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In France, general practitioners (GPs) prescribe benzodiazepines and Z-drugs (BZD/ZDs) widely, and especially to older adults. Several characteristics of patients and/or GPs linked to BZD/ZD overprescription have been described in the general population but not among older patients in primary care.To estimate the proportion of GP consultations by patients aged 65 and over that resulted in a BZD/ZD prescription, and determine whether any GP-related factors predicted BZD/ZD overprescription in this setting.We analyzed sociodemographic and practice-related GP characteristics, and aggregated data on consultations recorded prospectively by 117 GPs in a database between 2000 and 2010. Next, we used logistic regression models to look for factors potentially associated with BZD/ZD overprescription (defined as an above-median prescription rate).The GPs' mean age at inclusion was 47.4 (7.1), and 87.9% were male. During the study period, the median (95% confidence interval) proportion of consultations with patients aged 65 and over resulting in a BZD/ZD prescription was 21.8% (18.1-26.1) (range per GP: 5-34.1%). In a multivariable analysis, a greater number of chronic disease (OR [95% CI] = 2.10 [1.22-3.64]), a greater number of drugs prescribed per consultation (5.29 [2.72-10.28]), and shorter study participation were independently associated with BZD/ZD overprescription.BZD/ZD overprescription was associated with a greater chronic disease burden and the number of drugs prescribed per consultation but not with any sociodemographic or practice-related GP characteristics. Targeted actions are needed to help GPs limit their prescription of BZD/ZDs to older patients with multiple comorbidities and polypharmacy.In France, general practitioners (GPs) prescribe benzodiazepines and Z-drugs (BZD/ZDs) widely, and especially to older adults. Even though BZD/ZDs may not have a favorable risk–benefit ratio in older patients, we lack data on GP-related factors that might influence BZD/ZD overprescription in our population. The objectives of the present study were to (i) estimate the proportion of GP consultations by patients aged 65 and over that resulted in a BZD/ZD prescription and (ii) identify GP-related factors that were predictive of overprescription. To achieve this goal, we analyzed consultation notes registered by 117 GPs in a database curated by the French Society of General Practice between 2000 and 2010. About 22% of consultations by patients aged 65 and over resulted in a BZD/ZD prescription. With regard to the GPs, we did not find any sociodemographic or practice-related characteristics associated with overprescription. A greater chronic disease burden and the number of drug prescriptions (other than BZD/ZDs) per consultation was independently associated with overprescription. Targeted actions are therefore needed to help GPs limit their prescription of BZD/ZDs in older patients with multimorbidity and polypharmacy.

BackgroundDirect oral anticoagulants (DOACs) account for an increasing proportion of prescriptions in patients with non-valvular atrial fibrillation (NVAF) in primary care. Inappropriate dosing of DOACs is a common problem, with under-dosing being a particular issue. However, conflicting results have been reported about the factors independently associated with inappropriate dosing.AimTo describe inappropriate prescriptions of DOACs among patients in the CACAO French nationwide general practice cohort, and to identify the factors independently associated with inappropriate DOAC doses.Design and settingCross-sectional baseline analysis of the CACAO French national multicentre prospective cohort of adult patients in primary care receiving an oral anticoagulant who were recruited between April and October 2014.MethodA total of 1111 patients from the CACAO cohort who received a DOAC for NVAF were included in this study. Inappropriate prescriptions of DOACs were described (inappropriate dosage, contraindications, non-indications, interactions, and non-compliance with the precautions for use). Multivariate logistic models were used to investigate factors associated with inappropriate DOAC dosing (under-dosing and over-dosing).ResultsOverall, 438 patients (39.4%) received at least one inappropriate DOAC prescription. The most common inappropriate prescription was inappropriate dosage (n = 374, 33.7%), particularly under-dosing (n = 348, 31.3%). Multivariate analysis revealed that factors independently associated with under-dosing were older age, prescription of apixaban or dabigatran, and a CHA2DS2-VASc score ≥2 vs. a score = 1. Factors with over-dosing were kidney failure, a HAS-BLED score ≥3, and older age.ConclusionThe appropriateness of DOAC prescribing for NVAF can be improved, especially in older patients, and in patients with kidney failure, a higher risk of ischaemic stroke, and/or a higher risk of bleeding. GPs have a key role in increasing the proportion of appropriate DOAC prescriptions via informational, educational, and/or management strategies.

Postural tachycardia syndrome (PoTS) is a frequent polymorphic clinical syndrome, poorly known and, as a result, underdiagnosed especially in adolescents. It is a form of dysautonomia, but its exact physiopathology remains elusive. It is characterized by heterogeneous symptoms that accompany a disproportionate tachycardia upon the upright position. It can significantly impact adolescents' quality of life. Only a Schellong test is useful to make the diagnosis; however additional testing is frequently performed in order to exclude conditions that may mimic, exacerbate or impact management. Treatment in PoTS is primarily symptomatic. The main goal is to restore the patient's condition as quickly as possible. Its management is multidisciplinary and must involve the parents. The course of the syndrome is sometimes marked by relapses, but the prognosis is mostly favorable.Le syndrome de tachycardie posturale (STPo) est un syndrome clinique polymorphe sous-diagnostiqué. Il est fréquent et son impact est majeur sur la qualité de vie des adolescent-e-s. Il résulte d’une dysautonomie. Il est caractérisé par une tachycardie disproportionnée lors du passage en position debout, avec des symptômes hétérogènes. Seul un test de Schellong permet de poser le diagnostic ; des analyses complémentaires sont néanmoins fréquemment réalisées pour rechercher des affections qui peuvent mimer ou aggraver un STPo ou avoir un impact sur sa prise en charge. Son traitement est symptomatique avant tout. L’objectif est de reconditionner le patient, le plus rapidement possible. Sa prise en charge est multidisciplinaire et doit impliquer les parents. L’évolution vers la guérison est émaillée de rechutes, mais le pronostic est bon le plus souvent.

