COVID-19 psychological impact in general practitioners: A longitudinal study.

INTRODUCTION: COVID-19 may have negatively impacted the mental health of front-line healthcare workers, including general practitioners (GPs). This study sought to assess the psychological impact (stress, burnout and self-efficacy) of the COVID-19 outbreak in French GPs. METHODS: We carried out a postal-based survey of all GPs who worked in the French region of Normandy (departments of Calvados, Manche and Orne) from the exhaustive database of the Union Régionale des Médecins libéraux (URML Normandie) as of 15th April 2020 (one month after the first French COVID-19 sanitary lockdown). The second survey was conducted four months later. Four validated self-report questionnaires were used at both inclusion and follow-up: Perceived Stress scale (PSS), Impact of Event Scale-revised (IES-R), Maslach Burnout Inventory (MBI) and General Self-Efficacy scale (GSE). Demographic data were also collected. RESULTS: The sample consists of 351 GPs. At the follow-up, 182 answered the questionnaires (response rate: 51.8%). The mean scores of MBI significantly increased during follow-up [Emotional exhaustion (EE) and Personal accomplishment, P<0.01]. Higher burnout symptoms were found at the 4-month follow-up in 64 (35.7%) and 86 (48.0%) participants (43 and 70 participant at baseline), according respectively to EE and depersonalisation scores (P=0.01 and 0.09, respectively). CONCLUSION: This is the first longitudinal study that has shown the psychological impact of COVID-19 in French GPs. Based on validated a self-report questionnaire, burnout symptoms increased during follow-up. It is necessary to continue monitoring psychological difficulties of healthcare workers especially during consecutive waves of COVID-19 outbreak.

Positive and negative viral associations in patients with acute respiratory tract infections in primary care: the ECOVIR study.

Introduction: Acute respiratory infections (ARIs) are the most common viral infections encountered in primary care settings. The identification of causal viruses is still not available in routine practice. Although new strategies of prevention are being identified, knowledge of the relationships between respiratory viruses remains limited. Materials and methods: ECOVIR was a multicentric prospective study in primary care, which took place during two pre-pandemic seasons (2018-2019 and 2019-2020). Patients presenting to their General practitioner (GP) with ARIs were included, without selecting for age or clinical conditions. Viruses were detected on nasal swab samples using a multiplex Polymerase Chain Reaction test focused on 17 viruses [Respiratory Syncytial Virus-A (RSV-A), RSV-B, Rhinovirus/Enterovirus (HRV), human Metapneumovirus (hMPV), Adenovirus (ADV), Coronaviruses (CoV) HKU1, NL63, 229E, OC43, Influenza virus (H1 and H3 subtypes), Influenza virus B, Para-Influenza viruses (PIVs) 1-4, and Bocavirus (BoV)]. Results: Among the 668 analyzed samples, 66% were positive for at least one virus, of which 7.9% were viral codetections. The viral detection was negatively associated with the age of patients. BoV, ADV, and HRV occurred more significantly in younger patients than the other viruses (p < 0.05). Codetections were significantly associated with RSV, HRV, BoV, hMPV, and ADV and not associated with influenza viruses, CoV, and PIVs. HRV and influenza viruses were negatively associated with all the viruses. Conversely, a positive association was found between ADV and BoV and between PIVs and BoV. Conclusion: Our study provides additional information on the relationships between respiratory viruses, which remains limited in primary care.

Marital status and long-term cardiovascular risk in general population (Gubbio, Italy).

To investigate whether marital status is associated to long-term major fatal and non-fatal cardiovascular events in men and women from the Gubbio Population Study. The incidence of cardiovascular disease (CVD), including stroke and coronary heart disease (CHD) and CVD death together with all-cause mortality were analyzed. The analysis included 2832 persons (44% men, 54 ± 11 years old). Marital status was defined at entry as married (married or living conjugally) versus unmarried subjects (widowed, separated, divorced or single). Married and unmarried subjects did not differ concerning socio-demographic, anthropometric and biological variables at baseline. Over 191 months median follow-up, the incidence of CHD was lower among married versus unmarried women [HR: 0.63 (95% CI 0.41-0.96)] only; the same was true for CHD mortality [HR: 0.43 (95% CI 0.22-0.84)] and all-cause mortality [HR: 0.75 (95% CI 0.59-0.96)] independently of traditional risk factors (age, SBP, total and HDL cholesterol, cigarette smoke and BMI). In men, marital status was not associated to any of the investigated outcomes. In primary care, marital status should be investigated as it can be associated with long-term CHD and all-cause incidence and mortality risks among women.

