Assessment of Health Inequalities Among Older People Using the EPICES Score: A Composite Index of Social Deprivation.

BACKGROUND: Most of the indicators commonly used to assess social deprivation are poorly suited to study health inequalities in older people. The EPICES (Evaluation of Deprivation and Inequalities in Health Examination Centres) score is a new composite index commonly used to measure individual deprivation. OBJECTIVE: To assess the relationships between health indicators and the EPICES score in older people. Design, Setting, and participants: We performed a cross-sectional study using the data from the 2008 ESPS Survey (Health, HealthCare and Insurance Survey). Of the 4235 survey respondents aged 60 and over in 2008, 2754 completed the 11 items of the EPICES score and were included in the study. MAIN OUTCOMES AND MEASURES: Deprivation was measured using the EPICES score. Health indicators were: Disability, physical performance, cognitive decline, self-perceived health status, and health-care use and participation in prevention programs (missing teeth not replaced, healthcare renunciation, no hemoccult test [60-75 years] and no mammography [60-75 years]). RESULTS: Of the 4235 survey respondents aged 60 and over in 2008, 2754 completed the 11 items of the EPICES score and were included in the study. The mean age was 70.5± 8.2 years. 52.8% were women. 25.8% were living in poor households. According to the EPICES score, 35.1% were deprived. The EPICES score is linked to all the health indicators assessed in this study: Physical disability, cognitive decline; lifestyle and health care accessibility. These relationships increase steadily with the level of social deprivation. For example, the risk of having difficulties in walking 500m without help or an assistive device is multiplied by 13 (RR=13.5 [7.9-20.8]) in the elderly of quintile 5 (maximum precariousness). Limitations: The observational nature limits inferences about causality.CONCLUSION: The EPICES score is linked to health indicators. It could be a useful instrument to assess health inequalities in older people living in the community.

Rationale for carbon ion therapy in high-grade glioma based on a review and a meta-analysis of neutron beam trials.

PURPOSE: The standard treatment of high-grade glioma is still unsatisfactory: the 2-year survival after radiotherapy being only 10-25%. A high linear energy transfer (LET) ionising radiotherapy has been used to overcome tumour radioresistance. An overview of the field is needed to justify future prospective controlled studies on carbon ion therapy. MATERIALS AND METHODS: A meta-analysis of clinical trials on neutron beam therapy and a literature review of clinical investigations on light ion use in high-grade glioma were carried out. RESULTS: Four randomised controlled trials on neutron beam therapy were retained. The meta-analysis showed a non-significant 6% increase of two-year mortality (Relative risk [RR]=1.06 [0.97-1.15]) in comparison with photon therapy. Two phase I/II trials on carbon and neon ion therapy reported for glioblastoma 10% and 31% two-year overall survivals and 13.9 and 19.0 months median survivals, respectively. CONCLUSION: This meta-analysis suggests that neutron beam therapy does not improve the survival of high-grade glioma patients while there is no definitive conclusion yet regarding carbon therapy. The ballistic accuracy and the improved biological efficacy of carbon ions renew the interest in prospective clinical trials on particle beam radiotherapy of glioma and let us expect favourable effects of dose escalation on patients' survival.

Phosphodiesterase III inhibitors for heart failure.

BACKGROUND: In the treatment of chronic heart failure, vasodilating agents, ACE inhibitors and beta-blockers have shown an increase of life expectancy. Another strategy is to increase the inotropic state of the myocardium : phosphodiesterase inhibitors (PDIs) act by increasing intra-cellular cyclic AMP, thereby increasing the concentration of intracellular calcium, and lead to a positive inotropic effect. OBJECTIVES: This overview on summarised data aims to review the data from all randomised controlled trials of PDIs III versus placebo in symptomatic patients with chronic heart failure. The primary endpoint is total mortality. Secondary endpoints are considered such as cause-specific mortality, worsening of heart failure (requiring intervention), myocardial infarction, arrhythmias and vertigos. We also examine whether the therapeutic effect is consistent in the subgroups based on the use of concomitant vasodilators, the severity of heart failure, and the type of PDI derivative and/or molecule. This overview updates our previous meta-analysis published in 1994. SEARCH STRATEGY: Randomised trials of PDIs versus placebo in heart failure were searched using MEDLINE (1966 to 2004 January), EMBASE (1980 to 2003 December), Cochrane CENTRAL trials (The Cochrane Library Issue 1, 2004) and McMaster CVD trials registries, and through an exhaustive handsearching of international abstracting publications (abstracts published in the last 22 years in the "European Heart Journal", the "Journal of the American College of Cardiology" and "Circulation"). SELECTION CRITERIA: All randomised controlled trials of PDIs versus placebo with a follow-up duration of more than three months. DATA COLLECTION AND ANALYSIS: 21 trials (8408 patients) were eligible for inclusion in the review. 4 specific PDI derivatives and 8 molecules of PDIs have been considered. MAIN RESULTS: As compared with placebo, treatment with PDIs was found to be associated with a significant 17% increased mortality rate (The relative risk was 1.17 (95% confidence interval 1.06 to 1.30; p<0.001). In addition, PDIs significantly increase cardiac death, sudden death, arrhythmias and vertigos. Considering mortality from all causes, the deleterious effect of PDIs appears homogeneous whatever the concomitant use (or non-use) of vasodilating agents, the severity of heart failure, the derivative or the molecule of PDI used. AUTHORS' CONCLUSIONS: Our results confirm that PDIs are responsible for an increase in mortality rate compared with placebo in patients suffering from chronic heart failure. Currently available results do not support the hypothesis that the increased mortality rate is due to additional vasodilator treatment. Consequently, the chronic use of PDIs should be avoided in heart failure patients.

