A methodological framework allows the identification of personomic markers to consider when designing personalized interventions.

OBJECTIVES: To develop a methodological framework to identify and prioritize personomic markers (e.g., psychosocial situation, beliefs…) to consider for personalizing interventions and to test in smoking cessation interventions. STUDY DESIGN AND SETTING: (1) We identified potential personomic markers considered in protocols of personalized interventions, in reviews of predictors of smoking cessation, and in interviews with general practitioners. (2) Physicians, and patient smokers or former smokers selected the markers they considered most relevant during online paired comparison experiments. Data were analyzed with Bradley Terry Luce models. RESULTS: Thirty-six personomic markers were identified from research evidence. They were evaluated by 795 physicians (median age: 34, IQR [30-38]; 95% general practitioners) and 793 patients (median age: 54, IQR [42-64], 71.4% former smokers) during 11,963 paired comparisons. Physicians identified patients' motivation for quitting (e.g., Prochaska stages), patients' preferences, and patients' fears and beliefs (e.g., concerns about weight gain) as the most relevant elements to personalize smoking cessation. Patients considered their motivation for quitting, smoking behavior (e.g., smoking at home/at work), and tobacco dependence (e.g., Fagerström Test) as the most relevant elements to consider. CONCLUSION: We provide a methodological framework to prioritize which personomic markers should be considered when developing smoking cessation interventions.

Sustainable development in general practice.

BACKGROUND: As health care accounts for 4-5% of global carbon emissions, many health organisations have called for implementing sustainable development actions in health care. However, sustainable development measures in general practice are rarely implemented by physicians. The aim of this study was to explore the practices of general practitioners (GPs) in terms of sustainable development to identify which actions are appropriate and achievable. METHODS: A qualitative study was conducted in 12 French GPs using face-to-face or telephone interviews, transcribed verbatim and analysed through a global inductive analysis with constant comparison. Semi-structured interviews were focussed on waste management, relationships between health professionals, sustainable development, and GPs' activity. RESULTS: The mean age of the GPs was 42.8 years and they mainly worked in an urban environment. The interviews highlighted 4 themes. It appeared that a balance needs to be found between the environmental impact and the constraints related to medical care. To be able to think about integrating sustainable development into health care, GPs should make a personal commitment to change their routine. In practice, consumption should be reassessed, prescriptions and prevention reconsidered. These actions could be applied to the GPs' environment as role models for their patients, business leaders, and members of the healthcare system. CONCLUSION: GPs felt concerned by sustainable development and were already involved in its implementation in their practice. Tools are available to help GPs to continue to implement their actions described in this article, but their impact remains to be investigated.

In an era where global health is an increasing concern for the population, it appeared necessary to study the extent to which health professionals were willing to change their behaviours in their professional lives. This study was based on the interview of 12 French general practitioners and investigated their perspective on sustainable development and how they implemented it in their practice. Four main themes were highlighted. Some physicians did not spontaneously see the link between their practice and sustainable development. Our study showed that they were willing to adapt their practice despite organisational constraints and the difficulty in changing their behaviour.

Impact of integrating objective structured clinical examination into academic student assessment: Large-scale experience in a French medical school.