Prescriptions of antihypertensive drugs are influenced by the characteristics of general practitioners and their patients: a cross-sectional study in Normandy, France.

INTRODUCTION: Hypertension is associated with significant cardio-vascular morbi-mortality. However, hypertension control is low, especially in France. The reasons influencing general practitioners' (GPs) prescription of antihypertensive drugs (ADs) remains unclear. This study aimed at assessing the influence of GP and patient characteristics on AD prescriptions. METHODS: A cross-sectional study based on a sample of 2165 GPs was realized in Normandy (France) in 2019. The ration of AD prescription to overall prescription volume was calculated for each GP and allowed the definition of a 'low or high AD prescriber'. Associations of this AD prescription ratio with GP's age, gender, practice location, number of years of practice, number of consultations, number and age of registered patients, patients' income and number of patients with a chronic condition were assessed using univariate and multivariate analysis. RESULTS: Low prescriber GPs were 51.3±11.2 years-old and were mainly women (56%). In the multivariate analysis, low prescribers were associated with urban practice (OR: 1.47, 95%CI: 1.14-1.88), GP's younger age (OR: 1.87, 95%CI: 1.42-2.44), patient's younger age (OR: 3.39, 95%CI: 2.77-4.15), more patient consultations (OR: 1.33, 95%CI: 1.11-1.61), lower income patients (OR: 1.44, 95%CI: 1.17-1.76) and fewer diabetes mellitus patients (OR: 0.72, 95%CI: 0.59-0.88). DISCUSSION: Prescriptions of ADs are influenced by the characteristics of GPs and their patients. In future work, a more detailed assessment of all components of the consultation (in particular home blood pressure monitoring use) is necessary to explain AD prescription in general practice.

Relationship between lifestyle factors and hypertension: a cross-sectional analysis from the Gubbio study.

BACKGROUND: Hypertension (HTN) is a well-established and a major risk factor for cardiovascular disease. Lifestyle behaviours for its prevention and control are recommended within worldwide guidelines. Their relationship with HTN need more investigations. AIM: We aimed to investigate the associations between lifestyle, anthropometric and biological measurements and BP in the Gubbio residential study. METHODS: Cross-sectional analyses were performed using data from Gubbio study. Information concerning lifestyle factors were collected using self-reported questionnaire and were further completed with a baseline clinical examination and blood exams. Three BP measurements were performed following a standard protocol. Age-adjusted and multivariable logistic regressions were used to examine the relationships between lifestyle parameters and HTN separately for each sex. We used heterogeneity test to observe sex differences. RESULTS: There were 3,183 persons included (48% men, 43 ± 17 years old). Mean systolic BP (SBP) was 119 ± 16 mmHg and 10.6% were hypertensives. Age [OR: 129.70 (95%CI: 18.57-905.79) in women and OR: 8.37 (95%CI: 4.01-17.48) (p < 0.0001) in men] and BMI [OR: 2.14 (95%CI: 1.32-3.46) (p = 0.006) in women and OR: 1.81 (95%CI: 1.05-3.12), p = 0.03 in men], were positively associated with SBP in both sexes. Serum uric acid [OR: 3.86 (95%CI: 2.03-7.26), p = 0.04] was positively associated with HTN in women while fasting blood glucose [OR: 3.04 (95%CI: 1.55-5.97), p < 0.001] were associated to HTN only in men. DISCUSSION: In addition to age, BMI is associated with HTN in both sexes while sex differences were observed in the associations between serum uric acid, fasting blood glucose and HTN.

The Design and Implementation of the ECOVIR Project: A Primary Health Care Surveillance System to Strengthen Co-Detection of Respiratory Viruses in Normandy.

