STUDY OBJECTIVES:Sleep diary is a common tool in sleep medicine, but was barely validated in practice so far. Lack of light exposure is associated with sleep disorders, especially insomnia. For that purpose, our team developed a sleep diary with information about light exposure. Our objectives were to compare the proportion of informative usual sleep diaries (USD) and light/sleep diaries (LSD) and to evaluate factors influencing the quality of filling them. METHODS:A monocentric, prospective, controlled interventional study was conducted. Patients included were randomized into two parallel groups: distribution of an USD (used in common practice), versus distribution of a LSD (similar to the USD but with light exposure data). The main outcome was the proportion of diaries returned and correctly filled out. A multivariate logistic regression model was then used to identify factors associated with the correct filling. RESULTS:A total of 325 USD and 324 LSD were distributed. 295 (45.5%) diaries were returned by patients: 158 (48.6%) USD, 137 (42.3%) LSD. The proportion of correctly completed diaries was 25.2% for USD versus 20.4% for LSD, which corresponds to a difference in the proportion of -4.86% [-10.25%; +∞[. The hypothesis of non-inferiority of LSD compared to USD cannot therefore be retained for a non-inferiority threshold of -10%. Multivariate analysis identified the level of difficulty experienced by the patient as an important factor influencing the quality of completion (OR =  0.99 [0.979-0.998]). The proportion of returned sleep diaries was greater in the USD and LSD insomniac subgroup (p < 0.0001). CONCLUSIONS:The non-inferiority of this new diary was not reached but this study highlighted the importance of clear explanations, patient motivation and restricted amount of collected data. Interestingly, insomniac patients represent a major target population for this tool.

Respiratory tract infections (RTIs) are common in general practice, and represent the main cause of inappropriate antibiotic prescribing, contributing to antimicrobial resistance. This prospective study aims to identify factors associated with inappropriate antibiotic prescribing for RTIs in general practice (GP). The study was conducted in France with the assistance of 15 GP trainees in France, in collaboration with 25 general practitioners. Data were collected from randomly selected GP consultations using ICPC-2 coding, with specific grids for RTI-related visits. Antibiotic prescribing was considered appropriate if it adhered to established guidelines. Of 807 consultations, 173 involved RTIs. Antibiotics were prescribed in 35% of cases, and management was appropriate in 73% of these cases. Sinusitis and bronchitis were more likely to result in inappropriate antibiotic prescriptions. Factors associated with inappropriate prescribing included a light clinical examination (as opposed to systematic), patient considered “at risk”, repeated consultations, and diagnostic uncertainty. Providing a clear diagnostic explanation to patients reduced the risk of inappropriate prescribing. Physicians who received visits from pharmaceutical industry representatives were more likely to prescribe antibiotics inappropriately. This study highlights the complexity of clinical reasoning underlying this practice. Improving the thoroughness of clinical examination, enhancing patient communication, and maintaining independence from pharmaceutical promotion may help optimize antibiotic use. Additionally, rapid diagnostic tests and prescribing software can help reduce uncertainty.

Introduction. In France, most of the very elderly live at home, either in their own home or with a relative. Their institutionalization is largely due to insufficient anticipation of future difficulties: very few take part in their entry into a retirement home. However, not involving the individual in the process is damaging to their transition, with potentially physical and mental health consequences. How can we respect patients' autonomy and ability to give consent, while helping them to consider their own future? Aims. To explore an elderly person's perceptions in a complex homecare context, in order to better understand the issues and problems Method. A qualitative monograph study was conducted through repeated face-to-face in-depth interviews with a 91-year-old woman living alone at home and her formal and informal carers. The inductive thematic analysis, followed by a theorization. Results. For the elderly person, home represented a place of identity, social life and family: roots that motivated them to stay there the longest possible time. Ageing and dependency trigger dramatic changes in intra-family relationships that threaten the elderly person's freedom. The resulting loss of freedom imposed by other persons is experienced as mistreatment. Thanks to the cognitive dissonance between a certain denial of the reduction in their abilities and the adaptations made to their home, they manage to maintain their free choice. Conclusion. Ageing and dependency have an impact on family and social relationships, which requires constant ethical questioning in order to regularly reassess the situation and adapt if necessary. Primary care physicians are the first line of support for patients and their families.

