Five-Year Follow-Up of Diabetic Complications and Geriatric Alterations in French Older Patients with Type 2 Diabetes According to Treatment Modalities: The Observational Prospective GERODIAB Cohort

BACKGROUND

Little is known about clinical events occurring in older patients with type 2 diabetes mellitus according to their therapeutic modalities based on the prescription of insulin and/or oral antidiabetic drugs.

OBJECTIVE

The aim of this study was to compare the complications of diabetes and geriatric alterations that occurred according to three therapeutic modalities prescribed over 5 years.

METHODS

A total of 616 patients from the GERODIAB cohort (mean age 77.1 years) were divided into three groups: an insulin-only group (n = 200), a group receiving insulin and one or more oral antidiabetic drug (n = 169), and an oral antidiabetic drug group without insulin (n = 247). We compared the diabetic complications and geriatric alterations that occurred over 5 years in patients without these pre-existing complications.

RESULTS

At inclusion, there was a significant difference between glycosylated hemoglobin values, and between the frequencies of most diabetic complications and geriatric alterations, with higher frequencies in the insulin group and lower frequencies in the oral antidiabetic drug group. At the end of the follow-up, there was still a significant difference between the mean glycosylated hemoglobin of the three groups (mean for all patients 7.4 ± 0.8%). The frequencies of new clinical events were high and they were generally higher in the insulin group. They were not significantly different between the three groups, with the exception of four events: heart failure, retinopathy, transfer to a nursing home (more frequent in the insulin group), and hypoglycemia (more frequent in the insulin + oral antidiabetic drug group). Some frequencies of the total diabetic complications (including complications at inclusion and at the follow-up) in the oral antidiabetic drug group were close to those in the insulin group, although only at inclusion. Mortality was higher in the insulin group and lower in the oral antidiabetic drug group.

CONCLUSIONS

The increased frequency of hypoglycemia in the insulin + oral antidiabetic drug group raises doubts about the value of continuing a secretagogue drug when insulin is introduced. As the vast majority of patients were not yet receiving antidiabetic drugs with cardiovascular action, our results on heart failure could help in conducting specific studies on these drugs in older patients with type 2 diabetes.

The priming effect of repetitive transcranial magnetic stimulation on clinical response to electroconvulsive therapy in treatment-resistant depression: a randomized, double-blind, sham-controlled study

BACKGROUND

Electroconvulsive therapy (ECT) is one of the most effective treatments for treatment-resistant depression (TRD). However, due to response delay and cognitive impairment, ECT remains an imperfect treatment. Compared to ECT, repetitive transcranial magnetic stimulation (rTMS) is less effective at treating severe depression, but has the advantage of being quick, easy to use, and producing almost no side effects. In this study, our objective was to assess the priming effect of rTMS sessions before ECT on clinical response in patients with TRD.

METHODS

In this multicenter, randomized, double-blind, sham-controlled trial, 56 patients with TRD were assigned to active or sham rTMS before ECT treatment. Five sessions of active/sham neuronavigated rTMS were administered over the left dorsolateral prefrontal cortex (20 Hz, 90% resting motor threshold, 20 2 s trains with 60-s intervals, 800 pulses/session) before ECT (which was active for all patients) started. Any relative improvements were then compared between both groups after five ECT sessions, in order to assess the early response to treatment.

RESULTS

After ECT, the active rTMS group exhibited a significantly greater relative improvement than the sham group [43.4% (28.6%) v. 25.4% (17.2%)]. The responder rate in the active group was at least three times higher. Cognitive complaints, which were assessed using the Cognitive Failures Questionnaire, were higher in the sham rTMS group compared to the active rTMS group, but this difference was not corroborated by cognitive tests.

CONCLUSIONS

rTMS could be used to enhance the efficacy of ECT in patients with TRD. ClinicalTrials.gov: NCT02830399.

OntoBioStat: Supporting Causal Diagram Design and Analysis

Suitable causal inference in biostatistics can be best achieved by knowledge representation thanks to causal diagrams or directed acyclic graphs. However, necessary and sufficient causes are not easily represented. Since existing ontologies do not fill this gap, we designed OntoBioStat in order to enable covariate selection support based on causal relation representations. OntoBioStat automatic ontological causal diagram construction and inferences are detailed in this study. OntoBioStat inferences are allowed by Semantic Web Rule Language rules and axioms. First, statements made by the users include outcome, exposure, covariate, and causal relation specification. Then, reasoning enable automatic construction using generic instances of Meta_Variable and Necessary_Variable classes. Finally, inferred classes highlighted potential bias such as confounder-like. Ontological causal diagram built with OntoBioStat was compared to a standard causal diagram (without OntoBioStat) in a theoretical study. It was found that confounding and bias were not completely identified by the standard causal diagram, and erroneous covariate sets were provided. Further research is needed in order to make OntoBioStat more usable.

