[Antipsychotic prescription assessment in general practice: metabolic effects]. / Évaluation de la prescription d'antipsychotiques en médecine générale: conséquences métaboliques.

INTRODUCTION: Second-generation antipsychotics have improved living conditions of patients affected by severe mental illness. Some of them can induce weight gain with metabolic complications. Furthermore, they are prescribed to vulnerable patients, with comorbidity and high cardiovascular mortality rate. Prevention of a metabolic syndrome by simple measures improves patient's physical health. General practitioners are privileged partners for psychiatrists. OBJECTIVES: This study was conducted to assess the prevention and management of a metabolic syndrome in patients treated with antipsychotics in general practice. With this in mind, at first we needed to explore how general practitioners prescribe antipsychotics. METHODS: To assess the general practice, we interviewed 204 general practitioners in the Hauts-de-Seine. Our database was the yellow pages of this area (September 2007). We then conducted a random draw using random digits. We called 507 general practitioners, 410 of whom were sent a questionnaire. We received the return of 204 questionnaires. Each questionnaire consisted of four parts: the general practitioner's profile, psychiatry in his/her practice, the prescription of antipsychotics and the management of metabolic syndromes in patients treated with antipsychotics. RESULTS: The general practitioner's response rate was 49.7%. The results show that although they prescribe antipsychotics, general practitioners need more information on these molecules and on their side effects. Indeed 57% of them feel they are not given enough information on antipsychotics, but 69% have already initiated antipsychotic treatment and 17% do so regularly. Furthermore, a metabolic syndrome is insufficiently detected by general practitioners, although they know of its prevalence after the introduction of antipsychotic treatment. Thus, 81% reported having been confronted with this problem, but only 54% of them calculated the body mass index of patients taking antipsychotics, and 26% measured waist circumference. These results are consistent with studies tracking metabolic syndrome performed in all patients, so, general practitioners do not conduct specific monitoring of patients on antipsychotics. However, they are faced with difficulties related to adherence to treatment because of weight gain. In such cases, 16% of respondents start a new treatment, without a psychiatrist's opinion. These results confirm the results of previous studies on the risks of such prescriptions in general practice, when not supervised. CONCLUSION: In conclusion, we suggest that information of general practitioners about their role in prevention of metabolic syndromes should be improved, and psychiatrists and general practitioners should be informed on the necessity of joint care of patients affected by severe mental illness.

[Drawing up guidelines for the attendance of physical health of patients with severe mental illness]. / Elaboration de recommandations pour le suivi somatique des patients atteints de pathologie mentale sévère.

