Publications by authors named "Alain Mercier"

17 Publications

  • Page 1 of 1

The Patient Teacher in General Practice Training: Perspectives of Residents.

J Patient Exp 2019 Dec 2;6(4):287-295. Epub 2018 Oct 2.

Health Education and Practices Laboratory (LEPS EA3412), University Paris 13, Sorbonne Paris Cité, Bobigny, France.

Background: Patient teachers were involved in training general practice residents (GPRs) to strengthen the patient-centered approach. They teach a course on health democracy by themselves and teach in tandem with a physician teacher during reflective practice-based classes (named GEPRIs). We present the GPRs' representations of patient teacher characteristics and capacities and their perception of how useful patient teachers are to their professional development.

Methods: We administered a questionnaire based on a preliminary qualitative study to 124 GPRs. It explored (a) changes in the GPRs' representations about patient teacher characteristics and capacities with regard to teaching over the first year of the experiment; (b) GPRs' perception of patient teacher utility to their training and their contribution to developing patient perspective-related competencies.

Results: The response rate was 89.5% (111/124). The majority of GPRs agreed with 17 (before) and 21 (after) of the 23 patient teacher characteristics and with 17 (before) and 19 (after) of the 20 capacities. The agreement rate increased, overall, after patient teacher participation. The GPRs found patient teacher useful to their training in 9 of 11 topics (agreement rate 65%-92%). They felt they had developed the 14 patient knowledge-related competencies (agreement rate 62%-93%), and 52% to 75% of the GPRs rated the patient teachers' contribution to those competencies "high or very high," depending on the competency.

Conclusion: This study demonstrates the specific contribution of patient teachers to university-level medical training in France. The GPRs recognized that patient teachers helped them develop competencies by providing patient-specific content.
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http://dx.doi.org/10.1177/2374373518803630DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6908989PMC
December 2019

Consensus study to define appropriate inaction and inappropriate inertia in the management of patients with hypertension in primary care.

BMJ Open 2018 07 30;8(7):e020599. Epub 2018 Jul 30.

Department of Primary and Interdisciplinary Care, University of Antwerp, Wilrijk, Belgium.

Objectives: To elaborate and validate operational definitions for appropriate inaction and for inappropriate inertia in the management of patients with hypertension in primary care.

Design: A two-step approach was used to reach a definition consensus. First, nominal groups provided practice-based information on the two concepts. Second, a Delphi procedure was used to modify and validate the two definitions created from the nominal groups results.

Participants: 14 French practicing general practitioners participated in each of the two nominal groups, held in two different areas in France. For the Delphi procedure, 30 academics, international experts in the field, were contacted; 20 agreed to participate and 19 completed the procedure.

Results: Inappropriate inertia was defined as: to not initiate or intensify an antihypertensive treatment for a patient who is not at the blood pressure goals defined for this patient in the guidelines when all following conditions are fulfilled: (1) elevated blood pressure has been confirmed by self-measurement or ambulatory blood pressure monitoring, (2) there is no legitimate doubt on the reliability of the measurements, (3) there is no observance issue regarding pharmacological treatment, (4) there is no specific iatrogenic risk (which alters the risk-benefit balance of treatment for this patient), in particular orthostatic hypotension in the elderly, (5) there is no other medical priority more important and more urgent, and (6) access to treatment is not difficult. Appropriate inaction was defined as the exact mirror, that is, when at least one of the above conditions is not met.

Conclusion: Definitions of appropriate inaction and inappropriate inertia in the management of patients with hypertension have been established from empirical practice-based data and validated by an international panel of academics as useful for practice and research.
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http://dx.doi.org/10.1136/bmjopen-2017-020599DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6067345PMC
July 2018

General practitioner management related to skin cancer prevention and screening during standard medical encounters: a French cross-sectional study based on the International Classification of Primary Care.

BMJ Open 2017 01 30;7(1):e013033. Epub 2017 Jan 30.

INSERM U1232, Nantes, France.

