Predictive factors of functional remission in patients with early to mid-stage schizophrenia treated by long acting antipsychotics and the specific role of clinical remission.

BACKGROUND: Functional remission has become a major therapeutic objective in schizophrenia, but the probability of such positive outcome has a large variability, ranging from 15% to 51%. Additionally, how clinical remission constitutes a prerequisite for functional remission also remains unclear. METHODS: A prospective observational study was conducted in French schizophrenic patients who initiated treatment with a long-acting injectable (LAI) after an acute episode. Functional and clinical remissions were assessed using the FROGS and the Andreasen criteria, and the role of clinical remission and predictive factors of functional remission was evaluated. RESULTS: Three hundred three patients with schizophrenia (DSM-IV criteria) were followed for 12 months. At 12 months, 45.1% of the patients reached functional remission while 55.1% obtained clinical remission. Clinical remission facilitated functional remission (OR = 14.74), especially in patients with psychosis for less than 5 years (OR = 23.73). Other predictive factors concerned the family environment, education level, employment status, baseline functioning levels and level of insight. CONCLUSIONS: About half of patients treated with LAI reached functional remission after one year of follow-up. Reduced clinical symptoms and reaching clinical remission largely favored functional remission. These results stress the importance of continuous and appropriate symptomatic treatment to reach functional remission and maximize recovery chances.

Effectiveness of a Fully Automated Internet-Based Smoking Cessation Program: A Randomized Controlled Trial (STAMP).

Introduction: The Internet offers an interesting alternative to face-to-face and telephone-based support for smoking cessation. This study was designed to assess the effectiveness of a personalized and automated Internet-based program. Methods: French current adult smokers willing to quit within 2 weeks were recruited for a randomized controlled trial. The intervention consisted of an automated program of 45 e-mails ("e-coaching") sent over a 3-month period. The control group received a PDF version of a booklet on smoking cessation. Self-reported 7-day point prevalence smoking abstinence was measured at 6 months (primary outcome), at 3 and 12 months of follow-up (secondary outcomes). Results: 2478 smokers were randomized (1242 for e-coaching, 1236 for the booklet). Cessation rate in the intention-to-treat population was not significantly different between the two groups at 6 and 12 months, but was higher in the e-coaching group at 3 months than in the control group (27.5% vs. 23.5%, p = .02, odds ratio [OR] = 1.24, confidence interval [CI] = [1.03-1.49]). After adjustment for baseline conditions, the effect of the intervention in the per-protocol (PP) sample was significant at 3 months (adjusted odds ratio [aOR] = 1.72 [1.31-2.28], p < .001, N = 1042) and at 6 months (aOR = 1.27 [1.00-1.60], p = .05, N = 1082). GLM repeated measure analyses showed significant group by time interaction in the intent-to-treat and a significant group effect in the PP population. Conclusions: Analyzed intention-to-treat, e-coaching was superior to a booklet at 3 months (end of intervention) but no more superior at 6 and 12 months follow-up. Among those who actually followed the program, the effectiveness is also observed 3 months after the intervention is stopped. Implications: Analyzed intention-to-treat, our French tailored and personalized Internet-based cessation program was superior to a smoking cessation booklet at 3 months (end of intervention) but no more superior at 6 months follow-up. Among those who actually followed the program (PP population), the effectiveness is observed in the short-term but also 3 months after the intervention is stopped.

Functional remission in schizophrenia: A FROGS-based definition and its convergent validity.

Functional remission concerns only one third of schizophrenia patients who achieved symptomatic remission. We previously developed a scale devoted to functional remission, named the FROGS (Functional Remission Of General Schizophrenia). This instrument encompasses three clinically relevant dimensions. The aim of this study is to provide a threshold for functional remission relying on these three dimensions, and to compare its psychometric properties with other scales devoted to functional remission. We tested the characteristics of functional remission according to the FROGS. The FROGS was used in different European countries and compared to other valid scales (GAF, PSP and PSRS) in a sample of 295 schizophrenia patients. The association with different parameters as external validators was assessed, including clinical remission. A comparison of the classifying properties of each scale compared to the others was made. The four instruments were equally influenced by the PANSS score, the clinical remission according Andreassen's criteria, the number of past hospitalizations and the presence of a paid working activity. These findings provide a simple threshold for the FROGS, tightly linked to the definition of functional remission, with a good convergent validity. This instrument might be easily used to facilitate the assessment of functional remission in schizophrenia.