Level of evidence as a future gold standard for the content quality of health resources on the internet.

OBJECTIVE: An assessment of the quality of health information on the Internet is an absolute necessity. In this study 'sensitive' information was defined as information found in documents published on the Internet, which could be used in a medical decision. For sensitive information, the main criterion chosen for the quality of the information was an indication of the level of evidence. A survey was conducted using the CISMeF health catalogue to assess how often a score of the level of evidence is mentioned in the information accessible on the Internet in French-language health resources. METHODS: Since 1999, members of the CISMeF team have systematically been searching for all documents containing 'sensitive' information and verifying whether the level of evidence was explicitly indicated as a score at least once in the document. RESULTS: As of June 2001, 10,190 resources were included in CISMeF; including 2964 textual 'sensitive' resources (29.1%). Out of all these resources, only 4.7% (95% confidence interval: 4.0 - 5.5%) indicated the level of evidence. A statistically significant difference in the prevalence of indicating the level of evidence according to resource types (e.g., 18.1% for guidelines compared to 0.0% for teaching material), year of publication (almost three times greater in 1997-2001 compared with 1990-1996) and publishers was observed. CONCLUSION: As the number of people accessing the growing amount of information on the Internet is increasing daily, publishers have an ethical obligation to inform their readers about the validity of 'sensitive' information their sites contain. However, the vast majority of the French language Internet resources that were surveyed do not mention a score of the level of evidence for their sensitive information.

Thrombolytic therapy for acute ischemic stroke.

Available evidence of thrombolysis in acute ischemic stroke comes from a series of recent trials conducted in patients with acute stroke, and from a meta-analysis published in the Cochrane Library. The objective of this paper is to review the literature on tolerability and efficacy of thrombolytic therapy in patients with acute ischemic stroke, to find out what the level of evidence is for each thrombolytic drug, and what should consequently be done in the routine practice. This review is based on a bibliographic search of published meta-analyses of randomized trials, published randomized trials, and ongoing randomized trials, with the outcomes of disability, death, and symptomatic intracerebral hemorrhages (fatal or non-fatal). Our primary end-point is a combination of death and disability, in terms of "death or dependency", with dependency defined as a modified Rankin Score (mRS) of >/=3. The level of evidence for the efficacy of a thrombolytic treatment is considered sufficient if there is both a statistically significant effect in the meta-analysis of all randomized trials, without statistically significant heterogeneity, together with one adequately powered and designed conclusive trial. Streptokinase has a clearly harmful effect, without any demonstrated benefit and must not be used in patients with acute ischemic stroke. The level of evidence of an effect of intra-arterial pro-urokinase to reduce death or dependency is low, available data are sparse (only 220 patients), the estimation of its real efficacy and tolerability remains unclear, and its use in clinical practice is not presently justified. The efficacy of alteplase has been incompletely demonstrated because the results vary across trials and type of outcomes (death, death or dependency), and the cut-off of the disability scale. There is a significant heterogeneity in the effect on death or dependency. However, we can conclude that there is a beneficial effect, but its clinical application is limited because of the absence of adequate criteria to identify patients most likely to benefit from treatment. Overall the use of alteplase in patients with acute stroke was associated with some benefit, but it significantly increased total mortality in two trials. Given the observed confidence interval (CI), the results are compatible with, in the best situtation, 203 advoided death or dependency and 61 avoided death per 1000 treated patients, and at worst 77 avoided death or dependency and 38 extra deaths per 1000 treated patients. Further trials aimed at validating more discriminant selection criteria are mandatory.