Diagnostic Performance of Individual Symptoms to Predict SARS-CoV-2 RT-PCR Positivity and Symptom Persistence among Suspects Presenting in Primary Care during the First Wave of COVID-19.

This study aimed to estimate the diagnostic performance of patient symptoms and to describe the clinical course of RT-PCR-positive compared with RT-PCR-negative patients in primary care. Symptomatic COVID-19 suspects were assessed clinically at the initial consultation in primary care between March and May 2020, followed by phone consultations over a span of at least 28 days. Sensitivity and specificity were estimated for each symptom using the initial RT-PCR result as a reference standard. The proportions of symptomatic patients according to the RT-PCR test results were compared over time, and time to recovery was estimated. Out of 883 patients, 13.9% had a positive RT-PCR test, and 17.4% were not tested. Most sensitive symptoms were cough, myalgia, and a history of fever, while most specific symptoms were fever for ≥4 days, hypo/anosmia, and hypo/ageusia. At the final follow up (median time 55 days, range 28-105 days), 44.7% of patients still reported symptoms in the RT-PCR-positive group, compared with 18.3% in the negative group (p < 0.001), mostly with hypo/anosmia (16.3%), dyspnea (12.2%), and fatigue (10.6%). The discriminative value of individual symptoms for diagnosing COVID-19 was limited. Almost half of the SARS-CoV-2-positive patients still reported symptoms at least 28 days after the initial consultation.

Antigen rapid tests, nasopharyngeal PCR and saliva PCR to detect SARS-CoV-2: A prospective comparative clinical trial.

BACKGROUND: Nasopharyngeal antigen Rapid Diagnostic Tests (RDTs), saliva RT-PCR and nasopharyngeal (NP) RT-PCR have shown different performance characteristics to detect patients infected by SARS-CoV-2, according to the viral load (VL)-and thus transmissibility. METHODS: In October 2020, we conducted a prospective trial involving patients presenting at testing centres with symptoms of COVID-19. We compared detection rates and performance of RDT, saliva PCR and nasopharyngeal (NP) PCR, according to VL and symptoms duration. RESULTS: Out of 949 patients enrolled, 928 patients had all three tests performed. Detection rates were 35.2% (95%CI 32.2-38.4%) by RDT, 39.8% (36.6-43.0%) by saliva PCR, 40.1% (36.9-43.3%) by NP PCR, and 41.5% (38.3-44.7%) by any test. For those with viral loads (VL) ≥106 copies/ml, detection rates were 30.3% (27.3-33.3), 31.4% (28.4-34.5), 31.5% (28.5-34.6), and 31.6% (28.6-34.7%) respectively. Sensitivity of RDT compared to NP PCR was 87.4% (83.6-90.6%) for all positive patients, 94.5% (91.5-96.7%) for those with VL≥105 and 96.5% (93.6-98.3%) for those with VL≥106. Sensitivity of STANDARD-Q®, Panbio™ and COVID-VIRO® Ag tests were 92.9% (86.4-96.9%), 86.1% (78.6-91.7%) and 84.1% (76.9-89.7%), respectively. For those with VL≥106, sensitivity was 96.6% (90.5-99.3%), 97.8% (92.1-99.7%) and 95.3% (89.4-98.5%) respectively. No patient with VL<104 was detected by RDT. Specificity of RDT was 100% (99.3-100%) compared to any PCR. RDT sensitivity was similar <4 days (87.8%, 83.5-91.3%) and ≥4 days (85.7%, 75.9-92.6%) after symptoms onset (p = 0.6). Sensitivity of saliva and NP PCR were 95.7% (93.1-97.5%) and 96.5% (94.1-98.1%), respectively, compared to the other PCR. CONCLUSIONS: RDT results allow rapid identification of COVID cases with immediate isolation of most contagious individuals. RDT can thus be a game changer both in ambulatory care and community testing aimed at stopping transmission chains, and even more so in resource-constrained settings thanks to its very low price. When PCR is performed, saliva could replace NP swabbing. TRIAL REGISTRATION: ClinicalTrial.gov Identifier: NCT04613310 (03/11/2020).

An Online Influenza Surveillance System for Primary Care Workers in Switzerland: Observational Prospective Pilot Study.

