[Sometimes less is more. Preventing overdiagnosis by sharing decisions]. / Moins, c'est parfois mieux . Prévenir le surdiagnostic en partageant les décisions.

In this article, we will define «quaternary prevention¼, which consists in minimizing the iatrogenic effects of medical interventions, and more specifically the notion of «overdiagnosis¼. We will then discuss how a poor appreciation of the risks, on the part of both patients and clinicians, seems to fuel the phenomenon. We will discuss the interest of placing quaternary prevention within the broader framework of Shared Decision Making. We will focus on one of the stages of Shared Decision Making process, that of risk communication. Finally, we'll conclude that, fundamentally, clinicians should not only share information with patients, but also the power to decide.

Dans cet article, nous définirons la «prévention quaternaire¼, qui consiste à minimiser les effets iatrogènes de nos interventions et plus particulièrement de la notion de «surdiagnostic¼. Ensuite, nous discuterons en quoi une mauvaise appréciation des risques, chez les patients comme chez les thérapeutes, semble nourrir le phénomène. Nous discuterons de l'intérêt de replacer la prévention quaternaire dans le cadre plus large de la prise de décision médicale partagée (DMP) («Shared Decision Making¼). Nous nous attarderons sur une des étapes du processus de prise de DMP, celle de la communication des risques. Enfin nous conclurons que, fondamentalement, il s'agit pour les thérapeutes de non seulement partager l'information avec les patients, mais aussi le pouvoir de décider.

[SGLT2 inhibitors : on the borders of diabetology, cardiology, nephrology and primary care]. / Inhibiteurs des SGLT2 (gliflozines) : aux confins de la diabétologie, la cardiologie, la néphrologie et la médecine générale.

Sodium-glucose cotransporter type 2 inhibitors (SGLT2is or gliflozins) are now considered as a therapeutic breakthrough in clinical practice, not only for the management of type 2 diabetes (T2D), but also for the treatment of heart failure and chronic renal disease. Patients with T2D are exposed to a higher risk of atheromatic lesions, heart failure and renal insufficiency, all complications that can be reduced by a gliflozin as shown in several placebo- controlled randomised trials in at high risk patients. Unexpectedly, such cardio-renal protection has also been observed among non-diabetic patients with heart failure (both with reduced and preserved ejection fraction) or with chronic kidney disease (especially with albuminuria). Because of these properties, SGLT2is now occupy a privileged place in diabetology, cardiology and nephrology. However, they are still slow to settle in primary care practice, even in high risk patients who should benefit, an underuse possibly due at least partially to quite complex reimbursement criteria in Belgium.

Les inhibiteurs des sodium-glucose cotransporteurs type 2 (iSGLT2 ou gliflozines) ont réalisé une percée remarquable dans la pratique clinique, non seulement pour le traitement du diabète de type 2 (DT2), mais aussi pour celui de l'insuffisance cardiaque et de la maladie rénale chronique. Le patient avec DT2 est exposé à des lésions athéromateuses, une insuffisance cardiaque et une insuffisance rénale, toutes complications freinées par la prise d'une gliflozine comme démontré dans plusieurs essais cliniques contrôlés versus placebo chez des patients à haut risque. De façon a priori inattendue, cette protection cardio-rénale a également été prouvée chez des patients non diabétiques présentant une insuffisance cardiaque (avec fraction d'éjection réduite ou préservée) ou une maladie rénale chronique (notamment avec albuminurie). Au vu de ces propriétés, les iSGLT2 occupent maintenant une place privilégiée en diabétologie, en cardiologie et en néphrologie. Cependant, ils tardent encore à s'implanter en médecine de première ligne, y compris chez des patients à haut risque qui devraient pourtant en bénéficier et ce, probablement en partie à cause de critères de remboursement relativement complexes en Belgique.

[Functional disorders in primare care]. / Les troubles fonctionnels en Médecine générale.

