[Antibiotic therapy of upper respiratory tract infections in ambulatory care. Report of the National Observatory on Drug Prescription and Consumption].
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Ambulatory Care↗
Biomedical subjects
G Bouvenot
Publications and source records attributed to G Bouvenot.
Effects of folate supplementation in hyperhomocysteinemic pigs.
OBJECTIVES: The aim of this study was to evaluate the therapeutic effects of folic acid in the pig model of hyperhomocysteinemia. BACKGROUND: We have previously shown that pigs fed a methionine-rich diet develop hyperhomocysteinemia, arterial lesions and thrombotic events. Elevated homocysteine level is an independent risk factor for atherosclerosis that can be markedly lowered with daily folic acid administration. However, it is not known whether this treatment can prevent arterial lesions. METHODS: Three groups of pigs were studied: 8 control subjects received a standard diet; 8 received a methionine-rich diet for four months; 8 received a methionine-rich diet for 1 month and then the methionine-rich diet + 5 mg/day folic acid for 3 months. At month 4 after hemodynamic investigation, all the pigs were sacrificed. RESULTS: Control animals developed few usual vascular streaks. All the pigs fed a methionine-rich diet without folic acid treatment developed hyperhomocysteinemia (10.3+/-1.3 micromol/liter at basal state, 18.2+/-2.5 micromol/liter at one month and 14.6+/-3.8 micromol/liter at four months), hemodynamic abnormalities and diffuse arterial lesions with smooth muscle cell hyperplasia, endothelial alterations and elastic lamina dislocation. In this group, one pig died of venous thromboembolism and one of myocardial infarction. The pigs fed a methionine-rich diet + folic acid displayed similar arterial lesions and two had thrombotic events (one myocardial infarction and one pulmonary embolism), despite normalization of homocysteine levels (10.9+/-1.3 micromol/liter at basal state, 19.5+/-2.5 micromol/liter at one month and 11.4+/-3.8 micromol/liter at four months). CONCLUSIONS: In the pig model of hyperhomocysteinemia, 5 mg/day folic acid did not prevent arterial lesions or thrombotic events.
Animals↗
[French National Institute for observation of prescriptions and consumption of medicines. Prescription and consumption of antibiotics in ambulatory care].
The National Research Institute for Prescriptions and Consumption of medicines which was founded under the authority of the Minister of Health, is charged with the following missions: improved evaluation of the therapeutic needs of the population; more precise knowledge of therapeutic management; the identification of possible deviations in relation to systems of reference; recommendations in favor of correct use of medicines; and the optimization of patient management. Its first report concerned the antibiotic therapy of respiratory infections. In France, the average annual increase rate of the frequency of antibiotics consumption was in the region of 3.7%, between the periods 1980-1981 and 1991-1992. It essentially concerned cephalosporins and quinolones. Between 1991 and 1996 antibiotics sales increased on average by 2.1%, in units, per year. The increase of this consumption, which was not justified by any epidemiological evolution, is partly explained by the high frequency of antibiotic prescriptions during respiratory or ENT affections presumed to be of viral etiology: in 40% of rhinopharyngitis, 80% of acute bronchitis and more than 90% of anginas, whatever the age. Moreover the antibiotic treatments were not prescribed optimally: too long duration, insufficient dosages. Such phenomena are disturbing with regard to their consequences on the evolution of bacterial resistances. A comparison between French practices and those of Germany and the United Kingdom suggests that recourse to treatment is more frequent in France for the infectious diseases mentioned above, with more intensive utilization of antibiotics, in particular broad-spectrum penicillins. Recommendations have been made in favor of a rationalisation of practices.
Ambulatory Care↗
[Prescriptions and consumption of venotonic drugs in France (à propos of the report of the French National Institute for prescriptions and consumption of drugs)].
