces outils. Ils jugeaient qu'une quantité limitée et une présentation simplifiée des informations s'intégreraient mieux à leur pratique. La question de leur traduction et/ou adaptation éventuelle demeure complexe.

One-year persistent symptoms and functional impairment in SARS-CoV-2 positive and negative individuals.

BACKGROUND: Persistent symptoms of SARS-CoV-2 are prevalent weeks to months following the infection. To date, it is difficult to disentangle the direct from the indirect effects of SARS-CoV-2, including lockdown, social, and economic factors. OBJECTIVE: The study aims to characterize the prevalence of symptoms, functional capacity, and quality of life at 12 months in outpatient symptomatic individuals tested positive for SARS-CoV-2 compared to individuals tested negative. METHODS: From 23 April to 27 July 2021, outpatient symptomatic individuals tested for SARS-CoV-2 at the Geneva University Hospitals were followed up 12 months after their test date. RESULTS: At 12 months, out of the 1447 participants (mean age 45.2 years, 61.2% women), 33.4% reported residual mild to moderate symptoms following SARS-CoV-2 infection compared to 6.5% in the control group. Symptoms included fatigue (16% vs. 3.1%), dyspnea (8.9% vs. 1.1%), headache (9.8% vs. 1.7%), insomnia (8.9% vs. 2.7%), and difficulty concentrating (7.4% vs. 2.5%). When compared to the control group, 30.5% of SARS-CoV-2 positive individuals reported functional impairment at 12 months versus 6.6%. SARS-CoV-2 infection was associated with the persistence of symptoms (adjusted odds ratio [aOR] 4.1; 2.60-6.83) and functional impairment (aOR 3.54; 2.16-5.80) overall, and in subgroups of women, men, individuals younger than 40 years, those between 40-59 years, and in individuals with no past medical or psychiatric history. CONCLUSION: SARS-CoV-2 infection leads to persistent symptoms over several months, including in young healthy individuals, in addition to the pandemic effects, and potentially more than other common respiratory infections. Symptoms impact functional capacity up to 12 months post infection.

Decision aids for localized prostate cancer treatment choice: Systematic review and meta-analysis.

Patients who are diagnosed with localized prostate cancer need to make critical treatment decisions that are sensitive to their values and preferences. The role of decision aids in facilitating these decisions is unknown. The authors conducted a systematic review of randomized trials of decision aids for localized prostate cancer. Teams of 2 reviewers independently identified, selected, and abstracted data from 14 eligible trials (n = 3377 men), of which 10 were conducted in North America. Of these, 11 trials compared decision aids with usual care, and 3 trials compared decision aids with other decision aids. Two trials suggested a modest positive impact on decisional regret. Results across studies varied widely for decisional conflict (4 studies), satisfaction with decision (2 studies), and knowledge (2 studies). No impact on treatment choices was observed (6 studies). In conclusion, scant evidence at high risk of bias suggests the variable impact of existing decision aids on a limited set of decisional processes and outcomes. Because current decision aids provide information but do not directly facilitate shared decision making, subsequent efforts would benefit from user-centered design of decision aids that promote shared decision making.

[Intravenous furosemide for acute heart failure : continuous infusion or intermittent bolus ?] / Furosémide intraveineux dans l'insuffisance cardiaque aiguë : administration continue ou intermittente ?

Loop diuretics are strongly recommended by current guidelines for the treatment of acute heart failure. Intravenous furosemide can be administered either as a continuous infusion or as an intermittent bolus. The choice between these two routes is not always obvious in clinical practice. The understanding of their different mechanisms of action, as well as the notion of diuretic resistance, can help identify patients who may benefit from either of these two routes. This article aims at discussing these aspects and their pathophysiology, as well as summarizing the current body of evidence from randomized trials comparing continuous vs. intermittent administration of furosemide in acute heart failure.

Les diurétiques de l'anse sont fortement recommandés par les directives cliniques actuelles dans l'insuffisance cardiaque aiguë. Le furosémide intraveineux peut être administré sous formes continue et intermittente. En pratique clinique, le choix de la modalité d'administration n'est pas toujours évident. La compréhension de leur action et des mécanismes de résistance aux diurétiques permet d'identifier les situations cliniques qui répondent le mieux à l'une ou l'autre de ces méthodes d'administration. Cet article a pour but de discuter de ces différents aspects, notamment des mécanismes physiopathologiques en jeu, puis de synthétiser et évaluer le corpus d'évidences randomisées comparant ces deux modalités pour le traitement de l'insuffisance cardiaque aiguë.

