Updated meta-analytical approach to the efficacy of antihypertensive drugs in reducing blood pressure

BACKGROUND AND OBJECTIVE

Despite advances in the treatment of hypertension, control rates continue to be suboptimal in both Europe and the US. Strategies that improve hypertension control are therefore urgently needed. This study aimed to assess the relative efficacies of various antihypertensive drugs commonly used in France in reducing systolic and diastolic blood pressure (SBP and DBP) by using a meta-analytical approach. This update of a previously published meta-analytical approach extends the number of drugs evaluated from 13 to 19.

METHODS

A total of 80 randomised, controlled trials published between 1973 and 2007 involving 10 818 patients were selected for inclusion in the meta-analytical approach. Data were examined for 19 drugs, and 16 drugs were included in the analysis: hydrochlorothiazide, indapamide sustained-release (SR), atenolol, amlodipine, lercanidipine, manidipine, enalapril, ramipril, trandolapril, candesartan cilexetil, irbesartan, losartan, olmesartan medoxomil, telmisartan, valsartan and aliskiren. Weighted average reductions in SBP and DBP over a period of 8-12 weeks were calculated for each drug from information on both the mean and the variability in BP reduction. No trials evaluating furosemide, spironolactone or cicletanine satisfied the inclusion criteria for this analysis.

RESULTS

The average weighted reductions in SBP over 8-12 weeks were most marked with diuretics, and in particular indapamide SR 1.5 mg/day (mean change from baseline -22.2mm Hg), which reduced SBP to a greater extent than any of the other drugs evaluated (at any dosage considered). Average weighted reductions in DBP were generally similar with all classes of antihypertensives and ranged from -11.4mm Hg with the beta-adrenoceptor blocker atenolol and calcium channel antagonists to -10.3mm Hg with the angiotensin II type 1 receptor antagonists.

CONCLUSION

This new analysis supports the results of the earlier investigation, in that indapamide SR 1.5 mg/day appeared to be the most effective drug for producing significant reductions in SBP within 8-12 weeks, which is an essential element in optimising cardiovascular prevention among hypertensive patients. The clinical application of these results should take into consideration all the limitations discussed in this analysis.

Validation of the Multiple Sclerosis International Quality of Life questionnaire

This study aims to validate the Multiple Sclerosis (MS) International Quality of Life (MusiQoL) questionnaire, a multi-dimensional, self-administered questionnaire, available in 14 languages, as a disease-specific quality of life scale that can be applied internationally. A total of 1992 patients with different types and severities of MS from 15 countries were recruited. At baseline and day 21 ± 7, each patient completed the MusiQoL, a symptom checklist and the short-form (SF)-36 QoL questionnaire. Neurologists also collected socio-demographic, MS history and outcome data. The database was randomly divided into two subgroups and analysed according to different patient characteristics. For each model, psychometric properties were tested and the number of items was reduced by various statistical methods. Construct validity, internal consistency, reproducibility and external consistency were also tested. Nine dimensions, explaining 71% of the total variance, were isolated. Internal consistency and reproducibility were satisfactory for all the dimensions. External validity testing revealed that dimension scores correlated significantly with all SF-36 scores, but showed discriminant validity by gender, socio-economic and health status. Significant correlations were found between activity in daily life scores and clinical indices. These results demonstrate the validity and reliability of the MusiQoL as an international scale to evaluate QoL in patients with MS. Multiple Sclerosis 2008; 14: 219—230. http://msj.sagepub.com

Health status and quality of life in long-term survivors of childhood leukaemia: the impact of haematopoietic stem cell transplantation

We compared late side effects and quality of life (QoL) in 430 survivors of childhood acute leukaemia based on whether they had undergone haematopoietic cell transplantation (n=142) or not (n=288). Mean age was 18.2 years and mean follow-up duration was 11.9 years. Multivariate logistic regression analyses were performed to compare the risk of each type of late effect in the two groups. Based on age, VSP-A or SF36 questionnaires were used to assess QoL. For each QoL dimension, multiple linear regression was done to construct models of association with the treatment group. Transplanted patients experienced more side effects, including height growth failure, gonadal dysfunction, hypothyroidism and cataract. Children and adolescents in the two treatment groups reported similar QoL levels for almost all dimensions except a better perception of school work by young transplanted children and more difficulties in relating to the medical staff for transplanted adolescents. In adults, two differences in physical domain of QoL were detected but the calculated effect sizes were less than 0.2 in each case, suggesting an uncertain clinical significance. In spite of a higher risk of physical adverse events in the transplanted group, very few clinically significant differences in QoL are detectable.

