[Letter DGS/DH dated November 18, 1999 on the treatment of paranesthetic malignant hyperthermia (MH)].
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Anesthesia, General↗
Biomedical subjects
L Abenhaim
Publications and source records attributed to L Abenhaim.
[The mission of the Director General of the Ministry of Health].
In France, the health and solidarity department of Employment and solidarity Ministry have just been re-organised. The Directory General of the department of Health is experiencing a complete revision of its functions and organisation. This article presents the public health context which has been taken into account for this new organisation and explains its main principles and strategic orientations. The new organisation chart is clarified. It is made up by two departments and seven under-directions. Up to now, control and administrative supervision were predominant among Health General Direction functions. They are now oriented to administrate missions prioritizing the function of health doctrines' elaboration, of programmation, animation and coordination. As the guarantor of sanitary security, the Health General Direction has also to impulse a new partnership which does not only include health professional, social and health organisation and the economic actors: citizen in general and service users in particular have to be included to promote health democracy.
Administrative Personnel↗
Smoking. A risk factor for development of low back pain in adolescents.
STUDY DESIGN: A prospective, repeated-measures cohort design with high school students from Montreal, Canada. OBJECTIVES: To determine whether smoking was a risk factor for the development of low back pain or other musculoskeletal pain in a cohort of adolescents. SUMMARY OF BACKGROUND DATA: Smoking has been associated with low back pain in adults. Many adolescents smoke, and the prevalence of low back pain in this age group is 30%. A history of low back pain is predictive of future problems. METHODS: A total of 502 students from grades 7 to 9 were assessed from 3 schools. Data were collected at 3 times: at the beginning of the study, at 6 months, and at the end of a 12-month period. Students responded to a questionnaire addressing musculoskeletal health and life-style factors, which included smoking. Measurements of height, weight, trunk and leg flexibility, and trunk strength were obtained. Low back pain occurring at a frequency of at least once a week in the past 6 months was defined as the outcome. Multivariate methods were used to model the repeated-measures dichotomous outcome as a function of smoking and other covariates. RESULTS: Smokers experienced low back pain more than nonsmokers (odds ratio, 2.4; 95% confidence interval, 1.3-6.0). There was also a dose-response relationship between amount smoked and development of low back pain. Smokers tended to experience more upper limb or lower limb pain than nonsmokers, although this result was not significant. CONCLUSIONS: Smoking was found to increase the risk for low back pain in this cohort of adolescents.
Adolescent↗
The role of pharmacoepidemiology in pharmacovigilance: a conference at the 6th ESOP Meeting, Budapest, 28 September 1998.
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Journal Article↗
Colorectal cancer prevention by non-steroidal anti-inflammatory drugs: effects of dosage and timing.
Epidemiological studies show that non-steroidal anti-inflammatory drugs (NSAIDs) reduce colorectal cancer incidence. We measured the rate ratio for colorectal adenocarcinoma according to dosage and the timing of exposure by means of a case-control study, nested in a non-concurrent cohort linkage study, using the population of beneficiaries of the Saskatchewan Prescription Drug Plan from 1981 to 1995 with no history of cancer since 1970 as the source population. Four controls per case, matched on age and gender and alive when the case was diagnosed, were randomly selected. Dispensing rates, calculated over successive time periods, characterized NSAID exposure. We accrued 3844 cases of colon cancer and 1971 cases of rectal cancer. For colon cancer a significant trend towards a decreasing rate ratio was associated with increasing exposure during the 6 months preceding diagnosis (P-trend = 0.002). For both cancers, significant trends were associated with exposure 11-15 years before diagnosis (colon: P-trend = 0.01; rectum: P-trend = 0.0001). At the highest exposure levels the rate ratio for colon cancer was 0.57 (95% confidence interval (CI) 0.36-0.89); for rectal cancer it was 0.26 (95% CI 0.11-0.61). No protection was associated with exposure during other periods. The timing of NSAID use must be considered in planning intervention trials to prevent colorectal cancer. There may be a 10-year delay before any preventive effect will appear.
