[Metabolic testing rates after initiation of antipsychotic treatment in persons initially treated by conventional mood-stabilizers]. / Surveillance métabolique biologique après initiation d'un traitement antipsychotique chez des personnes traitées par lithium ou anticonvulsivants.

OBJECTIVES: To assess the rate of metabolic testing after initiation of second-generation antipsychotics (SGA) prescription in persons initially treated by conventional mood-stabilizers (lithium or anticonvulsants, as a proxy of bipolar disorder diagnosis) and to compare the rates of metabolic testing in these persons with those in persons with initiation of first-generation antipsychotics (FGA) prescription or with no antipsychotic prescription. METHOD: Data were anonymously extracted from the 2004 to 2006 French national health database of the Régime Social des Travailleurs Indépendants (RSI). Patients aged 18 years and over were included in the cohort if they fulfilled the following criteria over a three-month inclusion period: refunding of lithium or anticonvulsant over the 3 months without discontinuation (as a proxy of bipolar disorder diagnosis), no concomitant refunding over the 3months of antipsychotic, and no concomitant refunding over the 3 months of an anti-diabetic drug (as a marker of diabetes) or a lipid-lowering drug (as a marker of hyperlipidemia). Metabolic testing was assessed using information collected in the RSI database on the reimbursement of glucose-specific serum tests (glycaemia) and lipid-specific serum tests (total cholesterol). Serum glucose and lipid testings were assessed at baseline and at 12-week follow-up for the first episode of antipsychotic dispensing. Multivariate analyses were performed to compare the rate of metabolic testing in users of SGA to those of users of FGA and to those of non-users of antipsychotics. RESULTS: Three thousand one hundred and seventy patients were included. Of the 490 (15.4%) persons with a first episode of antipsychotic dispensing after the index date, 138 (4.3%) were dispensed only FGA over the first episode and 352 (11.1%) SGA (including 37 patients with both SGA and FGA dispensing). Metabolic testing at baseline and at 12-week follow-up was performed for 14% of persons with initiation of FGA and 12% with initiation of SGA. Almost no patient had both baseline and follow-up testing. Testing rates were lower for lipid testing than for glucose testing. Compared to persons with no antipsychotic, persons with SGA were significantly more likely to have metabolic testing at baseline and at follow-up, independently from other characteristics (adjusted OR=0.24, 95% CI 0.16 to 0.36). No difference was found between persons with SGA and those with FGA (adjusted OR=1.12, 95%CI 0.62 to 2.0). Regarding the other characteristics associated with likelihood of metabolic testing (irrespective of the treatment group), women were more likely than men to have metabolic testing at baseline but not at follow-up. Elderly persons and persons with low occupational status were more likely to have metabolic testing at follow-up. CONCLUSION: From a public health point of view, such findings indicate that the metabolic risks associated with SGA use in real-life conditions are widely underestimated. Regarding the temporal trends of antipsychotic prescription, with the dramatic rise of SGA use observed in most countries, it is a public health priority to improve metabolic monitoring in SGA users, irrespective of the underlying diagnosis. Since it is more complex to modify pre-existing inadequate practices than to initiate correct ones in new prescribers, great attention should be paid to the need for delivering strong messages regarding the metabolic risks associated with SGA prescription during the initial training of physicians.

Antipsychotic use patterns in persons initially treated with mood stabilizers: a naturalistic study.

INTRODUCTION: Little information is available on the pattern of use of antipsychotics in naturalistic conditions in persons initially treated with "conventional" mood stabilizers (lithium and anticonvulsants). METHODS: Data on community prescriptions were extracted from the 2004-2006 claims database of a French health care insurance fund for self-employed workers. Patients included were those continuously exposed to mood stabilizers without concomitant dispensing of antipsychotics over at least a 3-month period. RESULTS: Of the 3 958 persons included, 17.8% had at least one addition/switch to antipsychotics over the follow-up period. The most frequent pattern was addition of second-generation antipsychotics (SGAPs) (41%) or first-generation antipsychotics (FGAPs) (23%) to the mood stabilizer for a relatively short period of time. A switch from mood stabilizer to SGAPs (20%) or FGAPs (15%) was less frequent. Mood stabilizers alone were prescribed again in most patients with the addition of FGAPs (72%) or SGAPs (61%) to mood stabilizers. Conversely, the majority of patients with a switch from mood stabilizers to FGAPs (55%) or SGAPs (58%) went on with these latter treatments over the follow-up. CONCLUSIONS: SGAPs are preferentially prescribed in combination with mood stabilizers and their pattern of use is similar to that of FGAPs.

