[How to have a clear vision when considering all the different recommendations of moderate alcohol consumption?]. / Comment y voir clair face à toutes les recommandations relatives à la consommation d'alcool?

Although use of important amounts of alcohol has clearly been proven to have a negative health impact, large epidemiological studies show that a moderate quantity of alcohol might be beneficial in terms of total mortality, probably through cardiovascular protection. Many countries propose their own official recommandations with regard to moderate or low risk alcohol consumption. In this review, we compare some of these recommandations. Furthermore, risks and benefits of alcohol for the main groups of disease are analysed according to alcohol quantities and drinking patterns. Our final objective is to evaluate the small margin between potentially beneficial use of alcohol versus low risk use, and provide some practical recommandations for the physician advising an individual patient.

[What was new in ambulatory general internal medicine in 2011?]. / Nouveautés 2011 en médecine interne générale ambulatoire.

This review of articles published in 2011 covers a large spectrum of topics that are of interest for the practice of general internal medicine and of primary care. Authors discuss public health issues, such as sleep disorders and their relationship with subsequent weight disorders, and the benefits of commercial weight reduction programs. Clinical topics, such as the management of victims of sexual violence and screening strategies for lung cancer, streptococcal pharyngitis, functional bowel disorders and hypertension in ambulatory settings are also reviewed. Besides, authors cover therapeutic issues, such as the treatment of hand arthritis with chondroitin sulfate and the management of plantar warts with salicylic acids and cryotherapy.

[Urban health: the irremediable urbanization of life and medicine]. / Urban health: l'irrémédiable urbanisation de la vie et de la médecine.

Since 2007, the number of people living in cities exceeds that of rural areas. Thus, cities and their organizations have a major influence on all spheres of human life, especially health. This influence may generate inequality, suffering and disease, but also represent an opportunity for health and well-being. This paper introduces the concept of urban health, particularly in terms of primary care medicine and presents solutions that encompass a wide field (politics, urban planning, social inequality, education). Improving urban health requires collaboration of medical with non-medical actors, in order to become of development (re-) urban structure and promotes the health of all.

Systemic sclerosis and its pulmonary complications in The Netherlands: an epidemiological study.

UNLABELLED: The prevalence and incidence of systemic sclerosis (SSc) in The Netherlands is unknown. The same holds true for its leading causes of death: pulmonary fibrosis and pulmonary arterial hypertension (PAH), for which effective treatment options have recently become available. OBJECTIVE: To establish the prevalence and incidence of SSc and its pulmonary complications. METHODS: Detailed information on patients in the POEMAS registry, "Pulmonary Hypertension Screening, a Multidisciplinary Approach in Scleroderma", consisting of 819 patients, was combined with a nationwide questionnaire. RESULTS: By combining the two sources the prevalence of SSc was found to be 8.9 per 100 000 adults. The incidence was 0.77 patients per 100 000 per year. PAH was diagnosed in 9.9% of SSc patients. The prevalence of interstitial lung disease in SSc varied from 19% to 47% depending on the definition used. CONCLUSION: This study clarifies the epidemiology of SSc in The Netherlands and confirms the frequent occurrence of pulmonary complications, based on 654 cases. This can and will be studied further in the ongoing POEMAS study.

[Detecting psycho-active substance abuse: why, how and what for?]. / Dépister l'usage de substances psycho-actives: pourquoi, comment, et ensuite?

Misuse of psycho-active substances is frequent in primary care and concerns patients of all ages and conditions. Physicians should screen for use of such substances, especially in the case of tobacco dependence and/or clinical symptoms. Independently from the substance used (or from the behaviour), screening can be performed through clinical interviewing, focusing on the frequency and the quantity of the substance used, loss of control and its consequences, or through screening tools. Questionnaires (ASSIST; AUDIT; FACE) allow both screening and evaluation of the severity of misuse, guiding appropriate advice, treatment or referral to specialist. Motivational interviewing is the best option to discuss and induce behavioural changes.

