A critical appraisal of acute sore throat guidelines using the AGREE II instrument: a scoping review.

BACKGROUND: Conflicting international guidelines exist on the management of sore throat by antibiotics. OBJECTIVES: To assess with the Appraisal of Guidelines for Research and Evaluation II (AGREE) instrument the quality of guidelines for uncomplicated acute group A beta-haemolytic streptococcal (GABHS) sore-throat. To make a sensitivity analysis restricted to guidelines with a rigour of development score higher than 60% and to describe their recommendations on scores, tests, and antibiotic therapy, including their justification. METHODS: A guideline literature review of acute GABHS sore throat, published between January 2000 and December 2019 in primary care and secondary care. The PubMed database, the Canadian Medical Association Infobase on Clinical Practice Guidelines and the International Network Guidelines were used. The quality of guidelines was assessed using the AGREE II instrument. The guidelines were classified into 2 categories: high-quality guidelines had to rate >60% for the rigour of development score, the others were classified as low-quality guidelines. RESULTS: Significant heterogeneity between the 15 guidelines concerned the scores of the 6 assessment domains. Among them, 6 guidelines presented a score above 60% with regards to the rigor of development domain and used a systematic literature search method, citing meta-analyses of recent randomised clinical trials. Most of the 6 high-quality guidelines no longer recommended the systematic use of diagnostic scores and tests, nor antibiotic therapy to prevent acute rheumatic fever or loco-regional complications, except for high-risk patients. CONCLUSION: Major discrepancies emphasise the need for only high-quality guidelines, based on adequately assessed evidence. Restricted antibiotic prescriptions to severe cases or high-risk patients would avoid antibiotic resistance.

Trends in clomiphene citrate and gonadotropins use in women with infertility between 2010 and 2017: A population-based study in France.

PURPOSE: To describe temporal trends and assess factors associated with changes in the prescription of clomiphene citrate and gonadotropins between 2010 and 2017 in women with infertility aged 18-50 from metropolitan France. METHODS: 6321 prevalent women from a representative sample of the national medico-administrative database were identified. We performed a Cochran-Armitage trend test and calculated the rate ratios. A Poisson regression was used to derive the incidence rate ratios, for each treatment class. RESULTS: The prevalence rate and incidence rate of clomiphene citrate use significantly decreased by 20% (RR 0.80: 95% CI 0.71-0.90) and 23% (RR 0.77: 95% CI 0.66-0.89), respectively. Its initiation was higher in all age groups compared to the reference (18-24 years), with a downward gradient. It was also higher when the density of gynaecologists was higher and in disadvantaged areas. The prevalence rate and incidence rate of gonadotropin use increased by 11% (RR 1.11: 95% CI 1.01-1.22) and 33% (RR 1.33: 95% CI 1.14-1.55) respectively. Gonadotropin initiation was highest in the 31-35 age group, but it was also higher in the 25-30 and 36-40 age groups at a similar level (reference 18-24 years). Its initiation was higher when the density of gynaecologists was higher, but not associated with social deprivation. CONCLUSION: Our results showed an increase in gonadotropin use for infertility treatment in France during the 2010-2017 period and a decrease in clomiphene citrate use. Further work should be undertaken to analyse the use of these drugs in relation to women's care pathways.

Bisphosphonate Use and Hospitalization for Hip Fractures in Women: An Observational Population-Based Study in France.

Bisphosphonates are widely used in the treatment of women at risk of osteoporotic hip fracture; however, the overall effectiveness of bisphosphonates in the prevention of osteoporotic fractures has not been studied in real life. To investigate whether the use of bisphosphonates in women aged 50 years and over is associated with a decrease in hospitalization for osteoporotic hip fractures, a historical prospective cohort study was conducted between 2009 and 2016 from a permanent representative sample consisting of 1/97 of the French health insurance beneficiaries. Bisphosphonate use was defined according to medication persistence and adherence regarding bisphosphonate dispensations. The primary outcome was the hospitalization rate for osteoporotic hip fracture. Among the 81,268 women included, 2005 were exposed to bisphosphonates. The median time of bisphosphonate exposure was 12 (IQR, 3-29) and 17 (IQR, 5-42) months for the persistence and adherence definitions, respectively. Exposure to bisphosphonates was not associated with a decrease in hospitalization for hip fracture: weighted HRadherence = 0.66 (95% CI, 0.33 to 1.33); HRpersistance = 0.77 (95% CI, 0.38 to 1.57). In real life, bisphosphonate use does not appear to reduce hospitalization for hip fractures, as to date, it is probably prescribed as primary prevention and for a duration too short to be effective.