GOSPEL 3: Management of gout by primary-care physicians and office-based rheumatologists in France in the early 21st century - comparison with 2006 EULAR Recommendations.

INTRODUCTION: In 2006, recommendations about the management of gout were issued by the European League Against Rheumatism (EULAR). The objective of this work was to compare these recommendations to practice patterns of physicians working in private practices in France. METHOD: In a prospective multicenter nationwide study conducted in France, a random sample of primary-care physicians (PCPs) and private-practice rheumatologists (PPRs) was taken in 2009. Each physician included 2 consecutive patients with gout. Each patient was evaluated twice at an interval of 3-6months. Information on EULAR 2006 management modalities were collected in a standardized manner. RESULTS: Of 1003 patients, 771 were evaluated twice. Allopurinol was prescribed to 75.1% of patients in all and was initiated at the first study visit in 44 patients, among whom 19 (43.2%) 19 patients received the recommended starting dosage of 100mg/day. Colchicine therapy to prevent flares was prescribed to 74.3% of patients. Of the 522 patients on allopurinol therapy at the first visit, only 34.5% had serum uric acid levels≤360µmoL/L (mean dosage, 173 mg/day). Excessive dietary intake by patients who were overweight or obese was recorded in 31.5% of patients seen by PCPs and in 19.7% of those seen by OBRs. This finding prompted the delivery of nutritional advice to 45.8% of patients. Discontinuation of excessive alcohol intake was recommended to only 10% of patients. Diuretic therapy discontinuation was feasible in 175 patients but was recommended in only 7 patients. CONCLUSION: Differences between practice patterns and 2006 EULAR recommendations were identified. Simplifying the recommendations and teaching them during medical training and continued medical education may deserve consideration.

GOSPEL 2 - Colchicine for the treatment of gout flares in France - a GOSPEL survey subgroup analysis. Doses used in common practices regardless of renal impairment and age.

OBJECTIVES: The objective of this sub-study was to assess the use of colchicine for the treatment of gout flares in real life conditions in the GOSPEL cohort following the 2006 EULAR recommendations for gout management. METHODS: This national cross-sectional epidemiologic survey included outpatients with gout suffering from acute flare followed by randomly selected primary care physicians (n=398) and private practice rheumatologists (n=109) between October 2008 and September 2009 in France. Data regarding patient characteristics and treatment prescription was collected by each physician. Glomerular filtration rate (eGFR) was estimated using the Cockroft-Gault formula. Patients included in the survey for a gout flare filled in a specific self-questionnaire including colchicine effective intake and pain relief (numeric scale). RESULTS: This analysis focused on the 349 patients presenting with gout flare and treated with colchicine. Mean (±SD) prescribed dose of colchicine was 2.8 (±0.7) mg within the first 24hours and the cumulative dose over the first three days of treatment was 6.9 (±1.8) mg. Patients with mild decline in eGFR (eDFG 60-80mL/min) were prescribed an average initial dose of 2.8mg (±0.8) mg (n=58), 2.7 (±0.8) mg in chronic kidney disease (CKD) stage 3 (n=43) and 2.5 (±0.7) mg in CKD stage 4 (n=2). Cumulative doses of colchicine did not take into account either renal impairment or age. CONCLUSIONS: This study draws attention to some misuse of colchicine in daily practice and the prescription of excessive doses especially in case of renal impairment. eGFR should be enforced in daily practice.

Gait velocity is an indicator of cognitive performance in healthy middle-aged adults.