[Practitioners confronted with the four main health behavioral risk factors]. / Le généraliste face aux quatre principaux facteurs de risque comportementaux.

Four behavioural risk factors are common in primary care and are often clustered in individuals. Smoking is present from I cigarette per day, excessive alcohol use is defined either by drinking regularly more than 2-3 standard glasses per day or by occasional heavy drinking of more than 4-5 glasses at a time. Patients who don't have regular moderate physical activity of at least 30 minutes during 5 days of a week or intensive physical activity of at least 20 minutes 3 times a week are sedentary. A Body Mass Index of over 30 defines obesity. We propose a "generic" counselling tool in 5 steps, the 5 As, that can be used for any of the four behavioural risk factors during routine consultations. With this counselling guide, practitioners can help patients change behaviour in a motivational style that allows shared decision-making.

Opioid antagonist detoxification under anaesthesia versus traditional clonidine detoxification combined with an additional week of psychosocial support: a randomised clinical trial.

BACKGROUND: While detoxification under anaesthesia accelerates the detoxification procedure, there is a lack of randomised clinical trials evaluating its effectiveness compared to traditional detoxification procedures, and a lack of data on long-term abstinence. METHODS: Prospective randomised clinical trial. Analysis by intention to treat and per protocol. SETTING: Specialised substance abuse unit in a psychiatric teaching hospital and an intensive care unit of a general hospital. PARTICIPANTS: Seventy patients with opiate mono-dependence requesting detoxification: 36 randomised to RODA (treatment as allocated received by 26) and 34 randomised to classical clonidine detoxification (treatment as allocated received by 21). MAIN OUTCOME MEASURES: Successful detoxification, safety and self-reported abstinence at 3, 6 and 12 months after detoxification. RESULTS: Socio-demographics were similar in both groups at baseline. No complications were reported during or after anaesthesia. According to the intention to treat analysis, 28/36 (78%) RODA patients and 21/34 (62%) of the clonidine group successfully completed the detoxification process (p=0.14). In the intention to treat analysis, 30% of RODA patients were abstinent after 3 months compared to 14% in the clonidine group (p=0.11). No difference was found at 6 and 12 months (both groups showed less than 5% abstinence after 12 months). The per-protocol analysis showed similar results with no statistical differences either for ASI mean scores or for the SF36 questionnaire. CONCLUSION: Although the detoxification success rate and abstinence after 3 months were slightly better for the RODA procedure compared to clonidine treatment, these differences were not statistically significant and disappeared completely after 6 and 12 months.

Patterns of opiate use in a heroin maintenance programme.

RATIONALE: Little is known about patterns of opiate use by heroin addicts. OBJECTIVES: To describe opiate use over time among heroin addicts who had access to legally prescribed intravenous heroin and oral opiates. METHODS: Analysis of daily drug administration records of 37 patients enrolled in the Geneva heroin maintenance programme for 4-29 months (total 23,136 patient-days). RESULTS: The average dose of intravenous heroin was 466 mg/day; the total opiate dose, after conversion of oral opiates to heroin-equivalents, was 543 mg/day. Patients received intravenous heroin only on 39% of days, oral opiates only on 7% of days, and mixed regimens on 49% of days; the remaining 4% of days were spent outside the programme, usually on oral opiates. The daily dose of heroin-equivalents increased during the first trimester in the programme, by 30 mg/day per month (95% confidence interval 12-46 mg/day per month), but decreased gradually thereafter, by 12 mg/day per month (95% confidence interval, 8-17 mg/day per month). In patients who alternated between heroin and methadone, 1 mg methadone typically replaced 4.1 mg heroin. During follow-up, five patients switched to methadone maintenance, five underwent detoxification, and three were discharged for noncompliance with regulations. CONCLUSIONS: Heroin users who have facilitated access to legally prescribed drugs consume about 0.5 g heroin per day. Consumption patterns vary, but the daily amount of opiates remains stable or decreases over time. A substantial minority of patients elect for alternative treatments after several months of heroin maintenance.

Inpatient opiate detoxification in Geneva: follow-up at 1 and 6 months.

