Medication misuse in hospitalized patients with renal impairment

OBJECTIVES

The potential consequences of medication misuse in renal impairment have not been assessed in a population of in-patients. The purpose of this study was to determine the frequency and potential consequences of a lack of dosage adjustment in hospitalized patients with renal impairment.

DESIGN

Order sheets for in-patients having a creatinine above 0.7 mg/dl were analysed. We considered the appropriateness of prescriptions for medications having potential nephrotoxicity and/or eliminated through renal excretion or metabolism (TEM medications) and having manufacturer's guidelines for dosage adjustment in renal impairment.

MAIN MEASURES

On the basis of these guidelines, each line of prescription was rated as 'appropriate order', 'inappropriate dosage', or 'contra-indicated order'. Experts also rated prescriptions as potentially fatal or severe, serious, significant, or without potential for increased adverse effects.

RESULTS

Two hundred and two order sheets were completed for 164 patients. They totalled 1469 lines of prescription, 85% of which were TEM medications, with guidelines for dosage adjustment for 71% of them (n = 886). Of these 886 prescriptions, 34% were inappropriate, 14% being contra-indicated and 20% with inappropriate dosage given the patient's renal function. Among the 202 order sheets, 75% included at least one inappropriate prescription. Sixty-three per cent included at least one prescription with potentially adverse consequences, 3% of these having potentially fatal or severe consequences.

CONCLUSION

This study confirms that physicians do not take into account sufficiently patient renal function when prescribing. In light of these results, improving the quality of drug prescription in patients with renal impairment could be of importance for improving the quality of care.

Assessing residents' prescribing behavior in renal impairment

OBJECTIVE

Although fitting orders to renal function avoids overdosage and therefore iatrogenic risk, dosage adjustment is rarely made. The objective of this study was to assess residents' prescribing behavior in renal impairment, through a standardized simulated clinical setting.

METHOD

This criterion-referenced study was carried out in a French teaching hospital. The hospital had 118 residents; 71 of them were asked to complete a questionnaire including four vignettes, simulating drug prescription in four 'patients' with various degrees of renal impairment (16 orders). The patients had an order of gentamicin sulfate, diclofenac sodium, and amlodipine bensylate. For each drug, the resident could maintain the order, discontinue the order, or change the dosage. A fourth drug, enalapril maleate, was to be started, with three possible dosages and the possibility of not prescribing it. The reference chosen for assessment was the Vidal dictionary, which corresponds to the Physician's Desk Reference and is the French reference for prescription.

RESULTS

All the residents approached for the survey accepted the offer to complete the questionnaire. Among the 16 simulated orders, the median number of appropriate orders per resident was nine. Considering the renal function of their patients, 62% of residents wrote an inappropriate order for gentamicin, 42% wrote an inappropriate order for didofenac, and 52% wrote an inappropriate order for enalapril. Although no adjustment to renal function was required, 28% of the residents decreased the dosage of amlodipine and ordered an underdose.

CONCLUSION

Considering the iatrogenic risk related to the lack of dosage adjustment, attention should be drawn to increasing residents' awareness of dosage adjustment in renal impairment and to providing them with better information on patients' renal function.

Assessment of progression in knee osteoarthritis: results of a 1 year study comparing arthroscopy and MRI

OBJECTIVE

The objectives of this study were to determine the sensitivity to change of magnetic resonance imaging (MRI) quantification of chondropathy after 1 year in osteoarthritis of the medial tibiofemoral compartment and to assess the predictive value of subchondral bone marrow edema and bone abnormalities on progression of chondropathy.

DESIGN

Twenty patients with symptomatic knee osteoarthritis of the medial compartment underwent a prospective, longitudinal study. All patients were evaluated the same day at entry and after 1 year by plain weight-bearing radiographs, MRI with a three-dimensional gradient-echo sequence, using a 0.2-T dedicated MR unit, and arthroscopy. The medial tibiofemoral chondropathy was quantified blindly with MRI and arthroscopy using the French Society of Arthroscopy (SFA) score. Presence of subchondral bone marrow edema and bone abnormalities on initial MRI was recorded in order to evaluate their influence on both unchanged and worsened chondropathy after 1 year.