Psychomotor retardation, especially motor and cognitive slowing down, has been described many times in the elderly but to our knowledge, has never been examined in healthy middle-aged adults. The present study explores whether walking time may provide an early signal of cognitive performance, using 266 healthy adults ([18-65] years old, mean age: 45.7±12.9 years) who were also subdivided in 2 groups: under or over 50. Walking time (50 meters) and cognitive performances (mini-mental state examination, Benton Visual Retention Test and Rey Complex Figure) were assessed; total psychometric score was the sum of individual test scores. Analyses were controlled for age, gender, education level, height and weight. The mean psychometric scores were within the normal range. A substantial proportion of subjects exhibited low performance in some aspects of visuospatial memory, particularly in the older subset. In the total population, walking time was negatively correlated with all cognitive tests, particularly to total psychometric score (R = -0.817, p<0.0001); the unique contribution of walking time on all cognitive scores was very high (delta R-squared = 0.496). In the older subset, performances on walk and cognition were lower than in the younger subset. Total psychometric score showed the strongest correlation with walking time in the older subset (R = -0.867; p<0.001). In all subsets, walking time was the main explanatory variable of the total psychometric score (delta R-squared: ≤ 49 = 0.361; ≥50 = 0.613). These findings indicate that i) a significant proportion of adults without cognitive complaints exhibit low cognitive performance including visuospatial memory and longer walking time, ii) cognitive functioning is strongly correlated to walking time in healthy middle-aged adults, iii) gait velocity (GV) could be an indicator of cognitive performance in some important cognitive domains. These results warrant further investigation because such data may represent a marker for the detection of middle-aged adults who are at risk for further cognitive decline.

Gender differences in a cohort of major depressive patients: further evidence for the male depression syndrome hypothesis.

BACKGROUND: Previous studies have shown that major depressive patients may differ in several features according to gender, but the existence of a specific male depressive syndrome remains controversial. METHODS: As part of the EPIDEP National Multisite French Study of 493 consecutive DSM-IV major depressive patients evaluated in at least two semi-structured interviews 1 month apart, 125 (27.7%) were of male gender, whereas 317 (72.3%) were female, after exclusion of bipolar I patients. RESULTS: Compared to women, men were more often married, had more associated mixed features, with more bipolar disorder NOS, more hyperthymic temperaments, and less depressive temperaments. Women had an earlier age at onset of depression, more depressive episodes and suicide attempts. A higher family loading was shown in men for bipolar disorder, alcohol use disorder, impulse control disorders and suicide, whereas their family loading for major depressive disorder was lower. Men displayed more comorbidities with alcohol use, impulse control, and cardiovascular disorders, with lower comorbidities with eating, anxiety and endocrine/metabolic disorders. The following independent variables were associated with male gender: hyperthymic temperament (+), alcohol use disorder (+), impulse control disorders (+), and depressive temperament (-). LIMITATIONS: The retrospective design and the lack of specific tools to assess the male depressive syndrome. CONCLUSION: Study findings may lend support to the male depression syndrome concept and draw attention to the role of hyperthymic temperament, soft bipolarity as well as comorbidities as determinants of this syndrome. The latter could help recognize an entity which is probably underdiagnosed, but conveys a high risk of suicide and cardiovascular morbidity.

DSM-IV diagnosis in depressed primary care patients with previous psychiatric ICD-10 bipolar disorder.

BACKGROUND: In the past 20 years, much evidence has accumulated against the overly restrictive diagnostic concepts of hypomania in DSM-IV and DSM-IV-TR. We tested DSM-IV-TR and a broader modified version (DSM-IV-TRm) for their ability to detect bipolarity in patients who had been treated for bipolar disorders (BD) in psychiatric settings, and who now consulted general practitioners (GPs) for new major depressive episodes (MDE). METHODS: Bipolact II was an observational, single-visit survey involving 390 adult patients attending primary care for MDE (DSM-IV-TR criteria) in 201 GP offices in France. The participating GPs (53.3 ± 6.5 years old, 80.1% male) were trained by the Bipolact Educational Program, and were familiar with the medical care of depressive patients. RESULTS: Of the 390 patients with MDE, 129 (33.1%) were previously known as bipolar patients (ICD-10 criteria). Most of the latter bipolar patients (89.7%) had previously been treated with antidepressants. Only 9.3% of them met DMS-IV-TR criteria for BD. Conversely, 79.1% of the 129 bipolar patients met DMS-IV-TRm criteria for BD and showed strong associations with impulse control disorders and manic/hypomanic switches during antidepressant treatment. LIMITATIONS: Limited training of participating GPs, recall bias of patients, and the study not being representative for untreated bipolar patients. CONCLUSIONS: Very few ICD-10 bipolar patients consulting French GPs for MDE met DSM-IV-TR criteria for bipolar diagnosis, which suggests that DSM-IV-TR criteria are insufficient and too restrictive for the diagnosis of BD. DSM-IV-TRm was more sensitive, but 20% of bipolar patients were undetected.