Objective: The aim of this study was to assess general practitioner (GP) management practices related to skin cancer prevention and screening during standard medical encounters.

Setting: Data on medical encounters addressing skin cancer issues were obtained from a French database containing information from 17 019 standard primary care consultations.

Participants: Data were collected between December 2011 and April 2012 by 54 trainees who reported the regular practice of 128 GPs using the International Classification of Primary Care.

Outcome Measures: Reasons for encounters and the following care processes were recorded: counselling, clinical examinations and referral to a specialist. Medical encounters addressing skin cancer issues were compared with medical encounters that addressed other health problems using a multivariate analysis.

Results: Only 0.7% of medical encounters addressed skin cancer issues. When patients did require management of a skin cancer-related issue, this was more likely initiated by the doctor than the patient (70.7% vs 29.3%; p<0.001). Compared with medical encounters addressing other health problems, encounters that addressed skin cancer problems required more tasks (3.7 vs 2.5; p<0.001) and lasted 1 min and 20 s longer (p=0.003). GPs were less involved in clinical examinations (67.5% vs 97.1%; p<0.001), both complete (7.3% vs 22.3%, p<0.001) and partial examinations (60.2% vs 74.9%), and were less involved in counselling (5.7% vs 16.9%; p<0.001). Patients presenting skin cancer issues were referred to a specialist more often than patients consulting for other health problems (39.0% vs 12.1%; p<0.001). GPs performed a biopsy in 6.7% of all skin cancer-related encounters.

Conclusions: This study demonstrates discrepancies between the high prevalence of skin cancer and the low rate of medical encounters addressing these issues in general practice. Our findings should be followed by qualitative interviews to better understand the observed practices in this field.
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http://dx.doi.org/10.1136/bmjopen-2016-013033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5293869PMC
January 2017

General practitioners' justifications for therapeutic inertia in cardiovascular prevention: an empirically grounded typology.

BMJ Open 2016 May 13;6(5):e010639. Epub 2016 May 13.

Department of Primary and Interdisciplinary Care, University of Antwerp. Campus Drie Eiken, Antwerpen, Belgium.

Objective: To construct a typology of general practitioners' (GPs) responses regarding their justification of therapeutic inertia in cardiovascular primary prevention for high-risk patients with hypertension.

Design: Empirically grounded construction of typology. Types were defined by attributes derived from the qualitative analysis of GPs' reported reasons for inaction.

Participants: 256 GPs randomised in the intervention group of a cluster randomised controlled trial.

Setting: GPs members of 23 French Regional Colleges of Teachers in General Practice, included in the EffectS of a multifaceted intervention on CArdiovascular risk factors in high-risk hyPErtensive patients (ESCAPE) trial.

Data Collection And Analysis: The database consisted of 2638 written responses given by the GPs to an open-ended question asking for the reasons why drug treatment was not changed as suggested by the national guidelines. All answers were coded using constant comparison analysis. A matrix analysis of codes per GP allowed the construction of a response typology, where types were defined by codes as attributes. Initial coding and definition of types were performed independently by two teams.

Results: Initial coding resulted in a list of 69 codes in the final codebook, representing 4764 coded references in the question responses. A typology including seven types was constructed. 100 GPs were allocated to one and only one of these types, while 25 GPs did not provide enough data to allow classification. Types (numbers of GPs allocated) were: 'optimists' (28), 'negotiators' (20), 'checkers' (15), 'contextualisers' (13), 'cautious' (11), 'rounders' (8) and 'scientists' (5). For the 36 GPs that provided 50 or more coded references, analysis of the code evolution over time and across patients showed a consistent belonging to the initial type for any given GP.

Conclusion: This typology could provide GPs with some insight into their general ways of considering changes in the treatment/management of cardiovascular risk factors and guide design of specific physician-centred interventions to reduce inappropriate inaction.