RESULTS

After 1 year, no statistically significant changes were observed with plain radiographs and arthroscopy. At variance, a statistically significant worsening of chondropathy was found with MRI using the SFA-MR score (P=0.01). SFA-MR score was the most responsive outcome. Absence of subchondral bone abnormalities and bone marrow edema on initial MR assessment predicted absence of worsening of chondropathy after 1 year.

CONCLUSION

MRI appears promising for evaluating progression of knee osteoarthritis.

Rapid diagnosis of inflammatory synovial fluid with reagent strips

OBJECTIVE

To determine the usefulness of reagent test strips for screening inflammatory synovial fluid (SF).

METHODS

Consecutive patients undergoing diagnostic arthrocentesis, attending the Department of Rheumatology of a large tertiary care hospital were evaluated. All SF specimens obtained were tested using two techniques: (i) white blood cell (WBC) count with the differential according to standard practice (which is considered the gold standard) (an inflammatory SF was defined as a WBC count > or =2000 cells/mm3); and (ii) reagent strips used to test urine (Multistix 8 SG, Bayer Diagnostics) for the presence of leucocytes (a positive test was defined as a strip showing more than a trace for leucocytes). Sensitivity, specificity, predictive values and likelihood ratio (LR) of the reagent strip in diagnosing inflammatory SF were determined.

RESULTS

Two hundred and eight samples of SF were tested. The results of using the reagent strip were: sensitivity 76.9% (95% CI, 66.0-85.7%), specificity 86.9% (95% CI, 79.9-92.2%); positive LR, 5.88 (95% CI, 3.71-9.31) and negative LR, 0.27 (95% CI, 0.18-0.40). In 13 of the 19 false negative results, the differential cell count showed a predominance (> or =50%) of lymphocytes.

CONCLUSION

This study suggests that, in daily practice, the evaluation of SF by reagent strips could be of use to discriminate between inflammatory and non-inflammatory SF.

[Impact assessment of arthrosis education programs]

TWO COMPLEMENTARY APPROACHES: Education programs are an integral part of the treatment of osteoarthritis and should include information of prognosis as well as advise on lifestyle and/or use of antalgesics. They should also constitute a structured educational approach with the objective of reaching a certain level of comprehension.

EVALUATION

The efficacy of educational programs is difficult to demonstrate. However, results of recent evaluations based on the best methodological criteria should be helpful in defining optimal methods for patient education.

Management of nontuberculous infectious discitis. treatments used in 110 patients admitted to 12 teaching hospitals in France

The optimal management of pyogenic discitis is not agreed on. No randomized clinical trials of short-course or oral antibiotic regimens have been published to date. To shed light on this issue, we reviewed the management of patients admitted for pyogenic discitis to one of 12 networked rheumatology departments. In this cross-sectional observational study, each department included the first ten patients admitted starting in January 1997 for treatment of pyogenic discitis. One hundred ten patients met the inclusion criteria, 67 men and 43 women, with a mean age of 60.6 +/- 13.7 years (range, 17-86 years). Mean time from symptom onset to diagnosis was 39.6 +/- 39.8 days (range, 24 h-240 days). Blood cultures were positive in 47.3% of patients, and the percutaneous discal and vertebral biopsy in 63.6% of cases; these two investigations identified the causative organism in 79 cases (72.8%). Mean duration of the rheumatology department stay was 31.3 +/- 14.1 days (range, 4-78 days). Antibiotics were given intravenously to 103 (93.6%) patients, for a mean of 25.5 +/- 17.6 days (range, 4-124 days); duration of intravenous antibiotic therapy was longer than 4 weeks in 36.5% of patients. Only seven (6.4%) patients received primary oral antibiotics with no parenteral antibiotics. One hundred patients were given oral antibiotics at the same time as and after intravenous antibiotics, for a mean duration of 87.2 +/- 43.6 day (range, 20-278 days); Bracing was used in 98 (89.1%) patients. Although antibiotic selection was rational and in agreement with current recommendations, wide differences were noted across centers regarding intravenous treatment duration, hospital stay duration, and total treatment duration.