ObjectivesThe aim of this study was to determine the prevalence and forms of gender discrimination and sexual harassment experienced by medical students and physicians in French-speaking part of Switzerland.Design and settingWe conducted an online survey using a questionnaire of 9 multiple-choice and 2 open questions between 24 January 2019 and 24 February 2019. Our target population was medical students and physicians working at hospitals and general practitioners from the French-speaking part of Switzerland. The online survey was sent via social media platforms and direct emails. We compared answers between male-determined and female-determined respondents using either χ2 or Fisher’s exact tests.ResultsAmong 1071 responders, a total of 893 were included (625 females, 264 males, 4 non-binary and 1 non-binary and male). 178 were excluded because they did not mention their working place or were working only outside Switzerland. Because of the small number of non-binary participants, they were not contemplated in further statistical analysis. Of 889 participants left, 199 (31.8%) women and 18 (6.8%) men reported having personally experienced gender discrimination, in terms of sexism, difficulties in career development and psychological pressure. Among women, senior attendings were the most affected (55.2%), followed by residents (44.1%) and junior attendings (41.1%). Sexual harassment was equally observed among women (19.0%) and men (16.7%). Compared with men (47.0%), women (61.4%) expressed the need to promote equality and inclusivity in medicine more frequently (pConclusionsGender discrimination in medicine in French-speaking Switzerland affects one-third of women, in particular, those working in hospital settings and senior positions.

BACKGROUND: Colorectal cancer (CRC) is the third most common cancer in men and the second in women worldwide. During the period 2017-2018, in France, 32.1% of the eligible population completed screening, which is under the acceptable uptake rate. The FORCEPS study aimed to test whether a training program focused on improving general practitioners’ (GPs’) communication skills could increase their patients’ CRC screening rate. Our study reports on the construction of, participation in and evaluation of the e-learning training program tested in the FORCEPS study.METHODS: An interdisciplinary team designed an e-learning program for French GPs on the Moodle® platform. Learning activities related to the stated learning objectives and interactive approaches were specified. Two sessions took place, in May and November 2018. The training lasted 6 weeks. RESULTS: In all, 116 GPs registered for the training program. Seventy per cent of the GPs who registered for the first session opted to follow the training via e-learning rather than in person. Among the participants, 36.0% followed the training in its entirety during session 1, as did 24.0% during session 2. At the end of the training, none of the participating GPs self-assessed themselves as a “novice”, and the number of GPs self-assessing as “intermediate” or “experienced” increased. Overall, 62.9% of the participants were generally satisfied with the e-learning course.CONCLUSIONS: The web-based program focused on improving GPs’ communication skills to encourage CRC screening was chosen by a large majority of the participating GPs and received positive reviews. While GPs’ theoretical knowledge can be improved through our training program, it remains to be seen whether or not this will be reflected in their everyday practice, thus resulting in an increased CRC screening participation rate among patients.

National audience; Introduction : L’épidémie de COVID a présenté un défi majeur pour les acteurs et les organisations des soins primaires en France. L’objectif de ce travail réalisé par le réseau de recherche ACCORD, associant praticiens et chercheurs, est de décrire et d’analyser en interprofessionnalité les adaptations et organisations précoces des acteurs des soins primaires durant le premier confinement.Méthodes : Ce travail confronte du matériel quantitatif et qualitatif. Les données quantitatives résultent d’une exploitation croisée des six enquêtes en ligne réalisées par le réseau ACCORD, entre mars et mai 2020, auprès des médecins généralistes, sages-femmes et structures pluriprofessionnelles en France. Ces données ont été enrichies d’échanges collectifs pluriprofessionnels et pluridisciplinaires, conduits en groupes focaux lors d’un séminaire dématérialisé.Résultats : Durant la période considérée, une baisse importante de l’activité en soins primaires a été constatée. Les acteurs ont été nombreux à adapter leurs organisations pour concilier risque épidémique et maintien de l’accès et de la continuité des soins. Les sources d’information utilisées par les professionnels se sont avérées très variables. La crise a révélé des réseaux d’échange et de collaboration importants au niveau des territoires.Conclusion : Face à la crise sanitaire, les acteurs des soins primaires ont adapté leurs organisations et leurs pratiques de façon précoce et diversifiée, soulignant l’importance des organisations préexistantes et des collaborations à l’échelon territorial.

Background: The association between multimorbidities and polypharmacy among elderly individuals is well documented, and polypharmacy has been shown to increase the risk of adverse drug events (ADEs). However, little information is available about the risks associated with the lifelong use of medications to treat chronic multimorbidities. Objective: To determine the prevalence and nature of high-risk prescriptions among primary-care patients with chronic multimorbidities. Methods: We studied a weighted stratified random sample of 105 prescriptions for different patients with chronic multimorbidities taken from the Polychrome database established using information from the French primary-care record database (Observatoire de la MedecineGenerale). A medication review was conducted to identify contra-indications and potential drug-drug interactions for each prescription. Results: Contra-indications were identified for 60 (57.1%) prescriptions, potential drug-drug interactions for 70 (66.7%), absolute contra-indications for 9 (8.6%), and inadvisable drug combinations for 11 (10.5%). In all, 19 (18.1%) different patients were at risk for major ADEs. Cardiovascular and nervous-system drugs contributed 66.2% of contra-indications and 69.3% of potential drug-drug interactions. Conclusions: This exploratory study confirms the high prevalence and potential seriousness of prescriptions at risk for ADEs in a population of primary-care patients with chronic multimorbidities. The high prevalence of interactions involving the cardiovascular and nervous systems indicates that efforts to improve prescription practices should target these two categories of conditions and drugs in patients with chronic multimorbidities.