Guidelines for the use and management of long-acting injectable antipsychotics in serious mental illness.

BACKGROUND: Long-acting injectable (LAI) formulations are not widely used in routine practice even though they offer advantages in terms of relapse prevention. As part of a process to improve the quality of care, the French Association for Biological Psychiatry and Neuropsychopharmacology (AFPBN) elaborated guidelines for the use and management of antipsychotic depots in clinical practice. METHODS: Based on a literature review, a written survey was prepared that asked about 539 options in 32 specific clinical situations concerning 3 fields: target-population, prescription and use, and specific populations. We contacted 53 national experts, 42 of whom (79%) completed the survey. The options were scored using a 9-point scale derived from the Rand Corporation and the University of California in the USA. According to the answers, a categorical rank (first-line/preferred choice, second-line/alternate choice, third-line/usually inappropriate) was assigned to each option. The first-line option was defined as a strategy rated as 7-9 (extremely appropriate) by at least 50% of the experts. The following results summarize the key recommendations from the guidelines after data analysis and interpretation of the results of the survey by the scientific committee. RESULTS: LAI antipsychotics are indicated in patients with schizophrenia, schizoaffective disorder, delusional disorder and bipolar disorder. LAI second-generation antipsychotics are recommended as maintenance treatment after the first episode of schizophrenia. LAI first-generation antipsychotics are not recommended in the early course of schizophrenia and are not usually appropriate in bipolar disorder. LAI antipsychotics have long been viewed as a treatment that should only be used for a small subgroup of patients with non-compliance, frequent relapses or who pose a risk to others. The panel considers that LAI antipsychotics should be considered and systematically proposed to any patients for whom maintenance antipsychotic treatment is indicated. Recommendations for medication management when switching oral antipsychotics to LAI antipsychotics are proposed. Recommendations are also given for the use of LAI in specific populations. CONCLUSION: In an evidence-based clinical approach, psychiatrists, through shared decision-making, should be systematically offering to most patients that require long-term antipsychotic treatment an LAI antipsychotic as a first-line treatment.

Risks associated with gender differences in bipolar I disorder.

BACKGROUND: Previous studies have demonstrated that bipolar patients may differ in several features according to gender, but a number of the differences found remain controversial. METHODS: The demographic, illness course, clinical, comorbidity and temperament characteristics of a total of 1090 consecutive DSM-IV bipolar I manic inpatients were compared according to gender. RESULTS: Bipolar illness in women was characterised by the predominance of depression, as indicated by a depressive polarity at onset, higher rates of mixed mania, more suicidal behaviour, and a greater number of temperaments with depressive propensities. In contrast, the manic component was found to predominate in men. Men also had an earlier onset of their illness. Women displayed more comorbidities with eating, anxiety, and endocrine/metabolic disorders, whereas men were more comorbid with alcoholism and other forms of substance abuse, neurological, and cancer disorders. The following independent variables were associated with male gender: being single (+), depressive temperament (-), excessive alcohol use (+), cyclothymic temperament (-), excessive other substance use (+), mood congruent psychotic features (+), and manic polarity at onset (+). LIMITATIONS: The retrospective design and the sample being potentially not representative of the bipolar disorder population are limitations. CONCLUSIONS: Findings from this study tend to confirm most of the differences previously observed among bipolar men and women. Furthermore, these results draw attention to the risks that may be specifically linked to gender differences in bipolar I patients.

Characteristics and profiles of bipolar I patients according to age-at-onset: findings from an admixture analysis.