Aged↗
Pulmonary hypertension related to drugs and toxins.
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Anti-Inflammatory Agents, Non-Steroidal↗
Adolescent growth is not associated with changes in flexibility.
OBJECTIVE: To determine whether adolescent growth is associated with a decrease in flexibility. DESIGN: Longitudinal cohort study of urban high school students. MAIN OUTCOME MEASURES: Flexibility of hamstring muscles (popliteal angle), quadriceps muscles (quadriceps angle), lumbar extensor muscles (Schober test), and combined lower extremity-trunk muscles (Sit and Reach test). RESULTS: There was no relation between growth and changes in flexibility for the lumbar flexor muscles, hamstring muscles, or muscles involved in the Sit and Reach test. Although there was a slight decrease in flexibility of the quadriceps muscle with increases in growth, the very low r2adj value (0.01-0.06) strongly suggests that growth plays only a small role in determining the flexibility of individuals. CONCLUSION: These results strongly suggest that growth is not a cause of decreased flexibility during the peripubescent period.
Adolescent↗
Clinical prediction of deep vein thrombosis in patients with leg symptoms.
Symptoms and clinical signs individually are inaccurate for the diagnosis of DVT. However, when assessing patients with leg symptoms, clinicians have access to additional information, such as whether or not DVT risk factors are present that could improve the accuracy of clinical judgment. The purpose of this study was to identify which clinical variables best predict DVT, and to use these variables to create a clinical prediction index for DVT. We studied 271 university hospital patients with a first episode of symptomatic, clinically suspected DVT. The prevalence of DVT was 27%, of which 71% were proximal. At baseline, information was collected on demographic features, comorbidity, and symptoms and signs. A Bayesian model selection strategy was used to estimate the logistic regression model that best predicted DVT. Male sex [OR = 2.8 (1.5, 5.1)], orthopedic surgery [OR = 5.4 (2.2, 13.6)], warmth [OR = 2.1 (1.2, 3.9)] and superficial venous dilation on exam [OR = 2.9 (1.4, 5.7)] were independent predictors of DVT. Using the model, a clinical prediction index that categorized patients into different levels of DVT risk was created, and was useful in a theoretical strategy aimed to limit the need for contrast venography in patients with suspected DVT, such that 96% of study patients could have avoided contrast venography. This index should be evaluated prospectively in other patient populations.
Adult↗
Chronic venous disorders of the leg: epidemiology, outcomes, diagnosis and management. Summary of an evidence-based report of the VEINES task force. Venous Insufficiency Epidemiologic and Economic Studies.
BACKGROUND: To critically review the classification, epidemiology, outcomes, diagnosis and treatment of chronic venous disorders of the leg (CVDL), to issue evidence-based recommendations, and to identify areas requiring further research. METHODS: Articles identified by an extensive literature search were scored by members of an international task force. Only those articles with a moderate or strong rating for internal validity were retained. RESULTS: A scoring system weighing CVDL severity according to the probability of ulcer occurrence is proposed. Epidemiological data on the frequency of CVDL and its risk factors are reviewed. The following items are evaluated: costs associated with treatment; clinical outcomes related to CVDL and its treatment; available generic and disease-specific measures of quality of life; diagnostic procedures used to detect venous reflux; and efficacy of available treatments. CONCLUSIONS: CVDL is an important public health problem, based on its prevalence, cost and impact on quality of life. High-priority areas for research on CVDL are identified.
Chronic Disease↗
Is work status of low back pain patients best described by an automated device or by a questionnaire?
