Management of osteoporosis in fracture liaison service associated with long-term adherence to treatment.

SUMMARY: Adherence to osteoporosis treatment is not satisfactory. Our study evaluated persistence and compliance with these treatments prescribed specifically in the context of a fracture liaison service (FLS), an internal health care network, and showed that this type of organization in our institution was associated with high level of adherence. INTRODUCTION: Medical management of patients with a fragility fracture has been improved by health care internal network or FLS organized in large hospitals. However, treatment effectiveness is not only related to larger initiation rate but also to better long-term adherence. Therefore, we evaluated persistence and compliance in the context of osteoporosis treatment initiated in our institution's FLS, among postmenopausal women with a peripheral fragility fracture. METHODS: Patients with a specific osteoporosis treatment prescribed while visiting our FLS were contacted by phone to answer an evaluation questionnaire. A simplified questionnaire was sent to their general physicians when we were not able to reach patients on the phone. RESULTS: Of the 279 selected patients, 155 were evaluated. Of them, 90.3% had actually started their treatment and 80% were still under treatment after 1 year. After 27.4 ± 11.7 months of follow-up, 67.7% of patients were persistent with their treatment. In addition, 87% of the persistent patients declared to respect both treatment posology and administration conditions. Occurrence of adverse events was the first cause of treatment interruption within the first 6 months. CONCLUSIONS: Our data showed a high level of persistence with osteoporosis treatment when initiation was performed in an FLS, even on a long-term basis. Since follow-up and renewal of treatment were under routine daily practise, our study underlines how important the first prescription conditions are and provides additional interest in medical care network such as FLS.

Long-term effects of infliximab on bone and cartilage turnover markers in patients with rheumatoid arthritis.

BACKGROUND: Rheumatoid arthritis (RA) is associated with systemic bone loss, subchondral bone erosion and cartilage degradation under the control of pro-inflammatory cytokines, including tumour necrosis factor alpha (TNFalpha). Therefore, we tested the hypothesis that administration of infliximab, an anti-TNFalpha drug in the treatment of RA, would modulate systemic and local bone resorption and reduce cartilage degradation. METHODS: We performed a prospective study of a multicentric cohort of 48 women, mean (SD) age 54.2 (12.1) years old, with severe RA for 11.4 (7.8) years, who started infliximab after failure of other disease-modifying antirheumatic drugs. At baseline and 6, 22 and 54 weeks after initiating Infliximab therapy we measured the following biochemical markers: pro-collagen serum type I N-terminal propeptide (PINP), a marker of bone formation; serum C-terminal cross-linked telopeptide of type I collagen (CTX-I), a marker of cathepsin K-mediated bone collagen degradation believed to reflect systemic bone resorption; serum C-terminal cross-linked telopeptide of type I collagen (ICTP), an index of matrix metalloprotease (MMP) mediated type I collagen degradation reflecting preferential joint metabolism; and urinary CTX-II a biochemical markers of cartilage degradation. Total hip and lumbar spine bone mineral density (BMD) was assessed at baseline, and after 6 and 12 months by dual-energy x-ray absorptiometry (DXA). No patient received bisphosphonates while 77% were under oral glucocorticoids. RESULTS: BMD remained stable over 1 year. Serum CTX-I levels rapidly decreased by 19% and 28% at week 6 and week 22, respectively (analysis of variance (ANOVA) p = 0.032) values returning to pre-treatment level at week 54. By contrast, ICTP levels progressively declined with a maximal 25% decrease at week 54 (ANOVA p = 0.028). By contrast, PINP levels remained stable over time, which led to a 30 to 40% improvement in bone remodelling balance, as assessed by the ratios PINP/CTX and PINP/ICTP (p<0.05). There was no significant change of urinary CTX-II in the whole population, but a slight decrease (ANOVA p = 0.041) in those with pre-treatment levels above the upper limit of normal range. CONCLUSIONS: In summary, the improvement in the formation/resorption marker ratio suggests beneficial systemic and local bone effects of infliximab in patients with RA.