BACKGROUND: Many studies have used admixture analysis to separate age-at-onset (AAO) subgroups in bipolar patients, but few have looked at the phenomenological characteristics of these subgroups, in order to find out phenotypic markers. METHODS: Admixture analysis was applied to identify the model best fitting the observed AAO distribution of a sample of 1082 consecutive DSM-IV bipolar I manic inpatients who were assessed for demographic, clinical, course of illness, comorbidity, and temperamental characteristics. RESULTS: The model best fitting the observed distribution of AAO was a mixture of three Gaussian distributions. We could identify three AAO subgroups: early, intermediate, and late age-at-onset (EAO, IAO, and LAO, respectively). Patients in the EAO subgroup were more often single young males exhibiting severe mania with psychotic features, a subcontinuous course of illness with substance use and panic comorbidity, more suicide attempts, and temperamental components sharing hypomanic features. Patients with LAO showed a less severe picture with more depressive temperamental components, alcohol use and comorbid general medical conditions. A less typical phenotype was present in IAO patients. LIMITATIONS: The following are the limitations of this study: retrospective design, and bias toward preferential enrollment of patients with manic predominant polarity. CONCLUSIONS: This study confirms that bipolar I disorder can be subdivided into three subgroups based on AAO distribution and shows that patients from these subgroups differ in phenotypes.

Efficiency of brief interventions on alcohol-related risks in occupational medicine.

AIM: To evaluate the effectiveness of brief interventions (BIs) in reducing alcohol use among hazardous drinkers consulting their occupational doctors. DESIGN: Randomized controlled trial with 12-month follow-up, conducted between November 2004 and September 2006. SETTING: Fifteen French regional occupational medicine centers with 147 doctors and 157 assistants who were trained in BI and screening with the AUDIT questionnaire. PARTICIPANTS: We invited 33,488 individuals to fill out AUDIT. These patients were eligible if their scores were 6-12 for women and 7-12 for men, indicating hazardous drinking without dependence (found in 7.1% of respondents). INTERVENTION: After randomization, BIs (informative advice using motivational approach, with 10-minute average duration) were performed by the occupational doctors. The control group received information booklets from the doctors' assistants. MEASUREMENTS: Situations were evaluated 12 months after inclusion. OUTCOME MEASURES: AUDIT scores, self-reported alcohol consumption (SRAC) and biological assays. The main criteria were the differences observed between groups for SRAC, the AUDIT score at follow-up, and any reduction in score between inclusion and final assessment. Success of intervention, which was defined as an AUDIT score below the hazardous drinking threshold at follow-up, was considered to analyze the variables associated with the efficiency of intervention. RESULTS: The analyzed sample included 787 persons, among whom 435 were met again 12 months later. In the BI group, we found a lower AUDIT score (p = 0.01), a higher reduction in reported consumptions (-60 g/week versus -44 g/week, p = 0.04) and in AUDIT scores (p = 0.009). In the control group, 44.8% reduced their AUDIT scores below hazardous drinking thresholds, as compared to 51.6% in the BI group (p = 0.15). Success was associated with a significant reduction in biological and clinical indices. CONCLUSIONS: Though the high attrition rate led to careful conclusions, BIs seem to be efficient in occupational medicine, in comparison with written information, which also seems to influence drinking behavior.

Methodological differences between pharmacological treatment guidelines for bipolar disorder: what to do for the clinicians?

OBJECTIVE: Numerous guidelines for bipolar disorder have been published. The aim of this article is to underline the main differences between consensus-based guidelines (CBG) and evidence-based guidelines (EBG) currently available for the management of bipolar disorder. METHODS: A literature search for guidelines published since 2006 was performed. A qualitative analysis was then conducted to compare the methodologies and the guidelines contents. RESULTS: Comparison between CBG and EBG found more similarities than differences. However, discordances were found in the first-line choice of treatment (monotherapy or combination, use of lamotrigine or lithium in bipolar depression), time to reassessment and duration of maintenance treatment, introduction as from the acute phase a regimen compatible with long-term use and pharmacotherapy during pregnancy. CONCLUSIONS: The choice of policy, whatever the methodology used, is up to the authors and can, therefore, depend on their interpretation of the available scientific evidence. Combining both methodologies (CBG and EBG) enables us to meet the complete definition of evidence-based medicine.