In 1997, consumption of veinotonic drugs in France represented 3.8% of the sales of refundable patient medicines, that is to say nearly 3 Billion francs with a 2.8% mean annual increase in units sold from 1983 to 1997, whereas prices decreased and new presentations with stronger dosages and larger packagings appeared on the market. No French epidemiologic specificity could be evidenced as regards the prevalence of chronic venous insufficiency and its complications. In France, and in comparison with elastic support, veinotonic products are preponderant in the treatment of chronic venous insufficiency despite restrictive labelling of authorization (treatment of symptoms) and recommendations of good practice which consider them as a complementary treatment. They are the subject of 18 million prescriptions per year, by 69,000 doctors, mainly general practitioners. They are utilized over long periods, within a context of prescription rather than automedication. The number of patent medicines available (109), the status of refundable medicine, strong demand of patients and therapeutic habits have made France the world's foremost market for veinotonic products, with 70% of international sales. French particularism is indeed due to these factors and not to the prevalence of the condition to be treated.
Academies and Institutes↗
[Homocysteine and coronary events in coronary disease patients].
The objective of this study was to determine the prognostic value of serum homocysteine levels in patients with coronary heart disease. Homocysteine was assayed in 76 coronary patients with a mean age of 59.2 years hospitalized for myocardial ischaemia or myocardial infarction. Percutaneous transluminal angioplasty was performed in 47 (70%) of these patients during this hospitalization. The mean follow-up for these patients was 22 months (range: 11 to 67 months). In these patients, serum homocysteine levels were not correlated with the usual risk factors of coronary heart disease (age, sex, treated hypercholesterolaemia, smoking, diabetes) except for hypertension. It was strongly correlated with serum creatinine (R = 0.61; p = 0.0001). Eleven patients presented a major event during follow-up (8 deaths, 1 nonfatal myocardial infarction, 1 cardiac transplantation) and 16 underwent a revascularization procedure. The blood homocysteine level does not have any prognostic value for any coronary events. However, it is higher in patients who develop a major event than in those which do not (15.8 +/- 4 mumol/l versus 11.5 +/- 6.6 mumol/l, p = 0.05). Using multivariate analysis, taking into account age, serum creatinine and serum homocysteine, only serum homocysteine was predictive of major event-free survival (p = 0.02).
Adult↗
[Therapeutic evolution: towards a cloning of prescriptions].
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Drug Prescriptions↗
[Fragility of scientifically acquired data. The example of fluoride salts in osteoporosis].
Although there is a pathophysiological rationale for the use of sodium fluoride for the treatment of postmenopausal osteoporosis and a long history of clinical trials, there is no evidence today of its clinical efficacy. The use of sodium fluoride was a long-standing practice for many years which became official policy when strong scientific arguments suggested its efficacy. The lack of methodologically solid evidence however raised some doubts, echoed by the regulatory authorities, and led to a re-evaluation. The unacceptable risk/benefit ratio demonstrated by the new results was a major scientific event giving the scientific community a concrete example of why evidence provided by clinical research must be regularly revisited.
Clinical Trials as Topic↗
[Assessment of the placebo effect of symptomatic slow-acting anti-arthritics].
OBJECTIVES: Assess the importance of the mid-term placebo effect of symptomatic slow acting drugs given for osteoarthritis. METHODS: We analyzed six controlled trials available in the literature. Trial duration ranged from 2 to 6 months. The trials had been conducted to assess the symptomatic effect of diacerhein, avocado/soya unsaponifiable chondrontin sulfate and oxaceprolin given for osteoarthritis of the hip or knee. The main clinical outcomes assessed were functional impairment using the Lequesnes index and a visual analog scale. RESULTS: Globally, the trials showed decreased function impairment with a 2 to 3 points decrease in the Lequesnes index (15 to 20%) and a 10 to 16 mm fall in the visual analog scale (-20 to -30%) in the placebo groups. CONCLUSION: Our findings confirms the importance of the mid-term placebo effect in the clinical course of osteoarthritis in patients given slow-acting drugs. This placebo effect, observed under these circumstances, is an expression of what clinicians will look for in future drugs and should be helpful for calculating the number of patients required in future trials.