Concentration of remifentanil needed for tracheal intubation with sevoflurane at 1 MAC in adult patients.

BACKGROUND AND OBJECTIVE: Inhalation induction with sevoflurane provides acceptable conditions for tracheal intubation. Opioids significantly decrease the alveolar concentration needed to achieve tracheal intubation. The purpose of this study was to determine the target concentration of remifentanil providing excellent conditions for tracheal intubation with sevoflurane at 1 minimum alveolar concentration without muscle relaxant. METHODS: Twenty-four consecutive patients, aged 18-50 yr, ASA I or II, were studied. Induction of anaesthesia was performed with sevoflurane at age-adjusted minimum alveolar concentration. Remifentanil was simultaneously administered using target-controlled infusion with the Minto model. Target plasma concentration of remifentanil was selected for each patient according to an up-and-down method. RESULTS: The mean target concentration of remifentanil for successful tracheal intubation was 3.3 ng mL(-1) (95% confidence interval: 2.6-3.9 ng mL(-1)). Arterial pressure, heart rate and bispectral index did not increase after tracheal intubation in the group of patients with successful intubation. CONCLUSIONS: Remifentanil at 3.3 ng mL(-1) together with sevoflurane at 1 minimum alveolar concentration provides excellent conditions for tracheal intubation in 50% of patients.

[Anesthesia induction with sevoflurane in adult patients with predictive signs of difficult intubation]. / Induction anesthésique avec le sévoflurane chez le patient adulte avec des signes prédictifs d'une intubation difficile.

OBJECTIVE: This work was carried out to study induction with sevoflurane in adult patients with predictive signs of difficult intubation. STUDY DESIGN: Randomised prospective study. PATIENTS AND METHODS: The study had two parts. Part I: 15 patients without predictive signs of difficult intubation but with a cervical collar. Eight patients were anaesthetised with propofol 3 mg.kg-1 and fentanyl 2 micrograms.kg-1, seven with sevoflurane 8%. Part II: 20 patients with predictive signs of difficult intubation anaesthetised with sevoflurane 8%. RESULTS: In part I, all patients were intubated, the time for intubation was longer with sevoflurane, 6 vs 4 min. They were apneic only in the propofol group. After intubation, 7 cases of coughing (4 severe) occurred in the propofol group and 3 moderate coughing in the sevoflurane group. In part II, one patient experienced considerable agitation after oral airway insertion and was excluded. Other patients were intubated with sevoflurane. Seven patients were intubated with a bougie, three patients through an intubating LMA and one patient with a rigid bronchoscope. The other patients were intubated with a Macintosh blade. The mean time for intubation was 10 +/- 7 min and end tidal sevoflurane concentration after intubation was 4 +/- 0.6%. After intubation, 7 cases of coughing (3 severe) occurred but no desaturation < 95%. No significant haemodynamic variations occurred. CONCLUSION: Induction with sevoflurane 8% allowed tracheal intubation without major incidents. All patients breathed spontaneously. Sevoflurane can be recommended for induction in cases of predictive difficult intubation.

Characterization of a Pterostilbene Dehydrodimer Produced by Laccase of Botrytis cinerea.

ABSTRACT In the interaction between grapevines and Botrytis cinerea, one of the main aspects of pathogenicity is fungal ability to degrade phytoalexins synthesized by the plant in response to infection. Laccase-like stilbene oxidase activity in liquid cultures of B. cinerea has been shown to be related to the decrease of phytoalexin concentrations. Recent research and results presented in this paper determined the chemical structure of a pterostilbene metabolite produced by B. cinerea. Study of degradation of pterostilbene that has just one free hydroxy phenyl group function allowed us to determine the oxidative dimerization process undergone by grapevine phytoalexins after B. cinerea infection. The phytopathological significance of this degradation process in the B. cinerea interaction has also been discussed.