STUDY DESIGN: A prospective cohort study of patients with subacute occupational back pain. OBJECTIVES: To study the relation between a marketed opto-electric device measuring trunk kinematics, a widely used specific functional capacity questionnaire, and work status in back pain patients, and to assess the responsiveness to change in work status of the opto-electric device and the questionnaire. SUMMARY OF BACKGROUND DATA: Several instruments have been developed to evaluate the functional capacities of patients with back pain, but the relation between these instruments and work status has rarely been studied. METHODS: The relation between the opto-electric device, the questionnaire, and work status in patients with back pain was evaluated. The study population was a prospective cohort of patients with subacute back pain who were absent from regular work for more than 4 weeks. All data were compiled blindly on the same day, at study entry (4 weeks after work accident), and at 12, 24, and 52 weeks after the work accident. The validity of the questionnaire and opto-electric device scores was assessed with partial correlation analyses, standardized response mean, logistic regression analyses, and receiver operating characteristics curves. RESULTS: The correlation between the questionnaire and opto-electric device scores was low. The questionnaire scores were significantly related to work status, but the opto-electric device scores were not. The questionnaire was responsive to change in work status, whereas the opto-electric device was not. CONCLUSIONS: The opto-electric device scores were not related to either functional capacity scores (questionnaire) or work status in patients with low back pain, and the opto-electric device was not responsive to change in work status. Conversely, the questionnaire was related to work status and was responsive to change in work status.
Activities of Daily Living↗
Use of cyclical etidronate and prevention of non-vertebral fractures.
This study examined the effects of cyclical etidronate, when used in routine clinical practice, on the prevention of fracture. Information was obtained from 550 general practices in the UK that provide their medical records to the General Practice Research Database. A total of 7977 patients taking cyclical etidronate treatment and 7977 age-, sex- and practice-matched control patients with a diagnosis of osteoporosis were analysed. People taking cyclical etidronate had a significantly reduced risk of non-vertebral fracture (by 20%) and of hip fracture (by 34%) relative to the osteoporosis control patients. The relative risk of non-vertebral fracture was 0.80 (95% confidence interval 0.70-0.92), that of hip fracture 0.66 (0.51-0.85) and that of wrist fracture 0.81 (0.58-1.14). When fracture incidence rates were compared between the two groups, the rate of non-vertebral, hip and wrist fracture decreased significantly (P < 0.05) with increasing etidronate exposure. The results of this study complement and extend clinical observations supporting the anti-fracture efficacy of cyclical etidronate therapy.
Aged↗
Reliability study of the Leg-O-Meter, an improved tape measure device, in patients with chronic venous insufficiency of the leg. VEINES Group.(Venous Insufficiency Epidemiologic and Economic Study).
The objective of this study was to evaluate the inter-rater reliability of the Leg-O-Meter, an instrument designed to measure the ankle or calf circumference. The Leg-O-Meter consists of a tape measure fixed to a stand attached to a small board on which the patient is in standing position. For this study the tape measure of the Leg-O-Meter was fixed at 10 cm from the board in order to standardize all measurements. Informed consent to participate in the study was obtained from 39 patients consulting the phlebology clinic of Hôpital St-Michel, Paris, France. Participants were asked to enter a closed room where four independent and blinded observers consecutively took measurements of both legs with the Leg-O-Meter. The order of the observers was randomized between patients. Under the assumption of a two-way random effects model an intraclass correlation coefficient (ICC) was used to determine the reliability or reproducibility of a measure with the Leg-O-Meter. The overall reliability coefficient calculated by the ICC for the right and left leg were estimated at 97.09% [95.52%;100%]95% and 97.08% [95.86%;100%]95%, respectively. The authors conclude that the Leg-O-Meter gives a standardized and reliable measure of the circumference of the ankle. Furthermore, it is not invasive or costly.
Analysis of Variance↗
A population-based, randomized clinical trial on back pain management.