Implementation of a top five list to identify medical overuse in general practice according to patients' viewpoint in 2019 in France.

BACKGROUND: There is a current trend to reassess the adequacy of care. Establishing top five lists by involving patients is one way to address medical overuse. The objective of this study was to establish a patients' top five list in general practice in France. The secondary objective was to identify selection criteria. METHOD: Patients from the web-based cohort GrippeNet.fr were invited to establish their top five list from 15 care procedures previously selected by general practitioners on the basis of medical overuse. The care procedures were presented on a web-interface with guides written with the help of a patient association. A questionnaire was used to explore factors that may have influenced the choices of the participants. RESULTS: In total, 691 patients established the following top five list: 1/ Prescription of antibiotics for acute bronchitis, nasopharyngitis, otitis media with effusion, or uncomplicated influenza; 2/ Prescription of benzodiazepine and benzodiazepine-like agents for insomnia, generalised anxiety and all indications for older patients; 3/ Prescription of a homeopathic treatment (Influenzinum) for flu prevention; 4/ Prescription of antitussive or expectorant agents for acute cough or acute bronchitis care; 5/ Prescription of statins for the primary prevention of cardio-vascular risk in older patients. More than 70% of participants gave importance to the recommendations, effectiveness, and tolerance of the care procedures, whereas only half considered the cost. CONCLUSION: This study is the first to establish a patient's top-five list in general practice. This list provides direction for deciding the main targets in limiting medical overuse.

The evolution of anti-emetic prescriptions in primary care, between 2006 and 2016.

CONTEXT: Serious adverse events related to the use of domperidone and metoclopramide have been consistently reported in the literature for many years. This led to a restriction of their use in the early 2010s. OBJECTIVE: The main objective was to analyse the evolution of antiemetic prescription rate in French general practise between 2006 and 2016. The secondary objectives were to highlight prescription transfers for metopimazine and to quantify the impact on health expenditures. METHOD: All patients from a representative sample of a national administrative claims database, the French national health insurance database, were included between 2006 and 2016. Trends in annual anti-emetic prescription rates by general practitioners were analysed using logistic regression models adjusted for age, gender and the existence of cancer. The cost of theses changing prescription habits was quantified via Médic'AM, a public drug expenditure database. RESULTS: Around 669 020 individuals were included with a mean 8-year follow-up; 48 634 patients received an anti-emetic at least once between 2006 and 2016. Prescription rates for all antiemetics decreased significantly from 2.1% to 0.4%, especially for metoclopramide from 0.5% to 0.1%, for domperidone from 1.5% to 0.1% and for metopimazine from 0.4% to 0.2%, which is not in favour of prescription transfers. Expenses fell from 30 million euros in 2006 to 10 million in 2016. CONCLUSION: Decreases in anti-emetic prescription rates and public health expenditures preceded the publication of official recommendations to reduce the use of metoclopramide and domperidone, without prescription transfers for metopimazine.

A top 5 list for French general practice.

BACKGROUND: Medical overuse is an issue that has recently gained attention. The "Choosing Wisely" campaign invited each specialty in each country to create its own top five lists of care procedures with a negative benefit-risk balance to promote dialogue between patients and physicians. This study aims to create such a list for French general practice. METHODS: A panel of general practitioners (GPs) suggested care procedures that they felt ought to be prescribed less. Using the Delphi method, a short list of those suggestions was selected. Systematic literature reviews were performed for each item on the short list. The results were presented to the panel to assist with the final selection of the top five list. RESULTS: The panel included 40 GPs. The list includes: i/ antibiotics prescription for acute bronchitis, nasopharyngitis, otitis media with effusion, or uncomplicated influenza, ii/ systematic prostate specific antigen testing in men older than 50, iii/ prescription of cholinesterase inhibitors for mild cognitive impairment and for Alzheimer's disease and memantine for Alzheimer's disease, iv/ statins prescription in primary prevention of cardio-vascular risk in older patients, and v/ benzodiazepine or benzodiazepine-like agents prescription for generalised anxiety, insomnia, and for all indications in older patients. CONCLUSIONS: This study resulted in a French top five list in general practice using a panel of GPs. All the items selected have a negative risk-benefit balance and are frequently prescribed by French general practitioners. This list differs from other top five lists for general practice, reflecting the local medical culture.