Trial Registration Number: NCT00348855.
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http://dx.doi.org/10.1136/bmjopen-2015-010639DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4874143PMC
May 2016

Behavior and attitudes of residents and general practitioners in searching for health information: From intention to practice.

Int J Med Inform 2016 May 17;89:9-14. Epub 2016 Feb 17.

CISMeF, TIBS, LITIS EA 4108, Rouen University Hospital, rue de Germont, Rouen, France; UMR_S 1142, LIMICS, Inserm, Paris, France. Electronic address:

Background: Physicians are increasingly encouraged to practice evidence-based medicine (EBM), and their decisions require evidence based on valid research. Existing literature shows a mismatch between general practitioners' (GPs) information needs and evidence available online. The aim of this study was to explore the attitudes and behavior of residents in general medicine and GPs when seeking medical information online.

Methods: Five focus groups (FGs) involving residents in general medicine and GPs were conducted between October 2013 and January 2014. The overall number of participants recruited was 35. The focus group discussion guide focused on participants' experiences in searching for health information on the Internet, perceived barriers and possible solutions for improving the quality of their own search processes. Descriptive analysis was performed by three researchers.

Results: Participants described a wide range of research topics, covering all general medicine core competencies, and especially patient-oriented topics. They used a limited list of websites. Participants were not confident about their ability to assess the quality of the information they found. Their assessment of data quality was based on intuition, and they mainly sought concordance with their existing knowledge. The way the data were exposed was considered very important. Participants were looking for information that was directly linked to their clinical practice. Information seeking processes varied among participants. They felt they had not mastered query building for conducting searches, and were aware of the impact this shortcoming had on the quality of their search for information.

Conclusions: Residents in general medicine and GPs understood the importance of EBM and the need for objective and reliable information. The present study highlights the difficulties in identifying this kind of information, and suggests ideas for improvement. Available search tools should change in order to fill the gap with real-world clinical practice, for example by integrating a patient-centred approach.
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http://dx.doi.org/10.1016/j.ijmedinf.2016.02.003DOI Listing
May 2016

How do GP practices and patient characteristics influence the prescription of antidepressants? A cross-sectional study.

Ann Gen Psychiatry 2015 22;14(1). Epub 2015 Jan 22.

Department of Public Health, Vrije Universiteit Brussel, Brussels, Belgium.

Background: Under-prescription of antidepressants (ADs) among people meeting the criteria for major depressive episodes and excessive prescription in less symptomatic patients have been reported. The reasons influencing general practitioners' (GPs) prescription of ADs remain little explored. This study aimed at assessing the influence of GP and patient characteristics on AD prescription.

Methods: This cross-sectional study was based on a sample of 816 GPs working within the main health care insurance system in the Seine-Maritime district of France during 2010. Only GPs meeting the criteria for full-time GP practice were included. The ratio of AD prescription to overall prescription volume, a relative measure of AD prescription level, was calculated for each GP, using the defined daily dose (DDD) concept. Associations of this AD prescription ratio with GPs' age, gender, practice location, number of years of practice, number of days of sickness certificates prescribed, number of home visits and consultations, number and mean age of registered patients, mean patient income, and number of patients with a chronic condition were assessed using univariate and multivariate analysis.

Results: The high prescribers were middle-aged (40-59) urban GPs, with a moderate number of consultations and fewer low-income and chronic patients. GPs' workload (e.g., volume of prescribed drug reimbursement and number of consultations) had no influence on the AD prescription ratio. GPs with more patients with risk factors for depression prescribed fewer ADs, however, which could suggest the medications were under-prescribed among the at-risk population.

Conclusions: Our study described a profile of the typical higher AD prescriber that did not include heavy workload. In future work, a more detailed assessment of all biopsychosocial components of the consultation and other influences on GP behavior such as prior training would be useful to explain AD prescription in GP's practice.
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http://dx.doi.org/10.1186/s12991-015-0041-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4308843PMC
January 2015

Why do general practitioners prescribe antidepressants to their patients? A pilot study.