Déterminants de la qualité de vie des personnels hospitaliers soignants et médicaux en contexte COVID : enquête en un CHU lors de la première vague

Introduction

Matériels et méthodes

Résultats

Conclusion

Use of intravenous iron and risk of anaphylaxis: A multinational observational post-authorisation safety study in Europe

PURPOSE

This post-authorisation safety study estimated the risk of anaphylaxis in patients receiving intravenous (IV) iron in Europe, with interest in iron dextran and iron non-dextrans. Studies conducted in the United States have reported risk of anaphylaxis to IV iron ranging from 2.0 to 6.8 per 10 000 first treatments.

METHODS

Cohort study of IV iron new users, captured mostly through pharmacy ambulatory dispensing, from populations covered by health and administrative data sources in five European countries from 1999 to 2017. Anaphylaxis events were identified through an algorithm that used parenteral penicillin as a positive control.

RESULTS

A total of 304 210 patients with a first IV iron treatment (6367 iron dextran), among whom 13-16 anaphylaxis cases were identified and reported as a range to comply with data protection regulations. The pooled unadjusted incidence proportion (IP) ranged from 0.4 (95% confidence interval [CI], 0.2-0.9) to 0.5 (95% CI, 0.3-1.0) per 10 000 first treatments. No events were identified at first dextran treatments. There were 231 294 first penicillin treatments with 30 potential cases of anaphylaxis (IP = 1.2; 95% CI, 0.8-1.7 per 10 000 treatments).

CONCLUSION

We found an IP of anaphylaxis from 0.4 to 0.5 per 10 000 first IV iron treatments. The study captured only a fraction of IV iron treatments administered in hospitals, where most first treatments are likely to happen. Due to this limitation, the study could not exclude a differential risk of anaphylaxis between iron dextran and iron non-dextrans. The IP of anaphylaxis in users of penicillin was consistent with incidences reported in the literature.

International multicentre observational study to assess the efficacy and safety of a 0·5 mg kg-1 per day starting dose of oral corticosteroids to treat bullous pemphigoid

BACKGROUND

European guidelines propose a 0·5 mg kg^-1 per day dose of oral prednisone as initial treatment for bullous pemphigoid (BP). We assessed the safety and efficacy of this regimen depending on BP extent and general condition of the patients.

METHODS

In a prospective international study, we consecutively included all patients diagnosed with BP. Patients received a 0·5 mg kg^-1 per day dose of prednisone, which was then gradually tapered 15 days after disease control, with the aim of stopping prednisone or maintaining minimal treatment (0·1 mg kg^-1 per day) within 6 months after the start of treatment. The two coprimary endpoints were control of disease activity at day 21 and 1-year overall survival. Disease severity was assessed according to the Bullous Pemphigoid Disease Area Index (BPDAI) score.

RESULTS

In total, 198 patients were included between 2015 and 2017. The final analysis comprised 190 patients with a mean age of 80·9 (SD 9·1) years. Control of disease activity was achieved at day 21 in 119 patients [62·6%, 95% confidence interval (CI) 55·3-69.5]; 18 of 24 patients (75%, 95% CI 53·3-90·2), 75 of 110 patients (68·8%, 95% CI 59·2-77·3) and 26 of 56 patients (46.4%, 95% CI 33·0-60·3) had mild, moderate and severe BP, respectively (P = 0·0218). A total of 30 patients died during the study. The overall Kaplan-Meier 1-year survival was 82·6% (95% CI 76·3-87·4) corresponding to 90·9%, 83·0% and 80·0% rates in patients with mild, moderate and severe BP, respectively (P = 0·5). Thresholds of 49 points for BPDAI score and 70 points for Karnofsky score yielded maximal Youden index values with respect to disease control at day 21 and 1-year survival, respectively.

CONCLUSIONS

A 0·5 mg kg^-1 per day dose of prednisone is a valuable therapeutic option in patients with mild or moderate BP whose general condition allows them to be autonomous.

Ontological Models Supporting Covariates Selection in Observational Studies

In the context of causal inference, biostatisticians use causal diagrams to select covariates in order to build multivariate models. These diagrams represent datasets variables and their relations but have some limitations (representing interactions, bidirectional causal relations). The MetBrAYN project aims at building an ontological-based process to tackle these issues. The knowledge acquired by the biostatistician during a methodological consultation for a research question will be represented in a general ontology. In order to aggregate various forms of knowledge the ontology will act as a wrapper. Ontology-based causal diagrams will be semi-automatically built. Founded on inference rules, the global system will help biostatisticians to curate it and to visualize recommended covariates for their research question.