Introduction. The community health approach aims to reduce social inequalities in health. For interested healthcare providers, performing a community diagnosis of their area is an interesting first step. Such a diagnosis requires knowledge of the socio-economic determinants of the population in the health territory. The territorial health maps produced in 2016 by the Observatoire r & eacute;gional de la sant & eacute; of the Grand Est region establish, at a territorial level, five main types of priority neighbourhood de la ville (QPV) profiles. Type 1 is the least precarious and type 5 the most precarious. At an individual level, the EPICES score (<< & eacute;valuation de la pr & eacute;carit & eacute; et des in & eacute;galit & eacute;s de sant & eacute; dans les centres d'examens de sant & eacute;>>) is a precarity indicator that considers the multidimensional nature of precarity. Aim. To characterize three population groups' precarity, assessed by EPICES score according to the type of QPV profile they come from. Method. Measures and comparisons of EPICES scores for three samples of 250 patients consulting three multi -professional private health homes (MSPs) in three different QPVs in Strasbourg: one type 3, one type 4 and one type 5. Results. There was no statistically significant difference between the average EPICES scores of patients in the three MSPs (47.4 vs. 47.3 vs. 47.7; p = 0.98), and 74.5% of the population exceeded the precariousness cut-off point. Analysis of the answers to the eleven EPICES score questions showed a strong social network in the QPVs, but a lack of access to cultural and sports activities. Discussion. These data showed a discordance between the different typing of QPVs and the similarity of patients' EPICES scores. They raise questions for MSPs' teams, highlighting the fact that cross-referencing data from different indicators (health maps, EPICES scores) is an essential preliminary step in community diagnosis for structures wishing to engage in a community health approach.

Summary In the management of insomnia, physicians and patients are seeking alternative therapeutics to sleeping pills, in addition to sleep hygiene and cognitive behavioural therapy. Bright light therapy (LT) has proven its efficacy in circadian and mood disorders. We conducted a systematic literature review and meta‐analysis according to Cochrane and PRISMA guidelines and using the databases Medline, Cochrane, and Web of Science, with a special focus on light therapy and insomnia. Twenty‐two studies with a total of 685 participants were included, five of which with a high level of proof. Meta‐analysis was performed with 13 of them: light therapy for insomnia compared with control conditions significantly improved wake after sleep onset (WASO: SMD = −0.61 [−1.11, −0.11]; p = 0.017; weighted difference of 11.2 min ±11.5 based on actigraphy, and SMD = −1.09 [−1.43, −0.74] ( p < 0.001) weighted difference of −36.4 min ±15.05) based on sleep diary, but no other sleep measures such as sleep latency, total sleep time (TST), or sleep efficiency. Qualitative analysis of the review showed some improvement mainly in subjective measures. Morning light exposure advanced sleep–wake rhythms and evening exposure led to a delay. No worsening was observed in objective nor subjective measures, except for TST in one study with evening exposure. A light dose–response may exist but the studies’ heterogeneity and publication bias limit the interpretation. To conclude, light therapy shows some effectiveness for sleep maintenance in insomnia disorders, but further research is needed to refine the light parameters to be chosen according to the type of insomnia, in the hope of developing personalised therapeutics.

