[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.

Low exposure to sunlight is a risk factor for Crohn's disease.

BACKGROUND: Low sunshine exposure might contribute to the pathogenesis of inflammatory bowel disease (IBD). AIM: To assess the geographic distribution of IBD incidence in relation to sunshine exposure in France to test the hypothesis that higher sun exposure is associated with lower IBD risk. METHODS: Using the national health insurance database, incidence rates of Crohn's disease (CD) and ulcerative colitis (UC) were estimated for each of the 94 French administrative areas ('départements'), between 2000 and 2002. The surface UV radiation intensity was obtained by combining modelling and satellite data from Meteosat, the European meteorological satellite. Relationships between incidence rates and sun exposure were tested for significance by using a Poisson regression. We mapped smoothed relative risks (sRR) for CD and UC, using a Bayesian approach and adjusting for sun exposure, to search for geographical variations. RESULTS: Areas with a smoothed RR of CD incidence significantly above 1 corresponded to areas with low sunshine exposure, whereas those with high or medium sunlight exposure had smoothed RRs either lower than 1 or not significantly different from 1. There was no association between sun exposure and UC incidence. CONCLUSIONS: This geographic study suggests that low sunlight exposure is associated with an increased incidence of Crohn's disease. Further studies are needed to determine if this association is causal.

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.

Influence of medial meniscectomy on tibiofemoral joint space width.

OBJECTIVE: The aim of this study was to evaluate the influence of partial medial meniscectomy on tibiofemoral joint space width (JSW). DESIGN: Thirty-seven patients (mean age: 51 years), suffering from medial meniscal lesions, (post-traumatic (n=22) or degenerative (n=15)), and requiring arthroscopic partial meniscectomy, were enrolled in a prospective, controlled study. Bilateral weight-bearing radiographs in extended and flexed position were performed in the same Radiology Unit just before and 2 days after meniscectomy. During arthroscopy, the extent of meniscectomy was evaluated in percentage and medial chondropathy was quantified using the Société Française d'Arthroscopie (SFA) scoring system (SFA score: 0-100). Medial chondropathy was absent or mild (mean SFA score: 8+/-13). Meniscectomy removed an average of 61% of the posterior third of the medial meniscus, 51% of the middle third and 22% of the anterior third. Radiographs, before and after meniscectomy, were read singly and were analyzed by a single reader unaware of patient identity and date of radiographs. Medial JSW was measured at the narrowest point of the medial compartment using a 0.1mm graduated magnifying glass. RESULTS: Comparison of JSW before and after meniscectomy did not show any statistically significant difference (mm): 0.01+/-0.43 (p=0.83) and -0.05+/-0.56 (p=0.66) in the extended and flexed views, respectively. CONCLUSION: This preliminary study suggests that partial medial meniscectomy does not influence tibiofemoral JSW on weight-bearing X-rays. Consequently, joint space narrowing appearing after partial meniscectomy should lead to seeking postmeniscectomy cartilage degradation rather than being attributed to removal of the meniscus.

Type 2 diabetes mellitus among beneficiaries of the french national health insurance for self-employed workers (AMPI): comparison of the management of craftsmen or tradesmen with professionals patients.

BACKGROUND: Although the management of diabetes mellitus varies according to non medical factors, the influence of socioprofessional category has been not fully studied. This study compared the management of type 2 diabetes mellitus in craftsmen or tradesmen with professionals categories. METHODS: All claims to the French National Sickness Insurance Fund for self-employed workers (AMPI) from its mainland France beneficiaries in 1998 were retrospectively analysed. Patients were beneficiaries, insured or dependants of craftsmen or tradesmen, or professionals receiving oral hypoglycemic drugs during a 3-month inclusion period. Patients were compared on the proportion of care received in private practice over the preceding 12 months using adjusted odds ratio (OR). RESULTS: Compared to patients in professionals (n=1,456), patients in craftsmen or tradesmen (n=35,703) were statistically more likely to see a general practitioner (OR 3.867, 95% CI=3.048; 4.907), to have blood glucose test (OR 1.530, 95% CI=1.332; 1.757) and serum creatinine assay (OR 1.207, 95% CI=1.052; 1.270). They were statistically less likely to consult or have a specialist procedure (ophthalmologist, OR 0.792, 95% CI=0.698; 0.900; cardiologist, OR 0.749, 95% CI=0.658; 0.852; dentist, OR 0.679, 95% CI=0.596; 0.773; endocrinologist, OR 0.522, 95% CI=0.424; 0.642), microalbuminuria test (OR 0.749, 95% CI=0.622; 0.902) and serum creatinine assay or microalbuminuria test (OR 0.746, 95% CI=0.611; 0.912). The two groups did not differ on HbA1c, blood lipid tests and electrocardiogram. CONCLUSIONS: The management of type 2 diabetes mellitus differed between craftsmen or tradesmen and professionals patients. These results should be confirmed.