[Ocular manifestations of viral diseases]

Les infections virales peuvent toucher l’ensemble des tuniques oculaires et mettre en jeu la fonction visuelle à plus ou moins courte terme. Les kératites et kérato-uvéites liées au virus HSV-1 sont les atteintes les plus fréquentes. Les récurrences entraînent une opacification cornéenne irréversible qui en fait la première cause de cécité d’origine infectieuse dans les pays occidentaux, et justifient un traitement antiviral préventif au long cours. Le zona ophtalmique (10 à 20 % des zonas), peut s’accompagner d’atteintes oculaires sévères (kératites, kérato-uvéites), dont 30 % deviennent chroniques/récurrentes, et de douleurs post-zostériennes, redoutables dans le territoire trigéminé. Les rétinites nécrosantes liées aux herpesvirus (HSV, VZV, CMV), sont rares mais constituent des urgences fonctionnelles absolues nécessitant un traitement antiviral par voie intraveineuse et intravitréenne. Les conjonctivites à adénovirus constituent la première cause de conjonctivite infectieuse. Le plus souvent bénignes, elles sont extrêmement contagieuses et peuvent se compliquer de lésions cornéennes invalidantes persistant plusieurs mois, voire années. Certaines arboviroses s’accompagnent de manifestations oculaires inflammatoires. Dans le cas du Zika, les infections congénitales peuvent se compliquer d’atrophie maculaire et/ou optique. Les conjonctivites sont très fréquentes à la phase aiguë de la maladie à virus Ebola, dont 15 % des survivants présentent des atteintes inflammatoires chroniques sévères liées à la persistance du virus dans les tissus uvéaux. Enfin, dans le cadre de la COVID-19, les conjonctivites ne sont pas très fréquentes mais peuvent être inaugurales, voire au premier plan et sont associées à une excrétion virale lacrymale qui doit faire prendre toutes les précautions.

[Demodex and ocular surface disease]

Demodex is a saprophytic mite of the ocular adnexa, which can in certain circumstances proliferate on the skin of the face and on the eyelid margins. It is involved in facial rosacea (especially in the papulopustular form) and in the development or aggravation of anterior and/or posterior blepharitis or even keratoconjunctivitis, often in association with cutaneous lesions ; the pathophysiology is often multifactorial. Symptoms are non-specific, but the presence of cylindrical sleeves on the eyelashes is very suggestive of infestation, and certain techniques of biomicroscopic examination or imaging, such as confocal microscopy in vivo, allow direct visualization of the parasite. Parasitological examination of the eyelashes can confirm the diagnosis and can be improved by good sampling technique. Eyelid hygiene and oil-based ointments are the cornerstone of treatment. New specific treatments, in particular topical treatments based on tea tree oil, ivermectin, as well as pulsed light therapy and micro-exfoliation of the eyelid margin, can help to reduce the parasitic load and improve symptoms.

Comparative Real-Life Effectiveness and Safety of Dabigatran or Rivaroxaban vs. Vitamin K Antagonists: A High-Dimensional Propensity Score Matched New Users Cohort Study in the French National Healthcare Data System SNDS

BACKGROUND

Clinical trials have indicated that the direct-acting oral anticoagulants dabigatran and rivaroxaban have better risk/benefit profiles than do vitamin K antagonists (VKAs) for stroke prevention in non-valvular atrial fibrillation (NVAF).

OBJECTIVE

Our objective was to compare the 1-year real-life risk of major clinical events with dabigatran or rivaroxaban versus VKAs for NVAF.

METHODS

This was a high-dimensional propensity score (hdPS)-matched cohort study of new users of dabigatran, rivaroxaban or VKAs for NVAF in the French national healthcare systems database in 2013 followed-up for 1 year [22]. Hazard ratios (HRs) with 95% confidence intervals (CIs) for clinical events and death were determined during exposure.

RESULTS

In 2013, a total of 103,101 new anticoagulant users had definite NVAF: 44,653 VKA, 27,060 dabigatran, and 31,388 rivaroxaban. In matched populations, HRs were as follows for dabigatran versus VKAs (20,489 per group): stroke and systemic embolism (SSE) 0.75 (95% CI 0.63-0.88), clinically relevant bleeding (CRB) 0.58 (95% CI 0.51-0.66), hemorrhagic stroke (HS) 0.22 (95% CI 0.14-0.36), gastrointestinal bleeding (GIB) 0.98 (95% CI 0.80-1.19), acute coronary syndrome (ACS) 0.79 (95% CI 0.65-0.95), death 0.74 (95% CI 0.67-0.82), composite (any of the above) 0.71 (95% CI 0.66-0.76). For matched rivaroxaban versus VKA (23,053 per group) HRs were as follows: SSE 0.98 (95% CI 0.85-1.14), CRB 0.83 (95% CI 0.75-0.92), HS 0.65 (95% CI 0.49-0.87), GIB 1.08 (95% CI 0.90-1.30), ACS 0.84 (95% CI 0.71-1.00), death 0.77 (95% CI 0.71-0.84), composite 0.84 (95% CI 0.79-0.89). Numbers needed to treat to observe one fewer death were 49 ± 0.05 with dabigatran or rivaroxaban versus VKAs.

CONCLUSION

Consistent with results from clinical trials and other observational studies, dabigatran and rivaroxaban were at least as effective and safer than VKAs for the prevention of thromboembolic events in NVAF over 1 year in the French population.

STUDY REGISTRATION

European Medicines Agency EUPAS 13017 (www.encepp.eu) Clinicaltrials.gov id NCT02785354.