[Pain related to head and neck cancers during disease progression]. / Les douleurs liées aux cancers des voies aérodigestives supérieures lors de l'évolution.

Head and neck cancers can be revealed by pain symptoms caused by an excess of nociception. Other pain sometimes occurs during the cancer's progression such as neuropathic or mixed pain. These should incite the clinician to be watchful so as not to miss recurrence of the cancer. Treatment is complex, requiring management by a multidisciplinary team.

IRSN methodological guide to conducting workplace studies in compliance with French regulations.

Under French regulations governing radiation protection of workers, dosimetric workplace studies are mandatory. However, their practical implementation is not described. IRSN has developed a guide to help stakeholders in the radiological protection of workers conduct such studies. It proposes a general methodology applicable to most cases and 'workplace sheets', which apply this methodology to specific occupational settings. At present, two sheets are available: conventional radiology and interventional radiology.

[Pain when removing a silicon Blake drain]. / Douleur lors de l'ablation des drains en silicone de Blake.

OBJECTIVES: A prospective analysis of pain intensity and related factors observed when removing a Blake suction drain after head and neck surgery. MATERIALS AND METHODS: An inception cohort of 100 patients managed at a single institution (university teaching and tertiary referral center), by 10 surgeons, during the months of March-July 2004. Two different scales were used to evaluate pain (see and ). The variables under analysis were: age, gender, comorbidity, overall pain and psychological status, anti-pain treatment, type of disease (benign vs malignant), type of surgery performed, location of the drain, number of drains removed and delay from surgery. RESULTS: No complications were noted at the time of drain removal. The volume drained varied from 10 to 450 cc (mean value 90 cc). At the time of drain removal no pain was noted in 50% to 60% of patients according to the scale used. Minimal pain and strong pain were noted in 45% - 36% and 5% - 4% of patients, respectively. Among the variables under analysis, the age of the patient was the only variable significantly related to the intensity of pain noted at the time of removal of the drain whatewer scale was used for analysis. Pain was statistically more pronounced as age declined (p=0.011 and p=0.04 according to the scales used). CONCLUSION: At our department, due to its very good drainage ability, its facility of use and the very low intensity of pain noted at the time of removal, the Blake drain has replaced the time honoured Redon-Jost drain conventionally used after head and neck surgery.

[Prenatal screening of cytomegalovirus in France: an increasing frequency practices of screening from 2000 to 2003 despite no recommendation in favor]. / Dépistage prénatal du cytomégalovirus en France: une augmentation des pratiques de prescription de 2000 à 2003 malgré l'absence de recommandation favorable.

BACKGROUND: Screening cytomegalovirus infection in pregnant women is still controversial in 2004 in France. In this context, we evaluated the interest of such a screening in 2004 in France. This paper was designed to describe trends in CMV prenatal screening practices in 2000-2003 in France. METHODS: This retrospective study, describes the prescription of CMV screening in HIV-negative pregnant women giving birth in the private care sector, according to their occupational category and geographical area. Data were provided by the "Caisse d'Assurance-maladie des Travailleurs Indépendants" (independent workers health insurance fund). RESULTS: The study included 34.347 women, delivering in 2001-2004 (beginning of pregnancy in 2000-2003). The number of pregnant women screened for CMV increased significantly between 2000 (5.8%, 301/5.177), 2001 (11.1%, 1.130/10.139) and 2002 (22.1%, 2.701/12.223), (p<0.001), then was stable in 2003 (22.0%, 1.496/6.808). The percentage of women screened for CMV, at least once during pregnancy, doubled between 2001 and 2002 (p<0.001) in each occupational category and geographical area. It was significantly different between occupational categories (p<0.01), with a higher percentage of women in the self-employed and commercial agent occupational categories than in the craftsman category. There was also a significant difference between geographical areas (p<0.001), with a higher rate in Paris. CONCLUSION: This study providing baseline information on CMV practices showed: 1- a significant increase in the frequency of CMV screening among pregnant women over the period 2000-2002 with a stabilization in 2003; 2- a similar trend observed in each occupation category and geographical area but with a markedly higher frequency of screening practices in the Paris area and among self-employed women. A study measuring the effect of the 2004 ANAES recommendation suggesting not to screen for CMV during pregnancy should be conducted.

