Physical activity prescription for general practice patients with cardiovascular risk factors-the PEPPER randomised controlled trial protocol.

BACKGROUND: The health benefits of physical exercise have been shown to be important in the prevention of cardiovascular diseases in patients with hypertension, dyslipidaemia or diabetes. However, few strategies have demonstrated efficacy and practicality in the promotion of physical exercise among this group of patients in general practice. METHODS: The PEPPER clinical study is a randomised controlled trial to evaluate the efficacy over a period of 12 months, in terms of physical activity level, of an intervention based on structured information delivery, a personalised written physical activity prescription in number of steps per day, a pedometer and a pedometer logbook, in 35 to 74-year-old patients with cardiovascular risk factors. 140 patients will be recruited in 15 GP practices and randomised in the intervention group or in the control group where patients will receive verbal advice of physical exercise. The primary outcome is the change at three months in total energy expenditure measured by an accelerometer over a 7-day period. Secondary outcomes include changes at 3 and 12 months in physical activity levels (accelerometer and International Physical Activity Questionnaire), quality of life (SF-36), blood pressure, weight, waist circumference, perceived obstacles to physical activity and patient compliance with the recommended strategy. Both groups will be compared using mixed models. DISCUSSION: The results are expected at the end of 2019. If the intervention proves effective in durably increasing the level of physical activity, this strategy could be tested in a larger trial to examine its impact on cardiovascular diseases. TRIAL REGISTRATION: US National Institutes of Health Clinical Trials Registry NCT02317003 , December 15, 2014.

[Musculoskeletal disorders: Role of medical advisers and inter-professional relations]. / Troubles musculo-squelettiques?: rôles des médecins-conseils et relations interprofessionnelles.

INTRODUCTION: Musculoskeletal disorders (MSD) were responsible for 9.7 million days of sick leave in 2010 in France. They are also a leading cause of occupational exclusion. The objective was to study the role of medical advisers (Mas) in the care of patients with MSD and their interactions with general practitioners (GPs) and occupational health physicians (OPs). METHODS: We performed a qualitative study with semi-structured interviews with medical advisers from the Brittany region. Semistructured interviews were double-coded and were submitted to thematic analysis. RESULTS: Nine interviews were conducted with MAs from the general regime, agricultural regime, and independent workers regime. MAs described an increase in MSD, especially with complex forms. They explained that their activity was not limited to control, but that they also had an important role in limiting occupational exclusion. It is important to anticipate difficulties related to return to work in this setting. They reported contrasted but necessary relations with GPs who are at the centre of care. Return to work may require negotiation with OPs. CONCLUSION: Relations between MAs and GPs are partly based on control of prescriptions, which can create a climate of suspicion. Emphasizing the fight against occupational exclusion can provide new light on the role of MAs. Improving relations between MAs and GPs can be achieved by a better understanding of their respective roles.

Psychosocial Risk Factors, Interventions, and Comorbidity in Patients with Non-Specific Low Back Pain in Primary Care: Need for Comprehensive and Patient-Centered Care.

Non-specific low back pain (LBP) affects many people and has major socio-economic consequences. Traditional therapeutic strategies, mainly focused on biomechanical factors, have had moderate and short-term impact. Certain psychosocial factors have been linked to poor prognosis of LBP and they are increasingly considered as promising targets for management of LBP. Primary health care providers (HCPs) are involved in most of the management of people with LBP and they are skilled in providing comprehensive care, including consideration of psychosocial dimensions. This review aims to discuss three pieces of recent research focusing on psychosocial issues in LBP patients in primary care. In the first systematic review, the patients' or HCPs' overall judgment about the likely evolution of LBP was the factor most strongly linked to poor outcome, with predictive validity similar to that of multidimensional scales. This result may be explained by the implicit aggregation of many prognostic factors underlying this judgment and suggests the relevance of considering the patients from biopsychosocial and longitudinal points of view. The second review showed that most of the interventions targeting psychosocial factors in LBP in primary care have to date focused on the cognitive-behavioral factors, resulting in little impact. It is unlikely that any intervention focusing on a single factor would ever fit the needs of most patients; interventions targeting determinants from several fields (mainly psychosocial, biomechanical, and occupational) may be more relevant. Should multiple stakeholders be involved in such interventions, enhanced interprofessional collaboration would be critical to ensure the delivery of coordinated care. Finally, in the third study, the prevalence of psychosocial comorbidity in chronic LBP patients was not found to be significantly higher than in other patients consulting in primary care. Rather than specifically screening for psychosocial conditions, this suggests taking into account any potential comorbidity in patients with chronic LBP, as in other patients. All these results support the adoption of a more comprehensive and patient-centered approach when dealing with patients with LBP in primary care. As this condition is illustrative of many situations encountered in primary care, the strategies proposed here may benefit most patients consulting in this setting.