School-age human figure drawings by very preterm infants: Validity of the Draw-a-Man test to detect behavioral and cognitive disorders

Detecting an abnormal developmental trajectory in very preterm infants remains challenging. The objective of this study was to determine the correlation between the Draw-a-Man test (DAMT) and behavioral and cognitive disabilities in very preterm infants. From the school-age follow-up of the Premag study, which evaluated the neuroprotective effect of prenatal magnesium sulfate before 33 weeks of gestation, 281 human figure drawings were assessed (mean age, 11 years). Behavioral and cognitive disabilities were associated with delayed DAMTs but test performance indicators were insufficient to use DAMT as a screening or a diagnostic test.

Effectiveness and safety of 110 or 150 mg dabigatran vs. vitamin K antagonists in nonvalvular atrial fibrillation

AIMS

We compared the 1-year safety and effectiveness of dabigatran 110 mg (D110) or 150 mg (D150) twice daily to vitamin K antagonists (VKA) in patients with nonvalvular atrial fibrillation.

METHODS

New user cohort study of patients dispensed D110 or D150 vs. VKA in 2013 for nonvalvular atrial fibrillation, followed 1 year in the French Système National des Données de Santé (66 million persons). D110 and D150 users were matched 1:1 with VKA users on sex, age, date of first drug dispensing and high-dimensional propensity score. Hazard ratios [HR (95% confidence intervals)] for stroke and systemic embolism (SSE), major bleeding (MB) and death were computed using Cox proportional hazards or Fine and Gray models during exposure.

RESULTS

In 14 442 matched D110 and VKA patients, mean age 79, 49% male, 91% with CHA₂ DS₂ -VASc ≥2 and 8% with HAS-BLED score >3, incidence rates of SSE were 1.9% and 2.6% person-years [HR 0.69 (0.56-0.84)], MB 1.8% and 2.9% [0.62 (0.51-0.76)], death 7.2% and 8.6% [0.84 (0.76-0.94)]. In 8389 matched D150 and VKA patients, mean age 67, 67% male, 65% with CHA₂ DS₂ -VASC ≥2; < 5% HAS-BLED >3, incidence rates were for SSE 1.4% and 1.9% [0.76 (0.56-1.04)], MB 0.6% and 1.9% [0.30 (0.20-0.46)], death 1.6% and 3.6% [0.46 (0.35-0.59)]. Numbers needed to treat to observe one fewer death were 78 for D110, 88 for D150.

CONCLUSION

In real life D110 and D150 were at least as effective, and safer than VKA.

[Inefficacy of aflibercept in the treatment of idiopathic macular telangiectasia type 2 without neovascularization]

Idiopathic macular telangectasia type 2 is a rare disease consisting primarily of bilateral macular capillary telangiectasia, alterations of the ellipsoid zone and intraretinal cysts that may appear as cystoid macular edema in the absence of neovascularization. Our goal was to study the efficacy of aflibercept in the treatment of these cysts. Thus, we performed a series of three intravitreal injections of aflibercept in the right eye of a woman with a typical presentation of macular telangectasia type 2 complicated by cystoid macular edema without neovascularization. These injections did not significantly improve the anatomical or functional results. Other studies investigating the efficacy of other anti-VEGF in this disease led mainly to a decrease in macular thickness on OCT after injection, without any functional improvement. The anti-VEGFs therefore appear to be of little value in treating MacTel 2 intraretinal cysts without neovascularization.

[Association between the violence in the community and the aggressive behaviors of psychotics during their hospitalizations]

BACKGROUND

Violence is a common issue in psychiatry and has multiple determiners. The aim of this study is to assess the psychotic inpatients' violence in association with the violence of the neighborhood from which the patients are drawn and to estimate the impact of this environmental factor with regard to other factors.

METHOD

A prospective multicenter study was led in nine French cities. Eligible patients were psychotic involuntary patients hospitalized in the cities' psychiatric wards. During their treatments, any kind of aggressive behavior by the patients has been reported by the Overt Aggression Scale (OAS).

RESULTS

From June 2010 to May 2011, 95 patients have been included. Seventy-nine per cent of the patients were violent during their hospitalizations. In a bivariate analysis, inpatient violence was significantly associated with different factors: male gender, patient violence history, substance abuse, manic or mixed disorder, the symptoms severity measured by the BPRS, the insight degree and the city crime rate. In a multivariate analysis, the only significant factors associated with the patients' violence were substance abuse, the symptoms severity and the crime rates from the different patients' cities.

CONCLUSION

These results suggest that violence within the psychotic patients' neighborhood could represent a risk of violence during their treatments.

Comparison of methods for estimating the attributable risk in the context of survival analysis

Background

The attributable risk (AR) measures the proportion of disease cases that can be attributed to an exposure in the population. Several definitions and estimation methods have been proposed for survival data.