Background Underdiagnosis and undertreatment of chronic heart failure (CHF) are common in older patients, who are usually treated by general practitioners (GPs). In 2007, the French ICAGE study explored GPs’ attitudes to the management of this condition in older patients. Objectives To explore changes over time in GPs’ attitudes towards the management of CHF in patients aged ≥75 and to identify barriers to optimal management. Methods In 2015, we performed a qualitative study of 20 French GPs via semi-structured interviews and a thematic content analysis. The results were compared with the findings of a 2007 study. Results In 2015, the perceived barriers to diagnosis were the same as in 2007. Echocardiography was still the preferred diagnostic method but the GPs relied on the cardiologist to confirm the diagnosis. Many GPs were still unaware of the different types of CHF. In contrast, they reported greater knowledge of decompensation factors and the ultrasound criteria for CHF. They also prescribed a brain natriuretic peptide assay more frequently. Angiotensin-converting enzyme inhibitors and beta blockers were more strongly perceived to be core treatments. Few GPs initiated drug treatments and optimized dosages. Although patient education was never mentioned, the importance of multidisciplinary care was emphasized. Conclusion Our results evidenced a small recent improvement in the management of older patients with CHF. Appropriate guidelines and training for GPs, patient education and multidisciplinary collaboration might further improve the care given to this population.

BackgroundNo study has investigated factors associated with non-participation or partial participation in the different combination patterns of screening programmes for all three cancers, that is, breast, colorectal and cervical cancer.MethodsIn a retrospective cohort study, we sought to describe combinations of cancer screening participation rates among women in the Val-de-Marne area of France and to identify individual and contextual factors associated with non-participation or partial participation.ResultsWomen aged between 50 and 65 and who were eligible for all three screening programmes (n = 102 219) were analysed in multilevel logistic models, with the individual as the Level 1 variable and the place of residence as the Level 2 variable. The women who did not participate in any of the screening programmes were 34.4%, whereas 30.1%, 24% and 11.5% participated in one, two or all three screening programmes, respectively. Age below 55, a previous false-positive mammography, prior opportunistic mammography only, no previous mammography, membership of certain health insurance schemes (all P < 0.05) and residence in a deprived area (P < 0.001) were independently associated with non-participation or partial participation. We observed a stronger effect of deprivation on non-participation in all three cancers than in combinations of screening programmes.ConclusionOur findings suggest that the health authorities should focus on improving cancer screenings in general rather than screenings for specific types of cancer, especially among younger women and those living in the most socially deprived areas.

Reminders have been used in various settings, but failed to produce convincing evidence of benefits on patient adherence to colorectal cancer (CRC) screening. The aim of this study was to assess the effectiveness of sending general practitioners (GPs) printed reminders about CRC screening. We conducted a cluster-randomized controlled trial involving 144 GPs in the Val-de-Marne district (France), who provided care for any reason to 20 778 patients eligible for CRC screening between June 2010 and November 2011. Data were collected from the main statutory health-insurance programme and local cancer screening agency. GPs were randomly assigned in a 1 : 1 proportion to the intervention or the control group. Every 4 months, intervention-group GPs received a computer-generated printed list of patients who had not performed scheduled faecal occult blood test (FOBT) screening. The primary outcome was patient adherence to FOBT screening or exclusion from CRC screening for medical reasons. The screening adherence rate was 31.2% [95% confidence interval (CI) 30.3-32.1] in the control group and 32.9% (95% CI 32.0-33.8) in the intervention group [crude relative risk, 1.05 (95% CI 1.01-1.09), P

ObjectivesTo describe how general practitioners (GPs) adapted their practices to secure and maintain access to care in the epidemic phase. A secondary objective was to explore if GPs’ individual characteristics and type of practice determined their adaptation.DesignObservational study using an online questionnaire. Organisational changes were measured by a main question and detailed in two specific outcomes. To identify which GPs’ characteristics impacted organisational changes, successive multivariate logistic modelling was performed. First, we identified the GPs’ characteristics related to organisational changes with a univariate analysis. Then, we tested the adjusted associations between this variable and the following GPs’ characteristics: age, gender and type of practice.SettingThe questionnaire was administered online between 14 March and 21 March 2020. Practitioners were recruited by email using the contact lists of different French scientific GP societies.ParticipantsThe target population was GPs currently practising in France (n=46 056). We obtained a total of 7481 responses.Primary and secondary outcome measuresPrimary outcome: Proportion of GPs who adapted their practice. Secondary outcome: GPs’ characteristics related to organisational changes.ResultsAmong the 7481 responses, 5425 were complete and were analysed. 3849 GPs (70.9%) changed their activity, 3605 GPs (66.5%) increased remote consultations and 2315 GPs (42.7%) created a specific pathway for probable patients with COVID-19. Among the 3849 GPs (70.9%) who changed their practice, 3306 (91.7%) gave more answers by phone, 996 (27.6%) by email and 1105 (30.7%) increased the use of video consultations. GPs working in multi-professional group practices were more likely to have changed their activity since the beginning of the epidemic wave than GPs working in mono-professional group or single medical practices (adjusted OR: 1.32, 95% CI 1.12 to 1.56, p=0.001).ConclusionsFrench GPs adapted their practices regarding access to care for patients in the context of the COVID-19 epidemic. This adaptation was higher in multi-professional group practices.