[Representativeness of general practice university lecturers]. / Représentativité des médecins généralistes maîtres de stage universitaires.

OBJECTIVE: In order to develop primary care research by general practice university lecturers, it was necessary to evaluate the representativeness of this group of lecturers at the Angers Faculty of Medicine. METHODS: Declarative study based on self-administered questionnaires filled in by 216 university lecturers. The questionnaire was derived from that of the regional panel of the Research, studies, evaluation and statistics directorate of 2007, investigating the sociodemographic characteristics, professional organization, activities and certain professional practices of general practitioners. University lecturers were compared to the population of the panel by means of a Chi-square test of conformity. RESULTS: A total of 181 university lecturers participated in the survey, comprising 65% of men. The proportion of women was higher among university lecturers and the 45-54years age-group was underrepresented. The university lecturers group was significantly different from the panel in terms of predominantly group practice and shorter weekly working hours. No significant difference was observed for the type of town of practice ahd the continuing medical education participation rate. CONCLUSION: University lecturers present certain specificities, partly related to the reference population used. The development of research based on such a network appears to be feasible in terms ofrepresentativeness, provided these specificities are clearly described.

[Qualitative approach of medical support of spouse caregivers of Alzheimer patients]. / Approche qualitative de la prise en charge des aidants-conjoints de malades Alzheimer.

BACKGROUND: The caregivers of patients with Alzheimer's disease (AD) play a key role in their management. Half of them are spouses. This involvement may alter their own health, leading to exhaustion and depression. Since 2010, general practitioners (GPs) have been invited in France to offer an annual specific medical support to spouse caregivers. The aims of this study were to understand their experience of this situation by spouse caregivers, and how the spouse caregiver perceives the role of the GP in this context. METHODS: A qualitative approach was conducted using semi-structured interviews of 14 spouse caregivers recruited from adult day care in Angers, France. RESULTS: The analysis of interviews showed that AD was an existential crisis for the dyad AD patient/spouse caregiver. The emotional connection and the sense of commitment strongly involved the spouse caregivers into cares for the loved ones. Even if the frequency of medical consultations remained unchanged, caregivers were more prone to delay non-urgent cares for themselves. Moreover their intention to handle things on their own and the interaction with health professionals of the care recipients interfered with the involvement of the caregivers' GPs. CONCLUSIONS: Caregivers' adaptation to their spouses' AD resulted in both negative and positive behaviors. Instead of a mandatory annual consultation focused on caregivers' health, the improvement of communication between all support services, including caregivers' GPs, may help to enhance the medical support of spouse caregivers of AD patients.

[Teenagers' representations of food in the Pays de la Loire]. / Représentations d'adolescents des Pays de la Loire sur l'alimentation.

CONTEXT: The National Nutrition Health Study showed that the objectives of the National Nutrition Health Programme, launched in 2001 to promote the health of all French people, had not been achieved, especially in the adolescent population. The objective of this study was to identify teenagers' representations regarding food. It was carried out in order to more effectively tailor prevention messages to this particular population, which is particularly concerned by the "nutritional risk". METHODS: Qualitative investigations by semi-directive interviews with 46 teenage volunteers,from 5 high schools in 2 departments in the west of France. A content analysis was conducted inductively after full transcript of the interviews. RESULTS: The study showed that nutrition was a means of autonomy and emancipation from the parental influence. Teenagers were suspicious and anxious about the health risks associated with processed food. Fast food restaurants were a "place for teenagers" synonymous with pleasure and freedom. They valued "organic" and "homemade" foods. The sexual representations of food consisted of a "slim" image for girls and a "virile" image for boys. A close relationship between food and living beings was responsible for refusal of certain types of food. Although prevention messages were integrated in various ways, they were effectively recalled by teenagers. CONCLUSION: The nutritional representations of teenagers are poorly known and sometimes contrary to commonly health beliefs and must be taken into account when preparing nutrition prevention programmes.

Interventions focusing on psychosocial risk factors for patients with non-chronic low back pain in primary care--a systematic review.