Biopsychosoc Med 2014 30;8:17. Epub 2014 Jul 30.

Department of Primary and Interdisciplinary Care, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium ; Department of Public Health, Vrije Universiteit Brussel, Brussels, Belgium.

Background: The frequency of antidepressant (ADs) prescription is high, with general practitioners (GPs) responsible for about 80% of the prescriptions. Some studies considered prescriptions meet DSM criteria, while others stress inadequate use. The importance of biological and psychosocial determinants of GP prescription behaviour remains little explored. We aimed to describe the importance of these biological and psychosocial determinants and their weight in the daily practice of GPs'.

Methods: During a week chosen at random, 28 GPs collected the AD prescriptions made within the previous six months, regardless of the reason for the patient contact. Bio psychosocial and AD treatment characteristics were recorded for all patients. In a random sample of 50 patients, patient characteristics were assessed via a structured face-to-face interview with the GP.

Results: The frequency of AD prescription was 8.90% [3.94 -17.02]. The GPs initiated 65.6% [60.1-70.8] of the prescriptions. The rate of AD prescription for non-psychiatric conditions was 18%. Patients had from 1 to 9 conditions, showing a high level of multi-morbidity. There was a strong influence of past medical history and contextual problems, such as work related problems.

Conclusion: AD prescription is related to complex contextual situations and multi-morbid patients. GPs use a bio psycho social approach, rather than a purely biological assessment. Awareness of these influences could improve prescription by GPs.
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http://dx.doi.org/10.1186/1751-0759-8-17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4126991PMC
August 2014

The concept and definition of therapeutic inertia in hypertension in primary care: a qualitative systematic review.

BMC Fam Pract 2014 Jul 2;15:130. Epub 2014 Jul 2.

Department of General Practice, EES, University of Tours, 10 Boulevard Tonnellé, BP 3223, 37032 Tours, Cedex 1, France.

Background: Therapeutic inertia has been defined as the failure of health-care provider to initiate or intensify therapy when therapeutic goals are not reached. It is regarded as a major cause of uncontrolled hypertension. The exploration of its causes and the interventions to reduce it are plagued by unclear conceptualizations and hypothesized mechanisms. We therefore systematically searched the literature for definitions and discussions on the concept of therapeutic inertia in hypertension in primary care, to try and form an operational definition.

Methods: A systematic review of all types of publications related to clinical inertia in hypertension was performed. Medline, EMbase, PsycInfo, the Cochrane library and databases, BDSP, CRD and NGC were searched from the start of their databases to June 2013. Articles were selected independently by two authors on the basis of their conceptual content, without other eligibility criteria or formal quality appraisal. Qualitative data were extracted independently by two teams of authors. Data were analyzed using a constant comparative qualitative method.

Results: The final selection included 89 articles. 112 codes were grouped in 4 categories: terms and definitions (semantics), "who" (physician, patient or system), "how and why" (mechanisms and reasons), and "appropriateness". Regarding each of these categories, a number of contradictory assertions were found, most of them relying on little or no empirical data. Overall, the limits of what should be considered as inertia were not clear. A number of authors insisted that what was considered deleterious inertia might in fact be appropriate care, depending on the situation.

Conclusions: Our data analysis revealed a major lack of conceptualization of therapeutic inertia in hypertension and important discrepancies regarding its possible causes, mechanisms and outcomes. The concept should be split in two parts: appropriate inaction and inappropriate inertia. The development of consensual and operational definitions relying on empirical data and the exploration of the intimate mechanisms that underlie these behaviors are now needed.
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http://dx.doi.org/10.1186/1471-2296-15-130DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4094689PMC
July 2014

Profile of French general practitioners providing opportunistic primary preventive care--an observational cross-sectional multicentre study.

Fam Pract 2014 Aug 12;31(4):445-52. Epub 2014 Jun 12.

