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Biomedical subjects

P Ravaud

Publications and source records attributed to P Ravaud.

At least 73 records · Page 4Linked to original sources
PubMed1999

A large subset of neutrophils expressing membrane proteinase 3 is a risk factor for vasculitis and rheumatoid arthritis.

It has been shown previously that proteinase 3 (PR3), a neutrophil intracellular protease that is the main antigen of antineutrophil cytoplasm (ANCA) autoantibodies, is present on the plasma membrane of a subset of freshly isolated neutrophils. This study shows that the size of this subset of membrane PR3-positive (mPR3+) neutrophils is a stable feature of a given individual, most likely genetically controlled. It ranges from 0 to 100% of neutrophils and allows us to define a new polymorphism in the healthy population, with three discrete phenotypes corresponding respectively to less than 20% mPR3 + neutrophils (mPR3low) or to a mean percentage of 47% (mPR3intermediate) and 71.5% (mPR3high) mPR3+ neutrophils. The frequency of the mPR3high phenotype was significantly increased in patients with ANCA-associated vasculitis (85% versus 55% in healthy subjects). The percentage of mPR3+ neutrophils was not affected by disease activity, relapses, or therapy, and did not reflect in vivo cell activation. In addition, mPR3+ phenotypes were normally distributed in cystic fibrosis patients, indicating that infection and/or inflammation per se do not lead to a high percentage of mPR3+ neutrophils. The frequency of the mPR3high phenotype was not related to anti-PR3 autoimmunization, since it was increased in vasculitic patients regardless of the ANCA specificity (anti-PR3, anti-myeloperoxidase, or unknown). Interestingly, the frequency of the mPR3high phenotype was also increased in patients with rheumatoid arthritis. It was normal in type I-diabetes, a T cell-dependent autoimmune disease. It is proposed here that a high proportion of membrane PR3-positive neutrophils could favor the occurrence or the progression of chronic inflammatory diseases.

Adult↗
PubMed1999

Efficacy of epidural steroids in low back pain and sciatica. A critical appraisal by a French Task Force of randomized trials. Critical Analysis Group of the French Society for Rheumatology.

OBJECTIVE: Several randomized trials have suggested recently that epidural steroid injections may not be a valid treatment in common low back pain and sciatica. To clarify this issue, we conducted a critical appraisal of relevant randomized trials published up to 1997. Attention was directed to methodological quality, results, and clinical implications. METHOD: A Medline search identified 13 trials published between 1966 and 1997. Trial methodology was evaluated using a 100-point grid based on four groups of items, namely study population, therapeutic intervention, evaluation method, and data presentation and analysis. RESULTS: Methodology quality scores ranged from 12 to 84 and were unrelated to the results of epidural steroid therapy. Five trials demonstrated greater pain relief within the first month in the steroid group as compared to the control group. Eight trials found no measurable benefits. Obstacles to meaningful comparisons across studies included differences in the patient populations, steroid used, volume injected, and number of injections. None of the published studies used the injection modalities that are standard practice in France. CONCLUSION: Whether epidural steroids are effective in common low back pain and sciatica cannot be determined based on our review.

Evaluation Studies as Topic↗
PubMed1999

Arthroscopic evaluation of post-traumatic patellofemoral chondropathy.

OBJECTIVE: To evaluate clinically and arthroscopically post-traumatic patellofemoral chondropathy. METHODS: Fifty-nine patients with post-traumatic patellofemoral chondropathy were included in a cross sectional study and 46 of them completed a 6 month longitudinal study. Evaluation of the disease, performed once in the cross sectional study and twice (at entry and after 6 months) in the longitudinal study, included clinical and arthroscopic variables evaluating disease activity and severity. Arthroscopy was performed under local anesthesia in an outpatient procedure using a small arthroscope. Chondropathy was evaluated by the overall assessment of the investigator using a visual analog scale, and by the Société Française d'Arthroscopie (SFA) scoring system (SFA score: 0-100). Synovitis was assessed by the "synovitis score," which represents a composite index taking into account intensity, extent and location of synovial abnormalities. RESULTS: In the cross sectional study, severity of chondropathy correlated with age, body mass index, disease duration, functional impairment (Lequesne's index and maximum number of steps descended), patellofemoral crepitus on active motion, limitation of flexion, and presence and amount of synovitis. Knee effusion correlated with the presence of synovitis, but no correlation was found between pain or functional impairment and presence or amount of synovitis. In the longitudinal study, no statistically significant change in chondropathy was observed after 6 months followup despite a statistically significant improvement in pain, function, and knee effusion after this period. However, a statistically significant correlation was found between the progression of patellofemoral chondropathy and the presence and amount of synovitis at baseline. Synovitis was present at baseline in 10 patients. Changes in SFA scores were 1.2 +/- 1.6 and -0.1 +/- 1.0 in the groups of patients with and without synovitis, respectively (p = 0.0062). CONCLUSION: These data suggest that synovitis might have a deleterious effect on the evolution of post-traumatic patellofemoral chondropathy or might be a marker for active cartilage breakdown.