[Latest progress in internal medicine]. / Avancées récentes en médecine interne.

Internal medicine continues de evolve as a result of further insight and evidence for the efficacy of given interventions. Although numerous studies have addressed issues concerning the SARS-COV-2 epidemic, multiple novelties concerning other frequent pathologies have also been presented. Management strategies of cardiovascular disease, infectious diseases and venous thromboembolism are particularly concerned.

La médecine interne continue d'évoluer au fur et à mesure de nouvelles évidences d'efficacité par rapport aux diverses interventions. Une pléthore d'études a tenté de résoudre les multiples défis que représente l'épidémie au SARS-CoV-2, mais de multiples nouveautés concernant d'autres pathologies fréquentes sont également apparues. La prise en charge des maladies cardiovasculaires, de maladies infectieuses et la maladie thromboembolique sont particulièrement concernées.

Role of Intermediate Care Unit Admission and Noninvasive Respiratory Support during the COVID-19 Pandemic: A Retrospective Cohort Study.

BACKGROUND: The COVID-19 pandemic has led to shortage of intensive care unit (ICU) capacity. We developed a triage strategy including noninvasive respiratory support and admission to the intermediate care unit (IMCU). ICU admission was restricted to patients requiring invasive ventilation. OBJECTIVES: The aim of this study is to describe the characteristics and outcomes of patients admitted to the IMCU. METHOD: Retrospective cohort including consecutive patients admitted between March 28 and April 27, 2020. The primary outcome was the proportion of patients with severe hypoxemic respiratory failure avoiding ICU admission. Secondary outcomes included the rate of emergency intubation, 28-day mortality, and predictors of ICU admission. RESULTS: One hundred fifty-seven patients with COVID-19-associated pneumonia were admitted to the IMCU. Among the 85 patients admitted for worsening respiratory failure, 52/85 (61%) avoided ICU admission. In multivariate analysis, PaO2/FiO2 (OR 0.98; 95% CI: 0.96-0.99) and BMI (OR 0.88; 95% CI: 0.78-0.98) were significantly associated with ICU admission. No death or emergency intubation occurred in the IMCU. CONCLUSIONS: IMCU admission including standardized triage criteria, self-proning, and noninvasive respiratory support prevents ICU admission for a large proportion of patients with COVID-19 hypoxemic respiratory failure. In the context of the COVID-19 pandemic, IMCUs may play an important role in preserving ICU capacity by avoiding ICU admission for patients with worsening respiratory failure and allowing early discharge of ICU patients.

Decision aids linked to evidence summaries and clinical practice guidelines: results from user-testing in clinical encounters.

BACKGROUND: Tools for shared decision-making (e.g. decision aids) are intended to support health care professionals and patients engaged in clinical encounters involving shared decision-making. However, decision aids are hard to produce, and onerous to update. Consequently, they often do not reflect best current evidence, and show limited uptake in practice. In response, we initiated the Sharing Evidence to Inform Treatment decisions (SHARE-IT) project. Our goal was to develop and refine a new generation of decision aids that are generically produced along digitally structured guidelines and evidence summaries. METHODS: Applying principles of human-centred design and following the International Patient Decision Aid Standards (IPDAS) and GRADE methods for trustworthy evidence summaries we developed a decision aid prototype in collaboration with the Developing and Evaluating Communication strategies to support Informed Decisions and practice based on Evidence project (DECIDE). We iteratively user-tested the prototype in clinical consultations between clinicians and patients. Semi-structured interviews of participating clinicians and patients were conducted. Qualitative content analysis of both user-testing sessions and interviews was performed and results categorized according to a revised Morville's framework of user-experience. We made it possible to produce, publish and use these decision aids in an electronic guideline authoring and publication platform (MAGICapp). RESULTS: Direct observations and analysis of user-testing of 28 clinical consultations between physicians and patients informed four major iterations that addressed readability, understandability, usability and ways to cope with information overload. Participants reported that the tool supported natural flow of the conversation and induced a positive shift in consultation habits towards shared decision-making. We integrated the functionality of SHARE-IT decision aids in MAGICapp, which has since generated numerous decision aids. CONCLUSION: Our study provides a proof of concept that encounter decision aids can be generically produced from GRADE evidence summaries and clinical guidelines. Online authoring and publication platforms can help scale up production including continuous updating of electronic encounter decision aids, fully integrated with evidence summaries and clinical practice guidelines.