Institut national de la santé et de la recherche médicale (INSERM), Infection, Antimicrobials, Modelling, Evolution (IAME), Unité mixte de recherche (UMR) 1137, F-75018 Paris, University Paris Diderot, IAME, UMR 1137, Sorbonne Paris Cité, F-75018 Paris, AP-HP, Hôpital Bichat, INSERM, Centre d'Investigation Clinique (CIC) 007, F-75018 Paris, France.

Background: Preventive services provided opportunistically by GPs are insufficient. Reasons are most often gathered through GPs' self-reports, rather than through independent observation.

Objective: To assess with passive observers, the degree to which French GPs opportunistically perform primary preventive care during routine consultation.

Methods: Observational cross-sectional multicentre ancillary study of the French ECOGEN study. The study period extended from 28 November 2011 to 30 April 2012. The inclusion criteria were patients seen by GPs at surgery and home consultations in non-randomized pre-determined half-day blocks per week. The non-inclusion criteria were patient's refusal and consultations initially focused on primary prevention in response to patient's request (ancillary study's specific criterion). Using passive observers, data were collected based on the second version of International Classification of Primary Care. Preventive consultations were defined if at least one problem/diagnosis was considered by consensus as definitely related to primary prevention. For each one of the 128 participating GPs, aggregation of data was performed from all his/her consultations. Determinants of the proportion of preventive consultations per GP were assessed by multivariate linear regression.

Results: Considering 19003 consultations, the median proportion of preventive consultations per GP was 14.9% (range: 0-78.3%). It decreased with increased proportion of patients aged 18 or less (P = 0.006), with increased proportion of home visits (P = 0.008) and with increased proportion of consultations lasting under 10 minutes (P = 0.02). None of the GPs' personal characteristics were significantly associated.

Conclusion: Primary preventive care activity was related to the characteristics of GPs' patients and practice organizational markers and not to GPs' personal characteristics.
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http://dx.doi.org/10.1093/fampra/cmu032DOI Listing
August 2014

Delivering the faecal occult blood test: More instructions than shared decisions. A qualitative study among French GPs.

Eur J Gen Pract 2013 Sep;19(3):150-7

Université Paris Diderot, Sorbonne Paris Cité, Département de Médecine Générale , Paris , France.

Background: Colorectal cancer (CRC) is the third most common cancer worldwide. In France, mass screening has been established with FOBT since 2008. The participation rate remains too low. Previous studies were conducted to explore doctors' and patients' perspectives.

Objective: This study was conducted to explore GPs' performance during consultations in which patients ask for FOBT, focusing on two different aspects: the core content of the consultation and the communication style used between GPs and patients.

Methods: Nine purposively sampled GPs were asked to audiotape specific consultations. Content analysis was performed using Nvivo 9 software. Communication between doctors and patients was explored using RIAS coding.

Results: GPs audio taped specific parts of 35 different consultations when they discussed and delivered the FOBT. The core content included primarily biomedical statements with a large portion dedicated to technical aspects. The communication style was not patient-centred.

Conclusion: While the participation rate of mass screening in France is still low, the analysis of recorded consultations by French GPs confirms that the way of delivering FOBT can be improved.
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http://dx.doi.org/10.3109/13814788.2013.780162DOI Listing
September 2013

From qualitative data to GP training on CRC screening.

J Cancer Educ 2013 Sep;28(3):439-43

Département de Médecine Générale, Sorbonne Paris Cité, Université Paris Diderot, Paris, France.