General practitioners frequently encounter patients with functional disorders. The authors discuss the specific aspects of the management of this population in general practice, through the lens of the five functions that define this discipline. A classification of functional disorders and the analysis of prognostic factors are of great value in deciding on therapeutic strategies. The general practitioner can contribute to the disappearance of mild functional disorders by listening to the patient and by providing appropriate patient centered care. More severe situations are rarer and require a multidisciplinary approach to which the general practitioner should contribute.

Le médecin généraliste rencontre fréquemment des patients atteints de troubles fonctionnels. Les auteurs évoquent les aspects spécifiques de leur prise en charge en Médecine générale, sous le prisme des cinq fonctions qui définissent cette discipline. Une classification des troubles fonctionnels et l'analyse des facteurs de pronostic sont d'une grande utilité, pour décider des orientations thérapeutiques. Par une prise en charge adaptée, centrée sur le patient et sur son écoute, le médecin généraliste peut contribuer à la disparition des troubles fonctionnels légers. Les situations plus sévères sont plus rares. Elles nécessitent une prise en charge pluridisciplinaire à laquelle il est souhaitable que le médecin généraliste apporte sa contribution.

SARS-CoV-2 Natural Transmission from Human to Cat, Belgium, March 2020.

In March 2020, a severe respiratory syndrome developed in a cat, 1 week after its owner received positive test results for severe acute respiratory syndrome coronavirus 2. Viral RNA was detected in the cat's nasopharyngeal swab samples and vomitus or feces; immunoglobulin against the virus was found in convalescent-phase serum. Human-to-cat transmission is suspected.

Facteurs associés à la survie en milieu pénitentiaire : étude en République démocratique du Congo.

OBJECTIVE: The objective of this study was to identify factors associated with survival among prisoners at Mbuji-Mayi Central Prison, in Democratic Republic of Congo between January 2014 and December 2016. METHODS: This is a retrospective cohort study. The mortality rate was calculated during the 3-year follow-up period and the Kaplan-Meier survival curve was determined. Cox regression and risk ratio (HR) were used to analyze and quantify factors associated with survival. The study involved a total of 793 inmates. RESULTS: The average age of inmates was 33 ± 10 years (extremes: 17-67 years). The median follow-up time was 12 months for a total of 7,513 person-months. The number of deaths recorded was 135, for a mortality rate of 17.9/1,000 person-months. Risk factors associated with death were malnutrition (HR = 17.5; 95% CI = [12.1; 25.4]) and tuberculosis (HR = 11.8; 95% CI = [7.7; 17.8]). CONCLUSION: This study highlights a high rate of deaths in prisons and identifies the two potential factors (malnutrition and tuberculosis) that prison and health authorities need to address.

[Factors associated with prison survival: Study in the Democratic Republic of Congo]. / Facteurs associés à la survie en milieu pénitentiaire : étude en République démocratique du Congo.

OBJECTIVE: The objective of this study was to identify factors associated with survival among prisoners at Mbuji-Mayi Central Prison, in Democratic Republic of Congo between January 2014 and December 2016. METHODS: This is a retrospective cohort study. The mortality rate was calculated during the 3-year follow-up period and the Kaplan-Meier survival curve was determined. Cox regression and risk ratio (HR) were used to analyze and quantify factors associated with survival. The study involved a total of 793 inmates. RESULTS: The average age of inmates was 33 ± 10 years (extremes: 17-67 years). The median follow-up time was 12 months for a total of 7,513 person-months. The number of deaths recorded was 135, for a mortality rate of 17.9/1,000 person-months. Risk factors associated with death were malnutrition (HR = 17.5; 95% CI = [12.1; 25.4]) and tuberculosis (HR = 11.8; 95% CI = [7.7; 17.8]). CONCLUSION: This study highlights a high rate of deaths in prisons and identifies the two potential factors (malnutrition and tuberculosis) that prison and health authorities need to address.