Determinants of antidementia drug prescription in patients older than 65: A latent class analysis.

BACKGROUND: Antidementia drugs (cholinesterase inhibitors and memantine) are still widely prescribed despite their controversial effects and 2011 guidelines that no longer encourage their prescription. The objective was to assess which factors remained determinants of antidementia drug prescriptions. METHODS: A cross-sectional study was performed in 2013. Patients suffering from dementia, aged 65 and over, identified in the French national health insurance database were included. Because we anticipated a high correlation between age, comorbidities, and health care use, we first identified the patients' health status by a latent class analysis. Second, we performed adjusted logistic regression models. The explanatory variables were patients' health status, gender, prescription of nonpharmacological treatments (physical and speech therapies), prescription of psychotropic drugs, and access to health care. RESULTS: Among the 3873 patients included, 38% received antidementia drugs. Three latent classes of patients with different health status were identified. Patients with poor health status received significantly fewer antidementia drugs (P < .001). Patients with speech therapy or antidepressant drugs received significantly more antidementia drugs (P < .001), whereas patients with physical therapy received significantly fewer antidementia drugs (P = .006). CONCLUSION: Antidementia drugs were less likely to be prescribed for patients with poor health status. This result is encouraging for these frail patients who are more vulnerable to the adverse effects of treatments. At the same time, this result encourage targeting specifically patients in good health status for the use of a decision aid, in an attempt to limit prescriptions by involving patients and families.

Prevalence of Giant Cell Arteritis Relapse in Patients Treated With Glucocorticoids: A Meta-Analysis.

OBJECTIVE: The relapse rate of patients with giant cell arteritis (GCA) treated with glucocorticoids (GCs) alone varied widely in observational series and randomized controlled trials (RCTs). The purpose of this systematic review was to evaluate the prevalence of relapse and predisposing factors in patients receiving GCs alone. METHODS: We searched Medline up to December 2017. The prevalence of relapse was pooled using a random-effects model. RESULTS: A total of 34 studies (2,505 patients), comprising 8 RCTs, were included. The overall prevalence of relapse was 47.2% (95% confidence interval 40.0, 54.3) with a high heterogeneity (I2 = 93%). Prevalence of relapse was significantly higher for patients included in an RCT compared to those included in an observational study (P < 0.0001), but was not significantly different according to design (P = 0.06). The relapse rate was associated with year of publication (34 studies, rate increase of 8.3% for 1 decade; P < 0.0001) and with shorter GC regimens (17 studies, rate decrease of 1.7% for 1 additional month; P < 0.001), the duration of scheduled GC therapy being shorter in RCTs (12.8 months) compared to observational studies (28.8 months). The effective duration of GC therapy (P = 0.23), initial GC dose (P = 0.49), duration of follow-up (P = 0.14), sex (P = 0.29), and age (P = 0.43) were not associated with the prevalence of relapse. CONCLUSION: GCA relapses occur in half of patients and without improvement across decades in patients receiving GC alone, and the relapse rate is more related to short duration of GC administration than to the initial dose at induction. These results advocate for trial design with at least 12 months of GC therapy.

Avoiding disease mongering: A checklist for vascular physicians and researchers.

Disease mongering is an expression created in 1992 by a medical journalist, Lynn Payer, to qualify the "selling of sickness that widens the boundaries of treatable illness in order to expand markets for those who sell and deliver treatments". This interesting concept led us to question whether, as researchers with publication and career interests in superficial vein thrombosis, we were not shaping a benign condition into a disease. Since the publication of the CALISTO trial in 2010, anticoagulant management of superficial vein thrombosis remains debated. Issues raised, such as the cost-effectiveness of the treatment strategy, the use of a composite endpoint including death, the low event rate without mortality reduction and conflict of interest due to industrial funding. We searched Embase, Medline, Web of science, and Opengrey databases to review all aspects about disease mongering raised in the literature and created a checklist with seventeen items. We used this checklist as support for a narrative review, questioning known literature on superficial vein thrombosis. The main issues pointing towards disease mongering concerned definition and promotion; whereas management seemed rather spared. Many arguments could be counterbalanced, but researchers should pay particular attention to three major points: exaggeration of the severity of the disease and potential adverse outcomes without treatment, promotion by opinion leaders, and an openly declared, yet undoubtedly present, conflict of interest situation.

