Osteoporosis prevention: Where are the barriers to improvement in French general practitioners? A qualitative study.

BACKGROUND: Osteoporosis prevention, diagnosis and treatment remain suboptimal. OBJECTIVES: We conducted a qualitative study to understand barriers towards care initiation and levers to improve awareness and management of osteoporosis among general practitioners (GPs). METHODS: Semi-structured face-to face interviews were conducted with 16 GPs in the Rhône area of France to explore their knowledge and representations regarding osteoporosis. A thematic analysis of transcripts was performed to identify GPs' perceptions on osteoporosis diagnosis, prevention, treatment and patients' expectations. RESULTS: Interviewed GPs considered osteoporosis far less important than other chronic diseases. They questioned whether osteoporosis was a disease or normal aspect of ageing. They associated osteoporosis with fragility fractures, female sex, menopause, and old age but rarely with male sex. They regarded bone mineral density as the reference diagnostic test, but certain GPs indicated that they had difficulties to interpret the results and to know when to prescribe. Biphosphonates were mentioned as the reference treatment but some GPs expressed distrust about osteoporosis medications. Most of them did not think to screen for osteoporosis risk factors in their patients in a preventive medical approach. They mentioned the lack of time to implement prevention and were expecting clear and pragmatic guidelines, as well as information campaigns in general population to increase awareness on osteoporosis. CONCLUSION: GPs tended to underestimate the salience of osteoporosis. Clear recommendations, better awareness of GPs and the general population could improve osteoporosis prevention and treatment.

Vitamin D supplementation for diffuse musculoskeletal pain: results of a before-and-after study.

BACKGROUND: Several studies have shown that vitamin D supplementation could be useful for treating diffuse musculoskeletal (DMS) pain in adults. OBJECTIVES: The aim of this study was to evaluate the effects of correcting a vitamin D deficiency (≤ 50 nmol/l) on DMS pain and quality of life in adults. METHODS: A pragmatic prospective study was conducted in a general practice setting in the Rhone-Alps area between 1 February and 30 April 2009. Patients between the ages of 18 and 50 years old who consulted their general practitioner (GP) for DMS pain or chronic unexplained asthenia and had a deficient serum 25 (OH) D level with no signs of any other disease were enrolled in this study. The patients received high doses of vitamin D supplements (400 000 to 600 000 units). Mean pain evaluation scores were evaluated before and after vitamin D supplementation using mixed models and accounting for repeated measures. RESULTS: Before vitamin D supplementation, the adult study cohort (n = 49) had an adjusted mean serum 25 (OH) D level of 23.7 nmol/l, a mean pain evaluation score of 5.07 and a mean quality of life score of 3.55. After vitamin D supplementation, the adjusted mean serum 25 (OH) D level increased to 118.8 nmol/l (P < 0.001), the mean quality of life score increased to 2.8 nmol/l (P < 0.001) and the mean pain evaluation score decreased to 2.8 (P < 0.001). CONCLUSION: In this small before-and-after study, vitamin D supplementation decreased pain scores in adult patients with diffuse musculoskeletal pain and vitamin D deficiency. These results must be confirmed by further studies.

[Musculoskeletal chronic pains and Vitamin D deficiency. Study before after in general practice]. / Douleurs musculo-squelettiques non systématisées diffuses et déficit sévère en vitamine D. Étude avant-après en médecine générale.

OBJECTIVES: The objective of this study was to evaluate the effect of the correction of vitamin D deficiency (defined by a rate≤50 nmol/l) on the pain, fatigue and quality of life. METHODS: A pragmatic prospective study was conducted in Rhone-Alpes area, in general practices between February 1 and April 30, 2009. All patients aged 18 to 50 years consulting for diffuse musculoskeletal pain and/or chronic unexplained fatigue, with the only abnormality deficient serum vitamin D were enrolled in this study. They might agree to complete questionnaires on quality of life, pain assessment and control their vitamin D levels after treatment. RESULTS: Forty-nine complete records were analyzed. The deficiency was severe (mean 26 nmol/l). High doses of vitamin were necessary to correct deficiency, between 400,000 to 600,000 units. The correction of vitamin D deficiency resulted in a significant decrease in the level of pain intensity according to verbal rating scale (P=0.034) and the Digital Scale (P<0.001), consumption of analgesics (P=0.002) and discomfort in carrying out activities of daily living following: the shopping, cleaning, walking for more than a kilometer (P<0.001) and dressing (P=0.012). CONCLUSION: The correction has had a positive impact both physical, mental and social activities. Non-specific musculoskeletal pain or unexplained asthenia are common in primary care. Make a dosage of vitamin D and correct deficits is a necessity before performing complex and expensive examinations.

What perceptions do patients have of decision making (DM)? Toward an integrative patient-centered care model. A qualitative study using focus-group interviews.