Measurement of joint space width in hip osteoarthritis: influence of joint positioning and radiographic procedure.

OBJECTIVES: We assessed the influence of patient positioning and radiographic procedure, and defined a smallest detectable difference (SDD) in hip osteoarthritis (OA). METHODS: OA hip patients each had a standardized pelvic radiograph and, 5 min later, a modified pelvic radiograph with the feet internally rotated 5 degrees (part 1 of the study), the X-ray beam centred on the umbilicus (part 2), or another standardized pelvic radiograph (part 3). RESULTS: Corresponding mean differences in joint space width (JSW) measurements (limits of agreement) between views were +0.03 (-0.53 to +0.59), -0.31 (-1.15 to +0.53) and -0.02 (-0.48 to +0.44) mm. The two views differed significantly in mean JSW in part 2 of the study (P=1.6x10(-4)), but not in part 1 (P=0.375) and part 3 (P=0.580). The SDD estimate was 0.46 mm. CONCLUSIONS: Modifying the X-ray beam and foot rotation increases variability in JSW measurements. Use of urograms to evaluate radiological progression should be avoided. A change greater than 0.46 mm could define radiological hip OA progression.

Effect of multifaceted intervention promoting early switch from intravenous to oral acetaminophen for postoperative pain: controlled, prospective, before and after study.

PROBLEM: Need to improve the efficiency of postoperative pain management by early switching from intravenous to oral acetaminophen. DESIGN: Implementation of local guidelines aimed at improving nurses' and doctors' behaviour. A controlled, prospective, before and after study evaluated its impact on appropriateness and costs. BACKGROUND AND SETTING: Orthopaedic surgery department (intervention) and all other surgical departments (control) of a university hospital. Five anaesthetists and 30 nurses of orthopaedic department participated in study. KEY MEASURES FOR IMPROVEMENT: Reducing number of acetaminophen injections per patient, reducing consumption of acetaminophen injections; cost savings over a one year period. STRATEGIES FOR IMPROVEMENT: Multifaceted intervention included a local consensus process, short educational presentation, poster displayed in all nurses' offices, and feedback of practices six months after implementation of guidelines. EFFECTS OF CHANGE: Mean number of acetaminophen injections per patient decreased from 6.81 before intervention to 2.36 six months after. Monthly consumption of acetaminophen injections per 100 patients decreased by 320.9 (95% confidence interval 192.4 to 449.4) in intervention department and remained unchanged in control departments. Annual cost reduction was projected to be pound 15,100. LESSONS LEARNT: Simple and locally implemented guidelines can improve practices and cut costs. Educational interventions can improve professionals' behaviour when they are based on actual working practices, use interactive techniques such as discussion groups, and are associated with other effective implementation strategies.

Radiographic assessment of hip osteoarthritis progression: impact of reading procedures for longitudinal studies.

OBJECTIVE: To compare radiographic reading procedures and evaluate their impact on sample size in hip osteoarthritis (OA) longitudinal studies. METHODS: Pelvic radiographs performed twice, three years apart, in 104 patients with hip OA were read by a single reader using the Kellgren and Lawrence system, joint space narrowing scale, and joint space width (JSW). Reading procedures were (a) films read as single radiographs, (b) films grouped by patient but read in random order, (c) films grouped by patient and chronologically ordered, all with landmarks for JSW measurements, (d) films read as single radiographs, without landmarks for JSW measurements. JSW was measured at the narrowest point with a 0.1 mm graduated magnifying glass. RESULTS: More Kellgren and Lawrence or joint space narrowing grades were modified respectively with the single (42% and 37%) than with the paired (32% and 23%) or chronologically ordered (34% and 29%) reading procedures. Variability of JSW progression was principally related to mean progression (88.3%) and landmarks (almost 10%). Standardised response means were -0.71 with the paired reading procedure with landmarks, -0.68 with the single reading procedure with landmarks, -0.65 with the single reading procedure without landmarks. With landmarks, 10% more patients would be needed using single than paired reading. Using single reading, 10% more patients would be needed without landmarks than with landmarks. CONCLUSION: Kellgren and Lawrence grading seems to be influenced by the reading procedure, as is joint space narrowing grading, for assessing hip OA. Paired reading procedure with landmarks for JSW should be recommended in longitudinal studies.