[Health literacy, a lever to make health care systems more equitable? Tools to support professionals and involve institutions]. / La littératie en santé, un levier pour des systèmes de soins plus équitables Des outils pour armer les professionnels et impliquer les institutions.

This article briefly recalls why low levels of health literacy should be considered to constitute a public health issue. It then proposes the concept of health literacy as a possible lever to help health care systems to more effectively take social health inequalities into account. Finally, it provides concrete tools for field workers, both clinicians and quality of care managers, and emphasises the importance of an organizational approach to health literacy.

[HIV infection. A chronic disease that redefines collaboration between general practitioners and specialists. A qualitative study on opportunities and obstacles to collaboration]. / L’infection par le VIH : une maladie chronique redéfinissant la collaboration entre généralistes et spécialistes. Obstacles et opportunités.

PURPOSE: With the development of antiretroviral therapy, Human Immunodeficiency Virus [HIV) infection has become a chronic disease. In order to develop an efficient response to this new challenge, there is a need for closer collaboration between specialized units and general practitioners. This article identifies the opportunities for and the barriers to this collaboration. METHODS: Semi-structured interviews were conducted with patients living with HIV, general practitioners working in multidisciplinary group practice using the capitation system and infectiologists from one Belgian urban area. Interviews focused one xperiences and expectations in relation to diagnosis, follow-up and collaboration between general practitioners and infectiologists. RESULTS: Overall, infectiologists and general practitioners aspire to improved communication and collaboration. There are overlaps between general practitioner's and infectiologist's field of action. The general practitioner's intervention is sometimes restricted to common uncomplicated or psychosocial problems, in the context of unplanned and short contacts.Infectiologists prefer to focus on HIV problems, leaving general practitioners to take care of these patients' other health problems. The patient may be an obstacle to greater involvement of general practitioners due to fear of stigmatization from his family and social circle or lack of confidence in the general practitioner's skills. CONCLUSION: This research underlines the difficulties and gaps in the care of HIV patients and provides preliminary explanations for the lack of active cooperation between general practitioners and infectiologists. Overlaps between the areas of professional skills can result in uncovered aspects of care, which can have a negative impact on patients, but also on general practitioners and infectiologists. Collaboration between general practitioners and infectiologists should be based on a concerted decision, with clear allocation of tasks, taking into account the patient's expectations.

Immunogenicity profile of a 3.75-µg hemagglutinin pandemic rH5N1 split virion AS03A-adjuvanted vaccine in elderly persons: a randomized trial.

BACKGROUND: Elderly persons often experience a reduced immune response to influenza vaccination. We evaluated the usual dose of AS03(A)-adjuvanted H5N1 pandemic vaccine (3.75 µg hemagglutinin of A/Vietnam/1194/2004-like strain) compared with a double dose in an elderly population. METHODS: This phase 2, open-label study (NCT00397215; http://www.clinicaltrials.gov) randomized participants (age, ≥61 years) to receive, on days 0 and 21: (1) a single dose of AS03(A)-adjuvanted vaccine (n=152), (2) a single dose of nonadjuvanted vaccine (n=54), (3) a double dose of AS03(A)-adjuvanted vaccine (n=145), or (4) a double dose of nonadjuvanted vaccine (n=44). The primary end point was hemagglutination inhibition (HI) and neutralizing antibody response against vaccine antigen (according-to-protocol cohort). RESULTS: Day 42 geometric mean titers for HI antibodies were 126.8 and 237.3 for single and double doses of the AS03(A)-adjuvanted vaccine, respectively. Corresponding values for neutralizing antibodies were 447.3 and 595.8. Although the immune response was higher with the double dose, European Committee for Human Medicinal Products criteria for seroconversion and seroprotection rates were achieved in both AS03(A)-adjuvanted groups. Antigen-specific CD4 T cell responses were elicited. Immune response persistence at 6 months was high. Immune response in the non-adjuvanted groups was considerably less. CONCLUSIONS: The AS03(A)-adjuvanted H5N1 vaccine can be administered elderly persons at the same dose and schedule as in younger adults.