PURPOSE: Objective structured clinical examinations (OSCE) evaluate clinical reasoning, communication skills, and interpersonal behavior during medical education. In France, clinical training has long relied on bedside clinical practice in academic hospitals. The need for a simulated teaching environment has recently emerged, due to the increasing number of students admitted to medical schools, and the necessity of objectively evaluating practical skills. This study aimed at investigating the relationships between OSCE grades and current evaluation modalities. METHODS: Three-hundred seventy-nine 4th-year students of University-of-Paris Medical School participated to the first large-scale OSCE at this institution, consisting in three OSCE stations (OSCE#1-3). OSCE#1 and #2 focused on cardiovascular clinical skills and competence, whereas OSCE#3 focused on relational skills while providing explanations before planned cholecystectomy. We investigated correlations of OSCE grades with multiple choice (MCQ)-based written examinations and evaluations of clinical skills and behavior (during hospital traineeships); OSCE grade distribution; and the impact of integrating OSCE grades into the current evaluation in terms of student ranking. RESULTS: The competence-oriented OSCE#1 and OSCE#2 grades correlated only with MCQ grades (r = 0.19, P<0.001) or traineeship skill grades (r = 0.17, P = 0.001), respectively, and not with traineeship behavior grades (P>0.75). Conversely, the behavior-oriented OSCE#3 grades correlated with traineeship skill and behavior grades (r = 0.19, P<0.001, and r = 0.12, P = 0.032), but not with MCQ grades (P = 0.09). The dispersion of OSCE grades was wider than for MCQ examinations (P<0.001). When OSCE grades were integrated to the final fourth-year grade with an incremental 10%, 20% or 40% coefficient, an increasing proportion of the 379 students had a ranking variation by ±50 ranks (P<0.001). This ranking change mainly affected students among the mid-50% of ranking. CONCLUSION: This large-scale French experience showed that OSCE designed to assess a combination of clinical competence and behavioral skills, increases the discriminatory capacity of current evaluations modalities in French medical schools.

Sleep, Prospective Memory, and Immune Status among People Living with HIV.

Background: Persons living with HIV (PLWH) frequently report sleep complaints, but objective measurements are still lacking regarding sleep continuity, total sleep time per 24 h, and the links with both prospective memory performance and HIV infection parameters. Methods: PLWH (n = 96) and control (n = 96) groups (balanced for gender and age) were monitored by 24h-actigraphy for at least seven consecutive days. The prospective memory performance was assessed through a naturalistic, activity-based task performed twice a day on the actigraph. Results: PLWH had greater sleep latency and worse sleep continuity (higher fragmentation index) for night-time sleep and longest daytime nap (mean duration of the longest nap). Comparable results were reported for the prospective memory task; better performance scores were associated with several sleep parameters in controls but not in PLWH. Finally, within the PLWH group, being a long sleeper per 24 h (total sleep time > 8 h including more and long daytime naps) was associated with a greater severity of the disease (lower CD4 nadir and more frequent history of AIDS-defining events). Conclusions: These findings indicate that PLWH have more fragmented sleep and that the severity of HIV infection is associated with increased sleep duration.

Diagnostic Agreement Between Telemedicine on Social Networks and Teledermatology Centers.

PURPOSE: With increasing delays in obtaining a dermatological consultation, general practitioners (GPs) are using social networks for telemedicine to obtain advice on dermatological images. The objective was to analyze diagnostic agreement between telemedicine on social networks (Twitter and MedPics) and standard teledermatology services (TDS). METHODS: This retrospective observational study included images published on Twitter and MedPics by GPs in 2016. The contextualized images were evaluated by 2 teledermatology services in Paris, France and an expert committee. Diagnoses obtained from telemedicine on social networks, TDS, and the expert committee were collected for each image. The agreement between the diagnoses made on social networks and by TDS was measured using Cohen κ statistic. The number of correct diagnoses obtained using social networks and TDS as determined by agreement with the expert's diagnoses were compared with χ2 tests. RESULTS: Two hundred and seventy health professionals responded to the 60 selected images from social networks. The main diagnoses, according to the experts were: purpura (8.3%), eczema (6.7%), mycosis (6.7%), and viral infections (6.7%). Diagnostic agreement between telemedicine on social networks and TDS was moderate over the entire set of images (κ = 0.55; 95% CI, 0.42-0.68) and good for images containing dermatologist's answers (κ = 0.63; 95% CI, 0.45-0.85). The number of correct diagnoses was not statistically different between telemedicine on social networks and TDS on all images (60% vs 55%; P = .28) but was higher on social networks when a dermatologist answered (65% vs 55%; P <.01). CONCLUSIONS: Diagnostic agreement using social network images showed that use of this telemedicine tool could be a reliable means to alleviate the difficulties of accessing dermatology consultations although data safety probably needs to be improved.

A classification of methods used to personalize participative interventions revealed inadequate reporting in trial protocols.