Methods

Using simulations, we compared four methods for estimating AR defined in terms of survival functions: two nonparametric methods based on Kaplan-Meier’s estimator, one semiparametric based on Cox’s model, and one parametric based on the piecewise constant hazards model, as well as one simpler method based on estimated exposure prevalence at baseline and Cox’s model hazard ratio. We considered a fixed binary exposure with varying exposure probabilities and strengths of association, and generated event times from a proportional hazards model with constant or monotonic (decreasing or increasing) Weibull baseline hazard, as well as from a nonproportional hazards model. We simulated 1,000 independent samples of size 1,000 or 10,000. The methods were compared in terms of mean bias, mean estimated standard error, empirical standard deviation and 95% confidence interval coverage probability at four equally spaced time points.

Results

Under proportional hazards, all five methods yielded unbiased results regardless of sample size. Nonparametric methods displayed greater variability than other approaches. All methods showed satisfactory coverage except for nonparametric methods at the end of follow-up for a sample size of 1,000 especially. With nonproportional hazards, nonparametric methods yielded similar results to those under proportional hazards, whereas semiparametric and parametric approaches that both relied on the proportional hazards assumption performed poorly. These methods were applied to estimate the AR of breast cancer due to menopausal hormone therapy in 38,359 women of the E3N cohort.

Conclusion

In practice, our study suggests to use the semiparametric or parametric approaches to estimate AR as a function of time in cohort studies if the proportional hazards assumption appears appropriate.

Electronic supplementary material

The online version of this article (doi:10.1186/s12874-016-0285-1) contains supplementary material, which is available to authorized users.

Is the Risk of Wound Infection Related to Bilateral Internal Thoracic Artery Graft Potentiated by Age?

BACKGROUND

Older age and the use of bilateral internal thoracic artery (ITA) grafting are both considered risk factors for surgical wound infection (SWI) after coronary artery bypass grafting (CABG). The 2014 European Guidelines recommend that bilateral ITA grafting should be considered in patients aged younger than 70 years. Our aim was to investigate interaction between age and the number of ITA grafts.

METHODS

All patients aged 18 years and older who had undergone CABG with at least 1 ITA at Rouen University Hospital between 2001 and 2012 were selected. Data regarding surgical procedure (single/bilateral ITA grafting) were extracted from the medical information system. SWI was identified from prospective surveillance of patients according to Centers for Disease Control and Prevention criteria. Independent factors associated with SWI were assessed by logistic regression, and an interaction test between age (≤69 or ≥70 years) and the number of ITA grafts was performed.

RESULTS

SWI occurred in 71 of 2,726 patients (2.6%). Bilateral ITA grafting was associated with SWI (adjusted odds ratio [aOR], 2.55; 95% confidence interval, 1.51 to 4.30). After fitting an interaction term between age and number of ITA grafts, the aORs for SWI after bilateral ITA grafting substantially differed between patients aged 69 years and younger (aOR, 1.88; 95% confidence interval, 0.94 to 3.75) and 70 years and older (aOR, 3.52; 95% confidence interval, 1.69 to 7.33). However, this interaction failed to reach statistical significance (p = 0.2213), possibly because of insufficient statistical power (23.5%) despite the large sample size.

CONCLUSIONS

Age 70 years and older compared with age 69 years and younger was associated with higher occurrence of SWI after bilateral ITA grafting, but this interaction was not statistically significant. Larger studies are needed to test this interaction.

Patterns and effectiveness of bortezomib use according to age in the VESUVE cohort

Therapeutical options for older multiple myeloma patients have been improved with the advent of new drugs, yet there is a lack of observational data for such patients. To address this issue, an age-stratified analysis of the VESUVE cohort of bortezomib users was performed. Among the 779 patients included in the analysis, 358 (46%) were aged ≤ 65 years, 282 (36%) were between 65-75 years and 139 (18%) were more than 75 years old. There were few significant differences in treatment parameters across age groups; notably, older patients received a lower dose of bortezomib and more frequently experienced general or administration site conditions, metabolism or nutrition disorders and cardiac disorders. Overall best response rate and progression-free survival were similar across age groups. Taken together, these results indicate that older patients do benefit from bortezomib and that tailored treatment in real-life clinical practice does not compromise effectiveness.

Increased prevalence of psoriasis in patients with coronary artery disease: results from a case-control study

BACKGROUND

The incidence of myocardial events has been reported to be increased in patients with psoriasis.

OBJECTIVES

To investigate whether psoriasis is an independent risk factor for coronary artery disease (CAD).

METHODS

We compared the prevalence of psoriasis between case patients with a diagnosis of CAD based on coronary angiography findings and control patients with no CAD referred to the emergency surgery department for an acute noncardiovascular condition. Case and control patients were examined for the presence of psoriasis by two dermatologists. The prevalence of psoriasis was compared among patients with CAD according to CAD severity. Five-hundred cases and 500 age- and sex-matched controls were included.

RESULTS

Using matched univariate analysis, the prevalence of psoriasis was about twofold higher in CAD case patients than in control patients [8·0% vs. 3·4%, odds ratio (OR) 2·64; 95% confidence interval (CI) 1·42-4·88]. Using unconditional multivariate analysis, the association of psoriasis with CAD appeared to be borderline significant (OR 1·84; 95% CI 0·99-3·40). Psoriasis in patients with CAD was significantly associated with three-vessel involvement relative to one-or two-vessel involvement (13·1% vs. 6·1%; OR 3·07; 95% CI 1·50-6·25).