Evaluation of the safety and tolerability of rasagiline in the treatment of the early stages of Parkinson's disease.

OBJECTIVE: Rasagiline is a second-generation, irreversible MAO-B inhibitor (MAOB-I) previously shown to be efficacious and well-tolerated compared to placebo in the treatment of early Parkinson's disease (PD). ACTOR (ACceptabilité TOlérance Rasagiline) was a 15-week, multi-center, randomized, double-blind study aimed to assess the safety and tolerability of rasagiline compared to the dopaminergic agonist pramipexole in the treatment of early PD. METHODS: Patients with early, untreated idiopathic PD were randomized to receive 1 mg rasagiline (n = 53) or 1.5 mg pramipexole (n = 56) daily. The primary outcome was the number of patients experiencing a 'clinically important adverse event' (classified as a serious adverse event, an event leading to withdrawal or severe according to the patient). Safety outcomes were evaluated by the investigator and the patient. Analysis of the primary criterion was a comparative analysis using the chi-squared test. The Wilcoxon Mann-Whitney test was conducted to test the severity of patient-reported adverse events. Other tests performed include a covariance analysis and Student's t-tests. RESULTS: Mean disease duration was 3.4 months, and mean age was 62.6 years. Of patients taking pramipexole, 44.6% reported at least one 'clinically important' adverse event compared to 32.1% of patients taking rasagiline; non-inferiority of rasagiline was reached, with a difference in proportions of -12.6% [confidence interval of -27.8%; 2.6%]. There were no significant differences in clinical effectiveness between the treatments, measured by clinical and patient global impression of improvement (CGI-I, PGI-I) and PDQ-8 scales. A significant decrease in the incidence of gastrointestinal symptoms (p = 0.015) and sleep disorders (p = 0.027) was reported by physicians in the rasagiline group compared to the pramipexole group; the propensity to sleepiness improved significantly in the rasagiline group (p = 0.020), and worsened in the pramipexole group (p = 0.042). LIMITATIONS: Limitations of this study include the limited sample size due to the lower than anticipated recruitment and the accidental inclusion of a patient who had taken contraindicated medication. CONCLUSIONS: In this study, the safety profile of rasagiline had clinically favorable differences in gastrointestinal and sleep adverse events compared to pramipexole, whilst showing comparable clinician and patient-rated clinical effectiveness as a monotherapy for the treatment of early idiopathic PD.

Self-assessment and characteristics of mixed depression in the French national EPIDEP study.

BACKGROUND: Studies on mixed depression have been conducted so far on the basis of DSM-IV manic symptoms, i.e., a list of 7 symptoms which may provide limited information on the subsyndromal features associated with a full depressive episode. METHODS: As part of the EPIDEP National Multisite French Study of 493 consecutive DSM-IV major depressive patients evaluated in at least two semi-structured interviews 1 month apart, 102 (23.8%) were classified as mixed depressives (≥3 hypomanic symptoms), and 146 (34%) as pure depressives (0 hypomanic symptom), after exclusion of bipolar I patients; hypomanic symptoms were assessed with the Multiple Visual Analog Scales of Bipolarity (MVAS-BP, 26 items) of Ahearn-Carroll in a self assessment format. A narrower definition of mixed depression, resting on those MVAS-BP items referring to DSM-IV hypomanic symptoms was also tested, as a sensitivity analysis. RESULTS: Compared to pure depressives, mixed depressive patients had more psychotic symptoms, atypical features and suicide attempts during their index episode; their illness course was characterized by early age at onset, frequent episodes, rapid cycling, and comorbidities. Mixed depressive patients were more frequently bipolar with a family history of bipolar disorder, alcohol abuse, and suicide. A dose-response relationship was found between intradepression hypomania and several clinical features, including temperament measures. The following independent variables were associated with mixed depression: hyperthymic temperament, cyclothymic temperament, irritable temperament, and alcohol abuse. Using the narrower definition of mixed depression missed risk factors such as suicidality and comorbidities. LIMITATIONS: The following are the limitations of this study: retrospective design, recall bias, lack of sample homogeneity, no cross-validation of findings by hetero-evaluation of hypomanic symptoms. CONCLUSIONS: EPIDEP data showed the feasibility and face validity of self-assessment of intradepressive hypomania. They replicated previous findings on the severity and high suicidal risk of mixed depression profile. They confirmed, for mixed depression, that mixed states occur when mood episodes are superimposed upon temperaments of opposite polarity. They finally suggested that a definition of mixed depression only based on DSM-IV-TR hypomanic symptoms may not allow to identify the most unstable subforms of the entity.