Diagnostic accuracy of Augurix COVID-19 IgG serology rapid test.

AIMS: To validate the diagnostic accuracy of the Augurix SARS-CoV-2 IgM/IgG rapid immunoassay diagnostic test (RDT) for COVID-19. METHODS: In this unmatched 1:1 case-control study, blood samples from 46 real-time RT-PCR-confirmed SARS-CoV-2 hospitalized cases and 45 healthy donors (negative controls) were studied. Diagnostic accuracy of the IgG RDT was assessed against both an in-house recombinant spike-expressing immunofluorescence assay (rIFA), as an established reference method (primary endpoint), and the Euroimmun SARS-CoV-2 IgG enzyme-linked immunosorbent assays (ELISA) (secondary endpoint). RESULTS: COVID-19 patients were more likely to be male (61% vs 20%; P = .0001) and older (median 66 vs 47 years old; P < .001) than controls. Whole blood IgG-RDT results showed 86% and 93% overall Kendall concordance with rIFA and IgG ELISA, respectively. IgG RDT performances were similar between plasma and whole blood. Overall, RDT sensitivity was 88% (95% confidence interval [95%CI]: 70-96), specificity 98% (95%CI: 90-100), PPV 97% (95%CI: 80-100) and NPV 94% (95%CI: 84-98). The IgG-RDT carried out from 0 to 6 days, 7 to 14 days and > 14 days after the SARS-CoV-2 RT-PCR test displayed 30%, 73% and 100% positivity rates in the COVID-19 group, respectively. When considering samples taken >14 days after RT-PCR diagnosis, NPV was 100% (95%CI:90-100), and PPV was 100% (95%CI:72-100). CONCLUSIONS: The Augurix IgG-RDT done in whole blood displays a high diagnostic accuracy for SARS-CoV-2 IgG in high COVID-19 prevalence settings, where its use could be considered in the absence of routine diagnostic serology facilities.

[Granulocyte-Colony Stimulating Factors as adjunctive therapy in patients with neutropenic fever]. / Facteurs de croissance granulocytaire dans le traitement curatif des neutropénies fébriles.

Chemotherapy induced neutropenic fever requires a hospitalization in 20-30 % of cases and is then associated with a mortality above 10 %. Hospitalized patients require strict isolation, which sometimes results in a substantial physical and psychological burden. Granulocyte-colony stimulating factors (G-CSF) are established in the primary and secondary prevention of chemotherapy-induced neutropenia. However, their role as adjunctive therapy in patients with neutropenic fever is less clear. This review resumes current best evidence in this area and discusses current recommendations.

La neutropénie fébrile secondaire à une chimiothérapie nécessite une hospitalisation dans 20 à 30 % des cas, et est alors associée à une mortalité supérieure à 10 %. Les patients hospitalisés pour une neutropénie fébrile nécessitent des mesures d'isolement strictes, avec parfois des répercussions non négligeables sur les plans physique et psychique. Les facteurs de croissance granulocytaire (G-CSF) tiennent une place bien établie dans les préventions primaire et secondaire de la neutropénie liée aux cycles de chimiothérapie. Cependant, la place des G-CSF dans le traitement curatif de la neutropénie fébrile postchimiothérapie semble moins claire. Cet article a pour but de résumer l'évidence et discuter des recommandations actuelles dans cette indication thérapeutique.

[Treatment of subclinical hypothyroidism†: an update of the evidence and the new Rapid Recommendations]. / Traitement de l'­hypothyroïdie ­infraclinique†: mise à jour des ­connaissances et nouvelles «â€ Rapid ­Recommendations†¼ dans le BMJ.