Adult↗
PubMed1998

High-dose therapy and autologous peripheral blood stem cell transplantation in multiple myeloma: up-front or rescue treatment? Results of a multicenter sequential randomized clinical trial.

Results to date indicate that high-dose therapy (HDT) with autologous stem cell support improves survival of patients with symptomatic multiple myeloma (MM). We performed a multicenter, sequential, randomized trial designed to assess the optimal timing of HDT and autotransplantation. Among 202 enrolled patients who were up to 56 years old, 185 were randomly assigned to receive HDT and peripheral blood stem cell (PBSC) autotransplantation (early HDT group, n = 91) or a conventional-dose chemotherapy (CCT) regimen (late HDT group, n = 94). In the late HDT group, HDT and transplantation were performed as rescue treament, in case of primary resistance to CCT or at relapse in responders. PBSC were collected before randomization, after mobilization by chemotherapy, and, in the two groups, HDT was preceded by three or four treatments with vincristine, doxorubicin, and methylprednisolone. Data were analyzed on an intent-to-treat basis using a sequential design. Within a median follow-up of 58 months, estimated median overall survival (OS) was 64.6 months in the early HDT group and 64 months in the late group. Survival curves were not different (P = .92, log-rank test). Median event-free survival (EFS) was 39 months in the early HDT group whereas median time between randomization and CCT failure was 13 months in the late group. Average time without symptoms, treatment, and treatment toxicity (TWiSTT) were 27.8 months (95% confidence interval [CI]; range, 23.8 to 31.8) and 22.3 months (range, 16.0 to 28.6) in the two groups, respectively. HDT with PBSC transplantation obtained a median OS exceeding 5 years in young patients with symptomatic MM, whether performed early, as first-line therapy, or late, as rescue treatment. Early HDT may be preferred because it is associated with a shorter period of chemotherapy.

Adult↗
PubMed1998

Validation of the Ottawa ankle rules in France: a study in the surgical emergency department of a teaching hospital.

STUDY OBJECTIVE: To validate the Ottawa ankle rules to predict fractures in a French clinical setting when they are used by physicians not involved in their development. METHODS: We used a prospective patient survey by emergency physicians in a surgical emergency department of a university teaching hospital of the Assistance Publique-Hôpitaux de Paris. The study group consisted of 416 consecutive patients aged 18 years and older who presented with acute ankle or midfoot injuries in the surgical ED during a 4-month period. Radiography was performed in each patient after clinical evaluation findings were recorded. RESULTS: Forty-nine ankle and 22 midfoot fractures were diagnosed. The decision rules had a sensitivity of .98, a specificity of .45, and a negative predictive value of .99 in detecting ankle fractures, a sensitivity of 1.0, a specificity of .29, and a negative predictive value of 1.0 in detecting midfoot fractures. The rules failed to predict one avulsion fracture in the ankle group. Application of these rules by emergency physicians would have reduced ankle or midfoot radiography requests by 33%. CONCLUSION: Use of the Ottawa ankle rules by French emergency physicians not involved in the rules' development resulted in 99% sensitivity and had a potential of reducing radiography requests by 33%.

Adult↗
PubMed1998

Treatment of skeletal involvement in neoplastic bone diseases.

Skeletal complications are frequent and increase morbidity dramatically in patients with malignancies. The role of bone resorption has been stressed leading to a key role for osteoclasts in the bone lesions. Specific and sensitive markers of bone resorption are now available. Bisphosphonates, powerful inhibitors of osteoclasts, can benefit patients with neoplastic bone diseases.

Bone Density↗
PubMed1998

Variability in knee radiographing: implication for definition of radiological progression in medial knee osteoarthritis.