CONCLUSIONS

The prevalence of psoriasis is twofold higher in patients with CAD than in control patients without CAD. It is associated with a more severe coronary artery involvement.

School-age outcomes following a randomized controlled trial of magnesium sulfate for neuroprotection of preterm infants

In a French randomized trial, children at school-age demonstrated no evidence of harm from fetal exposure to MgSO4 before very preterm birth. Motor dysfunction/death, qualitative behavioral disorders, cognitive difficulties, school grade repetition, and education services were decreased in the children exposed to MgSO4, although the differences were not significant.

Risk of second bone sarcoma following childhood cancer: role of radiation therapy treatment

Bone sarcoma as a second malignancy is rare but highly fatal. The present knowledge about radiation-absorbed organ dose-response is insufficient to predict the risks induced by radiation therapy techniques. The objective of the present study was to assess the treatment-induced risk for bone sarcoma following a childhood cancer and particularly the related risk of radiotherapy. Therefore, a retrospective cohort of 4,171 survivors of a solid childhood cancer treated between 1942 and 1986 in France and Britain has been followed prospectively. We collected detailed information on treatments received during childhood cancer. Additionally, an innovative methodology has been developed to evaluate the dose-response relationship between bone sarcoma and radiation dose throughout this cohort. The median follow-up was 26 years, and 39 patients had developed bone sarcoma. It was found that the overall incidence was 45-fold higher [standardized incidence ratio 44.8, 95 % confidence interval (CI) 31.0-59.8] than expected from the general population, and the absolute excess risk was 35.1 per 100,000 person-years (95 % CI 24.0-47.1). The risk of bone sarcoma increased slowly up to a cumulative radiation organ absorbed dose of 15 Gy [hazard ratio (HR) = 8.2, 95 % CI 1.6-42.9] and then strongly increased for higher radiation doses (HR for 30 Gy or more 117.9, 95 % CI 36.5-380.6), compared with patients not treated with radiotherapy. A linear model with an excess relative risk per Gy of 1.77 (95 % CI 0.6213-5.935) provided a close fit to the data. These findings have important therapeutic implications: Lowering the radiation dose to the bones should reduce the incidence of secondary bone sarcomas. Other therapeutic solutions should be preferred to radiotherapy in bone sarcoma-sensitive areas.

Autoimmune disorders and quadrivalent human papillomavirus vaccination of young female subjects

OBJECTIVES

The aim of this study was to investigate whether the quadrivalent human papillomavirus (HPV) vaccine Gardasil is associated with a change in the risk of autoimmune disorders (ADs) in young female subjects.

DESIGN

Systematic case-control study of incident ADs associated with quadrivalent HPV vaccination in young women across France.

PARTICIPANTS AND SETTING

A total of 113 specialised centres recruited (from December 2007 to April 2011) females aged 14-26 years with incident cases of six types of ADs: idiopathic thrombocytopenic purpura (ITP), central demyelination/multiple sclerosis (MS), Guillain-Barré syndrome, connective tissue disorders (systemic lupus erythematosus, rheumatoid arthritis/juvenile arthritis), type 1 diabetes mellitus and autoimmune thyroiditis. Control subjects matched to cases were recruited from general practice.

ANALYSIS

Multivariate conditional logistic regression analysis; factors included age, geographical origin, smoking, alcohol consumption, use of oral contraceptive(s) or vaccine(s) other than Gardasil received within 24 months before the index date and personal/family history of ADs.

RESULTS

Overall, 211 definite cases of ADs were matched to 875 controls. The adjusted odds ratio (OR) for any quadrivalent HPV vaccine use was 0.9 [95% confidence interval (CI) 0.5-1.5]. The individual ORs were 1.0 (95% CI 0.4-2.6) for ITP, 0.3 (95% CI 0.1-0.9) for MS, 0.8 (95% CI 0.3-2.4) for connective disorders and 1.2 (95% CI 0.4-3.6) for type 1 diabetes. No exposure to HPV vaccine was observed in cases with either Guillain-Barré syndrome or thyroiditis.

CONCLUSIONS

No evidence of an increase in the risk of the studied ADs was observable following vaccination with Gardasil within the time periods studied. There was insufficient statistical power to allow conclusions to be drawn regarding individual ADs.

Management of upper respiratory tract infections by different medical practices, including homeopathy, and consumption of antibiotics in primary care: the EPI3 cohort study in France 2007-2008

Background

Prescribing of antibiotics for upper respiratory tract infections (URTI) varies substantially in primary care.

Objectives

To describe and compare antibiotic and antipyretic/anti-inflammatory drugs use, URTI symptoms' resolution and occurrence of potentially-associated infections in patients seeking care from general practitioners (GPs) who exclusively prescribe conventional medications (GP-CM), regularly prescribe homeopathy within a mixed practice (GP-Mx), or are certified homeopathic GPs (GP-Ho).