Impact of reminders and method of questionnaire distribution on patient response to mail-back satisfaction survey

Nonresponse and methods of data collection could affect satisfaction measurement. The goal of this study was to estimate the impact of (1) nonresponse and (2) distribution method on evaluation of patient satisfaction in a mail-back study measuring patient opinion of medical and nursing care. The study was conducted in an adult hospital. Patients were pseudo-randomized according to the initial mode of questionnaire distribution (given at hospital or sent by mail). Three reminders were made at 1-week intervals to nonrespondents, regardless of the method of initial questionnaire distribution. Groups were distinguished according to the delay of response: initial (before any reminder), middle (after one or two mailed reminders), and late respondents (after mailed reminders plus telephone contact). The study included consecutively discharged patients to obtain 300 patients per arm. 482 patients returned the questionnaire (248 in the group receiving the questionnaire at the hospital and 234 in the other group). Groups were compared for satisfaction scores and delay of response. Early respondents were compared with middle and late respondents for patient characteristics, modality of hospital care, and satisfaction scores. Multivariate analyses were performed. Participation rate before any reminder was higher when the questionnaire was mailed than when it was given at the hospital (45% versus 39.7%, p = 0.03). The initial method of distribution did not influence patient satisfaction level. Satisfaction did not differ between respondents with or without reminders. Distributing questionnaires by mail may be preferred to distribution at discharge to optimize response rate. Reminders do not seem necessary to estimate satisfaction of overall potential respondents.

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

OBJECTIVES

We assessed the influence of patient positioning and radiographic procedure, and defined a smallest detectable difference (SDD) in hip osteoarthritis (OA).

METHODS

OA hip patients each had a standardized pelvic radiograph and, 5 min later, a modified pelvic radiograph with the feet internally rotated 5 degrees (part 1 of the study), the X-ray beam centred on the umbilicus (part 2), or another standardized pelvic radiograph (part 3).

RESULTS

Corresponding mean differences in joint space width (JSW) measurements (limits of agreement) between views were +0.03 (-0.53 to +0.59), -0.31 (-1.15 to +0.53) and -0.02 (-0.48 to +0.44) mm. The two views differed significantly in mean JSW in part 2 of the study (P=1.6x10(-4)), but not in part 1 (P=0.375) and part 3 (P=0.580). The SDD estimate was 0.46 mm.

CONCLUSIONS

Modifying the X-ray beam and foot rotation increases variability in JSW measurements. Use of urograms to evaluate radiological progression should be avoided. A change greater than 0.46 mm could define radiological hip OA progression.

From clinical recommendations to mandatory practice. The introduction of regulatory practice guidelines in the French healthcare system

In an effort to control ambulatory care costs, regulatory practice guidelines (références médicales opposables or RMOs) were introduced by law in France in 1993. RMOs are short sentences, negatively formulated ("it is inappropriate to..."), covering medical and surgical topics, diagnosis, and treatment. Since their introduction, physicians who do not comply with RMOs can be fined. The fine is determined by a weighted combination of indices of harm, cost, and the number of violations. The impact of the RMO policy on physician practice has been questioned, but so far few evaluations had been performed. At the end of 1997, only 121 physicians had been fined (0.1% of French private physicians). The difficulty of controlling physicians, the large number of RMOs, and the lack of a relevant information system limit the credibility of this policy. The simultaneous development of a clinical guideline program to improve the quality of care and of a program to control medical practice can lead to a misunderstanding among clinicians and health policy makers. Financial incentives or disincentives could be used to change physician behavior, in addition to other measures such as education and organizational changes, if they are simple, well explained, and do not raise any ethical conflict. But these measures are dependent on the structure and financing of the healthcare system and on the socioeconomic and cultural context. More research is needed to assess the impact of interventions using financial incentives and disincentives on physician behavior.

[Evaluation of clinical decision rules]

The final goal of decision making rules is to help the clinician make a medical decision and limit heterogeneous practices. Three steps are needed to develop decision making rules for use in daily practice: 1) construction, 2) prospective validation, 3) study of its impact in terms of clinical practice and economics. The aim of this work was to review the details of these different steps basing the research on the Ottawa rules aimed at defining indications for radiography in patients presenting at the emergency room for ankle trauma.

A clinical decision support system for prevention of venous thromboembolism: effect on physician behavior

CONTEXT

Computer-based clinical decision support systems (CDSSs) have been promoted for their potential to improve quality of health care. However, given the limited range of clinical settings in which they have been tested, such systems must be evaluated rigorously before widespread introduction into clinical practice.

OBJECTIVE

To determine whether presentation of venous thromboembolism prophylaxis guidelines using a CDSS increases the proportion of appropriate clinical practice decisions made.