OBJECTIVES: (1) To assess reproducibility of medial knee joint space width (JSW) measurement in healthy subjects and osteoarthritic (OA) patients. (2) To define minimal relevant radiological change in knee JSW based on the reproducibility of its measurement. PATIENTS AND METHODS: (1) Healthy volunteers: in the first part of the study, 20 knees of healthy adult volunteers were radiographed in the weightbearing, anteroposterior extended view, twice, two weeks apart, using three different radiographic procedures: (a) without guidelines, (b) with guidelines and without fluoroscopy, (c) with guidelines and fluoroscopy. (2) Knee OA patients: in the second part of the study, 36 knees of OA patients were radiographed twice with guidelines and without fluoroscopy. JSW was measured blindly using a graduated magnifying glass. Based on the Bland and Altman graphic approach, cut off points defining minimal relevant radiological change are proposed. RESULTS: Standard deviation (SD) of differences in JSW measurement between two sets of knee radiographs in healthy subjects were 0.66 mm for radiography performed without guidelines, 0.37 mm for radiography performed with guidelines and without fluoroscopy, and 0.31 mm for radiography with guidelines and fluoroscopy. SD of differences in JSW measurement in OA patients were 0.32 mm for radiography performed with guidelines and without fluoroscopy. A minimal relevant change in JSW between two radiographs performed in healthy subjects can be defined by a change of at least 1.29 or 0.59 mm when radiographs are taken without guidelines, and with guidelines and fluoroscopy, respectively. When radiographs are taken with guidelines and without fluoroscopy, the change must be at least 0.73 mm. A similar figure, 0.64 mm was observed in knee OA patients. CONCLUSION: Definition of radiological progression varies greatly according to the radiographic procedure chosen. Use of guidelines reduces the threshold of progression required to consider that change between two measures is relevant.

Adult↗
PubMed1998

Osteoarthritis of the hip: agreement between joint space width measurements on standing and supine conventional radiographs.

OBJECTIVE: To assess the effect of standing position on joint space width (JSW) measurements of the hips with and without osteoarthritis (OA) on pelvic radiographs. METHODS: Adult patients aged 18 or more had pelvic anteroposterior conventional radiographs standing and supine performed by a single radiologist in the same radiology unit according to standardised guidelines. JSW measurements in mm were made by a single reader blind to patients' identity and type of view, using a 0.1 mm graduated magnifying glass directly laid over the radiograph, at the narrowest point for OA hips or at the vertical joint space for non-OA hips. Agreement of JSW between both views was assessed using the Bland and Altman graphical analysis. RESULTS: JSW was greater on standing than supine radiographs, for example, 7.1% for OA hips. Mean (SD) differences and limits of agreement (mm) between both views were 0.08 (0.27) and -0.46 to 0.62 for the 70 non-OA hips, 0.02 (0.31) and -0.60 to 0.64 for the 46 OA hips. Corresponding 95% confidence intervals of mean difference were 0.02, -0.14 mm and -0.07, -0.11 mm. CONCLUSIONS: Measurements of JSW of the hip on pelvic standing and supine radiographs are concordant. Changes less than or equal to 0.64 mm between the two views are similar or inferior to radiological progression of OA.

Adult↗
PubMed1998

Piroxicam therapy: a double blind, randomized, multicenter study comparing 2 versus 4 week treatment in patients with painful knee osteoarthritis with effusion.

OBJECTIVE: To compare the efficacy and safety of piroxicam 20 mg once a day for 14 or 28 days in patients with knee osteoarthritis (OA) and synovial effusion. METHODS: We conducted a multicenter, randomized, double blind study in 1905 outpatients. Efficacy was assessed by changes in synovial effusion, pain on a 100 mm visual analog scale (VAS), and impairment using Lequesne's functional index. Patients were classified at Day 28 as improved (defined as VAS and Lequesne index decrease of at least 30% from Day 14), worsened (defined as VAS and Lequesne index increase of at least 30% from Day 14), or unchanged. Safety was assessed on the basis of adverse events reported by the patients. RESULTS: After 14 days, changes in pain, synovial effusion, and functional impairment significantly decreased from baseline within each group (p < 0.001, respectively), but did not differ between the groups. Between 14 and 28 days, outcome measure changes were significantly better in the 28 day group, p = 0.01, 0.0001, and 0.0001, respectively. In the 28 day and 14 day groups, improvement with regard to pain was observed for 339 (52.4%) and 280 (29.4%) patients, respectively, (p < 0.0001), and with regard to functional impairment for 298 (31.5%) and 233 (24.3%) patients (p < 0.0001). Adverse events accounted for 7.5 and 6.7% of withdrawals in the 28 day and 14 day groups, respectively. CONCLUSION: When administration of piroxicam 20 mg is prolonged to 28 days, continuing benefit is observed for some patients with knee OA with painful synovial effusion without a significant difference in safety.

Aged↗
PubMed1997

Implementation of the Ottawa ankle rules in France. A multicenter randomized controlled trial.