Summary Melatonin has gained growing interest as a treatment of insomnia, despite contradictory findings, and a low level of evidence. A systematic review and meta‐analysis was conducted following PRISMA criteria, to assess the efficacy of melatonin and ramelteon compared with placebo on sleep quantity and quality in insomnia disorder, while also considering factors that may impact their efficacy. This review included 22 studies, with 4875 participants, including 925 patients treated with melatonin, 1804 treated with ramelteon and 2297 receiving a placebo. Most studies evaluated the acute efficacy of prolonged release (PR) melatonin in insomnia disorder. Compared with placebo, PR melatonin appears efficacious with a small to medium effect size on subjective sleep onset latency (sSOL) ( p = 0.031; weighted difference = −6.30 min), objective sleep onset latency (oSOL) ( p < 0.001; weighted difference = −5.05 min), and objective sleep efficiency (oSE) ( p = 0.043; weighted difference = 1.91%). For the subgroup mean age of patients ≥55, PR melatonin was efficacious on oSE with a large effect size ( p < 0.001; weighted difference = 2.95%). Ramelteon was efficacious with a large effect size at 4 weeks on objective total sleep time (oTST) ( p = 0.010; weighted difference = 17.9 min), subjective total sleep time (sTST) ( p = 0.006; weighted difference = 11.7 min), sSOL ( p = 0.009; weighted difference = −8.74 min), and oSOL ( p = 0.017; weighted difference = −14 min). Regarding long‐term effects, ramelteon has a large effect size on oTST ( p < 0.001; weighted difference = 2.02 min) and sTST ( p < 0.001; weighted difference = 14.5 min). PR melatonin and ramelteon appear efficacious compared with placebo for insomnia symptoms with PR melatonin showing mostly small to medium effect sizes. PR melatonin for individuals with a mean age ≥ 55 and ramelteon show larger effect sizes.

Abstract Background Upper respiratory tract infections (URIs) are common in general practice, and inappropriate antibiotic prescribing remains a major concern that contributes to antimicrobial resistance. This prospective study aims to examine the factors influencing inappropriate antibiotic prescribing for URIs in general practice. Methods The study was conducted during the winter of 2017 by 15 general practice trainees in Alsace, France, in collaboration with 25 general practitioners. Data from random general practice consultations were collected, and specific grids were used for URI-related consultations. Results Out of the 807 consultations, 173 were related to URIs. Antibiotics were prescribed in 35% of cases, and management was deemed appropriate in 75% of cases. Amoxicillin was the most frequently prescribed antibiotic. Certain infections, such as sinusitis and bronchitis, were more likely to result in inappropriate antibiotic prescriptions. Factors influencing inappropriate management included a light clinical examination compared to systematic clinical examination (OR 4.83, 95% CI: [1.55–15.08], p = 0.007), perceiving the patient as "at risk" (OR 7.05, 95% CI [2.55–19.50], p < 0.001), repeated consultations for the same reason (OR 4.13, 95% CI [1.51–11.27], p = 0.006), and diagnostic uncertainty (OR 4.99, 95% CI [1.40–17.71, p = 0.013). Diagnosis explanation decrease the risk of inappropriate management (OR 0.41, 95% CI [0.17–0.99], p = 0.047]. Physicians who received visits from pharmaceutical industry representatives were more likely to improperly prescribe antibiotics (OR 4.59, 95% CI [1.51–13.95]. Conclusions While inappropriate antibiotic prescribing for URIs remains significant, this study highlights the complexity of the clinical reasoning underlying this practice. The study identifies modifiable factors, including conducting a thorough clinical examination, patient explanation, and independence from pharmaceutical promotion. It also highlights the critical role of managing diagnostic uncertainty. Rapid diagnostic tests and antibiotic prescription software help to reduce uncertainty, but it is equally important to learn to work with uncertainty in daily practice. These findings remain valid in the post-COVID period and call for ongoing medical education and public health policies aimed at promoting prudent antibiotic use in general practice.

ObjectivesThe first COVID-19 lockdown led to a significantly reduced access to healthcare, which may have increased decompensations in frail patients with chronic diseases, especially older patients living with a chronic cardiovascular disease (CVD) or a mental health disorder (MHD). The objective of COVIQuest was to evaluate whether a general practitioner (GP)-initiated phone call to patients with CVD and MHD during the COVID-19 lockdown could reduce the number of hospitalisation(s) over a 1-month period.DesignThis is a cluster randomised controlled trial. Clusters were GPs from eight French regions.ParticipantsPatients ≥70 years old with chronic CVD (COVIQuest_CV subtrial) or ≥18 years old with MHD (COVIQuest_MH subtrial).InterventionsA standardised GP-initiated phone call aiming to evaluate patients’ need for urgent healthcare, with a control group benefiting from usual care (ie, the contact with the GP was by the patient’s initiative).Main outcome measuresHospital admission within 1 month after the phone call.ResultsIn the COVIQuest_CV subtrial, 131 GPs and 1834 patients were included in the intervention group and 136 GPs and 1510 patients were allocated to the control group. Overall, 65 (3.54%) patients were hospitalised in the intervention group vs 69 (4.57%) in the control group (OR 0.82, 95% CI 0.56 to 1.20; risk difference −0.77, 95% CI −2.28 to 0.74). In the COVIQuest_MH subtrial, 136 GPs and 832 patients were included in the intervention group and 131 GPs and 548 patients were allocated to the control group. Overall, 27 (3.25%) patients were hospitalised in the intervention group vs 12 (2.19%) in the control group (OR 1.52, 95% CI 0.82 to 2.81; risk difference 1.38, 95% CI 0.06 to 2.70).ConclusionA GP-initiated phone call may have been associated with more hospitalisations within 1 month for patients with MHD, but results lack robustness and significance depending on the statistical approach used.Trial registration numberNCT04359875.