Age-related changes in mental health are an important concern in today's world. Researchers have investigated the effects of video games on mental health for the past 30 years but research on the cognitive impact of smartphones is just beginning. Studies have shown contradictory results and need to be interpreted with caution. Users should be made aware of current knowledge on their potential risks and benefits, without demonizing these relatively new technologies. They should learn how to take advantage of the great potential of these modern devices (they can for example enhance curiosity, sense of purpose and creativity) without becoming enslaved by them.La santé mentale dans le vieillissement est une source importante d’appréhension dans le monde d’aujourd’hui. Tandis que la recherche sur les effets des jeux vidéo sur la santé mentale est menée depuis une trentaine d’années, celle portant sur les smartphones est balbutiante. Bien qu’ils fassent souvent l’actualité, les résultats des études sont discordants et sont à considérer avec prudence. Sans diaboliser ces technologies, notre tâche est aussi de sensibiliser la population aux potentielles dérives. Nous devons apprendre à nous en servir pour exploiter les innombrables possibilités sans en devenir esclave (par exemple, ces nouvelles technologies peuvent être source de capacités utiles telles que la créativité, la curiosité, la persévérance dans la réalisation d’un objectif).

Parmi les elements qui favorisent la creation de maisons ou de centres de sante pluridisciplinaires, il y a l’emergence de la polypathologie chronique en ambulatoire. A partir d’une typologie en huit classes de patients hypertendus, nous nous proposons d’exposer l’intrication entre organisation des soins et modification de la prise en charge. Nous developperons les effets de l’amenagement de la structure, et de la necessite de creer des profils de postes nouveaux pour les besoins de coordination?; l’accompagnement des patients au travers de l’education therapeutique, et des jeunes professionnels a l’exercice pluridisciplinaire. Les effets externes sont l’amelioration des flux ville-hopital notamment au travers de la reemergence du role consultant du second recours, et d’une meilleure gestion des entrees et sorties des patients. Mais sans changement des mentalites, sans nouveaux moyens de remunerations des professionnels liberaux, et sans developpement du systeme d’information en sante, ces evolutions ne seront pas perennes.

In order to improve vaccine coverage of children in Switzerland, physicians hold an essential role in communicating with hesitating parents. To do so, they must have well-referenced knowledge and provide written information to parents. They may also need sometimes to negotiate individual, more flexible, childhood immunization plans. Parents are faced with a wide range of information via the internet and the media, some of which pledges against vaccination. Physicians must be prepared and have knowledge of the main arguments set forward by anti-vaccine movements before discussing with parents. The use of techniques such as adding a personal touch to the discussion, or adapting the principles of motivational interviewing to immunization will help physician guiding the parent towards an informed choice, favorable to the child's vaccination.Afin d’améliorer la couverture vaccinale des enfants en Suisse, le médecin a un rôle à jouer dans la communication auprès du ou des parents hésitants. Pour cela, il doit avoir des connaissances bien référencées et transmettre de la documentation écrite. Négocier un plan de vaccination plus souple, individualisé à l’enfant peut s’avérer parfois nécessaire. Beaucoup d’informations contre la vaccination circulent sur internet et dans les médias. Le médecin doit y être préparé et connaître les principaux arguments des mouvements antivaccins pour pouvoir en discuter avec les parents qui y sont réceptifs. Utiliser des techniques comme l’ajout d’une touche personnelle à son discours ou adapter l’entretien motivationnel à la vaccination aidera le médecin à guider les parents vers un choix informé et éclairé favorable à la vaccination de leur enfant.

Contexte : La satisfaction du patient, au sein d’une relation medecin-malade de qualite, ameliore son observance, son adhesion therapeutique et in fine son etat de sante. L’objectif de cette etude etait d’analyser les facteurs influencant les qualites attribuees par les patients au bon medecin. Methode : Enquete transversale sous la forme d’un questionnaire telephonique, elabore apres une etude pilote, aupres de patients majeurs. Douze qualites attribuees au bon medecin dans les domaines medicaux, relationnels, ethiques ou organisationnels ont ete etudiees. Des facteurs d’ordre sociodemographiques, lies au parcours medical ou a l’etat de sante des patients ont ete pris en compte. Une declaration a la CNIL a ete deposee. Les analyses descriptives, univariees et multivariees ont ete realisees a l’aide du logiciel SAS 9.1. Resultats : Sur 1246 appels telephoniques, 302 patients ont ete inclus. La capacite a realiser un bon diagnostic, l’ecoute et l’integrite du medecin etaient les qualites les plus citees. La presence d’une maladie chronique etait associee a des exigences d’ecoute et de qualites relationnelles accrues, selon un gradient de severite de la maladie et apres ajustement multivarie. D’autres facteurs sociodemographiques ou lies a l’experience medicale du patient semblaient influer sur les qualites attendues du bon medecin. Conclusion : Ces resultats soulignent l’importance des qualites relationnelles dans la relation medecin malade. Celles-ci sont a promouvoir et a enrichir tout au long du cursus medical et de la carriere de soignant.