BACKGROUND: Low back pain (LBP) is a problem that is frequently encountered in primary care, and current guidelines encourage care providers to take into account psychosocial risk factors in order to avoid transition from acute to chronic LBP. OBJECTIVE: To review the effectiveness of interventions focusing on psychosocial risk factors for patients with non-chronic LBP in primary care. METHODS: A systematic search was undertaken for controlled trials focusing on psychosocial factors in adult patients with non-chronic, non-specific LBP in primary care by exploring Medline, Embase, PsycInfo, Francis, Web of Sciences and The Cochrane Library. The methodological quality of the studies included was assessed before analysing their findings. RESULTS: Thirteen studies were selected, seven being considered as having a low risk of bias. Information strategies were assessed by eight trials, with high-quality evidence of no effectiveness for pain, function, work issues and health care use, low-quality evidence of no effectiveness for self-rated overall improvement, satisfaction and pain beliefs and lack of evidence in terms of quality of life. Cognitive behavioural therapy was assessed by three trials, with very low-quality evidence of moderate effectiveness for pain, function, quality of life, work issues and health care use. There was lack of evidence concerning the effectiveness of individual and group education intervention or work coordination. CONCLUSION: Among the wide range of psychosocial risk factors, research has focused mainly on pain beliefs and coping skills, with disappointing results. Extended theoretical models integrating several psychosocial factors and multicomponent interventions are probably required to meet the challenge of LBP.

[Assessment of scientific production after initial medical education at the Faculty of Medicine of Angers from 2002 to 2008]. / La production scientifique issue de la formation initiale à la faculté de médecine d'Angers entre 2002 et 2008 : de bonne qualité mais insuffisante.

INTRODUCTION: The activity of scientific publication after initial medical education is unclear. The purpose of this study was to evaluate the proportion of MD theses and Board certification manuscripts resulting in a publication, their impact in terms of SIGAPS points and the main difficulties in the publication of this work. METHODS: MD theses sustained from 2002 to 2008 at the Faculty of Medicine of Angers have been identified from the "Système universitaire de documentation" (SUDOC), catalog, and specialty certification manuscripts (Board and Complementary Board) directly to diplomates. Publications were searched in Medline via Pubmed, ISI Web of Knowledge and in the three SIGAPS reports from 2002 to 2008. A survey aimed at determining the barriers to publication and the way to suppress them was launched to all MD directors and specialty mentors. RESULTS: Five hundred and ninety-eight theses were sustained, 311 (52%) in general medicine and 287 (48%) in specialties. One hundred and sixty-five theses have resulted in publication (28%) of which 97 (16%) indexed in Medline via Pubmed (11% in general medicine and 22% in specialty). Thirty-three of these 97 articles (35%) were published in journals of high quality classes A, B or C of SIGAPS classification. These articles from theses represented 4.17% of the SIGAPS scoring of the hospital calculated on a total of 2088 articles over this period. Two hundred and four specialty certification manuscripts resulted in 69 articles (33.8%), 50 (24.5%) indexed in Medline. The rate of publication of these specialty manuscripts, Board and Complementary Board, were respectively 31% (45/145) and 40.7% (24/59). They represented 1.9% (432 points) total SIGAPS score. The main barriers to publication were lack of time of directors, remote students after the promotion and the lack of logistic resources. CONCLUSION: Scientific publications issued from initial medical education at the Faculty of Medicine of Angers was of good quality but quantitatively insufficient, and contributed poorly to the University Hospital funding despite a significant number of diplomates. Logistical support should be considered in order to promote scientific production after initial medical education.

Psychosocial risk factors for chronic low back pain in primary care--a systematic review.

BACKGROUND: Low back pain (LBP) is a major public health problem, often encountered in primary care. Guidelines recommend early identification of psychosocial factors that could prevent recovery from acute LBP. METHODS: To review the evidence on the prognostic value of psychosocial factors on transition from acute to chronic non-specific LBP in the adult general population. Systematic review is the design of the study. A systematic search was undertaken for prospective studies dealing with psychosocial risk factors for poor outcome of LBP in primary care, screening PubMed, PsychInfo and Cochrane Library databases. The methodological quality of studies was assessed independently by two reviewers using standardized criteria before analysing their main results. RESULTS: Twenty-three papers fulfilled the inclusion criteria, covering 18 different cohorts. Sixteen psychosocial factors were analysed in three domains: social and socio-occupational, psychological and cognitive and behavioural. Depression, psychological distress, passive coping strategies and fear-avoidance beliefs were sometimes found to be independently linked with poor outcome, whereas most social and socio-occupational factors were not. The predictive ability of a patient's self-perceived general health at baseline was difficult to interpret because of biomedical confounding factors. The initial patient's or care provider's perceived risk of persistence of LBP was the factor that was most consistently linked with actual outcome. CONCLUSION: Few independent psychosocial risk factors have been demonstrated to exist. Randomized clinical trials aimed at modifying these factors have shown little impact on patient prognosis. Qualitative research might be valuable to explore further the field of LBP and to define new management strategies.