Nocturnal Legs Cramps are a frequent disorder, which have a negative impact on quality of life, particularly among patients over 60 years old. Lifestyle factors such as alcohol consumption have been shown to be associated with Nocturnal Leg Cramps. This study aimed to explore the association between nocturnal leg cramps and a sedentary lifestyle among elderly patients. A case-control study was conducted with a Bayesian approach for sensitivity analysis. Patients over 60 years old consulting their family doctor were recruited in the Alsace region, France. Cases were matched with controls free from cramps for age, sex, medical history and medications known to trigger cramps. The level of physical activity was assessed using the Dijon Physical Activity Score (DPAS). We performed univariate and multivariate analyses adjusting for alcohol consumption. 272 participants were matched into 136 pairs. 11% of all were sedentary persons. Adjusting for alcohol consumption, we observed an association between Nocturnal Leg Cramps and a sedentary lifestyle OR = 9.84 (95% credibility interval [1.74; 101.9]; posterior probability 99.68%). Our findings represent an additional argument to promote physical activity to patients over 60 years old. They also highlight the need to develop and evaluate physical activity interventions in the treatment of Nocturnal Legs Cramps.

Background General practitioners (GPs) regularly feel challenged by the care of depressed patients and may encounter several barriers in providing best management. GPs’ perspectives on barriers to depression care are a subject of growing interest but there is a lack of validated assessment tools. The aim of this study was to develop and validate a questionnaire assessing barriers to depression care (BDC-Q) encountered by GPs in France and the French-speaking part of Switzerland. Methods The BDC-Q was constructed in five steps: Item development, content validation, pretesting, testing phase and test-retest reliability. The questionnaire items were generated through a literature search. An expert panel of GPs ( n = 16) and psychiatrists ( n = 3) validated the content and 20 GPs pretested the questionnaire to provide response process validity evidence. We then tested the questionnaire among 116 GPs and used principal component analysis and internal consistency testing (Cronbach’s alpha) to structure it into consistent dimensions. Test-retest reliability using Pearson correlation coefficient was assessed with 30 GPs who completed the questionnaire twice after an interval of at least 2 weeks. Results The 25 items BDC-Q was structured in five dimensions: (i) provision of care by the general practitioner, (ii) considering patients’ attitudes towards depression, (iii) guidance for care, (iv) collaboration with mental health specialists and (v) access to mental health care. Conclusions The BDC-Q displays evidence of validity and reliability to meaningfully assess GPs’ perspectives on barriers to depression care. It can be used both at a practice level within a quality improvement strategy, and at a broader level, to inform health planners and tailor appropriate strategies to improve depression care in the community.

French general practitioners (GPs) are known to widely prescribe medications to treat insomnia despite their negative effects. GPs' easy access to self-medication may affect their mental representation of sleep and hypnotics, and subsequently their professional behaviour. Our aim was to examine the association between GPs' personal hypnotic drug consumption habits and their management of patients with sleep disturbances. A randomized sample of Alsatian GPs participated in a survey based on questionnaires including the Pittsburgh Sleep Quality Index, the Dysfunctional Beliefs About Sleep in 10 questions to characterize sleep, and an evaluation of their management strategies regarding sleep for both patients and themselves. Two-hundred and forty-nine GPs were included (response rate of 51%). Demographics of the GPs' samples were representative of those of the Alsatian GP population. Fifteen percent of the survey respondents met insomnia criteria. For the management of their own sleep disturbances, 14.3% of GPs were taking hypnotic drugs and 8.7% were taking anxiolytics, with greater drug consumption in the insomnia group. In a multivariate analysis, GPs who personally consumed these medications prescribed significantly more of them to patients, whereas their insomnia status had less impact. Other factors such as gender and type of practice were not associated with a higher prescription rate. Our results indicate that GPs' personal drug consumption can have a significant impact on the management of their patients, therefore suggesting that actions towards GPs' health improvement may also benefit their patients and the public.