Colorectal cancer (CRC) is the third most common cancer worldwide. In France, although mass screening has been performed using the guaiac fecal occult blood test since 2008, the participation rate remains too low. Previous studies have explored the perspectives of doctors and patients as well as the performance of general practitioners (GPs) by recording and analyzing consultations in which patients came and asked for fecal occult blood test. Results indicated that improvement was needed in patient-centered communication. This research aims to develop educational material and training programs for GPs in order to enhance their communication with patients on CRC screening, based on data from two qualitative studies. Triangulation of all qualitative data was performed and discussed with communication experts in order to develop educational material and training programs based on the patient-centered clinical method. Two different scenarios were developed to improve communication with patients: one for a compliant patient and another for a noncompliant patient. Two videos were made featuring a doctor and a simulated patient. A two-sequence training program was built, including role-playing and presentation of the video followed by a discussion. The qualitative data helped us to produce a useful, relevant training program for GPs on CRC screening.
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http://dx.doi.org/10.1007/s13187-013-0484-yDOI Listing
September 2013

Evidence of prescription of antidepressants for non-psychiatric conditions in primary care: an analysis of guidelines and systematic reviews.

BMC Fam Pract 2013 May 4;14:55. Epub 2013 May 4.

Department of General Practice, University of Rouen, Rouen, France.

Background: Antidepressants (ADs) are commonly prescribed in primary care and are mostly indicated for depression. According to the literature, they are now more frequently prescribed for health conditions other than psychiatric ones. Due to their many indications in a wide range of medical fields, assessing the appropriateness of AD prescription seems to be a challenge for GPs. The aim of this study was to review evidence from guidelines for antidepressant prescription for non-psychiatric conditions in Primary Care (PC) settings.

Methods: Data were retrieved from French, English and US guideline databases. Guidelines or reviews were eligible if keywords regarding 44 non-psychiatric conditions related to GPs' prescription of ADs were encountered. After excluding psychiatric and non-primary care conditions, the guidelines were checked for keywords related to AD use. The latest updated version of the guidelines was kept. Recent data was searched in the Cochrane Database of Systematic Reviews and in PubMed for updated reviews and randomized control trials (RCTs).

Results: Seventy-eight documents were retrieved and were used to assess the level of evidence of a potential benefit to prescribing an AD. For 15 conditions, there was a consensus that prescribing an AD was beneficial. For 5 others, ADs were seen as potentially beneficial. No proof of benefit was found for 15 conditions and proof of no benefit was found for the last 9. There were higher levels of evidence for pain conditions, (neuropathic pain, diabetic painful neuropathy, central neuropathic pain, migraine, tension-type headaches, and fibromyalgia) incontinence and irritable bowel syndrome. There were difficulties in summarizing the data, due to a lack of information on the level of evidence, and due to variations in efficacy between and among the various classes of ADs.

Conclusions: Prescription of ADs was found to be beneficial for many non-psychiatric health conditions regularly encountered in PC settings. On the whole, the guidelines were heterogeneous, seemingly due to a lack of trials assessing the role of ADs in treatment strategies.
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http://dx.doi.org/10.1186/1471-2296-14-55DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3648410PMC
May 2013

Impaired role of epoxyeicosatrienoic acids in the regulation of basal conduit artery diameter during essential hypertension.

Hypertension 2012 Dec 22;60(6):1415-21. Epub 2012 Oct 22.

Departments of Pharmacology, Rouen University Hospital, Rouen, France.