INTRODUCTION: Having a mental illness has been and remains even now, a strong barrier to effective medical care. Most mental illness, such as schizophrenia, bipolar disorder, and depression are associated with undue medical morbidity and mortality. It represents a major health problem, with a 15 to 30 year shorter lifetime compared with the general population. METHODS: Based these facts, a workshop was convened by a panel of specialists: psychiatrists, endocrinologists, cardiologists, internists, and pharmacologists from some French hospitals to review the information relating to the comorbidity and mortality among the patients with severe mental illness, the risks with antipsychotic treatment for the development of metabolic disorders and finally cardiovascular disease. The French experts strongly agreed on these points: that the patients with severe mental illness have a higher rate of preventable risk factors such as smoking, addiction, poor diet, lack of exercise; the recognition and management of morbidity are made more difficult by barriers related to patients, the illness, the attitudes of medical practitioners, and the structure of healthcare delivery services; and improved detection and treatment of comorbidity medical illness in people with severe mental illness will have significant benefits for their psychosocial functioning and overall quality of life. GUIDELINES FOR INITIATING ANTIPSYCHOTIC THERAPY: Based on these elements, the French experts propose guidelines for practising psychiatrists when initiating and maintaining therapy with antipsychotic compounds. The aim of the guidelines is practical and concerns the detection of medical illness at the first episode of mental illness, management of comorbidity with other specialists, family practitioner and follow-up with some key points. The guidelines are divided into two major parts. The first part provides: a review of mortality and comorbidity of patients with severe mental illness: the increased morbidity and mortality are primarily due to premature cardiovascular disease (myocardial infarction, stroke...).The cardiovascular events are strongly linked to non modifiable risk factors such as age, gender, personal and/or family history, but also to crucial modifiable risk factors, such as overweight and obesity, dyslipidemia, diabetes, hypertension and smoking. Although these classical risk factors exist in the general population, epidemiological studies suggest that patients with severe mental illness have an increased prevalence of these risk factors. The causes of increased metabolic and cardiovascular risk in this population are strongly related to poverty and limited access to medical care, but also to the use of psychotropic medication. A review of major published consensus guidelines for metabolic monitoring of patients treated with antipsychotic medication that have recommended stringent monitoring of metabolic status and cardiovascular risk factors in psychiatric patients receiving antipsychotic drugs. There have been six attempts, all published between 2004 and 2005: Mount Sinai, Australia, ADA-APA, Belgium, United Kingdom, Canada. Each guideline had specific, somewhat discordant, recommendations about which patients and drugs should be monitored. However, there was agreement on the importance of baseline monitoring and follow-up for the first three to four months of treatment, with subsequent ongoing reevaluation. There was agreement on the utility of the following tests and measures: weight and height, waist circumference, blood pressure, fasting plasma glucose, fasting lipid profile. In the second part, the French experts propose guidelines for practising psychiatrists when initiating and maintaining therapy with antipsychotic drugs: the first goal is identification of risk factors for development of metabolic and cardiovascular disorders: non modifiable risk factors: these include: increasing age, gender (increased rates of obesity, diabetes and metabolic syndrome are observed in female patients treated with antipsychotic drugs), personal and family history of obesity, diabetes, heart disease, ethnicity as we know that there are increased rates of diabetes, metabolic syndrome and coronary heart disease in patients of non European ethnicity, especially among South Asian, Hispanic, and Native American people. Modifiable risk factors: these include: obesity, visceral obesity, smoking, physical inactivity, and bad diet habits. Then the expert's panel focussed on all the components of the initial visit such as: family and medical history; baseline weight and BMI should be measured for all patients. Body mass index can be calculated by dividing weight (in kilograms) by height (in meters) squared; visceral obesity measured by waist circumference; blood pressure; fasting plasma glucose; fasting lipid profiles. These are the basic measures and laboratory examinations to do when initiating an antipsychotic treatment. ECG: several of the antipsychotic medications, typical and atypical, have been shown to prolong the QTc interval on the ECG. Prolongation of the QTc interval is of potential concern since the patient may be at risk for wave burst arrhythmia, a potentially serious ventricular arrhythmia. A QTc interval greater than 500 ms places the patient at a significantly increased risk for serious arrhythmia. QTc prolongation has been reported with varying incidence and degrees of severity. The atypical antipsychotics can also cause other cardiovascular adverse effects with, for example, orthostatic hypotension. Risk factors for cardiovascular adverse effects with antipsychotics include: known cardiovascular disease, electrolyte disorders, such as hypokaliemia, hypomagnesaemia, genetic characteristics, increasing age, female gender, autonomic dysfunction, high doses of antipsychotics, the use of interacting drugs, and psychiatric illness itself. In any patient with pre-existing cardiac disease, a pre-treatment ECG with routine follow-up is recommended. CONCLUDING REMARKS: Patients on antipsychotic drugs should undergo regular testing of blood sugar, lipid profile, as well as body weight, waist circumference and blood pressure, with recommended time intervals between measures. Clinicians should track the effects of treatment on physical and biological parameters, and should facilitate access to appropriate medical care. In order to prevent or limit possible side effects, information must be given to the patient and his family on the cardiovascular and metabolic risks. The cost-effectiveness of implementing these recommendations is considerable: the costs of laboratory tests and additional equipment costs (such as scales, tape measures, and blood pressure devices) are modest. The issue of responsibility for monitoring for metabolic abnormalities is much debated. However, with the prescription of antipsychotic drugs comes the responsibility for monitoring potential drug-induced metabolic abnormalities. The onset of metabolic disorders will imply specific treatments. A coordinated action of psychiatrists, general practitioners, endocrinologists, cardiologists, nurses, dieticians, and of the family is certainly a key determinant to ensure the optimal care of these patients.

Prognostic factors in cervical lymph node metastasis in upper respiratory and digestive tract carcinomas: study of 1,713 cases during a 15-year period.

A prospective study of 1,713 patients with squamous cell carcinoma of the head and neck submitted to neck dissection between 1957 and 1973 is presented. We confirm the prognostic significance of the histological analysis of the nodal metastasis. Capsular rupture is the most important factor regardless of the primary site or tumor size. The presence of tumor emboli within lymphatics, the number of invaded nodes, and the number of nodes with capsular rupture are of significance though to a lesser extent. Classification of the clinical characteristics or the nodes provided, in 70% of the patients, a good prediction of histological involvement. In the clinical estimation of histological invasion, an important parameter is the size of the largest node detected, and we suggest this characteristic should be included in the TNM classification of UICC.

Elective versus therapeutic radical neck dissection in epidermoid carcinoma of the oral cavity: results of a randomized clinical trial.

This study concerns 75 patients with squamous cell carcinoma of the oral cavity who were patients at the Gustave-Roussy Institute between December 1966 and July 1973. These patients were divided into two groups. The first group was comprised of 39 patients who underwent elective radical neck dissection; nodal involvement was present in 49% with capsular rupture in 13%. In the second group of 36, neck disease appeared during follow up in 19 cases. Therapeutic radical neck dissection was carried out in 17; the nodes were histologically positive in 15, 9 of which had a capsular rupture. In 2 cases, local or general conditions did not permit operative intervention. In this group, the involvement rate was 47% with a 25% capsular rupture rate. However, the comparison of the survival curves by the log-rank test did not reveal any differences, even though histologic prognostic factors were taken into account. These findings led to the conclusion that in squamous cell carcinoma of the oral cavity staged T1N0, T2N0, or T3N0 (from AJC's and UICC's clinical staging system), it seems possible, without risk, to delay neck dissection until a node is detectable, although it is reasonable to perform elective neck dissection in those cases in which the patient is unavailable for regular followup.