DESIGN

Time-series study conducted between December 1997 and July 1999.

SETTING

Orthopedic surgery department of a teaching hospital in Paris, France.

PARTICIPANTS

A total of 1971 patients who underwent orthopedic surgery.

INTERVENTION

A CDSS designed to provide immediate information pertaining to venous thromboembolism prevention among surgical patients was integrated into daily medical practice during three 10-week intervention periods, alternated with four 10-week control periods, with a 4-week washout between each period.

MAIN OUTCOME MEASURE

Proportion of appropriate prescriptions ordered for anticoagulation, according to preestablished clinical guidelines, during intervention vs control periods.

RESULTS

Physicians complied with guidelines in 82.8% (95% confidence interval [CI], 77.6%-87.1%) of cases during control periods and in 94.9% (95% CI, 92.5%-96.6%) of cases during intervention periods. During each intervention period, the appropriateness of prescription increased significantly (P<.001). Each time the CDSS was removed, physician practice reverted to that observed before initiation of the intervention. The relative risk of inappropriate practice decisions during control periods vs intervention periods was 3.8 (95% CI, 2.7-5.4).

CONCLUSIONS

In our study, implementation of clinical guidelines for venous thromboembolism prophylaxis through a CDSS used routinely in an orthopedic surgery department and integrated into the hospital information system changed physician behavior and improved compliance with guidelines. JAMA. 2000;283:2816-2821

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

OBJECTIVE

To compare radiographic reading procedures and evaluate their impact on sample size in hip osteoarthritis (OA) longitudinal studies.

METHODS

Pelvic radiographs performed twice, three years apart, in 104 patients with hip OA were read by a single reader using the Kellgren and Lawrence system, joint space narrowing scale, and joint space width (JSW). Reading procedures were (a) films read as single radiographs, (b) films grouped by patient but read in random order, (c) films grouped by patient and chronologically ordered, all with landmarks for JSW measurements, (d) films read as single radiographs, without landmarks for JSW measurements. JSW was measured at the narrowest point with a 0.1 mm graduated magnifying glass.

RESULTS

More Kellgren and Lawrence or joint space narrowing grades were modified respectively with the single (42% and 37%) than with the paired (32% and 23%) or chronologically ordered (34% and 29%) reading procedures. Variability of JSW progression was principally related to mean progression (88.3%) and landmarks (almost 10%). Standardised response means were -0.71 with the paired reading procedure with landmarks, -0.68 with the single reading procedure with landmarks, -0.65 with the single reading procedure without landmarks. With landmarks, 10% more patients would be needed using single than paired reading. Using single reading, 10% more patients would be needed without landmarks than with landmarks.

CONCLUSION

Kellgren and Lawrence grading seems to be influenced by the reading procedure, as is joint space narrowing grading, for assessing hip OA. Paired reading procedure with landmarks for JSW should be recommended in longitudinal studies.

Despite financial penalties, French physicians' knowledge of regulatory practice guidelines is poor

OBJECTIVE

To evaluate the level of awareness and knowledge of regulatory practice guidelines (references medicales opposables [RMOs] or regulatory medical references) implemented to control ambulatory care costs among French family physicians.

DESIGN

Observational study. Participants were asked to identify RMO topics among a list of actual and fictitious RMO topics and the RMOs themselves among a list of actual and fictitious RMOs.

SETTING

General practice in France.

SUBJECTS

Three hundred twenty-one family physicians.

MAIN OUTCOME MEASURE

Average score of 100 (95% confidence interval [CI]) on the awareness of RMO topics and knowledge of the RMOs.

RESULTS

The average overall score was 55.8 of 100 (95% CI, 53.3-58.3) for the awareness of the RMO topics and 50.5 (95% CI, 48.3-52.7) for knowledge of the RMOs themselves-53.2 (95% CI, 51.1-55.3) for diagnostic RMOs and 47.8 (95% CI, 45.6-50.0) for therapeutic RMOs. Chance would have yielded an expected mean score of 50. A statistically significant difference was noted between the average score for actual (62.2) and fictitious (43.2) RMOs, P<.001. None of the respondents correctly identified all 24 correct answers.

CONCLUSION

Despite implementation of RMO policy, the awareness and knowledge of RMOs among French family physicians seem weak. The number of RMOs and the difficulties in controlling physicians probably explain these results. Thus, it is doubtful that the RMO policy will have a long-term effect on physicians' behavior.