Objectifs?: evaluer les connaissances des femmes vis-a-vis des modalites pratiques du depistage du cancer du col de l’uterus, rechercher un lien entre leur niveau de connaissance et leur participation, et evaluer leur perception de l’implication des medecins generalistes (MG) dans la mise en œuvre de ce depistage.Methode?: enquete par questionnaire telephonique aupres d’un echantillon aleatoire de femmes âgees de 25 a 65 ans et habitant le departement du Val-d’Oise.Resultats?: 117 femmes ont repondu. Les modalites du depistage etaient globalement meconnues mais la participation etait bonne chez 87,9 % des femmes. Connaitre la possibilite de realiser des frottis (FCU) dans un laboratoire d’analyses et la necessite de poursuivre le depistage chez les femmes vaccinees contre HPV etait associe a une participation effective au depistage. De meme, la consultation d’un gynecologue au cours des 12 derniers mois etait associee a une meilleure participation. Selon 64,1 % des femmes, ce depistage n’avait jamais ete aborde par un MG. Seules 6,8 % des femmes avaient deja eu un FCU realise par un MG mais la majorite des femmes (59,8 %) etait favorable a une augmentation du nombre de FCU realises par les MG.Conclusion?: une meilleure connaissance des femmes vis-a-vis des modalites du depistage du cancer du col de l’uterus pourrait ameliorer leur participation. Les MG realisent peu de frottis et l’information qu’ils delivrent aux patientes devrait etre renforcee.

Objective Our aim was to determine whether physician-related factors influenced patient participation in colorectal cancer (CRC) screening programs and to identify patient characteristics associated with lower participation in order to facilitate the development of targeted actions to improve participation. Method A retrospective cohort study was conducted in a French department during its first CRC screening campaign from June 2007 to May 2010. Data for 157,766 patients followed by 903 general practitioners (GPs) were analyzed. Patient participation was assessed using multilevel logistic modeling. Results The overall participation rate was 30% (95% confidence interval [95% CI], 29.8–30.2) and varied across the 903 GPs from 0% to 75.5% (median, 30; interquartile range, 24–35). Inter-GP variance explained only 5.5% of the participation rate variance. Participation was significantly lower in males (odds ratio [OR], 0.79; 95% CI, 0.78–0.91), the youngest age group (55–59 years, OR, 0.61; 95% CI, 0.58–0.63), and patients living in socioeconomically deprived areas (OR, 0.82; 95% CI, 0.77–0.87). Conclusion Targeted actions to improve CRC screening participation should focus on patients younger than 60 years, males, and individuals living in deprived areas. Actions to enhance the influence of GPs on patient participation should be directed to the overall population of GPs.

Introduction Older patients raise therapeutic challenges, because they constitute a heterogeneous population with multimorbidity. To appraise this complexity, geriatricians have developed a multidimensional comprehensive geriatric assessment (CGA), which may be difficult to apply in primary care settings. Our primary objective was to compare the effect on morbimortality of usual care compared with two complex interventions combining educational seminars about CGA: a dedicated geriatric hotline for general practitioners (GPs) and CGA by trained nurses or GPs. Methods and analysis The Clinical Epidemiology and Ageing study is an open-label, pragmatic, multicentre, three-arm, cluster randomised controlled trial comparing two intervention groups and one control group. Patients must be 70 years or older with a long-term illness or with unscheduled hospitalisation in the past 3 months (750 patients planned). This study involves volunteering GPs practising in French primary care centres, with randomisation at the practice level. The multifaceted interventions for interventional arms comprise an educational interactive multiprofessional seminar for GPs and nurses, a geriatric hotline dedicated to GPs in case of difficulties and the performance of a CGA updated to primary care. The CGA is systematically performed by a nurse in arm 1 but is GP-led on a case-by-case basis in arm 2. The primary endpoint is a composite criterion comprising overall death, unscheduled hospitalisations, emergency admissions and institutionalisation within 12 months after inclusion. Intention-to-treat analysis will be performed using mixed-effects logistic regression models, with adjustment for potential confounders. Ethics and dissemination The protocol was approved by an appropriate ethics committee (CPP Ile-de-France IV, Paris, France, approval April 2015;15 664). This study is conducted according to principles of good clinical practice in the context of current care and will provide useful knowledge on the clinical benefits achievable by CGA in primary care. Trial registration number NCT02664454; Pre-results.

The invasive ant species Wasmannia auropunctata displays both ecologically dominant and non-dominant populations within its native range. Three factors could theoretically explain the ecological dominance of some native populations of W. auropunctata: (i) its clonal reproductive system, through demographic and/or adaptive advantages; (ii) its unicolonial social organization, through lower intraspecific and efficient interspecific competition; (iii) the human disturbance of its native range, through the modification of biotic and abiotic environmental conditions. We used microsatellite markers and behavioural tests to uncover the reproductive modes and social organization of dominant and non-dominant native populations in natural and human-modified habitats. Microsatellite and mtDNA data indicated that dominant and non-dominant native populations (supercolonies as determined by aggression tests) of W. auropunctata did not belong to different evolutionary units. We found that the reproductive system and the social organization are neither necessary nor sufficient to explain W. auropunctata ecological dominance. Dominance rather seems to be set off by unknown ecological factors altered by human activities, as all dominant populations were recorded in human-modified habitats. The clonal reproductive system found in some populations of W. auropunctata may however indirectly contribute to its ecological dominance by allowing the species to expand its environmental niche, through the fixation over time of specific combinations of divergent male and female genotypes. Unicoloniality may rather promote the range expansion of already dominant populations than actually trigger ecological dominance. The W. auropunctata model illustrates the strong impact of human disturbance on species' ecological features and the adaptive potential of clonal reproductive systems.