BACKGROUND: A better understanding of the influenza epidemiology among primary care workers could guide future recommendations to prevent transmission in primary care practices. Therefore, we designed a pilot study to assess the feasibility of using a work-based online influenza surveillance system among primary care workers. Such an approach is of particular relevance in the context of the coronavirus disease (COVID-19) pandemic, as its findings could apply to other infectious diseases with similar mechanisms of transmission. OBJECTIVE: This study aims to determine the feasibility of using a work-based online influenza surveillance system for primary care workers in Switzerland. METHODS: Physicians and staff of one walk-in clinic and two selected primary care practices were enrolled in this observational prospective pilot study during the 2017-2018 influenza season. They were invited to record symptoms of influenza-like illness in a weekly online survey sent by email and to self-collect a nasopharyngeal swab in case any symptoms were recorded. Samples were tested by real-time polymerase chain reaction for influenza A, influenza B, and a panel of respiratory pathogens. RESULTS: Among 67 eligible staff members, 58% (n=39) consented to the study and 53% (n=36) provided data. From the time all participants were included, the weekly survey response rate stayed close to 100% until the end of the study. Of 79 symptomatic episodes (mean 2.2 episodes per participant), 10 episodes in 7 participants fitted the definition of an influenza-like illness case (attack rate: 7/36, 19%). One swab tested positive for influenza A H1N1 (attack rate: 3%, 95% CI 0%-18%). Swabbing was considered relatively easy. CONCLUSIONS: A work-based online influenza surveillance system is feasible for use among primary care workers. This promising methodology could be broadly used in future studies to improve the understanding of influenza epidemiology and other diseases such as COVID-19. This could prove to be highly useful in primary care settings and guide future recommendations to prevent transmission. A larger study will also help to assess asymptomatic infections.

[Wellbeing of the doctor and health of the patient†: for a sustainable family medicine]. / Bien-être du médecin et santé du patient†: pour la durabilité de la médecine de famille.

The health sector is one of the most stressed occupational sectors. In family medicine, the risk is especially high: the prevalence of burnout increased. This article explores four facets of the problem : 1) the elements influencing physicians' satisfaction and well-being at work ; 2) prevention and detection of burnout in doctors ; 3) the impact of the doctors' stress on patient care and 4) the organization of the practice to improve the practitioners' well-being. The elements presented here are a summary of a meeting of physicians engaged in training and practice in family medicine, the objective being to identify ways to promote sustainable doctors in their practice !

Le secteur de la santé est l'un des domaines professionnels les plus exposés au stress. En médecine générale, spécialité tout particulièrement à risque, la prévalence de burnout est en augmentation. Le présent article explore quatre facettes du problème : 1) les éléments influençant la satisfaction et le bien-être au travail des médecins ; 2) la prévention et le dépistage du burnout du médecin ; 3) l'impact du stress du médecin sur la prise en charge des patients et 4) l'organisation du cabinet pour améliorer le bien-être des soignants. Les éléments présentés ici sont un compte-rendu d'une rencontre de médecins engagés dans la formation et la pratique en médecine de famille ayant pour objectif d'identifier des pistes pour des médecins plus durables dans leur cabinet !

Patients satisfaction in an academic walk-in centre: a new model of residents training achieved by family doctors.

BACKGROUND: Walk-in centres may improve access to healthcare for some patients, due to their convenient location and extensive opening hours, with no need for an appointment. Herein, we describe and assess a new model of walk-in centre, characterised by care provided by residents and supervision achieved by experienced family doctors. The main aim of the study was to assess patients' satisfaction about the care they received from residents and their supervision by family doctors. The secondary aim was to describe walk-in patients' demographic characteristics and to identify potential associations with satisfaction. METHODS: The study was conducted in the walk-in centre of Lausanne. Patients who consulted between 11th and 31st April were automatically included and received a questionnaire in French. We used a five-point Likert scale, ranging from "not at all satisfied" to "very satisfied", converted from values of 1 to 5. We focused on the satisfaction regarding residents' care and supervision by a family doctor. The former was divided in three categories: "Skills", "Treatment" and "Behaviour". A mean satisfaction score was calculated for each category and a multivariable logistic model was applied in order to identify associations with patients' demographics. RESULTS: The overall response rate was 47% [184/395]. Walk-in patients were more likely to be women (62%), young (median age 31), with a high education level (40% of University degree or equivalent). Patients were "very satisfied" with residents' care, with a median satisfaction score between 4.5 and 5, for each category. Over 90% of patients were "satisfied" or "very satisfied" that a family doctor was involved in the consultation. Age showed the greatest association with satisfaction. CONCLUSION: Patients were highly satisfied with care provided by residents and with the involvement of a family doctor in the consultation. Older age showed the greatest positive association with satisfaction with a positive impact. The high level satisfaction reported by walk-in patients supports this new model of walk-in centre.