Efficacy of teicoplanin monotherapy following initial standard therapy in Enterococcus faecalis infective endocarditis: a retrospective cohort study.

PURPOSE: Teicoplanin is often used in Enterococcus faecalis infective endocarditis as a relay in case of penicillin side effects, or in outpatients. We assessed the efficacy of teicoplanin used as continuation therapy after initial standard treatment of E. faecalis endocarditis. METHODS: All adult patients consecutively diagnosed between 1997 and 2016 for E. faecalis endocarditis were retrospectively reviewed. Patients who received standard therapy (ST) were compared to those switched to teicoplanin to complete the treatment (teicoplanin therapy, TT). RESULTS: Seventy-one patients were enrolled: 34 in the ST group and 37 in the TT group. Amoxicillin was replaced by teicoplanin after a median duration of 18 days (IQ25 - 75 12-21). Teicoplanin (5.8 ± 2.3 mg/kg) was administered for a median duration of 29 days (IQ25 - 75 25-34). Gentamicin therapy was similar. Overall duration of antimicrobial therapy was 42 days (IQ25 - 75 35-43) in the ST group, and 46 days (IQ25 - 75 43-49) in the TT group (p = 0.001). Global and endocarditis-related mortality rates were 22/34 (65%) and 13/34 (38%) in the ST group, and 14/37 (38%) and 3/37 (8%) in the TT group (p ≤ 0.05). Relapses occurred in 2/26 patients who survived the treatment phase in the ST group (8%) and in 3/37 in the TT group (8%, p = 0.68). All relapses in the TT group occurred in patients presenting prosthetic valve endocarditis. Finally, 20 patients were cured in the ST group (59%), and 33 patients in the TT group (89%, p = 0.003). CONCLUSIONS: In E. faecalis endocarditis, the switch to teicoplanin in selected patients following an initial phase of standard treatment represents an alternative, particularly for outpatient therapy. Caution should be exercised in cases of prosthetic valve endocarditis.

Non-steroids anti-inflammatory drugs and risk of peritonsillar abscess in pharyngitis: a French longitudinal study in primary care†.

BACKGROUND: The safety of non-steroids anti-inflammatory drugs (NSAIDs) in the context of pharyngitis is doubtful with contradictory results in the literature. OBJECTIVE: To evaluate the risk of peritonsillar abscess (PTA) associated to NSAIDs consumption during a pharyngitis episode observed in primary care. METHOD: A retrospective cohort study using Observatory of General Medicine Datalink from 1995 to 2010. All patients consulting a GP from the Datalink network for pharyngitis have been included. The occurrence of a PTA in the 15 days following the consultation for pharyngitis was matched. The association between PTA and prescriptions of NSAIDs was studied via an adjusted logistic regression model. RESULTS: During the study period, 105 802 cases of pharyngitis and 48 cases of PTA following a pharyngitis were reported, concerning respectively 67 765 and 47 patients. In the multivariate analysis, the risk of PTA was associated positively with a NSAIDs prescription (OR = 2.9, 95% CI = 1.6-5.2). Other factors associated with PTA occurrence were the prescription of corticosteroids (OR = 3.1, 95% CI = 1.3-7.6) and an age between 20 and 40 years (OR = 5.7, 95% CI = 2.5-13.0). The prescription of antibiotics was not significantly associated with PTA (P = 0.7). CONCLUSION: Prescription of NSAIDs in pharyngitis may increase the risk of PTA. This study encourages considering cautiously the balance between benefits and harms before prescription of NSAIDs for pharyngitis.

Factors associated with the duration of symptoms in adult women with suspected cystitis in primary care.