Method

The EPI3 survey was a nationwide population-based study of a representative sample of 825 GPs and their patients in France (2007–2008). GP recruitment was stratified by self-declared homeopathic prescribing preferences. Adults and children with confirmed URTI were asked to participate in a standardized telephone interview at inclusion, one-, three- and twelve-month follow up. Study outcomes included medication consumption, URTI symptoms' resolution and potentially-associated infections (sinusitis or otitis media/externa) as reported by patients. Analyses included calibration to account for non-respondents and groups were compared using multivate analyses adjusting for baseline differences with a propensity score.

Results

518 adults and children with URTI (79.3% rhinopharyngitis) were included (36.9% response rate comparable between groups). As opposed to GP-CM patients, patients in the GP-Ho group showed significantly lower consumption of antibiotics (Odds ratio (OR) = 0.43, 95% confidence interval (CI): 0.27–0.68) and antipyretic/anti-inflammatory drugs (OR = 0.54, 95% CI: 0.38–0.76) with similar evolution in related symptoms (OR = 1.16, 95% CI: 0.64–2.10). An excess of potentially-associated infections (OR = 1.70, 95% CI: 0.90–3.20) was observed in the GP-Ho group (not statistically significant). No difference was found between GP-CM and GP-Mx patients.

Conclusion

Patients who chose to consult GPs certified in homeopathy used less antibiotics and antipyretic/anti-inflammatory drugs for URTI than those seen by GPs prescribing conventional medications. No difference was observed in patients consulting GPs within mixed-practice. A non-statistically significant excess was estimated through modelling for associated infections in the GP-Ho group and needs to be further studied.

Risk of breast cancer by individual insulin use: an international multicenter study

OBJECTIVE Several studies have been published in 2009 suggesting a possible association between insulin glargine and increased risk of malignancies, including breast cancer. The objective of this study was to assess the relation between the individual insulins (glargine, aspart, lispro, and human insulin) and development of breast cancer. RESEARCH DESIGN AND METHODS Seven hundred seventy-five incident cases of primary invasive or in situ carcinoma breast cancer occurring in women with diabetes from 92 centers in the U.K., Canada, and France were matched to a mean of 3.9 diabetic community control subjects (n = 3,050; recruited from 580 general practices) by country, age, recruitment date, and diabetes type and management. The main risk model was a multivariate conditional logistic regression model with case/control status as the dependent variable and individual insulin use, 8 years preceding the index date, as the independent variable, controlling for past use of any insulin, oral antidiabetes drugs, reproductive factors, lifestyle, education, hormone replacement therapy and history of contraceptive use, BMI, comorbidities, diabetes duration, and annual number of physician visits. Glargine was also compared with every other insulin by computing all ratios using the variance-covariance matrix of logistic model parameters. RESULTS Adjusted odds ratios of breast cancer for each type of insulin versus no use of that insulin were 1.04 (95% CI 0.76-1.44) for glargine, 1.23 (0.79-1.92) for lispro, 0.95 (0.64-1.40) for aspart, and 0.81 (0.55-1.20) for human insulin. Two-by-two comparisons found no difference between glargine and the different types of insulins. Insulin dosage or duration of use and tumor stage did not change the results. CONCLUSIONS This international study found no difference in the risk of developing breast cancer in patients with diabetes among the different types of insulin with short- to mid-term duration of use. Longer-term studies would be of interest.

Coracoid process x-ray investigation before Latarjet procedure: a radioanatomic study

BACKGROUND

The purpose of this study was to determine whether a preoperative radiologic assessment of the coracoid process is predictive of the amount of bone available for coracoid transfer by the Latarjet procedure.

MATERIAL

Thirty-five patients with anterior instability undergoing a Latarjet procedure were included. A preoperative radiologic assessment was performed with the Bernageau and true anteroposterior (true AP) views.

METHODS

The length of the coracoid process was measured on both radiographic views and the values were compared with the length of the bone block during surgery. Statistical analysis was carried out by ANOVA and Wilcoxon tests (P < .05).

RESULTS

On radiologic examination, the mean coracoid process length was 29 ± 4 and 33 ± 4 mm on the Bernageau and true AP views, respectively. The mean bone block length during surgery was 21.6 ± 2.7 mm. A significant correlation was found (P = .032) between the coracoid process length on the true AP view and the intraoperative bone block length.

DISCUSSION

Preoperative planning for the Latarjet procedure, including graft orientation and screw placement, requires knowledge of the length of coracoid bone available for transfer. This can be facilitated with the use of preoperative standard radiographs, thus avoiding computed tomography. This planning allows the detection of coracoid process anatomic variations or the analysis of the remaining part of the coracoid process after failure of a first Latarjet procedure to avoid an iliac bone graft.

CONCLUSION

Radiologic preoperative coracoid process measurement is an easy, reliable method to aid preoperative planning of the Latarjet procedure in primary surgery and reoperations.

Étude de l’utilisation optimisée de la rispéridone à libération prolongée par un programme d’accompagnement des patients

Contexte et objectif

La non-observance des traitements représente un risque d’exacerbation chez les patients schizophrènes [1,2,3]. L’objectif était d’évaluer l’impact d’un programme d’accompagnement des patients recevant la rispéridone à libération prolongée (RLP) sur le taux d’hospitalisation psychiatrique.