Effect of an audiovisual message for tetanus booster vaccination broadcast in the waiting room.

BACKGROUND: General practitioners (GPs) often lack time and resources to invest in health education; audiovisual messages broadcast in the waiting room may be a useful educational tool. This work was designed to assess the effect of a message inviting patients to ask for a tetanus booster vaccination. METHODS: A quasi experimental study was conducted in a Belgian medical practice consisting of 6 GPs and 4 waiting rooms (total: 20,000 contacts/year). A tetanus booster vaccination audiovisual message was continuously broadcast for 6 months in 2 randomly selected waiting rooms (intervention group--3 GPs) while the other 2 waiting rooms remained unequipped (control group--3 GPs). At the end of the 6-month period, the number of vaccine adult-doses delivered by local pharmacies in response to GPs' prescriptions was recorded. As a reference, the same data were also collected retrospectively for the general practice during the same 6-month period of the previous year. RESULTS: During the 6-month reference period where no audiovisual message was broadcast in the 4 waiting rooms, the number of prescriptions presented for tetanus vaccines was respectively 52 (0.44%) in the intervention group and 33 (0.38%) in the control group (p = 0.50). By contrast, during the 6-month study period, the number of prescriptions differed between the two groups (p < 0.0001), rising significantly to 91 (0.79%) in the intervention group (p = 0.0005) while remaining constant in the control group (0.38% vs 0.39%; p = 0.90). CONCLUSIONS: Broadcasting an audiovisual health education message in the GPs' waiting room was associated with a significant increase in the number of adult tetanus booster vaccination prescriptions delivered by local pharmacies.

Geriatric day hospital: opportunity or threat? A qualitative exploratory study of the referral behaviour of Belgian general practitioners.

BACKGROUND: In order to address the challenges of an ageing population the Belgian government decided to allocate resources to the creation of geriatric day hospitals (GDHs). Although GDHs are meant to be a strategy to support general practitioners (GPs) caring for the frail elderly, few Belgian GPs seem to refer to a GDH. This study aims to explore the barriers and facilitating factors of GPs' referral to GDHs. METHODS: A qualitative study using focus group discussions (FGDs) was conducted. Fifteen FGDs were organized in the different Belgian regions (Flanders, Wallonia, Brussels). RESULTS: Contextual factors such as the unsatisfactory cooperation between hospital and GPs and organizational barriers such as the lack of communication on referral procedures between hospital and primary health care (PHC) were identified. Lack of basic knowledge about the concept or the local organization of GDH seemed to be a problem. Unclear task descriptions, responsibilities and activities of a GDH formed prominent points of discussion in all FGDs. Nevertheless a lot of possible advantages and disadvantages of GDHs for the patient and for the GP were mentioned. CONCLUSIONS: In the case of poor referral to GDHs, focusing on improving overall collaboration between primary and secondary health care is essential. This can be achieved by actively delivering adequate information, permanent communication and more involvement of PHC in the organization and functioning of GDHs. The absence of a transparent health care system with delineated role definitions, seems to hinder the integration of new initiatives like GDHs in the care process. Strategies to enhance referral to GDHs should use a comprehensive approach.

Value of Teledermoscopy in Primary Healthcare Centers: Preliminary Results of the TELESPOT Project in Belgium.