Acute respiratory infections (ARIs) need to be better understood and treated, as they are critical to public health, especially during crises such as the SARS-CoV2 pandemic. These are the most abundant infections in the general population and are seen primarily in primary care by general practitioners (GPs). Many different viruses are involved, according to epidemic variations. Viral co-detections account for a significant proportion of ARIs in hospital cohorts. The objective of the ECOVIR cohort was to study viral co-detections by setting up a biobank of respiratory tract samples from patients consulting their general practitioner for ARI symptoms. We report here on the course of the study: the design, the conduct, and the difficulties encountered. ECOVIR (Etude des CO-detections VIrales dans les prélèvements Respiratoires) was a prospective, multicenter cohort conducted in France during two epidemic seasons (2018-2019 and 2019-2020). We recruited GPs. Each GP investigator (GPI) saw patients weekly for examination, clinical data collection, and nasopharyngeal swabbing. Each sample was sent to the virology unit for biobanking and molecular analysis. Clinical and sociodemographic data were collected 7 days after inclusion. ECOVIR involved 36 GPIs. Patients with symptoms of an ARI were included (n = 685). The median number of inclusions was 16 patients per GPI over both seasons (IC25-75% [4.75; 27]). Patients aged 18 to 64 years were the most numerous (57%), followed by children (30%), and the elderly (13% over 65 years). This age distribution emphasizes the young adult and middle-aged population. Residents participated in the project and called patients on day 7 to obtain clinical and sociodemographic data. Our study triggered the creation of an original network, which plans to establish a functional link between research and primary health care. Primary care is unfortunately poorly represented in research protocols, particularly in respiratory infections, even though it is a cornerstone of our French health care system, as demonstrated every day in this period of crisis.

COVID-19 vaccines associated with vasovagal malaise: A retrospective study in two mass vaccination centers and analysis of the WHO pharmacovigilance database.

The association between COVID-19 vaccines and vasovagal malaise (VVM) has recently been reported in the literature. Our study aimed to describe COVID-19 vaccines associated VVM cases and to identify risk factors of COVID-19 vaccines associated VVM. To this end, we performed a descriptive study of VVM reports associated with COVID-19 vaccines from two French mass COVID-19 vaccination centers. We also extracted reports of VVM associated with all-COVID-19 vaccines in VigiBase®, the World Health Organization (WHO) pharmacovigilance database to analyze demographic data. In the two French mass vaccination center database, 408 entries reported VVM after the standard administration of tozinameran - Pfizer® (1.63/1,000 vaccinated persons). Of these cases, 213 (52.2%) occurred in women, and 193 (47.3%) occurred in the 18-29 year-old (yo) age group. In 232 cases (56.8%), patients had a history of anxiety related to needles or medical visits, 213 (52.2%) reported a fear of COVID-19 vaccination in particular, and 233 (57.1%) had a history of VVM. In VigiBase®, 336,291 notifications of COVID-19 vaccines associated with VVM were identified in the adult population during the period of analysis. The most reported age class was 18-44 years (52.4%), and women represented 71.7% of the reports. Reporting widely differed depending on the country. This study, performed in real-life conditions, highlights that VVM is associated with all-COVID-19 vaccines. Young age and history of anxiety related in young adults could be a triggering factor of vaccines-associated VVM. Further studies are needed to confirm our results.

La warfarine est-elle plus stable que la fluindione ? Étude rétrospective en soins premiers (étude STAB-AVK).

Malgré leur prescription en seconde intention après les anticoagulants oraux directs, les antivitamines K (AVK) sont encore largement utilisés en soins premiers. En France, la fluindione représentait 82 % des AVK prescrits en 2016 contre 13 % pour la warfarine. Pourtant, la warfarine est l'AVK de référence ailleurs dans le monde et sa demi-vie plus longue devrait la rendre plus adaptée avec des International Normalized Ratio (INR) plus stables. Les objectifs de notre travail étaient de comparer ces deux molécules en termes de stabilité de leur effet anticoagulant au long cours et sur la fréquence des INR réalisés. Nous avons mené une étude rétrospective de type exposé/non-exposé sur données issues d'un laboratoire de biologie médicale ornais concernant des patients majeurs traités par fluindione ou warfarine du 1er janvier 2014 au 31 décembre 2016 inclus, quelle que soit l'indication. La stabilité du traitement était évaluée par le temps passé dans l'intervalle thérapeutique (TTR), calculé selon la méthode de Rosendaal, à partir des INR dosés en pratique courante. Les comparaisons entre les deux groupes ont été faites par régression linéaire multi-niveaux avec analyse univariée puis multivariée avec ajustement sur l'âge, le genre et la fonction rénale. Deux-cent-quatre patients ont été inclus (77,0 ± 10,0 ans, 49,5 % de femmes), 170 sous fluindione et 34 sous warfarine. Le TTR moyen sous fluindione était de 68,0 % contre 72,0 % sous warfarine (p = 0,085). Le délai moyen entre deux INR était de 22,8 jours sous fluindione contre 31,1 jours sous warfarine (p = 0,049). Par rapport à la fluindione, la warfarine semble présenter un bénéfice en termes de qualité de vie pour les patients. Malgré nos résultats, nous invitons à privilégier la warfarine à la fluindione en soins premiers.