We investigated the influence of caste on nestmate discrimination in the ponerine ant Pachycondyla luteipes, where workers lack functional ovaries and are totally sterile. Both a mark-and-recapture field experiment and an introduction experiment in the laboratory revealed intermixing of both nestmate and non-nestmate workers between nests. In the laboratory experiment, conspecific workers, both nestmate and non-nestmates, were almost always accepted. Workers' internest hostility was weak and did not correlate with the distance between nests over the geographical scale studied (

The little fire ant Wasmannia auropunctata is able to develop highly dominant populations in disturbed areas of its native range, with a resulting negative impact on ant diversity. We report here on the tolerance of such populations towards several fungus-growing ants of the genus Cyphomyrmex (rimosus complex) in French Guiana. This tolerance is surprising given the usually high interspecific aggressiveness of W. auropunctata when dominant. In order to understand the mechanisms behind such proximity, aggressiveness tests were performed between workers of the different species. These behavioural assays revealed a great passivity in Cyphomyrmex workers during confrontations with W. auropunctata workers. We also found that the aggressiveness between W. auropunctata and two Cyphomyrmex species was more intense between distant nests than between adjacent ones. This dear-enemy phenomenon may result from a process of habituation contributing to the ants' ability to coexist over the long term.

One of the factors responsible for the creation of multidisciplinary health centres is the growth of outpatient management of multiple chronic conditions. Based on a classification of hypertensive patients into eight groups, the authors discuss the interrelations between health care organization and modification of management. They discuss the effects of modification of health care structures and the need to create new job positions for the purposes of coordination, support of patients in the form of therapeutic education and support ofyoung professionals in multidisciplinary practice. External effects are improvement of office-hospital flows, especially with the development of second-line consultant roles and improved management of patient admissions and discharges. However, to ensure sustainable changes, there must be a change of mentalities with new modalities of remuneration of private practitioners and development of the health information system.

Among the factors driving the invasive success of non-indigenous species, the “escape opportunity” or “enemy release” hypothesis argues that an invader’s success may result partly from less resistance from the new competitors found in its introduced range. In this study, we examined competitive interactions between the little fire ant Wasmannia auropunctata (Roger) and ant species of the genus Pheidole in places where both are native (French Guiana) and in places where only species of Pheidole are native (New Caledonia). The experimental introduction of W. auropunctata at food resources monopolized by the Pheidole species induced the recruitment of major workers only for the Guianian Pheidole species, which were very effective at killing Wasmannia competitors. In contrast, an overall decrease in the number of Pheidole workers and no recruitment of major workers were observed for the New Caledonian species, although the latter were the only ones able to kill the Wasmannia workers. These results emphasize the inappropriate response of native dominant New Caledonian species to W. auropunctata and, thus, the importance of enemy recognition and specification in the organization of ant communities. This factor could explain how invasive animal species, particularly ants, may be able to successfully invade species-rich communities.

Correspondance: arnaud.estoup@supagro.inra.fr; International audience; Highly polymorphic genetic markers provide a useful tool for estimating genetic parametersin studies of the evolution of sociality in insects. We isolated and characterized 12 polymorphicmicrosatellite loci in the invasive ant, Wasmannia auropunctata, and described experimental conditions for PCR (polymerase chain reaction) multiplexing and simultaneously genotyping these loci in two sets of five and seven markers. The number of alleles per locus ranged from two to 14 and the observed heterozygosity ranged from 0.233 to 0.967. Moreover, results of cross-species amplification tests are reported in three other species of Wasmannia and in two species of the genus Allomerus

The purpose of this study was to assess women's knowledge of cervical cancer screening, to examine the relationship between knowledge and screening participation, and to gain a better insight into GP involvement in screening.A telephone survey was conducted on a random sample of women aged 25-65 years living in Val-d'Oise, France.117 women responded to the survey. The results show that women were often not aware of screening modalities, although participation was high in 87.9 % of cases. Knowing that cervical smears (CS) can be performed in a medical laboratory and that HPV-vaccinated women should undergo screening were significantly associated with high participation. Women who had consulted a gynaecologist in the last 12 months were also significantly more likely to participate in screening. According to 64.1% of the respondents, the question of screening had never been discussed in GP consultations. Only 6.8% of the women had had a cervical smear performed by a GP, although most of the women (59.8%) felt that GPs should be more involved in cervical smear testing.Increased knowledge of cervical cancer screening among women may help to increase participation in screening. The study suggests that GPs should be more involved in cervical cancer screening and that their role in providing prevention information to female patients should be promoted.

Background The participation rate in organized breast cancer screening in France is lower than recommended. Non-participants either use opportunistic screening or do not use either screening modality. Objective To assess any differences in perceptions, attitudes and knowledge related to breast cancer screening between users of opportunistic screening and non-users of any screening mammograms and to identify potential barriers to participation in organized screening. Methods Six focus groups were conducted in May 2010 with 34 French non-participants in organized screening, 15 who used opportunistic screening (OpS group) and 19 who used no screening (NoS group). The guide used for both groups explored perceptions and attitudes related to health, cancer and screening; perceptions of femininity; and knowledge about breast cancer screening. Thematic content analysis was performed. Results Perceptions, attitudes and knowledge differed between the two groups. Women in the OpS group perceived a high susceptibility to breast cancer, visited their gynaecologist regularly, were unfamiliar with organized screening modalities and had doubts about its quality. NoS women had very high- or low-perceived susceptibility to breast cancer, knew about screening modalities, had doubts about its usefulness and expressed negative opinions of mammograms. Conclusions Differences in perceptions and attitudes related to breast cancer screening partially explain why some women choose opportunistic screening or no screening. General practitioners and gynaecologists are in a unique position to provide individually tailored preventative messages to improve participation in organized screening.