Two- and three dimensional measures of vestibular schwannomas and posterior fossa--implications for the treatment

BACKGROUND

There is no uniformly accepted method of reporting the size of vestibular schwannomas (VS) and to evaluate the individual tumour behaviour in the posterior fossa (PF). To help the treatment decision we investigated the VS and PF morphometry using a computerized method.

METHOD

Stereotactic fused CISS MR and CT scan images were obtained from 58 adult patients (31 males and 27 females) harbouring an unilateral VS (25 Koos II, 21 Koos III and 12 Koos IV). Using a Gammaplanworking station we screened for the following measures: anteroposterior (AP), craniocaudal (CC), transverse (T) and maximum (Max) diameters (Diam) of the intracisternal part of the tumour, VS and PF volumes.

FINDINGS

The Max Diam was the most accurate way to estimate the tumour volume (Spearman's rho >0.80). Among several parameters, the T Diam was the best measure to assess the brain shift (ROC analysis) with a cut off value at 14.5 mm (91.7% sensitivity and 93% specificity). VS volume and the ratio VS volume/PF volume were also efficient to predict a brain shift.

CONCLUSIONS

Max Diam and T Diam are bedside measured simple data of particular interest to respectively estimate the VS volume and predict the brain shift due to the tumour. The determination of cut-off values correlated to brain shift will provide guidelines at the time of the therapeutic decision between radiosurgical and microsurgical strategy.

[Reliability and validity of the Spanish version of the health and quality-of-life questionnaire, the Vecú et Santé Perçue de l'Adolescent (VSP-A)]

OBJECTIVE

To assess the psychometric properties of the Spanish version of the Vecú et Santé Perçue de l'Adolescent (VSP-A) in terms of reliability and validity.

DESIGN

Cross-sectional study.

SETTING

Pilot study parallel to the European Kidscreen project. Two secondary schools, one public and one private, were selected for their suitability in Barcelona and Gerona (Catalonia, Spain). The sample unit was the classroom.

PARTICIPANTS

A sample of 354 adolescents aged 12 to 18 years old was selected.

MAIN MEASUREMENTS

The Spanish VSP-A questionnaire was administered, and again a week later to check its test-retest stability. The KINDL questionnaire was administered in parallel.

RESULTS

The response rate was 82% (n=291). The Spanish version of the VSP-A showed good internal consistency and acceptable test-retest reliability (Cronbach's alpha: 0.69-0.92, intraclass correlation coefficient [ICC]: 0.69-0.74) in most domains. Domains measuring a similar concept in the VSP-A and KINDL had closer correlation coefficients than those measuring different constructs (P<.05), which demonstrates its convergent validity. Girls had worse self-perceived health than boys (lower vitality, physical and emotional well-being and self-esteem, and a lower general score on the VSP-A; p<.01). These differences were more obvious in older teens (16-18 years old).

CONCLUSIONS

The Spanish VSP-A showed good psychometric properties and results were consistent with the original French version. The results mean we have an adequate HRQL instrument for teens and for use in primary care and public health.

[Quality of life measurement: a fashion or a valid assessment?]

During 20 last years, there has been an exponential growth in the literature related to quality of life (QoL). The usual indicators of results are not always responsive to new strategies or new systems of care organization. While assessment of QoL by patients and by the medical community is an old concern, the issue of standardized instruments is more recent. Despite the need, the use of QoL questionnaires remains rare because of the lack of sufficiently dedicated tools. In the specific field of motoneuron diseases, a search of the literature should be helpful to clarify the definition of quality of life. It should also be helpful in determining the limits of the debate on quantification of an impression considered to be subjective. The goal is to clarify methods for standardizing QoL evaluation, to specify nosographic notions affecting the choice of measuring instruments, to recall the prerequisite of validation before use, and finally to specify the fields of application of such tools. Thus in the field of motoneuron diseases, recognizing the limitations of QoL instruments should enable a more enlightened approach to overall assessment of the burden of these diseases.