Professional practice for COVID-19 risk reduction among health care workers: A cross-sectional study with matched case-control comparison.

BACKGROUND: Health care workers (HCWs) are particularly exposed to COVID-19 and therefore it is important to study preventive measures in this population. AIM: To investigate socio-demographic factors and professional practice associated with the risk of COVID-19 among HCWs in health establishments in Normandy, France. METHODS: A cross-sectional and 3 case-control studies using bootstrap methods were conducted in order to explore the possible risk factors that lead to SARS-CoV2 transmission within HCWs. Case-control studies focused on risk factors associated with (a) care of COVID-19 patients, (b) care of non COVID-19 patients and (c) contacts between colleagues. PARTICIPANTS: 2,058 respondents, respectively 1,363 (66.2%) and 695 (33.8%) in medical and medico-social establishments, including HCW with and without contact with patients. RESULTS: 301 participants (14.6%) reported having been infected by SARS-CoV2. When caring for COVID-19 patients, HCWs who declared wearing respirators, either for all patient care (ORa 0.39; 95% CI: 0.29-0.51) or only when exposed to aerosol-generating procedures (ORa 0.56; 95% CI: 0.43-0.70), had a lower risk of infection compared with HCWs who declared wearing mainly surgical masks. During care of non COVID-19 patients, wearing mainly a respirator was associated with a higher risk of infection (ORa 1.84; 95% CI: 1.06-3.37). An increased risk was also found for HCWs who changed uniform in workplace changing rooms (ORa 1.93; 95% CI: 1.63-2.29). CONCLUSION: Correct use of PPE adapted to the situation and risk level is essential in protecting HCWs against infection.

Psychological impact of the COVID-19 outbreak in community pharmacists: A longitudinal study.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has negatively affected the mental health of frontline health care workers, including pharmacists. OBJECTIVES: The aim of this longitudinal study was to assess the psychological impact of the COVID-19 outbreak in French owner community pharmacists. METHODS: We conducted a postal-based survey to assess the psychological difficulties of the COVID-19 outbreak in French owner community pharmacists based on 3 psychologically validated self-report questionnaires: Perceived Stress Scale (PSS), Impact of Event Scale-revised (IES-R), and Maslach Burnout Inventory. The baseline assessment was during the first sanitary lockdown period and the second one 5 months later. RESULTS: The sample consists of 135 owner community pharmacists. At follow-up, 67 answered the questionnaires (response rate: 49.6%). The mean scores of the PSS and IES-R significantly decreased (P = 0.002). Fifteen pharmacists reported significant posttraumatic stress symptoms (23.1%) at baseline and 11 at follow-up (16.4%, P = 0.02). Age and sex were not significantly associated with persistent posttraumatic stress or burnout symptoms. CONCLUSION: This is the first longitudinal study that showed the psychological impact of owner community pharmacists as health care workers dealing with their community's COVID-19 outbreak. Based on validated self-report questionnaires, stress, posttraumatic stress, and burnout symptoms decreased during follow-up. It is necessary to continue monitoring psychological difficulties for health care workers, especially during consecutive waves of the COVID-19 outbreak.

General medicine and notification of adverse reactions: contributions of health insurance representatives / Cabinets de médecine générale et notification des effets indésirables médicamenteux : expertise d'un délégué de l'Assurance maladie

INTRODUCTION: In order to reduce the under-reporting of adverse drug reactions (ADR) in general practice, the Caen Normandie regional pharmacovigilance center (CRPV) has implemented a training program for the French health insurance representatives (DAM) of the Manche department in order to raise awareness among general practitioners (GPs) to ADR reporting. PURPOSE OF RESEARCH: During quarterly visits of DAM to GPs, the mode of operation and the value of pharmacovigilance reporting was presented. This pilot study presents the impact of these DAM visits to GPs in term of ADRs reporting quantification. RESULTS: Assessment of this first year showed a doubling of ADR reporting by GPs of the Manche department in 2019 compared to 2017 and 2018. This phenomenon was not found in the two control departments (departments of Calvados and Orne) where the information had not been issued. These ADRs first concerned drugs of the renin-angiotensin system, then psychotropic drugs and anti-infectives. These were cutaneous, then neurological and gastrointestinal ADRs, preferentially affecting women. CONCLUSIONS: This experimentation should continue on a larger scale. The longer-term evaluation of this tool also requires evaluating its relevance.