Subclinical hypothyroidism is frequent and its treatment by thyroid hormones is debated. Current guidelines tend to recommend a treatment for symptomatic adults or for thyrotropin (TSH) levels > 10 mIU/l. Nevertheless, new evidence from systematic review, -including 21 trials and 2192 participants, demonstrated that thyroid hormone replacement has no clinically relevant benefit on patients' symptoms or prognosis. An international and independent panel -including physicians, methodologists and patients issues a strong recommendation (BMJ Rapid Recommendation) against thyroid hormones therapy for adults with subclinical hypothyroidism. This recommendation does not apply to women who are pregnant or trying to conceive or to patients with TSH > 20 mIU/l.

L'hypothyroïdie infraclinique est une entité fréquente et les bénéfices d'un traitement de substitution hormonal sont peu clairs. Les diverses guidelines recommandent actuellement de traiter les adultes symptomatiques ou avec des niveaux de thyrotropine (TSH) > 10 mUI/l. Les études observationnelles montrent en effet une association entre le taux de TSH et le risque cardiovasculaire. Cependant, selon les nouvelles données (large étude randomisée, revue systématique incluant 21 études), le traitement de l'hypothyroïdie infraclinique chez l'adulte n'a pas démontré de bénéfice symptomatique ni pronostique. Un panel d'experts internationaux indépendants, incluant médecins, épidémiologistes et patients, s'est donc prononcé en défaveur d'un traitement hormonal de ­l'hypothyroïdie infraclinique chez l'adulte. Cette recommandation ne s'applique pas aux femmes enceintes ou essayant de concevoir, ainsi qu'aux patients avec des niveaux de TSH > 20 mUI/l.

[Contemporary novelties in internal medicine]. / Médecine interne hospitalière en revue.

Confronted with increasingly complex and interdependent medical situations, targeted clinical answers and recommendations are -increasingly the result of a comprehensive appraisal of existing -evidence. In addition, public health and economic stakes have to be considered and integrated into the decision process, diagnosis and management of numerous clinical entities. This selective overview covers some of these entities and demonstrate the expanding overlap between inpatient and outpatient practice.

Face à des problématiques médicales de plus en plus complexes et interdépendantes, des réponses et recommandations ciblées sont aujourd'hui proposées, basées sur une revue compréhensive de la littérature. Des enjeux de santé publique et d'économie de la santé viennent s'ajouter au processus décisionnel, diagnostique, et de prise en charge dans de nombreuses pathologies. Cette revue sélective traite de certains de ces sujets et démontre l'accroissement du chevauchement entre médecines hospitalière et ambulatoire.

[The BMJ Rapid Recommendations: towards a new model for the production of clinical practice guidelines]. / « BMJ Rapid Recommendations ¼ : vers un nouveau modèle de recommandations pour la pratique clinique.

Guidelines play a central role in clinical practice, but their development often does not meet trustworthiness standards, which makes them vulnerable to conflict of interest. Additional problems -include their insufficient updating, and current formats that do not support shared decision-making. To address these issues, we have created the Rapid Recommendations, in collaboration with the British -Medical Journal. In this innovative approach, we a) identify new practice-changing evidence ; b) incorporate them in updated -systematics reviews in about 45 days ; c) gather an international and unconflicted panel including patients and d) publish trust-worthy recommendation in about 90 days, along with new multilayered evidence summaries and tools that facilitate shared decision-making.

Les guidelines ont une place centrale dans notre pratique clinique, mais leur développement manque souvent de rigueur et de transparence, rendant leurs recommandations vulnérables aux conflits d'intérêts. S'y ajoutent les problèmes de mise à jour insuffisante, et des formats qui ne facilitent pas leur adaptation locale ou la décision médicale partagée. En -réponse à ces problèmes, nous avons conçu les RapidRecs en collaboration avec le British Medical Journal. Cette approche innovante consiste à : a) identifier des -nouvelles études pouvant changer la pratique ; b) les incorporer dans des revues systématiques en -environ 45 jours ; c) rassembler un panel international indépendant, sans conflit d'intérêts et incluant des patients et d) émettre des recommandations -selon GRADE en environ 90 jours, avec des outils didactiques -facilitant la décision -médicale partagée.