Activities of Daily Living↗
Low dosage and long treatment duration of beta-lactam: risk factors for carriage of penicillin-resistant Streptococcus pneumoniae.
CONTEXT: The spread of drug-resistant Streptococcus pneumoniae in the community is a public health problem in developed and developing nations, but whether antibiotic use is responsible for the increase in drug resistance is not known. OBJECTIVE: To analyze the relationship between penicillin-resistant S pneumoniae (PRSp) pharyngeal carriage and characteristics of beta-lactam use. DESIGN: Observational study of children attending 20 randomly sampled schools. SETTING: The Loiret, in the center of France. PARTICIPANTS: A total of 941 children, 3 to 6 years old. MAIN OUTCOME MEASURE(S): Pharyngeal carriage of S pneumoniae, antibiotic use, and medical events during the preceding 30 days. Pneumococcal penicillin G sodium minimal inhibitory concentrations and serotyping were performed. RESULTS: Medical illnesses and the use of antibiotics were not associated with PRSp carriage. However, oral beta-lactam use was associated with an increased risk of PRSp carriage (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.1-8.3; P=.03). Children treated by low daily doses of an oral beta-lactam (defined as lower than clinical recommendations) had an increased risk of PRSp carriage, as compared with children who did not (OR, 5.9; 95% CI, 2.1-16.7; P=.002). A treatment of long duration (>5 days) with a beta-lactam was associated with an increased risk of PRSp carriage (OR, 3.5; 95% CI, 1.3-9.8; P=.02). CONCLUSIONS: Our results suggest that a low daily dose and a long duration of treatment with an oral beta-lactam contribute to the selective pressure in promoting pharyngeal carriage of PRSp.
Anti-Bacterial Agents↗
Association of mild hyperhomocysteinemia with cardiac graft vascular disease.
In non-transplant patients mild hyperhomocysteinemia is an independent risk factor for vascular disease. The aim of this study was to determine whether hyperhomocysteinemia is associated with graft vascular disease. Fasting total plasma homocysteine was assessed in 18 patients with graft vasculopathy and 18 transplanted patients without graft vasculopathy matched for age, sex and the time since transplant. All were on cyclosporin. Graft vasculopathy was defined at coronary angiography as stenoses > or = 25%, or aneurysms. We found that hyperhomocysteinemia ( > or = 15 micromol/l) is common among transplanted heart recipients and significantly more frequent in the patients with graft vasculopathy (17/18 versus 11/18). Accordingly, the mean homocysteinemia was significantly higher in the group with graft vasculopathy (23.6+/-7.8 versus 16.9+/-7.1 micromol/l, P=0.01). The elevation of homocysteine plasma levels in the heart transplant recipients has probably multiple causes. The main cause seems to be renal failure. Additional causes could be azathioprine treatment or genetic polymorphisms. These results suggest that besides the immunological factors, homocysteine can play an additional role in the pathogenesis of graft vascular disease.
Adult↗
Inappropriateness and variability of antibiotic prescription among French office-based physicians.
OBJECTIVE: To describe oral antibiotic prescription in the community. DESIGN: Audit of anti-infective prescribing in office-based medical practice. SETTING: Center of France, in the Loiret, a 600,000 inhabitant administrative division. MAIN OUTCOME MEASURES: Clinical hypothesis and antimicrobial drugs used as well as daily doses and durations of treatment. RESULTS: Respiratory tract infections with a presumed viral etiology accounted for 36% of prescriptions. In children, a high percentage of antibiotic prescriptions were underdosed as compared to clinical recommendations, particularly in acute otitis media. The variability of the daily dose was high, with coefficients of variation over 40% in acute otitis media or acute tracheobronchitis. Whatever the clinical hypothesis, the duration of treatment was close to 8 days. In acute otitis media, the coefficient of variation was 14%, the lowest for all diagnoses. CONCLUSION: Our investigation identified two main areas for improving antimicrobial drug prescribing: (1) reduction of useless prescriptions in respiratory tract infections with a presumed viral etiology, and (2) increasing the prescribed daily dose of antimicrobials to the recommended levels.