Introduction: Pour réduire la sous-notification des effets indésirables médicamenteux (EIM) en médecine générale, le centre régional de pharmacovigilance (CRPV) Caen Normandie a mis en place une formation pour les délégués de la Caisse primaire d'assurance maladie de la Manche (CPAM 50) afin de sensibiliser les médecins généralistes (MG) à la déclaration des EIM. Ainsi, lors de la visite trimestrielle des délégués de la CPAM 50 aux MG, il était présenté le mode de fonctionnement et l'intérêt des déclarations de pharmacovigilance. But de l'étude: Cette étude pilote présente l'influence de ces visites post-formation des délégués de la CPAM 50 sur le nombre d'EIM déclarés. Résultats: Le bilan de cette première année de visites montre le doublement des EIM déclarés par les MG du département de la Manche en 2019 par rapport aux années 2017 et 2018. Ce phénomène n'a pas été retrouvé dans les deux départements témoins (départements du Calvados et de l'Orne), où l'information n'avait pas été délivrée. Ces EIM concernaient d'abord les médicaments du système rénine-angiotensine, puis les psychotropes et les anti-infectieux. Il s'agissait d'EIM cutanés puis neurologiques et gastro-intestinaux touchant préférentiellement les femmes. Conclusions: Cette expérimentation devra se poursuivre à plus large échelle. L'évaluation à plus long terme de ce dispositif permettra aussi d'en évaluer la pertinence.

Impact on mental health of the COVID-19 outbreak among general practitioners during the sanitary lockdown period.

BACKGROUND: COVID-19 outbreak can impact mental health including health care workers. AIM: The aim of this study was to assess the mental health impact of COVID-19 in French General Practitioners (GPs). METHODS: We carried out a postal-based survey during the first lockdown. Four psychological validated self-report questionnaires were used to assess stress,post-traumatic stress symptoms, burnout and self-efficacy (Perceived Stress scale, Impact of Event Scale-revised, Maslach Burnout Inventory and General Self-Efficacy scale). RESULTS: The sample consists of 332 general practitioners (43.50% women, mean age = 50.74 ± 11.91). General practitioners working in high epidemic location represented 27.71% of the sample (n = 92). Thirty four GPs reported significant post-traumatic stress symptoms (10.59%). High burnout symptoms were found in 79 (24.46%), 137 (42.41%) and 17 (5.26%) participants. Only General Self-Efficacy scores were significantly different according to epidemic location status with lower scores in GPs working in high epidemic location (33.37 ± 4.64 vs. 32.06 ± 5.43; P = 0.04). Women reported more stress and burnout symptoms than men (P = 0.01). CONCLUSIONS: This study showed the psychological impact of COVID-19 in GPs during the sanitary lockdown period including burnout and post-traumatic stress symptoms. Up to 42% of GPs reported psychological disturbances. Interventions to promote mental health well-being of healthcare workers need to be developing.

Impact of Sex on Office White Coat effect Tail: A Review.

Office white-coat effect tail (OWCET) is defined as a decrease of ≥10 mmHg in systolic blood pressure (SBP) between successive measurements after its waxing during an office visit. The influence of sex on the incidence of long-term major fatal and non-fatal cardiovascular events was studied in two Italian populational cohorts [from the Gubbio Study and the Italian Rural Areas of the Seven Countries Study (IRA)]. OWCET increased risk of cardiovascular disease (CVD) [HR: 1.591 (95% CI: 1.204-2.103)], coronary heart disease (CHD) [HR: 1.614 (95% CI: 1.037-2.512)] and stroke (STR) [HR: 1.696 (95% CI: 1.123-2.563)] events independently of age, serum and high density lipoprotein (HDL) cholesterol, cigarettes, body mass index (BMI) and SBP in women included in Gubbio study over an almost 20-year follow-up. However, risks of CVD, CHD or STR increased in men with OWCET neither in the Gubbio 20-year follow-up nor in the IRA 50-year follow-up. The correction of the regression dilutions bias between the first and the subsequent SBP measurements did not significantly change these outcomes. Primary care physicians should evaluate OWCET, especially in women, to improve stratification of long-term CVD, CHD and STR risks.

Haematologic malignancies associated with clozapine v. all other antipsychotic agents: a pharmacovigilance study in VigiBase®.