OBJECTIVES: To assess the impact of the implementation of the Ottawa ankle rules on radiography requests in French hospitals during a 5-month intervention period and the impact of using posters alone to sustain the effect of the rules during a 5-month postintervention period. DESIGN: Multicenter randomized controlled trial preceded and followed by observational studies of radiological practices. SETTING: The emergency departments of 5 Paris university teaching hospitals of the Assistance Publique-Hôpitaux de Paris. PATIENTS: A total of 2218, 1911, and 851 patients-all aged 18 years and older-who were seen for acute ankle or midfoot injuries in emergency departments during preintervention, intervention, and postintervention periods, respectively. INTERVENTION: Implementation of the Ottawa ankle rules by emergency department physicians in the intervention hospitals (using meetings, posters, pocket cards, and data forms). During the postintervention period, posters alone were used to sustain the intervention effect. MAIN OUTCOME MEASURE: Percentage of patients for whom radiography was requested. RESULTS: During the preintervention period, 98% and 98.5% of patients were referred for radiography in the intervention and control groups, respectively. During the intervention period, the mean proportions of patients referred for radiography by physicians was 78.9% in the intervention group and 99% in the control group (P=.03). Between preintervention and intervention periods, a relative reduction of 22.4% (95% confidence interval [CI], 19.8%-24.9%) in radiography requests was observed in the intervention group, while requests increased by 0.5% (95% CI, 0%-1.4%) in the control group. During the postintervention period, the proportion of radiography requests in the intervention hospitals was lower than the proportion observed in the preintervention period (83.1% vs 98%). CONCLUSIONS: Implementation of the Ottawa ankle rules significantly reduced radiography requests in French hospitals. Using a minimal postintervention implementation strategy, the effect of this intervention decreased but persisted after it was discontinued.

Ankle Injuries↗
PubMed1997

[Treatment of myeloma: role of intensive treatments].

CURRENT SITUATION: Since the introduction of melphalan, little progress has be obtained in the treatment of multiple myeloma. Complete remission is rarely achieved with classical single-drug or combined chemotherapy protocols: median survival remains low at 2 to 3 years. A NEW APPROACH: High-dose melphalan therapy with hemopoietic stem cell support it a new approach providing promising results. There is a dose effect and 70 to 80% of naive patients, at the cost of severe prolonged aplasia, respond to high-dose melphalan. HEMATOPOIETIC SUPPORT: Allogeneic or autologous bone marrow or blood stem cell grafts are used. Peripheral blood autographs can be used in most patients; contamination with tumoural cells is generally lower. The period of aplasia after chemotherapy and hematopoietic autograft is relatively short. MAIN INDICATIONS: For most authors, high-dose melphalan should be reserved for younger patients with active myeloma: complete remission is achieved in 20 to 30% of cases although relapse still occurs. Other techniques under study (several sequences of high-dose sessions, reduction of graft contamination) should help improve results.

Antineoplastic Agents, Alkylating↗
PubMed1997

From clinical guidelines to quality assurance: the experience of Assistance Publique-Hôpitaux de Paris.

OBJECTIVES: The objectives of this study are: to present the history of the development of clinical guidelines in France. to present the implementation of a program of clinical guidelines in Assistance Publique-Hôpitaux de Paris (AP-HP), the regional public hospital system of the Paris metropolitan area, and to discuss the lessons learned from this program, which provide a basis for a better policy of guidelines at a national level. CONTENT: The objective of the AP-HP program is to promote the appropriate use of clinical guidelines and to evaluate their impact on quality of care and/or costs. Experiments such as controlled trials are used to test the effectiveness of some implementation strategies, to verify that guidelines do improve the process of care and to improve physician compliance with clinical guidelines. Guidelines are developed in a context of budget constraint, and the general aim of the program is to promote the more efficient use of available health resources. RESULTS: In a context of health care inflation, the desire of public authorities is to use guidelines as a tool for cost control strategy, either for ambulatory care or for hospitals. AP-HP experience shows that it is very difficult to develop a national program of clinical guidelines and to implement it in every hospital, as was done in France (but not clearly evaluated) in ambulatory care (under the name 'references médicales'). Guidelines need to be locally adapted, and the best implementation strategies depend on local resources, for example the existence of a pertinent information system. The role of financial incentives is present in French policies, and the role of the drug industry needs to be evaluated.

France↗
PubMed1997

Radiographic assessment in osteoarthritis.

Plain film radiographs are widely used to quantify disease progression in osteoarthritis. Various methods proposed for assessing radiological progression include individual radiographic features (e.g., osteophytes), composite indices (e.g., Kellgren and Lawrence grading), and quantitative measures (e.g., joint space width measurement). We discuss the metrologic properties of these methods and suggest means for improving the quality of radiography in clinical trials.

Clinical Trials as Topic↗