[Long term outcome following 26 surgical ampullectomies]

BACKGROUND

Pancreaticoduodenectomy (PD) is the standard surgical treatment for malignant ampullomas but is still associated with a mortality and morbidity still ranging from 0 to 10% and from 15 to 40%, respectively. Ampullectomy is an alternative to PD for benign ampulloma or, in high-risk patients, for invasive carcinoma. The aim of this study was to report early and long term results of surgical ampullectomy for presumed benign ampullomas.

PATIENTS AND METHODS

From 1981 to 2004, 26 patients from two institutions underwent surgical ampullectomy. Of the 26 patients, 8 had familial adenomatous polyposis (FAP). Surgical ampullectomy was indicated on a multisciplinary basis.

RESULTS

Final pathological examination revealed 15 adenomas, 4 in situ adenocarcinomas, 2 endocrine tumors, and 5 other benign lesions. There was no postoperative mortality. Specific morbidity was 8% (N=2). Mean follow-up was 86+/-70 months (range: 3-204). Actuarial overall 5-year survival was 92%. There were 4 local recurrences (none in patients with FAP). Four patients died during follow-up (including 3 from initial disease).

CONCLUSION

Ampullectomy is a good alternative to PD in case of benign or non-invasive malignant ampullary lesion, including in selected cases of FAP.

Média et santé publique : l’exemple de la canicule pendant l’été 2003 en France

BACKGROUND

The summer of 2003 was the hottest for France in the last 50 years with record day and nighttime temperatures. INSERM statistics estimated that 14,802 heat-related deaths occurred during August 2003 heat wave in France. In the aftermath of this crisis, we thought that it was useful to analyze how the French media dealt with public health during the period from June 1 to August 31, 2003. The objective was to analyze French coverage of public health information during the August 2003 heat wave.

METHODS

Manual and computerized analysis of newspaper and radio reports published from June 1 to August 31, 2003. Articles were obtained by searching the EUROPRESS database. Text analysis was performed using the ALCESTE software package.

RESULTS

A total of 1,599 articles were analyzed. Few articles contained warnings about heat exposure and preventive measures. Public health policy was relegated to third place after business and ecology themes. The special problems of the high-risk populations were not mentioned until after the rising death toll was known and emphasis was placed on the implications of the crisis in the political process. The findings of this study show the poor performance of public health policy in France and that media must be given guidance to fulfil its role in providing public health information.

CONCLUSION

This crisis discloses the absence of public health culture in France and involves the "social exclusion" related to a breakdown of social cohesion. More cooperation is needed between the media and public health professionals to avoid future heat-wave and other public health crises. France must develop a public health culture to promote involvement of both the community and individuals in public health issues.

153Samarium-EDTMP et contrôle de la douleur liée aux métastases osseuses des cancers bronchiques

INTRODUCTION

The treatment of bone metastasis from lung cancer is palliative in nature with elimination of pain being the primary goal. Management is based on pharmacologicalmethods (steroids, morphine, and pamidronate) and radiotherapy. However, other treatments have been developed including the systemic radiopharmaceutical 153Sm-EDTMP.

CASE REPORTS

We report data from 6 lung cancer patients with bone metastases treated with 153Sm-EDTMP. Demographic and therapeutic data, pain evaluation by visual analogue scale (VAS) and change in opioid analgesia requirements (expressed as intravenous morphine equivalent) as well as survival were studied. Pain associated with bone metastasis (median VAS = 8 [7-9], median morphine dose = 167 mg [100-800 mg]) did not significantly improve (median VAS after 153Sm-EDTMP = 8.5 [5-10], median morphine dose after 153Sm-EDTMP = 185 mg [30-2 200 mg]) in this group of patients.

CONCLUSION

Our results combined with current data in the literature concerning the use of this treatment in the treatment of bone pain associated with metastatic lung cancer suggest that at present its use cannot be recommended outside the context of clinical of clinical trials.

[Retrospective survey of the management of patients treated for acute myocardial infarction in Provence-Alpes-Côte d'Azur]

OBJECTIVE

The aim of the study is to assess the characteristics, outcomes and factors associated with delay of reperfusion therapy in patients with myocardial infarction in the Provence Alpes Côte d'Azur (PACA).