OBJECTIVE: The aim of this study was to identify factors associated to the duration of symptoms of cystitis. PATIENTS AND METHODS: We conducted a nested survival study using Druti study data. Druti was a cross-sectional survey conducted in adult women visiting a general practitioner in France, for a suspected urinary tract infection between January 2012 and February 2013. For this study, urine cultures were systematically performed for all women. The evolution of symptoms were monitored daily for two weeks. This nested study considered only women with suspected cystitis from Druti; women with pyelonephritis were excluded. To identify independent predictors for duration of symptoms, a Cox proportional hazards regression model was performed. RESULTS: In Druti, 449 patients had a suspected cystitis. Among them, 440 had a follow up at two weeks. Out of the 440 patients, 424 had a prescription of antibiotic treatment (96.4%). The urine culture was positive for 326 patients (74.1%). The median duration of symptoms after consultation was two days (interquartile 1-3). The absence of urinary frequency (median two days versus three days, p = 0.008), age over 55 years (median two days versus three days, p<0.001) and patient's bet about the presence of a urinary tract infection (median two days, p = 0.021) were associated to a longer duration of symptoms. Positive culture (p = 0.99) and presence of a multi-drug resistant organism (p = 0.38) did not influence the duration of symptoms. CONCLUSION: In a real-life study, factors influencing the duration of symptoms are clinical factors. The delay before re-evaluation in case of persistent symptoms after treatment could be adapted according to the initial clinical examination.

Drugs for Dementia and Excess of Hospitalization: A Longitudinal French Study.

BACKGROUND: The impact of adverse effects of drugs for dementia on the risk of hospitalization has not been much studied despite the impact of hospitalizations on cognitive decline. OBJECTIVE: To determine if the main adverse effects of cholinesterase inhibitors and memantine may be associated with excess of hospitalization and to quantify the subsequent impact on healthcare expenditures. METHODS: A representative sample of the French national health insurance beneficiaries aged 65 and older and suffering from dementia were included and followed from 2007 to 2014. Binary logit models for longitudinal data (GEE estimation technique) were used to estimate the excess of hospitalization events related to the adverse effects of anti-dementia drugs and then to derive the additional costs of hospitalizations for the public health insurance fund. RESULTS: In total, 7,668 patients were followed, generating 111,133 individual observations over the 8-year period. Treated patients were hospitalized significantly more than non-treated patients (adjusted Odd Ratio (OR) = 1.08, 95% confidence interval (95% CI) = [1.02 to 1.13], p = 0.004), mainly with cholinesterase inhibitors for cardiac (OR = 1.21, 95% CI = [1.01 to 1.46], p = 0.034) and gastrointestinal events (OR = 1.43, 95% CI = [1.01-2.05], p = 0.045), especially with rivastigmine. When extrapolated to the entire population, this corresponded to an annual additional cost of € 55,000. CONCLUSION: Prescription of antidementia drugs, more specifically rivastigmine, increases the risk of hospitalizations via their cardiac and gastrointestinal adverse effects and lead to additional health care expenditures. Even though these results must be confirmed, they may encourage cautious consideration of the balance between benefits and harms before a prescription is given.

Digital, analogue, or redundant speedometers for truck driving: Impact on visual distraction, efficiency and usability.

Existing literature does not draw conclusions as to which speedometer type is better for truck driving. A digital speedometer would be more beneficial when obtaining absolute and relative readings, while an analogue speedometer would be more efficient and less distracting when detecting dynamic speed changes. Redundant speedometers, which simultaneously present digital and analogue speedometers, appear increasingly in vehicles, but no information is available on their ergonomic qualities. This study compared three speedometers: digital speedometers, analogue speedometers, and redundant speedometers. This study compared the efficiency, usability and visual distraction measures for all three types of speedometers in a simulated truck driving setting. The task-dependant results were confirmed for the digital and analogue speedometer. The redundant speedometer combined the benefits of each type presented separately, which highlights interesting theoretical and applied implications.

Trends in Drug Prescription Rates for Dementia: An Observational Population-Based Study in France, 2006-2014.