OBJECTIVES: The objective of the study was to develop a classification of methods used to personalize participative interventions in randomized controlled trials (RCTs). STUDY DESIGN AND SETTING: We conducted a systematic review including protocols of RCTs assessing participative interventions in PubMed and ClinicalTrials.gov between June 2018 and May 2019. Data extraction was performed by two independent reviewers. We developed a precise classification of methods used to personalize interventions. Then, protocols were reviewed to determine whether personalization was sufficiently described to enable replication. RESULTS: We included 109 protocols. The classification used four components and 13 subcomponents accounting for decision points (when interventions were personalized), tailoring variables (on what interventions were personalized), decision rules (how and by whom interventions were personalized), and nature of the subsequent tailoring (what was personalized in the interventions). In 95% of protocols, at least one component or subcomponent of our classification was not adequately reported to enable the replication of the intervention. Components the least well described were tailoring variables (72% of protocols insufficiently described) and the nature of the subsequent tailoring (46% of protocols). CONCLUSION: This study provides the first detailed classification of methods used to personalize interventions. This is required to transparently implement personalization and improve reporting in RCTs.

Comparison of mammography results from individual and organized screening for breast cancer.

BACKGROUND: In France, the coexistence of individual screening (IS) and organized screening (OS) for breast cancer induces difficulties for primary care practitioners to position themselves. This study assessed whether the risk of having a mammography with a high risk of malignancy (BI-RADS 4 or 5) was different between patients aged from 50 to 74year performing it as part of an IS or of the OS. METHOD: This cross-sectional multicenter study included women aged 50-74, with no personal history of breast cancer, performing mammography in radiology centers in Paris (France). The nature of the screening (OS or IS), breast cancer risk (high risk: BI-RADS 4 or 5), risk factors and clinical breast examination (CBE) abnormalities were collected. Patients in the IS and OS group were matched on age, breast density, history of benign lesions and family history of breast cancer using a propensity score. The association between the nature of screening and the risk of malignancy was evaluated by conditional logistic regression. RESULTS: Among 2190 included patients, 77 % performed a mammography with the IS and had more CBE abnormalities (23 % vs 11 %, p<0,001), a history of benign lesion (15 % vs 11 %, p=0.01) and a family history of breast cancer (42 % vs 29 %, p<0,001). After matching 503 OS patients with 941 IS patients, the risk of malignancy and the nature of the screening were not associated (OR=0.72 [0.35-1.47], p=0.50). CONCLUSION: The risk of malignancy was not different whether the mammography was performed as part of the OS or IS.

Patient-Physician Agreement in Reporting and Prioritizing Existing Chronic Conditions.

PURPOSE: In this study, we aimed to assess (1) the agreement between patient self-reports and general practitioner (GP) reports of the chronic conditions affecting the patients and (2) the agreement between patients and GPs on health priorities in a primary care setting. METHOD: Patients were recruited in the Parisian area of France by a convenience sample of GPs; eligibility criteria required that the GP was the patient's listed primary care provider for at least 12 months. Participants were asked to report all the patient's current chronic conditions by using a previously developed list of 124 chronic conditions and write a list of up to 3 priority conditions. RESULTS: From April to May 2017, 233 patients were recruited from 16 GP practices. Agreement between the number of conditions reported by patients and by GPs was moderate (intraclass correlation coefficient 0.59, 95% CI, 0.50 to 0.69). Agreement between patient self-reports and GP reports of each chronic condition ranged from very good (eg, κ = 0.85 for hypothyroidism) to poor (eg, κ = 0.12 for chronic anxiety disorder). Among the 153 patient-GP pairs for which both the patient and GP wrote a priority list, 45 (29.4%) of patients' first priorities did not appear anywhere on the corresponding GPs' lists, and 19 (12.4%) pairs had no matching priority condition. CONCLUSIONS: Agreement between patients and their GPs varied widely depending on the diseases reported. Low agreement on health priorities suggests a need for improvement to ensure better alignment between patient and physician perspectives.

Accuracy of clinical breast examination's abnormalities for breast cancer screening: cross-sectional study.