Background. Microalbuminuria has been shown to predict cardiovascular events in hypertensive patients. European guidelines recommend an assessment of microalbuminuria once every two years. We undertake a study to describe (i) proportion of microalbuminuria assessment in hypertensive patients in family practice in France, (ii) factors influencing this assessment and (iii) impact on antihypertensive treatment. Method. Electronic medical records of five general practice offices in a French region have been analysed. Results. One on four hypertensive patients had a microalbuminuria assessment between 2014 and 2016 (23,29%, IC95 = 19,7-27.3; n = 116). A third of microalbuminuria assessment was positive (33,3%, IC95 = 24,9-42,6; n = 39). Age was associated with microalbuminuria assessment (p = 0,02). Patients with positive microalbuminuria assessment were most likely to have a change in their hypertensive therapy (64,1% (n=25) vs 17% (n=14) p < 0,001). Change in hypertensive therapy was most frequently an ACE inhibitor or ARB. Conclusion. Microalbuminuria assessment is rarely done in French hypertensive patients. Changes in hypertensive therapy using ACE inhibitors and ARB when microalbuminuria assessment is positive is in phase with current scientific evidences.

Contexte. La microalbuminurie chez le patient hypertendu est un marqueur du risque de développement de complications cardiovasculaires. Les recommandations européennes proposent ainsi un dosage tous les deux ans de la microalbuminurie. L’objectif de notre étude était (i) de décrire la proportion de dosage de la microalbuminurie chez les patients hypertendus en médecine générale en France et (ii) d’explorer les facteurs influençant ce dosage (iii) ainsi que les conséquences en termes de prescription d’antihypertenseurs. Mé thodes. Les données informatiques des dossiers de cinq cabinets de médecine générale en Alsace ont été analysées de manière rétrospective. Résultats. La microalbuminurie était dosée chez environ un patient sur quatre sur la période 2014-2016 (23,29 %, IC95 = 19,7-27,3 ; n = 116) et était positive dans un tiers des cas (33,3 %, IC95 = 24,9-42,6 ; n = 39). Seul l’âge était associé significativement au fait de bénéficier ou non du dosage de la microalbuminurie (p = 0,02). Le groupe de patients avec un dosage de microalbuminurie positif a davantage eu de modifications de traitement antihypertenseur sur la période étudiée que le groupe avec un dosage négatif ( 64,1 % [n = 25] vs 17 % [n = 14] ; p < 0,001). Cette modification consistait principalement en une introduction d’IEC ou d’ARA2. Conclusion. Ces données indiquent que la microalbuminurie est actuellement modérément dosée chez les patients hypertendus français. L’intensification du traitement antihypertenseur et le choix des IEC ou des ARA2 en cas de microalbuminurie positive est conforme aux données de la littérature.

Narcolepsy type 1 is a rare disabling sleep disorder mainly characterized by excessive daytime sleepiness and cataplexy, an emotion-triggered sudden loss of muscle tone. Patients have a selective degeneration of hypocretin-producing neurons in the dorsolateral posterior hypothalamus with growing evidence supporting the hypothesis of an autoimmune mechanism. Few case studies that reported intravenous immunoglobulin therapy (IVIg) suggest the efficacy of IVIg when administered early after disease onset, but the results are controversial. In these retrospective case observations, IVIg cycles were initiated within one to four months after cataplexy onset in a twenty-seven-year-old man, a ten-year-old girl, and a seven-year-old boy, all three with early onset typical narcolepsy type 1. Efficacy of treatment (three IVIg cycles of 1 g/kg administered at four-week intervals) was evaluated based on clinical, polysomnographic, and multiple sleep latency test (mean latency and SOREM) follow-up. Two patients reported decreased cataplexy frequency and ameliorated daytime sleepiness, but no significant amelioration of polysomnographic parameters was observed. Given the possibility of spontaneous improvement of cataplexy frequency with self-behavioral adjustments, these observations would need to be confirmed by larger controlled studies. Based on the present study and current literature, proof of concept is still missing thus prohibiting the consideration of IVIg as an efficient treatment option.