GOSPEL: prospective survey of gout in France. Part I: design and patient characteristics (n = 1003).

OBJECTIVES: To assess diagnoses and management of acute and chronic gout in primary care and rheumatology settings relative to 2006 European League Against Rheumatism (EULAR) gout recommendations. Secondary objectives were to describe patient demographics, clinical features, lifestyle modifications, and short- and mid-term outcomes. METHODS: Prospective, cross-sectional, descriptive survey of patients with chronic gout, acute gout, or suspected gout, included by randomly selected general practitioners (GPs, n = 398) and rheumatologists (n = 109) between October 2008 and September 2009, in France. At the first visit, a structured questionnaire was completed. Each patient completed self-questionnaires at the first visit and 3 to 6 months later. RESULTS: We included 1003 patients, including 879 (87.6%) males (mean age, 61.6 ± 11.4 years; 28.1% obese) and 124 (12.4%) females (70.2 ± 11.9 years; 33.1% obese). Mean disease duration was 8.0 ± 8.3 years and mean time since hyperuricemia diagnosis 8.2 ± 8.4 years. Mean annual number of flares was 1.9 ± 1.5. ACR criteria for gout were met in 855 pts. Gout was acute in 487 (48.6%) patients and chronic in 241 (24.4%). Tophi (19.4% of patients) were associated with disease duration but not gender or chronic kidney disease (CKD). The main co-morbidities were hypertension (53.8%), dyslipidemia (47.2%), and hyperglycemia/diabetes mellitus (15.0%). CKD 3-5 was present in 43% of patients but was identified by physicians in only 5.2%. CKD severity was significantly associated with age, gender, hypertension, and diuretic use. CONCLUSION: This cohort will prove valuable for addressing the concordance with EULAR recommendations and for future studies of gout in everyday practice, most notably regarding metabolic syndrome, other co-morbidities, and identification of difficult-to-treat patients.

Health management of older persons with chronically medicated psychotic disorders: the results of a survey in France.

BACKGROUND: The medical care of elderly patients with psychotic disorders is a matter of major concern. The aim of the study was to investigate health conditions and treatment of elderly patients with psychotic disorders in France. METHODS: The SAGE (Schizophrenia AGEd) study (observational, cross-sectional) was a survey conducted among 123 physicians in France, regarding prescriptions of antipsychotic drugs in elderly patients (≥60 years) suffering from psychotic disorders. The survey was based on a questionnaire addressing the mental and somatic health management of the patients. RESULTS: Data from 930 patients (mean age: 70.4 years) were collected. Most patients (58.5%) suffered from schizophrenia, 20.8% had delusional disorder and 20.6% hallucinatory chronic psychosis (very-late-onset schizophrenia-like psychosis). 70.8% of them were outpatients, while 29.2% were inpatients. The severity of psychotic symptoms was assessed in 97.8% of patients, but cognitive function was only evaluated in 41.6%. Some 46.5% of patients were treated with atypical antipsychotics alone, 36.2% with classical antipsychotics alone and 17.3% received a combination of both, atypical and classical antipsychotics; 36.3% patients were given antiparkinsonian medication, of whom only 17.8% as preventive treatment; 51.1% of patients had somatic comorbidities, particularly cardiovascular disorders (34.0%). Evaluation of renal and/or liver function to adjust the dose of treatment was done in only 32.1% of patients. Over the previous 12 months, almost half of the patients had had no ECG, glycemia or creatininemia investigated and HDL-cholesterol and triglycerides were available for less than one-third of them. CONCLUSIONS: Antipsychotic and antiparkinsonian drug prescriptions in French aged psychotic patients follow only partially the clinical guidelines and recommendations of consensus conferences. Moreover, cognitive, cardiac and metabolic aspects are not fully managed as expected.