INTRODUCTION: Teledermoscopy using smartphone-based applications is becoming more and more important in a setting of increasing frequency of skin cancer and difficult access to specialized care. The TELESPOT project aimed to provide rapid diagnosis and speed up patient flow between primary healthcare centers and a tertiary care center in Belgium. The aim of the present study is to describe the development of an in-house smartphone-based dermoscopy application, evaluate its real-life value in a series of primary healthcare centers, and present preliminary diagnostic data. METHODS: Modified Likert scales were used to assess patient and general practitioner (GP) satisfaction rates for the system. Furthermore, a total of 105 photographic and dermoscopic images were acquired in a series of 80 patients at participating centers. RESULTS: Overall, patient and GP satisfaction levels were 89% and 94%, respectively. High-priority management was recommended in 7.6% of cases (8/105: 3 basal cell carcinoma, 1 primary cutaneous B-cell lymphoma, 1 Spitz melanocytic nevus, 1 congenital nevus, 1 in situ melanoma, and 1 invasive melanoma, proven by histology). CONCLUSIONS: The primary healthcare centers were highly satisfied with the TELESPOT project in terms of user-friendliness, efficacy, and reliability as well as in providing a reinforced image of first-line medicine efforts in combating skin cancer.

Prevalence of tuberculosis and associated risk factors in the Central Prison of Mbuji-Mayi, Democratic Republic of Congo.

BACKGROUND: Tuberculosis still remains a major public health concern in several provinces of the Democratic Republic of Congo, especially in prison settings. The present study aimed at determining tuberculosis (TB) prevalence and associated risk factors in inmates of the Mbuji-Mayi Central Prison. METHODS: This cross-sectional study was performed over a 6-month period (January to June 2015) in Mbuji-Mayi Central Prison. A total of 733 inmates were screened systematically for TB. The diagnosis was based on clinical examination and bacteriological tests. RESULTS: Tuberculosis was diagnosed in 130 inmates, what amounts to a 17.7 % prevalence (95 % confidence interval [CI] 15.1-20.6 %). The mean age ± SD of infected inmates was 31 ± 9.5 years old, and 94.8 % of them were male. Inmates were detained for a median period of 24 months (range: 3 months to 12 years). A cough lasting more than 2 weeks, body temperature higher than 39 °C, and weight loss were the predominating clinical signs. Factors independently associated with TB infection were overcrowding; highest population attributable fraction ([PAF] 88.2 %; adjusted odds ratio [OR] 9.8 [95 % CI 3.1-31.6]); malnutrition (body mass index of less than 18.5 kg/m(2)) (PAF 35.6 %; adjusted OR 2.1 [1.3-3.0]); and a detention period equal to or greater than 12 months (PAF 38.7 %; adjusted OR 2.1 [1.4-3.1]). CONCLUSIONS: Improving detention and sanitary conditions, as well as providing an adequate and early healthcare, are urgently needed to reduce TB prevalence in the prison environment.

[From chronic disease to multimorbidity: Which impact on organization of health care]. / De la maladie chronique à la multimorbidité : quel impact sur l'organisation des soins de santé ?

Healthcare systems are concerned with the growing prevalence of chronic diseases. Single disease approach, based on the Chronic Care Model, is known to improve specific indicators for the targeted disease. However, the co-existence of several chronic disease, or multimorbidity, within a same patient is the most frequent situation. The fragmentation of care, as consequence of the single disease approach, has negative impact on the patient and healthcare professionals. A person centred approach is a method addressing the combination of health issues of each patient. The coordination and synthesis role is key to ensure continuity of care for the patient within a network of healthcare professionals from several settings of care. This function is the main characteristic of an organized first level of care.

Long-term outcome of the humoral and cellular immune response of an H5N1 adjuvanted influenza vaccine in elderly persons: 2-year follow-up of a randomised open-label study.