STUDY DESIGN: Population-based randomized clinical trial. OBJECTIVES: To develop and test a model of management of subacute back pain, to prevent prolonged disability. SUMMARY OF BACKGROUND DATA: The present management of back pain seems inadequate, and development of innovative models has been urged. METHODS: A model for the treatment of subacute work-related back pain has been developed and evaluated in a population-based randomized clinical trial. Workers (n = 130) from eligible workplaces in the Sherbrooke area (N = 31), who had been absent from work for more than 4 weeks for back pain, were randomized, based on their workplace, in one of four treatment groups: usual care, clinical intervention, occupational intervention, and full intervention (a combination of the last two). The duration of absence from regular work and from any work was evaluated using survival analysis. Functional status and pain were compared at study entry and after 1 year of follow-up. RESULTS: The full intervention group returned to regular work 2.41 times faster than the usual care intervention group (95% confidence interval 1.19-4.89; P < 0.01). The specific effect of the occupational intervention accounted for the most important part of this result, with a rate ratio of return to regular work of 1.91 (95% confidence interval = 1.18-3.10; P < 0.01). Pain and disability scales demonstrated either a statistically significant reduction or a trend toward reduction in the three intervention groups, compared with the trend in the usual care intervention group. CONCLUSIONS: Close association of occupational intervention with clinical care is of primary importance in impeding progression toward chronicity of low back pain.
Adolescent↗
A study of the longitudinal utilization and switching-patterns of non-steroidal anti-inflammatory drugs using a pharmacy based approach.
The extent of the heterogeneity of drug utilization among NSAID users has not been extensively studied. We studied the longitudinal prescribing and switching patterns of NSAID users in a 1-year follow-up study in four German pharmacies. The study population consisted of 526 persons with an average age of 57 years. We observed that the legend duration of prescription increased with age; 14.3 days for patients aged 44 or younger to 25.1 days for persons 75 years or older, and was dependent on disease chronicity; 16.0 days for acutely ill persons compared to 23.9 days for chronic patients. The average legend duration also varied between different types of NSAIDs, from 18.0 days for ibuprofen to 29.1 days for tiaprofen. Switching from one type of NSAID to another proved to be related to the legend duration of prescription and patient characteristics such as compliance with NSAID therapy, duration of the disease and the effectiveness (poor tolerability or insufficient effect) of the NSAID therapy reported by the patients 4 weeks after recruitment. We conclude that NSAID users cannot be viewed as an homogeneous group of patients with respect to exposure time to the drug. This heterogeneity should be considered in the exposure definition, the 'time-window' design of observational studies dealing with risk comparisons in particular.
Journal Article↗
Upper gastrointestinal adverse events and cyclical etidronate.
PURPOSE: Recently, there have been several published case reports of esophagitis associated with the use of aminobisphosphonates. The objective of this study was to evaluate the upper gastrointestinal (GI) safety of cyclical etidronate, an alkylbisphosphonate, in routine clinical practice. PATIENTS AND METHODS: Information was obtained from 550 general practices in the United Kingdom that provide the medical records to the General Practice Research Database. A group of 7977 cyclical etidronate takers and 2 age-, gender-, and practice-matched control groups (1 with osteoporosis and 1 without) were analyzed. RESULTS: For cyclical etidronate takers, the average age was 71.6 years and total follow-up was 10,328 person-years. The risk of upper GI events (inflammation or ulcer of esophagus, stomach, or duodenum) was comparable between patients taking etidronate and the two control groups. The adjusted relative risk of upper GI events was 0.92 (95% confidence interval [CI] 0.78 to 1.09) for etidronate takers compared with osteoporosis controls and 1.12 (CI 0.91 to 1.37) compared to nonosteoporosis controls. For esophagitis and esophageal ulcers, the relative risks were 0.83 (CI 0.64 to 1.08) and 0.97 (CI 0.71 to 1.31) respectively. The incidence of upper GI events during nonsteroidal anti-inflammatory drug (NSAID), aspirin, or corticosteroid use was similar across the three groups. The upper GI risks of etidronate NSAID users were 0.71 (CI 0.45 to 1.11) and 2.06 (CI 0.98 to 4.35) compared with NSAID users in the two control groups. CONCLUSIONS: These results support the GI tolerability and safety profile of cyclical etidronate in routine clinical practice. Concomitant use of cyclical etidronate with NSAIDs, aspirin, or corticosteroids did not increase the incidence of upper GI events.