[Dark or white chocolate? Cocoa and cardiovascular health]. / Chocolat noir ou chocolat blanc? Le cacao et la santé cardiovasculaire.

Epidemiological data show that a regular dietary intake of plant-derived foods reduces the risk of cardiovascular disease. Recent research indeed demonstrates interesting data about cocoa consumption, with high concentrations of polyphenols, and beneficial effects on blood pressure, insulin resistance and platelet function. Although still debated, a range of potential mechanisms through which cocoa might exert their benefits on cardiovascular health have been suggested: activation of nitric oxide, antioxidant, anti-inflammatory, anti-platelet effects, which might in turn improve endothelial function, lipid levels, blood pressure and insulin resistance. This article reviews available data about the effects of the consumption of cocoa and different types of chocolate on cardiovascular health, and outlines potential mechanisms involved on the basis of recent studies.

[Fibromyalgia: how to appreciate work capacity?]. / Fibromyalgie, comment évaluer la capacité de travail?

Fibromyalgia is a chronic pain syndrome of which there remains difficult to evaluate the functional repercussion. As in other affections without, or with weak shown organic substrate, the evaluation of the work capacity requires a rigorous approach, which adopts an integrative bio-psycho-social model. Diagnostic classification poses problems insofar as the same syndromic association can result in different diagnoses. The object of this article is to highlight some difficulties related to the coexistence of medical and legal logics which can sometimes be divergent. Generalization, on the legal and administrative side, of simple dichotomic rules, must in no manner lead the physician to make the saving of taking into account the complexity.

Sigmoidal equation for lung and chest wall volume-pressure curves in acute respiratory failure.

To assess incidence and magnitude of the "lower inflection point" of the chest wall, the sigmoidal equation was used in 36 consecutive patients intubated and mechanically ventilated with acute lung injury (ALI). They were 21 primary and 5 secondary ALI, 6 unilateral pneumonia, and 4 cardiogenic pulmonary edema. The lower inflection point was estimated as the point of maximal compliance increase. The low constant flow inflation method and esophageal pressure were used to partition the volume-pressure curves into their chest wall and lung components on zero end-expiratory pressure. The sigmoidal equation had an excellent fit with coefficients of determination >0.90 in all instances. The point of maximal compliance increase of the chest wall ranged from 0 to 8.3 cmH2O (median 1 cmH2O) with no difference between ALI groups. The chest wall significantly contributed to the lower inflection point of the respiratory system in eight patients only. The occurrence of a significant contribution of the chest wall to the lower inflection point of the respiratory system is lower than anticipated. The sigmoidal equation is able to determine precisely the point of the maximal compliance increase of lung and chest wall.

A program based on a 'selective' least-squares method for respiratory mechanics monitoring in ventilated patients.

This paper proposes a program for continuous estimation of respiratory mechanics parameters in ventilated patients. This program can be used with any ventilator providing airway pressure and flow signals without additional equipment. Overall breathing resistance, dynamic elastance (E) and positive end expiratory pressure (P(0)) are periodically estimated by multiple linear regression on selected parts of breathing cycles. Experimental validation together with justification of the selection procedure are based on signals obtained while ventilating a lung mechanical analogue with various intensive care ventilators. Clinical validity has been tested on 12 ventilated patients. The quality of estimation has been assessed by mean square difference between measured and reconstituted pressure (MSE), coefficient of determination (R(2)) and the condition number (a confidence index), and by comparison of E and P(0) with corresponding static values. The high R(2) and the low MSE obtained on most clinical cycles indicate that selected parts of cycles obey closely the model underlying parameter estimation. Agreement between static and dynamic parameters demonstrates the clinical validity of our program.