Is spa therapy cost-effective in rheumatic disorders?

OBJECTIVE: To evaluate the cost-effectiveness of spa therapy for rheumatic diseases and sequelae of bone and joint injuries. PATIENTS AND METHODS: A prospective randomized, case-control design was used with health care cost reimbursements during the year before and after spa therapy as the measure of efficacy. Spa therapy is reimbursed by the national health insurance system in France, subject to prior agreement. The 220 patients who filed applications for spa therapy with the national health insurance payment center for northern France during the first half of 1994 were included in the study. Seventy-two patients met national health insurance system criteria for spa therapy (Group 1), the remaining 148 patients were assigned at random to spa therapy (Group 2, n = 74) or no spa therapy (Group 3, n = 74). This method allowed us to avoid selection bias during recruitment of our control group. RESULTS: Perceived morbidity was evaluated based on health care utilization, expressed as numbers of health care investigations or procedures and as days of medication use in mean recommended dosages. Health care cost reimbursements by the national health insurance system failed to decrease during the year after spa therapy, and increased in those patients who had already received spa therapy on one or more occasions. Only in the first-ever spa patients were decreases in health care utilization in the area of rheumatology seen during the year after spa therapy; the largest decreases were for use of nonsteroidal antiinflammatory drugs (from 49 to 26 days) and muscle relaxants. No differences in health care utilization were found in patients who had received spa therapy on at least one other occasion. Also, when criteria for spa therapy were not met, no differences in health care utilization were found between patients who did and did not receive spa therapy. CONCLUSION: These data suggest that current national health insurance policies regarding the reimbursement of spa therapy need to be reevaluated.

[Psychological management of patients with head and neck cancer]. / Prise en charge psychologique des patients atteints d'un cancer de la tête et du cou.

We recall the particular features of head and neck cancer in terms of the patient's image of his body and discuss the main character traits encountered in patients with this type of cancer. Psychological factors which must be taken into consideration in therapeutic management are presented. Five specific situations are discussed: announcing the diagnosis, proposing the initial therapeutic scheme, palliative treatment, end of life situations. The role of each member in the health care team is discussed in light of what the patient expects.

[Scanner and mechanical lumbar diseases in private practice. Apropos of 106 patients covered by the Caisse Maladie Régionale du Nord]. / Scanner et pathologie lombaire mécanique en pratique libérale. A propos de 106 patients ressortissants de la Caisse Maladie Régionale du Nord.

The aim of this study was to prospectively evaluate use of computed tomography (CT) of the lumbar spine in office practice. The "Caisse Maladie Régionale du Nord" provides health insurance to self-employed retailers and craft persons (92,500 people at the end of 1991). The authors prospectively studied 106 patients insured by this organisation (60 males, 46 females, mean age: 51.27 years) who underwent CT of the lumbar spine between August 2, 1991 and January 23, 1993. They examined all insurance claims (physician visits, surgery, drugs, physiotherapy, laboratory tests, imaging studies, and hospitalizations) filed by each study patient during the 4 months before and the 4 months after the index CT. Reason for the CT, specified on 65 of the 106 radiologist reports, were isolated low back pain and nerve root pain in 26.2% and 56.9% of the patients respectively. CT findings were discal prolapse in 27 patients (25.5%), facet joint osteoarthritis in 33 patients (31.3%), discal protrusion in 29 patients (27.4%) and were considered as normal in 19 patients (18%). CT was preceded by plain radiographs in 50% of patients, by a rheumatologist visit in 31%, by a visit to the sole general practitioner in 51%, by local steroid injection in 15%. During the 4 months subsequent to the index CT, 14 (13.2%) patients had surgery and one underwent chemonucleolysis. These findings suggest that consensus conference recommendations concerning lumbar spine CT are not currently being followed in France.