Assessing smallest detectable change over time in continuous structural outcome measures: application to radiological change in knee osteoarthritis.

Interpreting changes in continuous structural outcome measures is a common problem in clinical research and in daily practice. We propose a method for estimating whether difference observed between two successive measures in an individual constitutes a statistically relevant change or a change induced by variability. This statistically relevant change is based on an analysis of reproducibility. The continuous structural outcome measure investigated as an example was joint space width (JSW) measurement on standard X-rays, which is known to be the primary end-point for assessing structural osteoarthritis progression. The results of the present study demonstrate that cutoffs are closely dependent on all sources of variabilities in JSW measurement such as joint positioning, radiographic procedure, and the measurement process itself. Therefore, we suggest to determine cutoffs for each study using a representative sample of the population studied and using the procedures and methods of measurement of the specific study. This approach may easily be extended to other continuous structural outcome measures.

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.

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.

Capacity of the clinical picture to characterize low back pain relieved by facet joint anesthesia. Proposed criteria to identify patients with painful facet joints.

STUDY DESIGN: Prospective randomized study to compare the efficacy of facet joint injection with lidocaine and facet joint injection with saline in two groups of patients with low back pain, with and without clinical criteria that were determined in a previous study to implicate the facet joint as the primary source of the pain. OBJECTIVES: To assess the efficacy of single facet joint anesthesia versus placebo (saline injections) and to determine clinical criteria that are predictive of significant relief of LBP after injection. SUMMARY OF BACKGROUND DATA: There is no syndrome that discriminates between lower back pain caused by facet joint and that caused by other structures. Single or double facet joint anesthesia, and single photon emission computed tomography are expensive and time-consuming procedures for selecting patients in controlled clinical trials with large populations. METHODS: Results of a previous study showed that seven clinical characteristics were more frequent in patients who responded to facet joint anesthesia than in those who did not. In the current study, a group of 43 patients with lower back pain who met at least five criteria were compared with 37 patients who met fewer criteria. Patients randomly received injection of either lidocaine or saline into the lower facet joints. The result was considered positive if more than 75% pain relief was determined by visual analog scale. The patient, the radiologist, and the investigator were blinded. An analysis of variance was used to seek an interaction between clinical group effect and injection effect, and logistic regression analysis to select the best set of variables that would be predictive of minimum pain relief of 75% after the injection. RESULTS: There was a significant interaction between clinical group and injection effect (P = 0.003). In patients with back pain, lidocaine provided greater lower-back pain relief than saline (P = 0.01). Lidocaine also-provided greater pain relief in the back pain group than in the nonpain group (P = 0.02). The presence of five among seven variables (age greater than 65 years and pain that was not exacerbated by coughing, not worsened by hyperextension, not worsened by forward flexion, not worsened when rising from flexion, not worsened by extension-rotation, and well-relieved by recumbency), always including the last item, distinguished 92% of patients responding to lidocaine injection and 80% of those not responding in the lidocaine group. CONCLUSIONS: A set of five clinical characteristics can be used in randomized studies to select lower back pain that will be well relieved by facet joint anesthesia. These characteristics should not, however, be considered as definite diagnostic criteria of lower back pain originating from facet joints.

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%.

Quantitative MR imaging evaluation of chondropathy in osteoarthritic knees.