OBJECTIVES: The guidelines for breast cancer screening with clinical breast examination (CBE) are diverging CBE is recommended in France, whereas it is not recommended in the United States and Canada, given the lack of clear benefit and the risk of overmedication. To assess the accuracy of abnormalities found during CBE for in breast cancer screening. STUDY DESIGN: A cross-sectional study included women over 18 years with no history of breast cancer coming for a mammography at 3 ambulatory radiology practices in Paris. A questionnaire collected the risk of breast cancer on mammography according to the Breast Imaging-Reporting And Data System (Bi-RADS) (high risk: Bi-RADS 4 or 5 versus lower risk: other Bi-RADS categories), the risk factors for breast cancer and the breast clinical abnormalities (none, mass, skin abnormality, oedema, pain, nipple discharge, lymph nodes…) For each abnormality, sensitivity, specificity, positive (PPV) and negative (NPV) predictive values were calculated. RESULT: Among the 3218 included patients (mean age 55.1 +/-10 years), 713 (22.2%) had an abnormal CBE and 133 (4.1%) had high-risk mammography. The sensitivity of CBE was 36%[28%;45%] and the specificity was 78%[77%;80%]. The PPV and NPV for each clinical abnormality were low, except for nipple discharge, retraction and lymph nodes, for which the PPV were 10.5[3.7;29.9], 6.6[1.4;31.6], and 5.0[1.5;17.1], respectively, but these abnormalities were rare (0.5%, 0.2% and 0.5% respectively). These values were similar across all age groups. CONCLUSION: The accuracy of CBE for breast cancer screening appeared to be low which did not support recommending regular CBE in France.

Sleep Disturbance and Total Sleep Time in Persons Living with HIV: A Cross-Sectional Study.

Short and long sleep durations have been associated with inflammation and chronic diseases. To study the association between sleep duration/quality and HIV disease severity, a cross-sectional study was conducted in patients living with HIV (PLWHs) using self-administered questionnaires assessing total sleep time, insomnia (ICSD-3 criteria), and poor sleep quality (PSQI > 5). Multivariable logistic regression identified the factors associated with sleep disorders and with HIV features. 640 Parisian ambulatory PLWHs were included. The prevalence of insomnia was 50 and 68% of patients had a PSQI > 5. Patients with CD4 count < 500 cells/mm3 were more likely to be long sleepers (> 8 h/day) (OR 1.49; 95% CI [1.10-1.99]: p < 0.01), and less likely to be short sleepers (< 6 h/day) (OR 0.69; 95% CI[0.50-0.96]; p = 0.04) or to experience insomnia (OR 0.59; 95% CI[0.40-0.86]; p < 0.01). HIV features were not associated with a PSQI > 5. Thus, insomnia and impaired sleep quality were highly prevalent in well-controlled PLWHs and the severity of HIV infection was associated with long sleep times.

Bacterial resistance in urinary tract infections in patients with diabetes matched with patients without diabetes.

BACKGROUND: With bacterial resistances having increased, patients with diabetes who are at higher risk of urinary tract infection (UTI) need to be studied. The study aim was to compare bacterial resistances to ofloxacin, cefixim, co-trimoxazole, nitrofurantoin and fosfomycin in UTI between patients with and without diabetes. METHODS: A cross-sectional study was conducted in ambulatory laboratories, including patients over 18 coming for urinalyses. Patients with diabetes were matched with two patients without diabetes based on risk factors for UTI using a propensity score. RESULTS: Among 1119 patients with UTI, 124 patients with diabetes were matched with 246 patients without diabetes. In patients with diabetes, the bacteria identified were: Escherichia coli (71%), Klebsiella (6%), Staphylococcus (5%), Enterococcus (4%), Proteus (2%) and Pseudomonas (1%); these findings were similar to those found in patients without diabetes. Resistances to ofloxacin and cefixim regardless of the bacteria were increased in patients with diabetes after matching on age, sex and history of UTI (respectively: OR=2.09; p=0.04 and OR=3.67; p=0.05). Regarding E. coli resistance, there was no difference whatever the antibiotic. CONCLUSION: The increased ofloxacin and cefixim resistance in patients with diabetes should be considered when prescribing probabilistic antibiotics, and could lead to changes in first-line treatments in UTI.