The aim of this study was to identify predictors of treatment success and of relapse, 1 and 6 months after inpatient opiate detoxification in an 8-bed unit in Geneva. Of all 73 patients admitted between June 1994 and June 1995, a majority (73%) successfully finished opiate detoxification. Detoxification was performed mainly with methadone tapering; the average duration of hospitalisation was 15 days. Factors associated with treatment failure were: cocaine abuse, presence of legal problems, and short duration of hospital stay. After 1 month, 65% of the patients were using drugs (half of them were dependent again, half of them had used occasionally) and 35% were completely abstinent (21% when excluding those in residential treatment). Predictors of rapid relapse were cocaine abuse and little concern with own psychological situation at baseline. After 6 months, 50% were physically dependent again, 13% had lapsed occasionally, 37% were abstinent (28% when excluding those in residential treatment). Only high benzodiazepine use at baseline was associated with medium term abstinence. Addiction severity index composite scores had considerably improved between baseline and 6 months. Prevention of relapse to opiate use after inpatient detoxification, especially for those with a concurrent cocaine abuse, should be improved.

Do gender differences in CD4 cell counts matter?

OBJECTIVE: To examine the effect of gender on disease progression and whether gender differences in CD4 lymphocyte counts persisted for the entire course from HIV seroconversion until (death from) AIDS. METHODS: CD4 lymphocyte counts were modelled in 221 female and 443 male seroconverters following seroconversion, backwards from AIDS and backwards from death using regression analysis for repeated measurements. RESULTS: In the period before use of highly active antiretroviral therapy (HAART), progression to AIDS and to death were marginally slower in women than in men as assessed by proportional hazards analysis. Women seroconverted for HIV, developed AIDS and died at higher CD4 cell counts than men (women: 815, 146 and 44 x 10(6) cells/l, respectively; men: 727, 49 and 22 x 10(6) cells/l, respectively), although differences were only statistically significant at AIDS onset. Declines in CD4 lymphocyte counts were not significantly affected by gender and absolute differences between men and women were stable, with exception for the trajectory close to AIDS when the decline became steeper for men than women. CONCLUSION: These gender differences in CD4 lymphocyte counts suggest a delay of initiation of therapy in women compared with men (our model predicted that women reach the threshold of starting HAART at about 12 months later than men). If this delay unfavourably influences progression, treatment guidelines should be revised so that women can benefit equally from HAART.

Geographical variation in disease progression in HIV-1 seroconverted injecting drug users in Europe?

BACKGROUND: Human immunodeficiency virus (HIV) disease progression might vary by geographical region due to differences in the spectrum of HIV-related illnesses and (access to) health care. Therefore, the effect of geographical region, next to the effect of other potential cofactors, on disease progression in 664 injecting drug users (IDU) with documented HIV seroconversion from eight cohorts in Europe was studied. METHODS: Kaplan-Meier methods and Cox proportional hazards analysis were performed to assess the effect of geographical region, other sociodemographics, drug use and repeated HIV exposure on progression from HIV seroconversion to immunosuppression, AIDS and death with AIDS. We considered the confounding effect of study-design related factors (e.g. setting of follow-up), and accounted for pre-AIDS death from natural causes by imputing when each endpoint would have occurred, had they not died without AIDS. RESULTS: Estimates of progression to AIDS and death with AIDS were substantially faster after taking pre-AIDS mortality into account. Median incubation time from seroconversion to the first CD4 count < 200 cells/microliter was 7.7 years (95% CI: 7.1-8.3) and to AIDS 10.4 years (95% CI: 9.8-infinity). The 10-year survival was 70.3% (95% CI: 62.8-76.6). The relative hazards (RH) of AIDS for IDU from central and southern Europe compared with IDU from northern Europe was 1.9 (95% CI: 1.2-3.0) and 1.2 (95% CI: 0.6-2.3), respectively, before, and 1.5 (95% CI: 0.7-3.2) and 1.1 (95% CI: 0.6-2.3) after taking differences in study-design related factors into account. Accounting for these factors, the RH of death with AIDS was 0.9 (95% CI: 0.3-2.5) for central and 1.2 (95% CI: 0.4-3.4) for southern Europe compared with northern Europe. For the first CD4 count < 200 cells/microliter these figures were 0.8 (95% CI: 0.5-1.4) and 0.8 (95% CI: 0.5-1.4). Age at seroconversion was the strongest predictor of disease progression. No statistically significant differences in disease progression were found by gender, foreign nationality, drug use and potential repeated HIV exposure. CONCLUSIONS: We found no evidence for regional variability in HIV disease progression among European IDU. Future studies evaluating geographical differences should consider the confounding effect of study-design related factors and differential non-AIDS mortality. As age is an important determinant of disease progression, it should be considered in recommending treatment.