PURPOSE: To determine the validity and the reliability of T1-weighted three-dimensional gradient-echo magnetic resonance (MR) imaging for quantification of articular cartilage abnormalities of osteoarthritic knees. MATERIALS AND METHODS: Forty-three patients (mean age, 63 years) with knee osteoarthritis (American College of Rheumatology criteria) of the medial tibiofemoral compartment underwent a prospective, cross-sectional study. Knees were examined with a T1-weighted three-dimensional gradient-echo sequence (1.4-mm contiguous sections), with use of a 0.2-T dedicated MR unit, before arthroscopic exploration. The tibiofemoral articular cartilage abnormalities were quantified blindly on both the MR and arthroscopic images with the French Society of Arthroscopy (SFA) score (0-100) and grading scheme (five grades). RESULTS: There was a statistically significant correlation between the SFA-arthroscopic score and the SFA-MR score (r = .83) and between the SFA-arthroscopic grade and the SFA-MR grade (weighted kappa = 0.84). The deepest cartilage lesions graded with arthroscopy and MR imaging showed correlation in the medial femoral condyle (weighted kappa = 0.83) and in the medial tibial plateau (weighted kappa = 0.84). The intraobserver reliability of the SFA-MR score was higher (r = .94) than the interobserver reliability (r = .80). CONCLUSION: Quantification of chondropathy with MR imaging is feasible and well correlated with anatomic cartilage breakdown.

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.

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.

Effect of psoas training on postmenopausal lumbar bone loss: a 3-year follow-up study.

The present study completed a previous randomized trial that demonstrated the protective effect of 1-year psoas training on lumbar bone loss in postmenopausal women. Computerized tomography had been carried out at the beginning (CT1) and at the end (CT2) of this trial. In the present study, 67 women having completed the first trial were asked to practice psoas exercises (60 hip flexions in sitting position with a 5 kg weight on the knee) for 2 additional years with a third CT control at the end of this period (CT3). The aim of this complementary study was to assess the compliance rate and long-term effect on bone of daily psoas muscle training over a longer period. Twenty-one women performed this daily psoas training for 3 years from CT1 to CT3, and 14 acted as controls during the same period. Fourteen women were controls during the first year (from CT1 to CT2) but practiced psoas training during the following 2 years (from CT2 to CT3). Four women were psoas trained during the first year (from CT1 to CT2) and subsequently crossed over to the control group for the last 2 years. The compliance rate was 42%, with an attendance rate of 88%. The lumbar bone loss was lower in the 21 women trained over the 3 years (-3.26 +/- 28.45 mg/cm3) than in the 14 untrained women (-16.79 +/- 8.51 mg/cm3) (P = 0.02). The bone loss was not significantly reduced between the two periods of the study in the 12 women having been controls from CT1 to CT2 and having crossed over to the active training group from CT2 to CT3. Psoas training may be effective against lumbar bone loss. We conclude that specific training may play a contributing role in the preventive strategy to avoid osteoporosis.

[Causes and evolutive profiles of osteoarthrosis]. / Causes et profils évolutifs des arthroses.

In osteoarthritis, risk factors, clinical expression and outcome are greatly heterogeneous. This heterogeneity is observed not only from one subject to another but depends also on the site of osteoarthritis. Risk factors are not necessarily the same as those marking a worse prognosis. For these factors, general risk factors influencing or marking a generalized predisposition to the condition and local risk factors resulting on abnormal biomechanical loading at specific joint sites must be distinguished.

Assessment of joint space width in patients with osteoarthritis of the knee: a comparison of 4 measuring instruments.

OBJECTIVE: To evaluate the intra and interobserver reproducibility of 4 measuring instruments for assessing joint space width in knee osteoarthritis (OA) and to estimate the effects of patients, instrument, session order, and reader variation. METHODS: We studied 30 patients with unilateral tibiofemoral OA selected to represent a broad range of radiographic changes. Joint space width (JSW) was measured on plain anteroposterior weight bearing radiographs. Using an experimental design, 3 readers assessed JSW 3 times with 4 measuring instruments (ruler, caliper, graduated magnifying glass, digitized assessment). RESULTS: Intra and interobserver reproducibility was high with all measuring instruments (intraclass correlation coefficients from 0.95 to 0.98 and from 0.91 to 0.97, respectively). Analysis of variance (ANOVA) showed a patient effect (p < 10(-6)), a reader effect (p = 0.0001), an instrument effect (p = 0.0001), and a session order effect (p = 0.04). The variance component estimates were patients 55%, readers 34%, session order 2%, instruments 8%. ANOVA performed separately for each instrument showed that session order differences always represented less than 1% of the total variance. The reader component accounted for 0% of the total variance for the ruler, 2% for the digitized method, 16% for the caliper, and 18% for the graduated magnifying glass. CONCLUSION: Ruler and digitized assessment have better reliability than caliper and graduated magnifying glass.