Administration, Oral↗
Trends in antimicrobial drug use in the community--France, 1981-1992.
Trends in the use of antimicrobials in France between 1980-1981 and 1991-1992 were analyzed. Data were obtained from surveys of health and ambulatory care, which were based on national probability samples. In a 3-month period in 1980, 17% of the population of France was treated with an antibiotic, compared with 25% in 1991 (P < .001). The frequency of respiratory tract infections with a presumed viral etiology that were diagnosed and treated with antibiotics increased by 86% for adults and 115% for children in the 11-year period. The proper use of cephalosporins must be encouraged, and vigilance is required in view of the increased improper use of fluoroquinolones, mainly for respiratory tract infections with a presumed viral etiology.
Adult↗
Medico-economic analysis of diacerein with or without standard therapy in the treatment of osteoarthritis.
This 9-month pragmatic study compared 2 therapeutic regimens in the management of osteoarthritis of the hip and knee. Patients received either diacerein 100 mg/day plus standard osteoarthritic therapy for 6 months, followed by a 3-month monitoring period without diacerein, or standard therapy alone for the entire 9-month period. A total of 207 patients with osteoarthritis of the knee and hip were enrolled. Improvements in Lequense's functional index and quality-of-life scores (revised Arthritis Impact Measurement Scales Health Status Questionnaire and Nottingham Health Profile), and decreases in nonsteroidal anti-inflammatory drug and analgesic consumption were significantly greater with diacerein plus standard therapy than with standard therapy alone. The overall assessment of therapy by patients was good or excellent for 60% of those who received diacerein plus standard therapy, compared with 26% who received standard therapy alone. Medical and paramedical procedures carried out in addition to those stipulated in the protocol (medical consultations, physiotherapy, nursing, etc.), osteoarthritis-related, were fewer and less costly in the diacerein plus standard therapy group than in the standard therapy group. The average outpatient cost (in 1995 French francs) of osteoarthritis treatment in the standard therapy group was FF2272 compared with FF2360 in the diacerein plus standard therapy group. The cost-effectiveness ratios per point scored on Lequesne's index were FF1893 for the standard therapy group and FF1072 for the diacerein plus standard therapy group, leading to a saving of 43% with diacerein plus standard therapy. The marginal cost (additional cost corresponding to the clinical benefit obtained by adding diacerein to standard treatment) was FF88 per point scored on Lequesne's index.
Aged↗
Short-term evaluation of periradicular corticosteroid injections in the treatment of lumbar radiculopathy associated with disc disease.
OBJECTIVES: The purpose of this study was to evaluate the feasibility and efficacy of periradicular corticosteroid injections performed under fluoroscopic guidance in the treatment of pain originating in the lumbosacral nerve roots. METHOD: Forty patients presenting with lumbosciatica or femoral neuralgia unresponsive to conventional conservative treatment were admitted to the study. Patients with nerve root pain due to infectious, tumorous or inflammatory diseases were excluded, as were patients who needed immediate surgery. Pain was evaluated using a visual analog scale on the day of the injection and ten (D10) and ninety (D90) days later. RESULTS: All patients were evaluated as scheduled on D10 and D90. The mean visual analog scale score decreased from 53.3 mm at baseline to 30.1 mm on D10 and to 21.8 mm on D90. Ninety per cent of patients had a visual analog pain score decrease on D10 and 85% on D90. Reported side effects were two cases of mild spontaneously regressive acne and one case of radicular pain exacerbation of less than one day's duration. CONCLUSION: Periradicular injections of corticosteroids done under fluoroscopic guidance as an outpatient procedure was effective and safe in our study and may deserve to be used as part of the conservative management of lumbar nerve root pain before resorting to more invasive methods.