Substance abuse and drug-related death, suicidal ideation, and suicide: a review.

The high mortality rate among drug users, which is partly due to the HIV epidemic and partly due to drug-related accidental deaths and suicides, presents a major public health problem. Knowing more about prevalence, incidence, and risk factors is important for the development of rational preventive and therapeutic programs. This article attempts to give an overview of studies of the relations between substance abuse, suicidal ideation, suicide, and drug-related death. Research in this field is hampered by the absence of clear definitions, and results of studies are rarely comparable. There is, however, consensus about suicidal ideation being a risk factor for suicide attempts and suicide. Suicidal ideation is also a predictor of suicide, especially among drug users. It is correlated with an absence of family support, with the severity of the psychosocial dysfunctioning, and with multi-drug abuse, but also with requests for treatment. Every clinical examination of a drug user, not only of those who are depressed, should address the possible presence of suicidal ideation, as well as its intensity and duration.

Prevalence and incidence rate of HIV, hepatitis B and C among drug users on methadone maintenance treatment in Geneva between 1988 and 1995.

OBJECTIVES: To evaluate the prevalence and incidence rates of infection with HIV, hepatitis B (HBV) and hepatitis C (HCV), in a cohort of drug users (DU) in Geneva, Switzerland. DESIGN: Prospective open cohort study. SETTING: Private methadone maintenance treatment (MMT) programme. PATIENTS, PARTICIPANTS: Over 700 DU in treatment between 1988 and 1995 were tested biannually for HIV, HBV and HCV infection. INTERVENTION: None. MAIN OUTCOME MEASURE: Prevalence for HIV, HBV and HCV at study entry, determined by gender, by injection behaviour, by year of start of MMT and incidence rates for HIV, HBV and HCV, assuming equal risk of seroconversion on each day of the interval between last negative and first positive test. RESULTS: The prevalence at entry into treatment declined dramatically over time for all three viruses. Comparing DU entering treatment before 1988 to those entering treatment after 1993, the prevalence of HIV was 38.2% versus 4.5%, of HBV 80.5% versus 20.1%, and of HCV 91.6% versus 29.8%, respectively. Follow-up rate was 80%. The incidence rates for HIV and HBV were 0.6% and 2.1% per person-year of follow-up, respectively. For HCV the rate was higher (4.2%) especially among women (9.6%). CONCLUSION: These data suggest that DU have changed HIV risk-taking behaviour in response to HIV prevention campaigns. Current prevention efforts should focus on improvement of HCV prevention, identification of high-risk individuals and maintaining safe behaviour.

Treatment failure and methadone dose in a public methadone maintenance treatment programme in Geneva.

The aim of this study was to identify predictors of treatment failure in a methadone maintenance treatment programme in Geneva. All patients (n = 149) starting treatment between May 1993 and May 1995 were followed until end of treatment or 31st July 1996. The proportion of depressed patients decreased significantly over time, as did the proportion of those injecting illegal drugs. The overall treatment failure was 21%. The probability of treatment failure was higher for women than for men (RR 2.2, P = 0.03) and decreased in successive cohorts. There was no correlation between the methadone dose at 2 months and treatment outcome, probably because doses were individualised and the associated level of psycho-social services high.