METHODS

This retrospective study included all patients hospitalized with myocardial infarction in the PACA between January and June 2000. Myocardial infarction patients were identified using the Programme de Médicalisation des Systèmes d'Information. Univariate and multivariate analysis were performed.

RESULTS

A total of 2049 patients were admitted in 74 hospitals. Mean patient age was 68.9. Treatment consisted of coronary angioplasty alone in 53.3% of cases, thrombolysis alone in 4.5% and angioplasty after thrombolysis in 7.7%. The complication rate was 27.4% and mortality was 9.5%. The median time from first awareness of symptoms to the first action taken by the patient (1) was 1 hour 30 minutes. The time from the first action taken by the patient to revascularisation (2) was 3 hours 30 minutes. The time between the first awareness and revascularisation (3) was 8 hours 45 minutes. Multivariate analysis showed that the following factors were associated with increased delay: (1). no prior myocardial infarction, occurrence of symptoms at home. (2). age > 65 years, absence of chest pain, consultation with a physician before hospitalization, non-medical transport, transfer from one hospital to another, treatment by angioplasty alone. (3). age > 65 years, absence of chest pain, consultation with a physician before hospitalization, non-medical transport, treatment by angioplasty alone.

CONCLUSIONS

Alerting emergency services more quickly would shorten treatment delay not only by ensuring quicker transport to a properly equipped hospital but also by allowing prompt pre-hospital thrombolytic therapy.

L'analyse des réseaux sociaux appliquée au système de santé

BACKGROUND

Social network analysis is a method for describing and contextualising the structural relationships amongst social entities. The aim of this study was to assess the relationships between hospitals through the use of an example of a hospital that takes care of myocardial infarction in the region of Provence Alpes Côte d'Azur (PACA).

METHOD

This retrospective study included all patients hospitalised for acute coronary syndrome in the PACA region between January and June 2000. The description analysis consisted of making a graph describing the transfer of patients between hospitals to calculate indicators for the centrality of the hospital and its prestige. The graph was also used to determine and measure the sub-group cohesion (cliques) and the density of the hospital network.

RESULTS

A total of 2049 patients suffering from myocardial infarction were admitted to 78 hospitals during the study period. There were 867 transfers from one hospital to another. 51 cliques were highlighted; 29 hospitals do not belong to a clique. Among the 49 hospitals who do belong to sub-groups, 50% are linked to two cliques. Eight hospitals belong to more than 8 sub-groups, and the maximum number of sub-groups to which a hospital is linked is 12. The density of the hospital network is 0.12.

CONCLUSIONS

Social network analysis is a field of research open and adaptable to the public health scene. This method could be applied to the evaluation of health and hospital administration and management networks.

Dehiscences of the bronchial joining after pneumonectomy for cancers: Incidence, gravity and risk factor

Objectives To assess the incidence, severity and risk factors of bronchial fistula following pneumonectomy for cancer. Patients and methods From 1989 to 2003, 690 consecutive patients underwent a pneumonectomy for thoracic cancer in Sercive of Thoracic Surgery of the Teaching Hospital of Sainte Marguerite in Marseilles (France). The M/F sex ratio was 5,44 . Mean age was 59+/-9,9 years [16 - 81]. Clinical and surgical variables were studied retrospectively, and their possible association with the occurrence of a bronchial fistula was assessed by univariate and multivariate analysis. Results Fifty one patients (7,7%) experienced a bronchial fistula. This complication accounted for 56% (45/80) of the cases of reoperation and 25,5% (13/51) of early deaths. At univariate analysis, the following factors were identified as statistically significant: tobacco consumption (p<0,003), presence of COPD (p =0,02), preoperative radiotherapy (p=0,03), previous thoracic surgery (p=0,03), right side of the resection (p<0,001), hand-fashioned bronchial suture (p=0,05) and squamous cell histology (p= 0,04). Multivariate logistic regression analysis disclosed tobacco consumption (p=0,002), presence of COPD (p=0,01), previous thoracic surgery (p=0,03), extended procedures (p=0,05), right pneumonectomy (p<0,001) and squamous cell histology (p=0,02) as independent predictors of bronchial fistula. Conclusion The occurrence of a bronchial fistula following pneumonectomy is a frequent life threatening event, especially in cases of right sided resections and extended procedures. Tobacco cessation, preoperative rehabilitation, and reinforcement of the bronchial suture are possible means of prevention.