OBJECTIVE: To understand patients' perceptions of decision making and identify relationships among decision-making models. METHODS: This qualitative study was made up of four focus group interviews (elderly persons, users of health support groups, students, and rural inhabitants). Participants were asked to report their perceptions of decision making in three written clinical scenarios (hypertension, breast cancer, prostate cancer). The analysis was based on the principles of grounded theory. RESULTS: Most patients perceived decision making as shared decision making, a deliberative question-response interaction with the physician that allowed patients to be experts in obtaining clearer information, participating in the care process, and negotiating compromises with physician preferences. Requesting second opinions allowed patients to maintain control, even within the paternalistic model preferred by elderly persons. Facilitating factors (trust, qualitative non-verbal communication, time to think) and obstacles (serious/emergency situations, perceived inadequate scientific competence, problems making requests, fear of knowing) were also part of shared decision making. CONCLUSION AND PRACTICE IMPLICATIONS: In the global concept of patient-centered care, shared decision making can be flexible and can integrate paternalistic and informative models. Physicians' expertise should be associated with biomedical and relational skills through listening to, informing, and advising patients, and by supporting patients' choices.

Risk factors for vitamin D deficiency in women aged 20-50 years consulting in general practice: a cross-sectional study.

OBJECTIVE: Vitamin D deficiency is often unidentified, although treatment is simple and inexpensive. Our objective was to estimate the influence of concealing clothes and other risk factors for vitamin D deficiency in women aged 20 to 50 years consulting general practitioners. METHODS: 13 GPs in the Rhone Alps area planned to recruit 300 women (100 veiled and 200 non-veiled) from January to March 2008. Serum 25(OH)D and PTH were measured in one single laboratory (Biomnis(®)) by a radio-immunoassay method. A survey was administered about dietary habits, sun exposure, and quality of life. RESULTS: Among 247 women enrolled, 196 were analysed: 61 wearing concealing clothes (31.2%) and 135 without (68.8%). As expected, 25(OH)D serum level was significantly lower in covered women (20.1 versus 38.9 nmol/l P < 0.001). Of women who did not wear concealing clothing, 39.3% had severe hypovitaminosis D (25(OH)D concentration < 30 nmol/l). Women wearing concealing clothes had more often other known risk factors such as dark skin (P < 0.001), less sunlight exposure, or a higher Body Mass Index (P = 0.009). Besides concealing clothing (OR 6.37, 95% CI: 1.35-30.09), multivariate analyses revealed two independent risk factors for vitamin D deficiency: no full-body sun exposure (OR: 3.06, 95% CI: 1.18-7.94) and no outdoor sports (OR: 2.81, 95% CI: 1.11-7.12) for threshold 52 nmol/l. CONCLUSION: Young women consulting their GP had hypovitaminosis D more often than expected. Besides concealing clothing, absence of full body sun exposure during summer and of outdoor sports practice could suggest a possible vitamin D deficiency.

[Cervical smears among women after 65 years. One-year retrospective descriptive study]. / Frottis du col de l'utérus chez les femmes de plus de 65 ans. Etude descriptive rétrospective réalisée sur une année.

BACKGROUND: The recommendations of the French consensus (Lille 1990) advise the stop of the tracking by cervical smears of cancer at 65-years-old, if the former follow-up were regular and if the last two smears were normal. 33% cervical cancers are after 65-years-old. AIM: How many pathological smears are after 65 years? METHOD: Descriptive, retrospective study analyzing the results of 12339 smears of women of more than 65 years, carried out during one year in the same laboratory of anatomo-pathology. They were analysed with Bethesda's system. RESULTS: 2.67% of smears are of insufficient quality (CI 95%: 2, 46%; 3%); 2.43% of smears are pathological (CI 95%: 2, 2%; 2, 7%). That pathological smear's rate is comparable to the one found among women of less than 65-years-old (2 to 3%). The squamous cell carcinoma's rate is more important in this group. CONCLUSION: This work encourages us to continue smear's practice among women of more than 65 years.

Mechanical stimuli regulate the allocation of biomass in trees: demonstration with young Prunus avium trees.

BACKGROUND AND AIMS: Plastic tree-shelters are increasingly used to protect tree seedlings against browsing animals and herbicide drifts. The biomass allocation in young seedlings of deciduous trees is highly disturbed by common plastic tree-shelters, resulting in poor root systems and reduced diameter growth of the trunk. The shelters have been improved by creating chimney-effect ventilation with holes drilled at the bottom, resulting in stimulated trunk diameter growth, but the root deficit has remained unchanged. An experiment was set up to elucidate the mechanisms behind the poor root growth of sheltered Prunus avium trees. METHODS: Tree seedlings were grown either in natural windy conditions or in tree-shelters. Mechanical wind stimuli were suppressed in ten unsheltered trees by staking. Mechanical stimuli (bending) of the stem were applied in ten sheltered trees using an original mechanical device. KEY RESULTS: Sheltered trees suffered from poor root growth, but sheltered bent trees largely recovered, showing that mechano-sensing is an important mechanism governing C allocation and the shoot-root balance. The use of a few artificial mechanical stimuli increased the biomass allocation towards the roots, as did natural wind sway. It was demonstrated that there was an acclimation of plants to the imposed strain. CONCLUSIONS: This study suggests that if mechanical stimuli are used to control plant growth, they should be applied at low frequency in order to be most effective. The impact on the functional equilibrium hypothesis that is used in many tree growth models is discussed. The consequence of the lack of mechanical stimuli should be incorporated in tree growth models when applied to environments protected from the wind (e.g. greenhouses, dense forests).