BACKGROUND: Since the 2011 French guidance updates, cholinesterase inhibitors and memantine are considered optional in the management of dementia and leave physicians free to prescribe based on their clinical expertise. OBJECTIVES: The aims of this study were to analyze the influence of these recent guidance updates on the prescription rates of these drugs and to quantify the impact of potential changes on healthcare expenditures. METHODS: Patients over 65 years old from a representative sample of a national administrative claims database, the French national health insurance database, were retrospectively included from 2006 to 2014. Trends of annual prescription rates were tested using adjusted segmented regression analysis. Drug costs with and without prescribers' behavioral changes were estimated. RESULTS: A total of 119,731 individuals were included and followed during the study period. Among them, 5514 individuals were treated for dementia. According to the unadjusted segmented regression model, there was a significant increase in prescription rates between 2006 and 2010, from 2.23% (95% confidence interval 2.13-2.34) to 2.73% (95% confidence interval 2.62-2.84) of the study population. Since 2011, the trend has reversed with a significant decrease until 2014, from 2.64% (95% confidence interval 2.54-2.75) to 1.92% (95% confidence interval 1.84-2.01). In the multivariate analysis, we also found a gradual decline since 2011, particularly for patients aged 65-69 years and with one or more other chronic diseases. Cost savings associated with prescribers' behavioral changes were estimated at €108 million. CONCLUSION: Drugs prescribed for dementia are on a declining trend with important cost savings, and this was concomitant with guidance updates that left physicians to rely on their clinical expertise while managing dementia.

Automotive HMI design and participatory user involvement: review and perspectives.

Automotive human-machine interface (HMI) design is facing new challenges due to the technological advances of the last decades. The design process has to be adapted in order to address human factors and road safety challenges. It is now widely accepted that user involvement in the HMI design process is valuable. However, the current form of user involvement in industry remains at the stages of concept assessment and usability tests. Moreover, the literature in other fields (e.g. information systems) promotes a broader user involvement with participatory design (i.e. the user is fully involved in the development process). This article reviews the established benefits of participatory design and reveals perspectives for automotive HMI quality improvement in a cognitive ergonomic framework. Practitioner Summary: Automotive HMI quality determines, in part, drivers' ability to perform primary driving tasks while using in-vehicle devices. User involvement in the design process is a key point to contribute to HMI quality. This article reports the potential benefits of a broad involvement from drivers to meet automotive HMI design challenges.

The patient, the doctor, and the patient's loyalty: a qualitative study in French general practice.

BACKGROUND: The term loyalty can be defined as the attachment that characterises someone who consistent in their feelings, affections, or habits. By introducing the Declaration of General Practitioner (or preferred doctor declaration) in 2004, France adopted a formal incentive for patients to be faithful to their doctor since it entailed optimal coverage of medical care by their national health insurance There has been no research evaluating the impact of this measure and to determine the components of doctor-patient loyalty. AIM: To explore what builds and maintains patients' loyalty to their GP. DESIGN AND SETTING: Qualitative study based on semi-structured interviews close to Paris (the département of Yvelines'), France. METHOD: Twenty-eight patients were interviewed in five surgeries of self-employed GPs with different demographics. Interviews were transcribed and a thematic analysis conducted to categorise the data. Phenomenological analysis was used to analyse the transcripts. RESULTS: Patient loyalty is based mainly on trust. Trust can be reinforced by certain comforting factors such as the ability to listen, a sense of carefulness, and the quality of care. Loyalty is both a dynamic construct and a relational exchange subject to various influences. Patients find advantages in being loyal. The model of the 'family doctor' has always been the archetype of loyalty for several generations within one family. A GP's inability to meet all of the patient's requirements is not necessarily a determining factor in breaking the patient's loyalty. CONCLUSION: Loyalty is more complex than commonly assumed and involves dimensions of trust, listening, quality of care, availability, and familiarity. The observations drawn out from this study warrant a larger scale investigation.

Effectiveness of a Forward Collision Warning System in simple and in dual task from an electrophysiological perspective.

Forward Collision Warning Systems (FCWS) are expected to assist drivers; however, it is not completely clear whether these systems are of benefit to distracted drivers as much as they are to undistracted drivers. This study aims at investigating further the analysis of the effectiveness of a surrogate FCWS according to the attentional state of participants. In this experiment electrophysiological and behavioural data were recording while participants were required to drive in a simple car simulator and to react to the braking of the lead vehicle which could be announced by a warning system. The effectiveness of this warning system was evaluated when drivers were distracted or not by a secondary cognitive task. In a previous study, the warning signal was not completely effective likely due to the presence of another predictor of the forthcoming braking which competes with the warning. By eliminating this secondary predictor in the present study, the results confirmed the negative effect of the secondary task and revealed the expected effectiveness of the warning system at behavioural and electrophysiological levels.