BACKGROUND: Older individuals often have a reduced immune response to influenza vaccination, which might be improved by administering a higher vaccine dose. We compared the immune response to two single doses of the AS03A-adjuvanted H5N1 pandemic vaccine (3.75 µg hemagglutinin of A/Vietnam/1194/2004) with that of two double vaccine doses (7.5 µg hemagglutinin) in adults aged ≥61 years. Here we report the 2-year persistence of the humoral and cellular immune response. METHODS: In this phase II, open-label study, healthy participants aged 61 to 88 years (median 68 years) were randomised (3:1:3:1) to receive two single doses of the AS03A-adjuvanted vaccine (1xH5N1-AS) or the non-adjuvanted vaccine (1xH5N1), or two double doses of the AS03A-adjuvanted vaccine (2xH5N1-AS) or the non-adjuvanted vaccine (2xH5N1), 21 days apart. Serum haemagglutination inhibition antibodies and cellular immune responses against A/Vietnam/1194/2004 were measured in all groups at months 12 and 24; neutralising antibodies were assessed in a subset of the adjuvanted groups. Serious adverse events and adverse events of specific interest were recorded. RESULTS: At month 24, haemagglutination inhibition antibody seroprotection rates were 37.2% (95% CI 27.0% to 48.3%) for 1xH5N1-AS, 30.9% (95% CI 21.1% to 42.1%) for 2xH5N1-AS, 16.2% (95% CI 6.2% to 32.0%) for 1xH5N1, and 8.3% (95% CI 1.0% to 27.0%) for 2xH5N1. Haemagglutination inhibition antibody geometric mean titres were 17.6 (95% CI 13.7 to 22.5) for 1xH5N1-AS, 18.4 (95% CI 14.2 to 23.8) for 2xH5N1-AS, 12.3 (95% CI 8.9 to 16.9) for 1xH5N1 and 9.8 (95% CI 6.7 to 14.4) for 2xH5N1. The median frequency of antigen-specific CD4+ T cells per 106 T cells (25th quartile; 75th quartile) was 852 (482; 1477) for 1xH5N1-AS, 1147 (662; 1698) for 2xH5N1-AS, 556 (343; 749) for 1x-H5N1 and 673 (465; 1497) for 2xH5N1. Neutralising antibody geometric mean titres were 391.0 (95% CI 295.5 to 517.5) in the 1xH5N1-AS group and 382.8 (95% CI 317.4 to 461.6) in the 2xH5N1-AS group. CONCLUSIONS: Antibody levels declined substantially in all groups. Seroprotection rates, geometric mean titres for haemagglutination inhibition antibodies, and CD4+ T-cell responses tended to be higher in the AS03A-adjuvanted groups. There was no clear benefit, in terms of long-term persistence of the immune response, of doubling the dose of the adjuvanted vaccine. No safety concern was observed up to 24 months post-primary vaccination. TRIAL REGISTRATION: NCT00397215 (7 November 2006).

[Criteria of the patient's decision concerning vaccination against influenza AH1N1, in Belgium and France]. / Critères de décision du patient concernant la vaccination contre la grippe AH1N1, en Belgique et en France.

INTRODUCTION: We have analyzed the reasons evoked by the patients to decide or not to be vaccinated against AH1N1 influenza, in France and Belgium. METHODS: Semi-structured interviews were performed, recorded and transcribed for analysis. Fifty-eight interviews were performed with patient living in the region of Midi-Pyrénées, France (21 interviews) and in the province of Liège, Belgium (37 interviews). The patients were recruited by general practitioners. Within the sample, some patients were vaccinated against AH1N1 influenza and others were not. RESULTS: Five criteria influenced the decision to be vaccinated or not: how people understand the epidemic and the threats it represents; their representation about the vaccine (and its harmlessness); their beliefs and representations about vaccination; the influence of the health professionals' opinion; the discussions between the patient and his acquaintances; and how the patient seeks for information. CONCLUSION: These elements can be considered as criteria influencing the decision about any vaccination. They reflect the patient's subjectivity, the patient's perception of vaccination. Investigating these dimensions in the patient's mind can help the practitioner to positively influence the reluctant patients. Identifying threats and received ideas should allow the doctor to correct them and accept vaccination.

Lifestyle Behaviours and Plasma Vitamin C and ß-Carotene Levels from the ELAN Population (Liège, Belgium).