In young healthy subjects, epoxyeicosatrienoic acids synthesized by endothelial cytochrome P450 epoxygenases maintain basal conduit artery diameter during altered NO availability. Whether this compensatory mechanism is effective during essential hypertension is unknown. Radial artery diameter, blood flow, and mean wall shear stress were determined in 14 nontreated essential hypertensive patients and 14 normotensive control subjects during 8 minutes of brachial infusion for inhibitors of cytochrome P450 epoxygenases (fluconazole, 0.4 µmol/min) and NO synthase (N(G)-monomethyl-L-arginine, 8 µmol/min) alone and in combination. In controls, the radial artery diameter was reduced by fluconazole (-0.034 ± 0.012 mm) and N(G)-monomethyl-L-arginine (-0.037 ± 0.010 mm) and to a larger extent by their combination (-0.137 ± 0.011 mm), demonstrating a synergic effect. In contrast, the radial diameter in hypertensive patients was not affected by fluconazole (0.010 ± 0.014 mm) but was reduced by N(G)-monomethyl-L-arginine (-0.091 ± 0.008 mm) to a larger extent than in controls. In parallel, N(G)-monomethyl-L-arginine decreased local plasma nitrite to a lesser extent in hypertensive patients (-14 ± 5 nmol/L) than in controls (-50 ± 10 nmol/L). Moreover, the addition of fluconazole to N(G)-monomethyl-L-arginine did not further decrease radial diameter in patients (-0.086 ± 0.011 mm). Accordingly, fluconazole significantly decreased local epoxyeicosatrienoic acid plasma level in controls (-2.0 ± 0.6 ng/mL) but not in patients (-0.9 ± 0.4 ng/mL). Inhibitors effects on blood flow and endothelium-independent dilatation to sodium nitroprusside were similar between groups. These results show that, in contrast to normotensive subjects, epoxyeicosatrienoic acids did not contribute to the regulation of basal conduit artery diameter and did not compensate for altered NO availability to maintain this diameter in essential hypertensive patients.
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http://dx.doi.org/10.1161/HYPERTENSIONAHA.112.201087DOI Listing
December 2012

The IDEAL study : towards personalized drug treatment of hypertension.

Therapie 2012 May-Jun;67(3):195-204. Epub 2012 Aug 9.

Department of Clinical Pharmacology, Hospices Civils de Lyon, Lyon, France; UMR 5558, CNRS, Villeurbanne, France; Claude Bernard Lyon 1 University, Lyon, France.

Objective: To identify markers (phenotypic, genetic, or environmental) of blood pressure (BP) response profiles to angiotensin converting enzyme inhibitors (ACEIs) and diuretics.

Methods: IDEAL was a crossover (two active and two wash out phases), double-blind, placebo-controlled trial. Eligible patients were untreated hypertensive, aged 25 to 70. After two visits, patients were randomized to one of four sequences. The main outcome was BP differences between the active treatment and placebo.

Results: One hundred and twenty-four patients were randomised: mean age 53, men 65%, family history of hypertension 60%. Average BP fall at each visit before randomisation was about 2% of the initial level reflecting both a regression to the mean and a placebo effect.

Conclusion: The results are expected to improve knowledge in drug's mechanisms of action and pathophysiology of hypertension, and to help in personalizing treatment. The estimation of BP responses to each drug in standardized conditions provided a benefit to each participant.
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http://dx.doi.org/10.2515/therapie/2012031DOI Listing
January 2013

Epoxyeicosatrienoic acids contribute with altered nitric oxide and endothelin-1 pathways to conduit artery endothelial dysfunction in essential hypertension.

Circulation 2012 Mar;125(10):1266-75

Department of Pharmacology, Rouen University Hospital, France.

Background: We sought to clarify, using functional and biological approaches, the role of epoxyeicosatrienoic acids, nitric oxide (NO)/reactive oxygen species balance, and endothelin-1 in conduit artery endothelial dysfunction during essential hypertension.

Methods And Results: Radial artery diameter and mean wall shear stress were determined in 28 untreated patients with essential hypertension and 30 normotensive control subjects during endothelium-dependent flow-mediated dilatation induced by hand skin heating. The role of epoxyeicosatrienoic acids and NO was assessed with the brachial infusion of inhibitors of cytochrome P450 epoxygenases (fluconazole) and NO synthase (N(G)-monomethyl-l-arginine [L-NMMA]). Compared with controls, hypertensive patients exhibited a decreased flow-mediated dilatation in response to postischemic hyperemia as well as to heating, as shown by the lesser slope of their diameter-shear stress relationship. In controls, heating-induced flow-mediated dilatation was reduced by fluconazole, L-NMMA, and, to a larger extent, by L-NMMA+fluconazole. In patients, flow-mediated dilatation was not affected by fluconazole and was reduced by L-NMMA and L-NMMA+fluconazole to a lesser extent than in controls. Furthermore, local plasma epoxyeicosatrienoic acids increased during heating in controls (an effect diminished by fluconazole) but not in patients. Plasma nitrite, an indicator of NO availability, increased during heating in controls (an effect abolished by L-NMMA) and, to a lesser extent, in patients, whereas, inversely, reactive oxygen species increased more in patients (an effect diminished by L-NMMA). Plasma endothelin-1 decreased during heating in controls but not in patients.