[Dyslipidemias and cardiovascular diseases: towards a new perspective]. / Dyslipidémies et maladies cardiovasculaires: vers de nouvelles perspectives.

During the last decades, new developments in the detection and therapy of dyslipidemia provided a firm conviction for the efficacy and the safety of lipid-lowering therapies in primary and secondary prevention of cardiovascular diseases. To be cost-effective in primary prevention, the statin-therapy needs to select high risk patients. According to the guidelines, the global assessment of cardiovascular risk is based on traditional risk factors (RF-CV). The emergence of new RF-CV is helpful. However, at every level of risk factor exposure, there is a substantial variation of atherosclerosis. Thus, subclinical disease measurements, representing the end result of risk exposure may be useful for improving cardiovascular risk prediction. Using the high resolution B-mode ultrasound to detect plaques both on femoral and carotid arteries in asymptomatic patients, our results show the advantages and limits of a non invasive method to improve the selection of eligible patients requiring a more aggressive lipid-lowering therapy.

Non-invasive detection of respiratory muscles activity during assisted ventilation.

The instantaneous pressure applied by the respiratory muscles [Pmus(t)] of a patient under ventilatory support may be continuously assessed with the help of a model of the passive respiratory system updated cycle by cycle. Inspiratory activity (IA) is considered present when Pmus goes below a given threshold. In six patients, we compared IA with (i) inspiratory activity (IAref) obtained from esophageal pressure and diaphragmatic EMG and (ii) that (IAvent) detected by the ventilator. In any case, a ventilator support onset coincides with an IA onset but the opposite is not true. IA onset is always later than IAref beginning ((0.21 +/- 0.10 s) and IA end always precedes IAref end (0.46 +/- 0.16 s). These results clearly deteriorate when the model is not updated.

High risk for hyperlipidemia and the metabolic syndrome after an episode of hypertriglyceridemia during 13-cis retinoic acid therapy for acne: a pharmacogenetic study.

BACKGROUND: Administration of 13-cis retinoic acid (isotretinoin) for acne is occasionally accompanied by hyperlipidemia. It is not known why some persons develop this side effect. OBJECTIVE: To determine whether isotretinoin triggers a familial susceptibility to hyperlipidemia and the metabolic syndrome. DESIGN: Cross-sectional comparison. SETTING: University hospital in Lausanne, Switzerland. PARTICIPANTS: 102 persons in whom triglyceride levels increased at least 1.0 mmol/L (> or =89 mg/dL) (hyperresponders) and 100 persons in whom triglyceride levels changed 0.1 mmol/L (< or =9 mg/dL) or less (nonresponders) during isotretinoin therapy for acne. Parents of 71 hyperresponders and 60 nonresponders were also evaluated. MEASUREMENTS: Waist-to-hip ratio; fasting glucose, insulin, and lipid levels; and apoE genotype. RESULTS: Hyperresponders and nonresponders had similar pretreatment body weight and plasma lipid levels. When reevaluated approximately 4 years after completion of isotretinoin therapy, hyperresponders were more likely to have hypertriglyceridemia (triglyceride level > 2.0 mmol/L [>177 mg/dL]; odds ratio [OR], 4.8 [95% CI, 1.6 to 13.8]), hypercholesterolemia (cholesterol level > 6.5 mmol/L [>252 mg/dL]; OR, 9.1 [CI, 1.9 to 43]), truncal obesity (waist-to-hip ratio > 0.90 [OR, 11.0 (CI, 2.0 to 59]), and hyperinsulinemia (insulin-glucose ratio > 7.2; OR, 3.0 [CI, 1.6 to 5.7]). In addition, more hyperresponders had at least one parent with hypertriglyceridemia (OR, 2.6 [CI, 1.2 to 5.7]) or a ratio of total to high-density lipoprotein cholesterol that exceeded 4.0 (OR, 3.5 [CI, 1.5 to 8.0]). Lipid response to isotretinoin was closely associated with the apoE gene. CONCLUSION: Persons who develop hypertriglyceridemia during isotretinoin therapy for acne, as well as their parents, are at increased risk for future hyperlipidemia and the metabolic syndrome.