Several factors, including fruit and vegetables intakes, have been shown to significantly influence the plasma concentrations of the two antioxidants vitamin C and ß-carotene. Deficiency levels of 6 mg/L (34.2 µM) for vitamin C and of 0.22 mg/L (0.4 µM) for ß-carotene have been suggested below which cardiovascular risk might be increased. The present study performed on 897 presumably healthy subjects aged 40-60 years aimed to examine how modifiable lifestyle factors may be related to vitamin C and/or ß-carotene deficiency. Gender, smoking, lack of regular physical activity and of daily fruit consumption (≥2/day), and social status (in particular, unemployment) were found to be significant risk factors for vitamin C deficiency. For ß-carotene deficiency, the same factors were identified except social status; moreover, overweight and OC use in women were also found to have a deleterious effect. For non exposed subjects, the probability of developing vitamin C deficiency was 4% in men and 2.4% in women. This probability increased to 66.3% for men and to 44.3% for women (and even to 50.4% under OC use), when all risk factors were present. For ß-carotene deficiency, the corresponding probabilities were equal to 29.7% in men and 13.7% in women (no risk factor present), and to 86.1% for men and 69.9% (91.6% for OC use) for women (all factors present), respectively.

[Four years of application of the law that decriminalizes euthanasia in Belgium]. / Quatre ans d'application de la loi de dépénalisation de l'euthanasie en Belgique.

Legislation decriminalizing euthanasia came into effect in Belgium in 2002. Its application is monitored by a federal Commission, which submitted 2 reports to the Parliament, one covering the first 15 months of application and the other the years 2004 and 2005. This article analyzes and comments on the contents of these 2 documents, which provide interesting information on the medical practice of euthanasia in Belgium.

[Vitamin D deficiency in elderly men living in urban areas, at home or in institutions]. / Déficit en vitamine D chez l'homme âgé vivant à domicile ou en institution en milieu urbain.

OBJECTIVES: Many studies report severe vitamin D deficiency in the elderly and its involvement in various health problems (not limited to bone metabolism disorders). Most papers concern elderly women, however, and little is known about this problem among elderly men. This study focused on vitamin D deficiency in elderly men living in urban areas, whether at home or in an institution. METHODS: Between December 2005 and June 2006, we randomly recruited from general practices 336 men aged 65 years or more, living either at home or in institutions for the elderly. The variables studied were: age, residence (home or institution), fall and fracture history, independence (Katz), mobility (TUG), balance, outdoor walking, blood 25-OH-D level, glomerular filtration rate (MDRD) and PINI index. RESULTS: Of the 336 men, 45 (13%) were excluded because they were already receiving vitamin D treatment. The study thus included 291 patients, 174 community-dwelling and 117 institutionalized. The latter were significantly older and had less independence. Their 25-OH-D levels were also significantly lower than for community-dwelling subjects. The prevalence of severe vitamin D deficiency (25-OH-D < 12 ng/mL) was 79% among men in institutions and 57% among those living in the community (p<0.0001), and for mild and moderate vitamin D deficiency (12-32 ng/mL), 21% and 42%, respectively. Overall, only 2 men, both living at home, had normal vitamin D levels (25-OH-D > or = 32 ng/mL). In institutions, factors predictive of severe deficiency were TUG > or = 30s, walking distance < or = 100 m and lack of outdoor walking. Among the men living at home, none of the variables studied was associated with severe vitamin D deficiency. DISCUSSION: Potential biases of the study are discussed. Seasonal variations of vitamin D levels were small and comparable in both groups. The study confirms the high prevalence of vitamin D deficiency in elderly men. These results could probably be extended to other European cities with similar characteristics. The problem of interpreting 25-OH-D results with respect to current laboratory norms for defining severe or moderate vitamin D deficiency (12 and 32 ng/mL, respectively) is also discussed. CONCLUSION: Vitamin D deficiency is widespread and severe in elderly men, especially those living in institutions. Moderate to severe deficiency is also frequent among men living at home. Vitamin D supplementation should be routinely prescribed in institutions for the elderly and probably also to any individual over 65 years. Laboratory norms should be harmonized and consistent with recent medical evidence.