PURPOSE Nocturnal leg cramps are a specific kind of cramps affecting almost one-half of patients aged 60 years and older. They reduce patients’ quality of sleep and have a negative impact on their quality of life. The aim of this study was to evaluate the association between nocturnal leg cramps and the consumption of alcoholic beverages in patients aged 60 years and older attending general practices. METHODS Case-control study with a Bayesian approach for sensitivity analysis. Participants were voluntary ambulatory patients aged 60 years and older consulting their family doctor. They were recruited in 67 general practices across the Alsace region. Cases (patients having cramps), were matched with controls (patients free from cramps) for age, sex, medical history, and medications known to trigger cramps. Alcohol consumption was assessed through a standardized food frequency questionnaire. RESULTS We found an association between the global consumption of alcoholic beverages and nocturnal leg cramps (OR = 6.5, 95% credibility interval, 1.68-38.05; posterior probability 99.82%). CONCLUSION We identified an association between alcohol consumption and nocturnal leg cramps among patients aged 60 years and older attending general practices. These findings have implications for the prevention of cramps.

Évaluer la non-infériorité d’un agenda plus complexe par rapport à l’agenda habituel dans la qualité du remplissage des données de base, et les déterminants de la qualité du recueil. Étude prospective randomisée, analysée per-protocole dans une population adulte, consultant pour toute pathologie du sommeil. Le premier groupe recevait un agenda habituel (H), le second groupe un agenda sommeil-lumière (L). Des critères préétablis distinguaient les agendas correctement remplis des autres. Sur 682 agendas distribués (340 L et 342 H) 247 ont été retournés (respectivement 38 % H et 34 % L de retour) et inclus pour analyse. Les deux groupes étaient comparables pour les caractéristiques sociodémographiques et les pathologies du sommeil. Le taux d’agendas bien remplis était respectivement de 51,5 % H, et 47,0 % L. L’hypothèse de la non-infériorité de L pour une différence de 0,1 sur la proportion d’agendas remplis selon les critères préétablis n’a pu être retenue (−0,045 IC95 = [−0,15 1]). Donner des explications lors de la remise de l’agenda améliore significativement la qualité du recueil (OR = 2,08 IC95 = [1,43 4,76]). Nous avons été surpris par le faible taux de retour d’agendas bien remplis. Bien que la non-infériorité de l’agenda sommeil-lumière n’ait pas été démontrée, les informations sur l’exposition à la lumière recueillies sont intéressantes pour le diagnostic et la thérapeutique. Les explications fournies lors de la remise des agendas conditionnent la qualité du remplissage.

Background. Patients use self-care to relieve symptoms of common colds, yet little is known about the prevalence and patterns across Europe. Methods/Design. In a cross-sectional study 27 primary care practices from 14 countries distributed 120 questionnaires to consecutive patients (≥18 years, any reason for consultation). A 27-item questionnaire asked for patients' self-care for their last common cold. Results. 3,074 patients from 27 European sites participated. Their mean age was 46.7 years, and 62.5% were females. 99% of the participants used ≥1 self-care practice. In total, 527 different practices were reported; the age-standardized mean was 11.5 (±SD 6.0) per participant. The most frequent self-care categories were foodstuffs (95%), extras at home (81%), preparations for intestinal absorption (81%), and intranasal applications (53%). Patterns were similar across all sites, while the number of practices varied between and within countries. The most frequent single practices were water (43%), honey (42%), paracetamol (38%), oranges/orange juice (38%), and staying in bed (38%). Participants used 9 times more nonpharmaceutical items than pharmaceutical items. The majority (69%) combined self-care with and without proof of evidence, while ≤1% used only evidence-based items. Discussion. This first cross-national study on self-care for common colds showed a similar pattern across sites but quantitative differences.