[How much does a caesarean section cost in Madagascar? Socio-economical aspects and caesarean sections rate in Toamasina, Madagascar 1999-2001]

The maternal mortality is a major issue of public health in developing countries. Essential obstetric cares, especially caesarean section, play a crucial role in the decrease of maternal mortality. WHO, FNUAP and UNICEF estimate that the minimum acceptable rate of caesarean section in developing countries must reach 5% to guarantee safety for both the new-born and the mother. In Madagascar; the average national rate of caesarean section was 0.6% in 1997. In the area of Toamasina, this rate was 0.7%. To increase the number of women who can access to those essential obstetric cares, several solutions may be followed. One of them is to develop health insurance for pregnant women. This kind of solution seems to be well accepted and equitable. To reach this goal, this study was carried out to define sociodemographic characteristics of women who got caesarean section in Toamasina, to assess the cost of a caesarean section at the CHR (regional hospital) of Toamasina, and to measure the evolution of the caesarean section rate in the area. A retrospective survey was carried out for the years 1999, 2000 and 2001 including all women who got a caesarean section in the area of Toamasina: in the hospital of Toamasina and in the one of Fenerive-Est. Data were collected in both hospitals. 748 women were included in the survey The cost-analysis consisted in a partial medico-economic cost analysis which was measured from the patient's point of view. Sociodemographic characteristics are comparable with the results found in the literature. The mean age of the women involved was 28+/-7 years. The main indications for caesarean section were foeto-pelvic disproportion (37%) and placenta praevia (12%). The maternal mortality rate was 3%. The rate of infantile mortality was 18%. The cover rate of caesarean section in the area of the CHR is estimated respectively at 0.58%, 0.67% and 0.71% for the years 1999, 2000 and 2001. Data collection step was very difficult to carry out. The rates of death among the mother (0.3%) and among the new-born (18%) were definitely too important. But, these rates were comparable with those found in the bibliography. The cover rate of the caesarean section is too low, however it was increasing during these 3 years. About 2000 women per year needed a caesarean without having it. The cost for the society of the morbidity and the mortality caused by the lack of availability of caesarean section is drastic. The price of a caesarean section is about 250 000 Fmg (approximately 36 euros). The average income is about 170 000 Fmg (25 euros) per month per inhabitant. Thus, the price asked was dramatically too high for a majority of people. The availability of caesarean section had to be improved in the area of Toamasina. More than ten years after the first International Conference about the Maternity without Risk in Nairobi, it appeared that something had to be done quickly in Madagascar. The solution to develop a public health insurance, or others actions, seemed to be relevant and urgent.

[Hydrocephalus and vestibular schwannomas treated by Gamma Knife radiosurgery]

The occurrence of hydrocephalus in association with a vestibular schwannoma (VS) is a well-known phenomenon. It is usually supported, albeit never demonstrated, that radiosurgery increases the risk of hydrocephalus. The purpose of this study is to investigate this Issue in our own series of patients in order to provide more data. Between July 1992 and January 2002, among the 1000 VS that have been treated at the Timone hospital using a Gamma knife, 43 patients displayed a hydrocephalus, 32 of them before the treatment (group A) and 11 of them only after the treatment (group B). It is of note that in both groups, age at the time of treatment (median age of 70 in A & B) and Volume of tumor were comparable and significantly higher than for the whole treated population. Following radiosurgery, 75% of the patients from the group A did not require a shunt whereas all the patients from the group B did, including 3 who also had significant tumor progression requiring surgery. Occurrence of a de novo hydrocephalus was a rare event (1%) that required a shunt early after radiosurgery, at a mean interval of 14.8 Months (4-31). Results from this study suggest that radiosurgery does not significantly increase the risk of hydrocephalus during the natural history of a VS. We can postulate that Gamma Knife radiosurgery might provide a protective influence on hydrocephalus decompensation since the number of preexisting hydrocephalus that necessitated a shunt after the treatment was small. More investigations involving more patients will bring more arguments in the near future.