The invasive ant species Wasmannia auropunctata displays both ecologically dominant and non-dominant populations within its native range. Three factors could theoretically explain the ecological dominance of some native populations of W. auropunctata: (i) its clonal reproductive system, through demographic and/or adaptive advantages; (ii) its unicolonial social organization, through lower intraspecific and efficient interspecific competition; (iii) the human disturbance of its native range, through the modification of biotic and abiotic environmental conditions. We used microsatellite markers and behavioural tests to uncover the reproductive modes and social organization of dominant and non-dominant native populations in natural and human-modified habitats. Microsatellite and mtDNA data indicated that dominant and non-dominant native populations (supercolonies as determined by aggression tests) of W. auropunctata did not belong to different evolutionary units. We found that the reproductive system and the social organization are neither necessary nor sufficient to explain W. auropunctata ecological dominance. Dominance rather seems to be set off by unknown ecological factors altered by human activities, as all dominant populations were recorded in human-modified habitats. The clonal reproductive system found in some populations of W. auropunctata may however indirectly contribute to its ecological dominance by allowing the species to expand its environmental niche, through the fixation over time of specific combinations of divergent male and female genotypes. Unicoloniality may rather promote the range expansion of already dominant populations than actually trigger ecological dominance. The W. auropunctata model illustrates the strong impact of human disturbance on species' ecological features and the adaptive potential of clonal reproductive systems.

Correspondence: E-mail: orivel@cict.fr; International audience; The biology of most invasive species in their native geographical areas remains largely unknown. Such studies are, however, crucial in shedding light on the ecological and evolutionary processes underlying biological invasions.The present study focuses on the little fire ant 2. Wasmannia auropunctata, a species native to Central and South America that has been widely introduced and which has become invasive throughout the tropics. We characterise and compare several ecological traits of native populations in French Guiana with those in one of its introduced ranges, New Caledonia.We found ecologically heterogeneous populations of 3. W. auropunctata coexisting in the species’ native geographical area. First, we found populations restricted to naturally perturbed areas (particularly floodplains) within the primary forest, and absent from the surrounding forest areas. These populations were characterised by low nest and worker densities. Second, we found dominant populations in recent anthropogenic areas (e.g. secondary forest or forest edge along road) characterised by high nest and worker densities, and associated with low ant species richness. The local dominance of W. auropunctata in such areas can be due to the displacement of other species (cause) or the filling-up of empty habitats unsuitable to other ants (effect). With respect to their demographic features and ant species richness, the populations of native anthropogenic habitats were to a large extent similar to the invasive populations introduced into remote areas.4. The results point to the need for greater research efforts to better understand the ecological and demographic features of invasive species within their native ranges

Correspondance: foucaud@supagro.inra.fr; International audience; Reproduction systems are controlling the creation of new genetic variants as well as how natural selection can operate on these variants. Therefore, they had historically been one of the main foci of evolutionary biology studies. The little fire ant, Wasmannia auropunctata, has been found to display an extraordinary reproduction system, in which both males and female queens are produced clonally. So far, native sexual populations of W. auropunctata have not been identified. Our goals were to identify such sexual populations and investigate the origins of female parthenogenesis and male clonality. Using mitochondrial DNA and microsatellite markers in 17 native populations, we found that traditional sexual populations occurred in W. auropunctata and are likely the recent source of neighboring clonal populations. Queen parthenogenesis has probably evolved several times through mutational events. Male clonality is tightly linked to queen parthenogenesis and thus appears to be female controlled. Its origin could be accounted for by 2 mutually exclusive hypotheses: either by the expected coevolution of the 2 sexes (i.e., a variant of the maternal genome elimination hypothesis) or by a shared mechanistic origin (i.e., by the production of anucleate ovules by parthenogenetic queens). Our results also show that W. auropunctata males and females do not form separate evolutionary units and are unlikely to be engaged in an all-out battle of sexes. This work opens up new perspectives for studies on the adaptive significance and evolutionary stability of mixed sexual and clonal reproduction systems in living organisms

We studied the foraging and predatory behaviors of the invasive African myrmicine ant, Pheidole megacephala (F.) in its native range. Workers can singly capture a wide range of insects, including relatively large prey items. For still larger prey, they recruit at short range those nestmates situated within reach of an alarm pheromone and together spread-eagle the insect. These behaviors are complimented by a long-range recruitment (of nestmates remaining in the nest) based on prey size. P. megacephala scouts also use long-range recruitment when they detect the landmarks of termites and competing ant species, thus permitting them to avoid confronting these termites and ants solitarily. To cite this article: A. Dejean et al., C. R. Biologies 330 (2007).