Conclusions: These results show that an impaired role of epoxyeicosatrienoic acids contributes, together with an alteration in NO/reactive oxygen species balance and endothelin-1 pathway, to conduit artery endothelial dysfunction in essential hypertension.

Clinical Trial Registration: https://www.eudract.ema.europa.eu. Unique identifier: RCB2007-A001-10-53.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.111.070680DOI Listing
March 2012

Understanding the prescription of antidepressants: a Qualitative study among French GPs.

BMC Fam Pract 2011 Sep 24;12:99. Epub 2011 Sep 24.

Department of General Practice, Rouen University and CIC Inserm 0204, Rouen University, Rouen, France.

Background: One-tenth of France's population is prescribed at least one antidepressant, primarily by General Practitioners. The reasons for this high prescription rate remain unclear. One-third of these prescriptions may not comply with clinical practice guidelines, and 20% are potentially unrelated to any psychiatric condition. Our aim was to explore how GPs declare they use antidepressants in daily practice and understand their reasons for prescribing them.

Method: Six focus groups including a total of 56 rural and urban GPs, with four interviews were performed. The topic guide focused on reasons for prescribing antidepressants in various primary care situations. Phenomenological analysis was performed by four researchers.

Results: Antidepressants were seen as useful and not harmful. Personal assessment based on experience and feeling determined the GPs' decisions rather than the use of scales. Twenty-four "non-psychiatric" conditions possibly leading to prescription of antidepressants in primary care were found.

Conclusions: The GPs reported prescribing antidepressants for a wide range of conditions other than depression. The GPs' decision making process is difficult and complex. They seemed to prefer to focus on their difficulties in diagnosing depression rather than on useless overtreatment. Instead of using the guidelines criteria to detect potential cases of useful prescription, physicians tend to use their own tools based on gut feelings, knowledge of the patient and contextual issues.
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http://dx.doi.org/10.1186/1471-2296-12-99DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3188468PMC
September 2011

Obstacles to colorectal screening in general practice: a qualitative study of GPs and patients.

Fam Pract 2011 Dec 6;28(6):670-6. Epub 2011 May 6.

Département de médecine générale, Denis Diderot University Paris 7, 16 rue Henri, Huchard 75018, Paris, France.

Background: The faecal occult blood test (FOBT) has proven efficiency at screening populations for an average risk of colorectal cancer. Mortality related to this cancer decreases by 15-18% among adults, 50-74 years old, tested every 2 years. A participation rate of at least 50% is desirable. This rate has not yet been reached in most French regions.

Objective: To explore the obstacles to mass colorectal screening in France.

Method: In 2009, five focus groups were conducted in different areas to explore physicians' obstacles to FOBT screening. The patients' obstacles were assessed in semi-structured interviews. A purposive sampling had been carried out for both GPs and patients. The focus groups were coded using Nvivo 8(®) software by three researchers; the interviews manually coded by two researchers.

Results: GPs reported insufficient training and some doubted the relevance of screening. They expressed concern of having insufficient time for the test during a consultation, as well as practical and administrative obstacles. Some GPs experienced difficulty persuading patients who had no signs of colorectal disease. Obstacles for patients were mainly difficulties in doing screening themselves and a perception of health care that didn't match with screening. Information and organization were also important points to improve. The screening process was considered complex both by GPs and by patients.

Conclusions: Numerous obstacles to colorectal screening, from both the physicians' and the patients' perspectives, were found. The major goal to improve mass screening may be to increase awareness and understanding of both physicians and patients regarding this process.
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http://dx.doi.org/10.1093/fampra/cmr020DOI Listing
December 2011