[Results and indications of gamma knife radiosurgery for large vestibular schwannomas]

Regular treatment of large vestibular schwannomas (VS) is surgical resection of the tumor with attempt of facial nerve preservation. In a very reduced number of tumors, microsurgery is not warranted mainly because of controlateral deafness or the risk of life-threatening open surgery. The purpose of this study was to analyze the results of Gamma Knife radiosurgery delivered for large VS. Between July 1992 and January 2002, we treated 50 patients harboring a large VS defined as a Koos grade IV tumor. Data and follow-up were available for 45 tumors involving 44 patients, including 12 neurofibromatosis type 2. Mean age at the time of treatment was 43,5 (range: 14-84), mean diameter of the tumor in the CPA was 18mm (range: 12-30) and the mean Volume was 4301 mm3 (range: 1340-11405). Gamma knife treatment was undertaken using on average 13.4 isocenters (range: 4-48) and 10.2 Gy at the tumor margin (range: 8-14). Median follow-up was 45.5 Months (from 24 to 108 Months). Tumor control was 69% (interval confidence: 52-83%) and 3 patients had to be operated because of continuous tumor growth. Statistical analysis showed that tumor Volume was correlated to Gamma Knife failure in a uni-and multivariate model (p=0.027). No brain stem complication was observed. No facial nerve deterioration was found and hearing preservation could be obtained at a useful level in 12 out of 20 patients (60%). These results suggest that in a highly selected subgroup of patients with large VS, radiosurgery can be an interesting alternative to open surgery, particularly if hearing preservation is required. Information should be given to the patients that the risk of failure is greater than for small and medium sized VS.

[Radiosurgery of vestibular schwannomas after microsurgery and combined radio-microsurgery]

Significant morbidity is expected after microsurgery for recurrent or growing residual vestibular schwannoma (VS). In order to avoid this procedure, radiosurgery appeared as an interesting alternative. The purpose of this study is to analyze the results of Gamma Knife radiosurgery in this indication. Between July 1992 and January 2002, 60 patients (including 12 NF2 patients) underwent radiosurgical treatment after one or more attempts of surgical resection (including 27 growing remnant VS and 19 recurrent VS) and could be followed with enough informations, out of 103 patients (10% of the VS population treated during the same period). Mean interval between surgical removal and radiosurgery was 71.5 Months (1.8-127.8 Months). Technical difficulties during the procedure were observed in the 12 cases, mainly due to problems in identifying the target. Median follow-up was 51.6 Months. Four out of 58 patients (7%, confidence interval: 1.9-16.7) were diagnosed as failure. Statistical study failed to find significant parameters influencing failure. Facial and trigeminal nerves were not impaired while one case of severe bulbopontine radio-induced injury leading to a lower cranial nerve deficit was observed. These results show that, in spite of additional difficulties to treat these patients with radiosurgery, this treatment is efficient with acceptable morbidity and can avoid another microsurgical procedure. The strategy of planned combined micro-and radiosurgical treatment of large VS deserves additional investigations to be validated.

[Surgical management of vestibular schwannomas secondary to type 2 neurofibromatosis]

To evaluate the results of Gamma Knife radiosurgery treating vestibular schwannomas (VS) secondary to type 2 neurofibromatosis (NF2) we reviewed our clinical experience. Among the VS that have been treated between July 1992 and January 2002, we could analyze retrospectively the data of 50 VS from 37 patients. Fourteen patients had the mild phenotype while 23 were affected by the severe form. Before radiosurgery, one or two microsurgery attempts had been undertaken in 16 VS. Tumor Volume ranged from 120 to 14405 mm3 (mean: 3468 mm3) at the time of treatment; 12 tumors were Koos stade 4. Median clinical and radiological follow-up was 62 Months and ranged from 27 to 123 Months. The 5-Year and 10-Year actuarial survival rates without failure justifying tumor removal were 90 and 85% respectively. The 5-Year actuarial survival rate without hearing decreasing was 36% when selecting the cases of useful hearing (Gardner I & II) at the time of treatment. Severe phenotype (p=0.05) and dose (>12 Gy) delivered at the tumor margin (p=0.032) were correlated to hearing deterioration at univariated analysis. Permanent facial neuropathy occurred in 2%. Even though the level of tumor control and hearing preservation is not the same as for sporadic VS, these results show that Gamma Knife radiosurgery is a valuable alternative treatment for VS in NF2 patients. Future orientation of early proactive radiosurgical treatment of intracanalicular VS will probably improve these results.