Acne Vulgaris↗
[ECG anomalies and axis deviations in heart transplant recipients: MRI studies].
The electrocardiogram is often abnormal after orthotopic cardiac transplantation. This study was conducted in order to evaluate the frequency of these abnormalities in a population of 29 patients transplanted according to the conventional mode or the total mode. We also investigated the correlation between these abnormalities and the presence of left ventricular hypertrophy or deviation of the left ventricular long axis. The left ventricular mass was measured by TM echocardiography. The position of the left ventricular long axis was determined by MR on a ultrarapid sequence. The ECG was normal in 5 patients. The abnormalities revealed in the other 24 patients were: an rSr' or rsr' appearance in V1 with a QRS complex less than 0.12 sec in 11 patients, complete right block in 1 patients, repolarization abnormalities (apart from those associated with branch blocks) in 8 patients, left axis deviation of the QRS in 5 patients, a biphasic P wave in V1 with a Morris index greater than 4 mV.sec in 5 patients, and double atrial activity in 3 patients. These abnormalities were observed regardless of the type of transplantation, with the exception of double atrial activity which was only observed in the group of patients undergoing conventional transplantation. On average, the long axis of the left ventricle was more horizontal and deviated to the left compared to age- and sex-matched controls. All patients with left axis deviation of the QRS had left ventricular hypertrophy versus 13 of the 24 patients without QRS axis deviation and abnormalities of position of the anatomical left ventricular long axis. Our results therefore suggest that the frequent presence of right branch block in heart transplant recipients is due to factors other than the position of the heart in the thorax, for example right ventricular hypertrophy.
Adult↗
[Initial and continuous education. Entreaty for better education of physicians in therapeutics].
Concrete education on therapeutical decision must constitute a major institutional objective during the higher academic period of the medical students. The current therapeutics constitutes a branch of instruction based on the up-to-date of the "medical science" and on the evidence evaluation. However, such evidence-based medicine still biased, evolutionary and thus provisory valid; whereas at the same time it must be appropriate and suitable for the patients benefit. Data issued from medical science are on the basis of the interactive and pragmatic apprenticeship of the therapeutical decision and prescription with a personalized approach of patient and at each step of its disease. The continuous postgraduate education programs following the initial Academic instruction contributes to up date the knowledges and moreover the professional experience and practice. This evolution is performed with respect of both the individual ethic-related to the patient and the collective ethics in terms of public health.
Curriculum↗
A pragmatic cost-effectiveness study of routine epidural corticosteroid injections for lumbosciatic syndrome requiring inhospital management.
A multicenter randomized study was conducted using a pragmatic approach to evaluate the benefits and costs of routine epidural corticosteroid injections for the treatment of lumbosciatic syndrome requiring inhospital management. The primary evaluation criterion was whether other treatments were required after one to three injections. The 108 patients were randomly allocated to treatment with or without routine epidural corticosteroids. Rest and a nonsteroidal antiinflammatory drug were used in all patients. The two groups were comparable at baseline except for a larger proportion of males in the routine epidural corticosteroid group. Patients in the routine epidural corticosteroid group were more likely to require other treatments, but the difference was only of borderline significance after adjustment for gender. Results showed that physicians based their treatment decisions primarily on whether an improvement in the clinical status of the patient was apparent at the second visit. None of the other factors studied influenced treatment decisions. Clinical efficacy criteria were identical in the two groups. Hospital costs contributed most of the total cost, and the mean cost was higher in the routine epidural corticosteroid group. These data suggest that adding an epidural injection as a first-line treatment to rest and a nonsteroidal antiinflammatory drug for the treatment of lumbosciatic syndrome requiring inhospital management results in additional costs and no gain in efficacy.
Adolescent↗
Recommendations for the registration of agents used in the prevention and treatment of glucocorticoid-induced osteoporosis.
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Animals↗