Aged↗
Rates of hypoglycemia in users of sulfonylureas.
OBJECTIVE: To identify the demographic and clinical characteristics of sulfonylurea users. To assess the risk of hypoglycemia in patients treated with sulfonylureas in clinical practice, and to characterize the risk in relation to the different drugs used. RESEARCH DESIGN AND METHODS: A cohort of 33,243 sulfonylurea users chosen from 719 clinical practices in the United Kingdom were identified through the VAMP-Research database. Information on demographic characteristics, medical diagnoses and use of medical services was obtained through the computerized records. For a stratified sample of 500 patients, general practioners completed a structured questionnaire on the duration, treatment, and complications of diabetes mellitus, obesity, alcohol use, and smoking history. Patients with a diagnosis of hypoglycemia, as recorded in the database within a time-window of a sulfonylurea prescription, were identified. Incidence rates per person-year of sulfonylurea therapy were estimated. RESULTS: Other than a longer duration of diabetes in users of chlorpropamide, no differences were observed among users of different sulfonylurea agents with respect to diabetic complications, adequacy of diabetic control, obesity, smoking, and excessive alcohol consumption. A diagnosis of hypoglycemia during sulfonylurea therapy was recorded in 605 people over 34,052 person-years of sulfonylurea therapy, which converted into an annual risk of 1.8%. The risk in glibenclamide users was higher than in users of other types of sulfonylureas uses. Duration of therapy, concomitant use of insulin, sulfonylurea-potentiating or antagonizing and concomitant use of beta-blockers were predictive of the risk of developing hypoglycemia. DISCUSSION: Drug use patterns showed comparability among users of different sulfonylurea agents. Our findings suggest that the rate of diagnosis of hypoglycemia made by physicians is higher for glibenclamide than for other sulfonylureas. An epidemiological study with objectively diagnosed hypoglycemia should be undertaken to confirm these results.
Adult↗
Determinants of initiation and suboptimal use of anti-ulcer medication: a study of the Quebec older population.
OBJECTIVES: To describe the use of anti-ulcer medication in the Quebec older population; to examine determinants of initiation, suboptimal use, and switches between products. DESIGN: Population-based retrospective cohort study. SETTING: Universal health program for older adults in Quebec. PARTICIPANTS: 5000 users and 5000 non-users of anti-ulcer medications were selected randomly. Use was defined as the presence in the 1991 prescription database of an anti-ulcer prescription. Among users, 1697 (34%) were new users and were considered as the exposure group. Subjects were followed for 365 days after inclusion. MEASUREMENTS: Measured were patient's age, gender, prescribed duration of anti-ulcer medication, concomitant medications, and gastrointestinal diagnostic procedures. RESULTS: A total of 17% of new users had unusually short courses; 18% were long-term users. There was no difference in duration for omeprazole compared with other anti-ulcer medications. First-time use of NSAIDs was the strongest predictor of initiation of anti-ulcer medication (odds ratio = 3.21; 95% CI, 2.66-3.88). Twenty-six percent of users switched brands. Only 9.5% of new users underwent a diagnostic procedure before initiation of therapy, and 49% of long-term users ever underwent such procedure. CONCLUSION: Despite a relatively homogeneous recommended duration of therapy, patterns of use of anti-ulcer medication among older people are highly variable, and treatment is often not accompanied by a diagnostic procedure.
Age Factors↗
The VEINES study (VEnous Insufficiency Epidemiologic and Economic Study): an international cohort study on chronic venous disorders of the leg. VEINES Group.
The aim of the VEINES study is to address some gaps in knowledge regarding the multidimensional repercussions of venous disorders and the measurement of outcomes. Its objectives are to describe and compare defined clinical presentations of venous-related leg disorders with regard to natural history, clinical outcome, functional capacity, quality of life, and economic impact. A secondary objective is to develop or identify and test standardized instruments for the evaluation of therapeutic effectiveness. This paper presents an overview of the design of the study and of the options chosen for the recruitment process and the outcome measures.
Chronic Disease↗