BACKGROUND: Clozapine is mainly used in patients with treatment-resistant schizophrenia and may lead to potentially severe haematologic adverse events, such as agranulocytosis. Whether clozapine might be associated with haematologic malignancies is unknown. We aimed to assess the association between haematologic malignancies and clozapine using Vigibase®, the WHO pharmacovigilance database. METHODS: We performed a disproportionality analysis to compute reporting odds-ratio adjusted for age, sex and concurrent reporting of antineoplastic/immunomodulating agents (aROR) for clozapine and structurally related drugs (loxapine, olanzapine and quetiapine) compared with other antipsychotic drugs. Cases were malignant lymphoma and leukaemia reports. Non-cases were all other reports including at least one antipsychotic report. RESULTS: Of the 140 226 clozapine-associated reports, 493 were malignant lymphoma cases, and 275 were leukaemia cases. Clozapine was significantly associated with malignant lymphoma (aROR 9.14, 95% CI 7.75-10.77) and leukaemia (aROR 3.54, 95% CI 2.97-4.22). Patients suffering from those haematologic malignancies were significantly younger in the clozapine treatment group than patients treated with other medicines (p < 0.001). The median time to onset (available for 212 cases) was 5.1 years (IQR 2.2-9.9) for malignant lymphoma and 2.5 years (IQR 0.6-7.4) for leukaemia. The aROR by quartile of dose of clozapine in patients with haematologic malignancies suggested a dose-dependent association. CONCLUSIONS: Clozapine was significantly associated with a pharmacovigilance signal of haematologic malignancies. The risk-benefit balance of clozapine should be carefully assessed in patients with risk factors of haematologic malignancies. Clozapine should be used at the lowest effective posology.

Perceived Cognitive Impairment in Breast Cancer Survivors and Its Relationships with Psychological Factors.

Cognitive complaints are common adverse effects in cancer patients. Identifying subjects at risk could make it possible to limit their impact. We aimed to explore the relationship between current cognitive complaints and demographic and psychological factors in a group of breast cancer survivors. Through an online survey, cancer survivors reported current cognitive complaints using the FACT-Cog questionnaire (Perceived Cognitive Impairment) and answered questions about their demographics, lifestyle and cancer-related characteristics. Anxiety, depression, fatigue and post-traumatic stress symptoms were also assessed. We used multivariable logistic regression models to explore the relationships between current cognitive complaints and social and psychological factors. Among the 1393 breast cancer survivors, 47.2% (n = 657) reported current cognitive complaints. Chemotherapy (OR = 2.26, 95%CI = 1.67-3.05), age (OR21-44 vs. >65 = 0.14, 95%CI = 0.07-0.27), sleep difficulties (ORnever vs. often = 2.41, 95%CI = 1.47-3.95), frequency of psychotropic treatments (ORnever vs. >1/week = 1.70, 95%CI = 1.23-2.36), post-traumatic stress symptoms (OR = 2.05, 95%CI = 1.57-2.69) and employment status (ORfull-time or part-time vs. sick leave = 1.64, 95%CI = 1.08-2.49) were strongly associated with current cognitive complaints. In this large study, about half of breast cancer survivors reported cognitive complaints, particularly after chemotherapy. Some risk factors should be detected early to reduce persistent cognitive complaints after cancer: mainly sleep difficulties, post-traumatic stress symptoms and psychotropic medications.

[INR and vitamin K antagonists management by the primary care physicians in Normandy]. / Gestion de l'INR et des antivitamines K par les médecins généralistes de Normandie.

The main objective of our study was to carry out a statement of the knowledge and the management of the VKA by the General Practitioners (GPs) of Normandy and to evaluate their experience of the use of DOA with a questionnaire; 471 of the 1951 GPs requested responded. When the INR was stable in a patient affected with atrial fibrillation, the GPs participating dosed it again 4 weeks later, modified the dosage when the INR was below 1.9 or upper 3.2. The risk of stroke was overestimated to 6.2% per year with fluindione and to 31.5% without curative anticoagulation. The mean TTR was overstated to 84%. When the INR was at 4.4, the risk of serious cerebral bleeding was overestimated at 12.4%. 80.26% of the GPs skipped the next dose and 11.25% controlled the INR the day after. So, few GPs used the HAS protocol. After the INR decreased to 3.6, the GPs diminished the dose of 14.62%. 70% of the GPs, responded using only their experience for AVK management. Fluindione was the most to use VKA by 52.7% of them although 24.42% thought it was the most effective. The majority of GPs thought the DOA were a least as effective than the VKA, without being responsible of more bleeding (77.92%) and improved the quality of life of the patients (88.54%). Although the DOA's prescriptions increase, the improvement of the VKA management have to stay a concern for the GPs.