Correspondance: estoup@supagro.inra.fr; International audience; A unique reproductive system has previously been described in Wasmannia auropunctata, a widespread invasive ant species, where males are produced clonally, female queens are parthenogens, and female workers are produced sexually. However, these findings were mostly based on samples originating from only a limited part of the native range of the species in South America. We used microsatellite markers to uncover the reproductive modes displayed by a large number of nests collected in various invasive W. auropunctata populations introduced 40 years ago into New Caledonia, where the species now forms a single 450-km-long supercolony. Although the main reproduction system in New Caledonia remained clonality for both male and female reproductives, we found evidence of rare sexual reproduction events that led to the production of both new queen and male clonal lineages. All clonal lineages observed in New Caledonia potentially derived from sexual reproduction, recombination, and mutation events from a single female and a single male genotype. Hence, the male and female gene pools are not strictly separated in New Caledonia and the two sexes do not follow independent evolutionary trajectories. Our results also suggest genetic determination for both parthenogenesis and caste. We discuss the evolutionary implications of the emergence of sex in the clonal reproduction system of introduced populations of W. auropunctata

International audience; Sexual reproduction can lead to major conflicts between sexes and within genomes1, 2, 3, 4. Here we report an extreme case of such conflicts in the little fire ant Wasmannia auropunctata. We found that sterile workers are produced by normal sexual reproduction, whereas daughter queens are invariably clonally produced. Because males usually develop from unfertilized maternal eggs in ants and other haplodiploid species, they normally achieve direct fitness only through diploid female offspring. Hence, although the clonal production of queens increases the queen's relatedness to reproductive daughters, it potentially reduces male reproductive success to zero. In an apparent response to this conflict between sexes, genetic analyses reveal that males reproduce clonally, most likely by eliminating the maternal half of the genome in diploid eggs. As a result, all sons have nuclear genomes identical to those of their father. The obligate clonal production of males and queens from individuals of the same sex effectively results in a complete separation of the male and female gene pools. These findings show that the haplodiploid sex-determination system provides grounds for the evolution of extraordinary genetic systems and new types of sexual conflict

Due to the unbalanced distribution of their fauna and flora, which leads to the creation of a niche opportunities, it is generally accepted that island communities offer weak biotic resistance to biological invasion. In order to empirically test this statement, we compared resource use by ants in the understorey of an undisturbed New Caledonian rain forest recently invaded by the little fire ant, Wasmannia auropunctata. We tested the exploitation of: (1) food sources by placing baits on all trees with trunks greater than 5 cm in diameter; and (2) nesting sites on two tree species likely to shelter ant colonies. In non-invaded areas, the native ants occupied only 44.6% of the baits after 2 h of exposure, while in invaded areas all the baits were occupied by numerous W. auropunctata workers. Similarly, in non-invaded areas only 48.9% of Meryta coriacea (Araliaceae) trees and 64.5% of Basselinia pancheri (Arecaceae) sheltered ants, while in invaded areas W. auropunctata nested in 92.6–98.3% of these trees. Also, workers attended native Margarodidae (Hemiptera) for which they promoted the development of populations significantly larger than those attended by native ants. Thus native ants appear unable to efficiently exploit and defend several of the available food sources and nesting sites, providing a niche opportunity for an invader like W. auropunctata.

This study was conducted on the reactions of Pheidole megacephala scouts when finding liquid food sources situated on territories marked by competing dominant ant species or on unmarked, control areas to see if the number of recruited nestmates is affected and if soldiers behave in ways adapted to the situation. We show that scouts recruit more nestmates, particularly soldiers, on marked rather than on unmarked areas. This recruitment allows P. megacephala to organize the defence and rapid depletion of these food sources prior to any contact with competitors. Soldiers can carry liquid foods both (1) in their crops like other Myrmicinae and (2), in a new finding concerning myrmicine ants, under their heads and thoraxes like certain poneromorph genera because the droplets adhere through surface tension strengths. Later, the liquids stored in the crop are distributed to nestmates through regurgitations during trophallaxis and the external droplets are distributed through "social buckets", or the mode of liquid food transfer common in poneromorphs. Their flexibility to use or not use the latter technique, based on the situation, corroborates other reports that Pheidole soldiers have a relatively large behavioral repertoire.

We examined intraspecific colonial aggressiveness in Wasmannia auropunctata (Roger), a tramp species originating from the neotropics. By observing the results of one-on-one confrontations, we compared the behavioral responses of workers originating from six New Caledonian locations (introduced range) and four Brazilian cocoa plantations (original range). We recorded interindividual “aggressive” behavior on four levels ranging from physical contact, with no aggressive response, to prolonged aggressiveness, including stinging by one or both ants. In Brazil, we often observed high intraspecific aggressiveness between populations originating from distant locations, indicating that W. auropunctata may behave as a multicolonial species in its native range. In New Caledonia, paired encounters resulted in low agonistic behavior, as shown by the absence of “full attacks” (which include stinging by one or both opponents). Our results suggest that W. auropunctata behaves as a single supercolony throughout New Caledonia and that the scale of its unicoloniality (widespread colonies with interconnected nests without aggressiveness between workers originating from distant areas) is different in introduced and native populations. According to the present study, it seems likely that differences in intraspecific aggressiveness between native and introduced populations of W. auropunctata contribute to its invasive success.

Dans un contexte de depenses de sante croissantes, de scandales pharmaceutiques, d’emergence de patients polypathologiques chroniques, la prescription des medecins generalistes est regulierement remise en cause. Mais la gestion au quotidien du patient polypathologique par ces praticiens est mal connue. Nous avons donc reunis 60 medecins generalistes, pendant une journee, pour, d’une part, reflechir sur leur pratique et, d’autre part, discuter en groupes de pairs autour de diagnostics et de prescriptions reelles de patients polypathologiques chroniques. Les resultats presentes ici montrent le reseau complexe qui se noue en arriere fond de la relation medecin-malade dans ce contexte. La conclusion est qu’il ne sera pas possible d’ameliorer la prise en charge de ces patients en ambulatoire sans une reorganisation majeure du systeme de soins et un changement culturel dans la cooperation entre professionnels de sante.