[Early suspension of private practice: the current trends for general practitioners in three counties in western France]. / Cessations anticipées d'activité des médecins généralistes libéraux dans les trois départements de l'ouest de la France. Quelle réalité?

The purpose of this study is to conduct a census of general practitioners in order to better understand their early withdrawal from primary care practice and to assess the impact of such withdrawal on current medical demography. The study covers the withdrawals from January 2000 to December 2005 in three western French counties. Data were collected through the district councils of the practitioners'guild, followed by a questionnaire filled in by 75 doctors. The participation rate was 60%. The study reveals that only 29% of these withdrawals are due to retirement. More than one in two doctors left to pursue another paid employment, and more than 25% chose to relocate their practice in a different area of the county. Two thirds of them were practicing in rural or semi-rural locations. Less than half, 47%, were replaced by a successor. General practitioners surveyed did not stop all professional medical care provision and service activities. Their careers are complex, and they are mobile professionals. The main reasons for suspending their activities in a given location were essentially related to the difficulties they had in dealing with their work loads and in maintaining a healthy work-life balance. They have noted that they will leave a range of possibilities open, either looking for private practice or not, exploring the possibility of primary care or not; the basis of their decision is whether a new position will correspond to their desire of mobility and meet their needs for more free.

[Exploring the prospects for general practitioners over 55 years old from three counties of western France]. / Perspectives d'activité pour les médecins généralistes de plus de 55 ans dans l'ouest de la France.

OBJECTIVE: Medical demography and the practice of medicine will be influenced by the personal plans of GPs and their decisions to stop practicing in the coming years. This study aims to understand the events that could potentially worsen the medical demography in terms of shortages of GPs for primary care in the short term. METHOD: 455 GPs (all aged over 55 years) practicing in three districts of western France were selected to participate in this prospective study. 258 valid and complete questionnaires (56%) were received. With the use of a special programme, SPSS version 1.5, an overall comprehensive analysis and one by geographical sub-regional groups were performed. RESULTS: When queried about their plans or wishes for their practice between the present time and their age of 65, of the responding physicians, 27% wanted to continue working under the same conditions, 10% were undecided, and 63% wanted to stop or adjust their professional activity before age 65. The main reasons and factors motivating these plans were their current time constraints, the workload related to administrative tasks and the continuity of care; moreover, GPs noted the demands and expectations of patients, professional burnout and difficulties in obtaining a healthy work-life balance as factors contributing to these plans. DISCUSSION: Physicians who wanted to stop practicing (30%) were the least satisfied with their work and seem to have anticipated this plan of action given that they reduced their number of hours in the office and on-call. Those who wish to adapt their work time (33%) are for the most part satisfied even if they work more, but 70% want to reduce their work hours. CONCLUSION: The impact of these projects is a potentially heavy one, especially since two of the counties concerned have a low medical density and high rate of practicing physicians. Government measures currently proposed do not seem to respond to the evolution of private practice expected by GPs over 55 years.

[Long-term patient follow-up conducted during the supervised self-directed training in ambulatory primary care. One-semester assessment carried out in Angers, France]. / Suivi au long cours du patient lors du stage autonome en soins primaires ambulatoires supervisé. Evaluation sur un semestre à Angers.

To assess the taking charge of the patients requiring a follow-up with the long course by the trainees during the Saspas, to identify the obstacles to its setting up and to propose prospects of improvement are the main objectives of this work. The trainees of Angers carried out a collection concerning each patient seen three times or more during the semester of winter 2006-2007. At the end of semester, they answered a questionnaire and participated in a focus group. There were great inequalities between the trainees. They had seen between 13 and 51 patients three times or more (average=22). The proportion of chronic disease varied from 24 to 68%. Most frequently met were those of the 50 first results of consultation of the SFMG. Four of the 11 trainees made a follow-up of pregnancy, three a follow-up of infant. When the first consultation concerned a situation requiring a follow-up with the long course, the trainees had proposed a new appointment in 38.6% of the cases, 95% of the patient had it honoured. The obstacles identified were inherent in the organization of the training course, the secretariat, the Masters of training course, the trainees and the patients. These obstacles are perfectible by a work on the appointement management privileging the patients concerned with a follow-up to the long course, on the organization of the training courses, on the invesment of the trainees and the masters of training course.