Méthodes

Une cohorte de 506 patients schizophrènes traités par RLP a été recrutée dans 36 centres et suivie 12 mois. Le programme d’accompagnement consistait en un rappel téléphonique 48 heures avant la date prévue de l’injection et dans les trois jours suivants, au besoin. Les centres observants étaient ceux ayant appliqué le programme pour 50 % ou plus des injections prévues. Les patients observants étaient ceux qui s’étaient présentés dans les cinq jours de la date prévue de l’injection pour au moins 80 % des injections. L’effet de l’observance (centre, patient, ou les deux combinés) sur le taux d’hospitalisation a été estimé par un modèle de Poisson avec appariement, ajusté sur un score de propension résumant les facteurs de risque.

Résultats

Environ 75 % des patients ont été observants et leur taux d’hospitalisation était similaire aux non-observants (32,8 et 31,7 par 100 patients-années [PA], respectivement). Les centres observants traitaient des patients moins sévères (hospitalisation dans l’année précédente [64,2 vs. 44,1 %] et meilleurs scores sur les échelles psychiatriques [CGI maximum, BPRS, EGF]). L’observance des centres avait un effet moins important sur le taux d’hospitalisation des patients observants (28,2/100 PA pour les centres observants vs 38,3/100 PA pour les centres non observants) que chez les patients non observants (11,7/100 PA vs 41,0/100 PA, respectivement). L’effet chez les patients non observants était maintenu dans les analyses ajustées.

Conclusion

Le taux d’hospitalisation chez les patients traités par RLP était comparable entre les patients observants et non observants, mais ce taux était amélioré dans les centres observants au programme d’accompagnement des patients à observance faible.

The performance of functional methods for correcting non-Gaussian measurement error within Poisson regression: corrected excess risk of lung cancer mortality in relation to radon exposure among French uranium miners

A broad variety of methods for measurement error (ME) correction have been developed, but these methods have rarely been applied possibly because their ability to correct ME is poorly understood. We carried out a simulation study to assess the performance of three error-correction methods: two variants of regression calibration (the substitution method and the estimation calibration method) and the simulation extrapolation (SIMEX) method. Features of the simulated cohorts were borrowed from the French Uranium Miners' Cohort in which exposure to radon had been documented from 1946 to 1999. In the absence of ME correction, we observed a severe attenuation of the true effect of radon exposure, with a negative relative bias of the order of 60% on the excess relative risk of lung cancer death. In the main scenario considered, that is, when ME characteristics previously determined as most plausible from the French Uranium Miners' Cohort were used both to generate exposure data and to correct for ME at the analysis stage, all three error-correction methods showed a noticeable but partial reduction of the attenuation bias, with a slight advantage for the SIMEX method. However, the performance of the three correction methods highly depended on the accurate determination of the characteristics of ME. In particular, we encountered severe overestimation in some scenarios with the SIMEX method, and we observed lack of correction with the three methods in some other scenarios. For illustration, we also applied and compared the proposed methods on the real data set from the French Uranium Miners' Cohort study.

Methodology for a multinational case-population study on liver toxicity risks with NSAIDs: the Study of Acute Liver Transplant (SALT)

PURPOSE

The European Committee for Human Medicinal Products (CHMP) requested a multinational study with the aim to investigate the risk of acute liver failure (ALF) leading to registration for transplantation in patients exposed to non-steroidal anti-inflammatory drugs (NSAIDs). The method of this multinational, multicentre, retrospective case-population study, named SALT (Study of Acute Liver Transplant), is documented here.

METHODS

This was a multicentre, multinational retrospective case-population study performed in France, Italy, Portugal, Greece, Ireland, the Netherlands and the UK. The study period was 3 years (1 January 2005-31 December 2007). Cases were patients ≥ 18 years of age with ALF at the time of registration on the transplant list for liver transplantation who had been exposed to an NSAID within 30 days preceding the initial symptoms of liver disease (index date). Exposure was defined as exposure to any NSAID. Per country rates of NSAID-exposed transplantation-registered ALF were computed as the ratio of the number of cases identified in the country to total population exposure. Overall and per-drug sales for NSAIDs and for paracetamol were obtained from Intercontinental Marketing Services (IMS) Health for all participating countries. Population exposure was measured as the defined daily dose and as estimated annual number of patients exposed (primary endpoint) with 95 % confidence intervals.

RESULTS

The study protocol was approved by the CHMP. Of the 57 eligible liver transplant centres, 54 agreed to participate in the study. All national authorizations were received with relevant administrative burden, mainly due to bureaucracy.

CONCLUSION

The present study created a multinational research network to estimate population-based absolute rates of drug-exposed ALF leading to registration on the transplantation list. This study design was chosen to obtain a fast response to a public health issue, namely, that of an increased risk of a rare, very serious adverse reaction. This model could be used to study other drug-related issues in ALF.