Breast cancer occurred after Hodgkin's disease: clinico-pathological features, treatments and outcome: analysis of 214 cases.

BACKGROUND: Secondary tumours (ST) represent a major concern in survivors of Hodgkin's disease (HD). Breast cancer (BC) is the most frequent ST among young treated women. MATERIAL AND METHODS: One hundred and eighty-nine women treated for HD by radiotherapy (RT) and/or chemotherapy (CT) subsequently developed 214 BCs. RESULTS: Median age at HD diagnosis was 25 years (34% were less than 20). Median interval between HD and BC was 18.6 years, with a 42-year median age at first BC. According to the TNM classification, there were 30 (14%) T0 (non palbable lesions), 86 (40%) T1, 56 (26%) T2, 13 (6%) T3T4 and 29 (14%) Tx. There were 25 (13.2%) contralateral BC. 160 (75%) and 15 (7%) tumours were infiltrating ductal and lobular carcinomas, 7 (3.3%) were other subtypes and 27 (22%) DCIS. The rate of axillary nodal involvement was 32%. Among 203 operated tumours, 79 (39%) were treated by breast conserving surgery (BCS), with RT in 56 (71%) cases. CT and hormonal treatment were delivered in 51% and 45% of the patients. With a 50-month median follow-up, local recurrence occurred in 12% of the tumours (9% after mastectomy, 21% after lumpectomy alone and 13.7% after lumpectomy with RT). Metastasis occurred in 47 (26%) patients. The risk factors were pN+, pT, high SBR grade and young age (< 50 years). The ten-year overall and specific survival rates were 53% and 63.5%, respectively. The ten-year specific survival rates were 79% for pT0T1T2, 48% for pT3T4 (p = 0.0002) and 79% for pN0 versus 38.5% for pN+ (p = 0.00026). Among 67 deaths, 43 (73%) were due to BC. CONCLUSION: Patients and physicians should be aware that BC is the most frequent secondary tumour in young women treated for HD. The new RT modalities (lower doses and involved fields) may decrease the risk in the future. However, these women require a careful monitoring as from 8 to 10 years after HD treatment, combining mammography, ultrasound and MRI according to several ongoing studies. BC with whole breast irradiation is feasible in some selected cases.

Impact of an educational program on the management of bipolar disorder in primary care.

OBJECTIVE: Government agencies and industry have recently undertaken educational programs for the management of bipolar disorder in primary care, but their medical impact is not well known. Therefore, we conducted a survey among general practitioners to evaluate the impact of the Bipolact Educational Program on the diagnosis and treatment of bipolar disorder. METHODS: A total of 45 general practitioners attending the Bipolact Educational Program (trained group) were compared with a control group of 50 untrained general practitioners on their ability to: (i) diagnose bipolar I and II disorders and (ii) treat bipolar disorder patients appropriately. RESULTS: Trained physicians, but not untrained physicians, showed a significant improvement (p < 0.0001, chi-square test) in the ability to identify patients as having bipolar I (from 10.4% to 28.8%) and bipolar II disorder (from 20.1% to 45.8%). This trend resulted in a strong decrease in nonidentified bipolar disorder patients (from 64.6% to 19.5%). Trained physicians, but not the untrained group, greatly increased the number of prescriptions for mood stabilizers for bipolar disorder patients, from 25.6% to 43.2% (p = 0.0013, chi-square test). Finally, trained physicians reduced the number of antidepressant prescriptions for bipolar disorder patients (the control group also reduced the number of antidepressant prescriptions, suggesting some bias in the survey). CONCLUSION: A well-designed education package on diagnosis and management of bipolar disorder greatly increased the likelihood of physicians correctly assigning a subtype, namely bipolar I or bipolar II disorder, to patients already perceived as having some form of bipolar illness, and to prescribing mood stabilizers instead of antidepressants to these patients.