Follow-up of individual patients on two DXA scanners of the same manufacturer

Measuring and monitoring changes in bone mineral density (BMD) is usually done by dual-energy X-ray absorptiometry (DXA). Replacement of old devices is becoming increasingly frequent. To cross-calibrate two Hologic devices, a QDR 1000 and a QDR 4500A, we measured three phantoms - a Hologic spine phantom, a Hologic block phantom (without and with subregions analysis) and a European Spine Phantom - 20 times each without repositioning on both devices. The mean difference between BMD obtained on the two devices was 0.003, 0.033, 0.051 and -0.045 g/cm2 respectively. We also measured the spine and hip of 60 women aged 19-78 years twice on the same day on both devices. Another group of 30 women aged 52-83 years were measured twice on the QDR 4500 A device (15 days apart). We analyzed the data using Pearson's correlation coefficient, and Bland and Altman's method, and calculated the smallest detectable difference (SDD). Results on the two devices were highly correlated: r2 = 0.99, 0.95, 0.96 for spine, femoral neck and total hip BMD respectively. SDD was higher for scans done on different devices than for those done twice on the same device: the SDDs were 0.048, 0.046 and 0.047 g/cm2 for spine, femoral neck and total hip BMD respectively measured on two different devices, while the equivalent values were 0.034, 0.036 and 0.027 g/cm2 using a single device. The difference in BMD results was not dependent on BMD. Our results suggest that, although devices are properly cross-calibrated, differences among them great enough to be clinically relevant can be observed in vivo.

Construction of a scale measuring inpatients' opinion on quality of care

OBJECTIVE

To develop a reliable and valid measure of patient opinions on quality of hospital care.

DESIGN

Issues of importance to patients and possible scale items were generated by literature review and non-structured interviews of patients, former patients, health care providers and researchers. Semi-structured interviews with inpatients and pilot studies were conducted to modify or remove ambiguous questions and reduce skewed responses. A study was then made to select from these questions relevant items and variables correlated to patient evaluation of quality of care. A principal-components analysis was performed to select items and assess construct validity. Cronbach's alpha coefficients were calculated to estimate the reliability of the scale. Time reliability and concurrent validity were also considered.

SETTING

An 800-bed French short-stay teaching hospital in Paris.

STUDY PARTICIPANTS

Five-hundred and thirty-four consecutive patients hospitalized in eight medical and surgical wards.

RESULTS

A 26-item scale was developed. Component analysis indicated two subscales: 'medical information' and 'relationship with staff and daily routine'. Levels of reliability were satisfactory: Cronbach's alpha coefficient exceeded 0.87 for overall scale and subscales. Concurrent validity and time reliability were also satisfactory. Multivariate analysis showed that, taking into account patients and hospitalization characteristics linked to scores (age, health status, number of hospitalizations, comorbidity, time since diagnosis, admission pattern, private patient and difficulties reported by staff), these scores differed among departments.

CONCLUSION

A reliable, valid measure of inpatients' opinions on quality of care has been developed in a French hospital and variables that have to be taken into account to compare hospital departments have been selected. Items selected in the scale emphasized the importance that patients give to receiving medical information.

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

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

[Are mortality indicators acceptable indicators for the quality of health care?]

IMPORTANCE OF PUBLISHING MORTALITY RATES: Mortality rates for certain interventions or disease states have been used over the last decade as indicators of the quality of care provided by a given hospital, unit or, medical team. If published, these rates would be a useful tool for decision makers in the process of fund allocations, for public information, and for promoting improved care in hospitals or units with a low classification. METHODOLOGICAL LIMITATIONS: It is difficult to adjust an indicator of mortality to disease-related risk factors and any modification of this adjustment can have major consequences on the validity of subsequent comparisons. The differences in mortality observed between hospitals and physicians can reflect not only differences in quality of care but also differences in approaches to disease-related risk factors, therapeutic choices, or coding practices. The lack of statistical power is a major limiting factor in interpreting differences in mortality rates. To evidence a statistically significant difference in mortality between two hospitals whose rates are respectively 0.5% and 1% (for example in total hip replacement patients), it would be necessary to include 4673 patients, a number which would correspond to 20 years data for a hospital performing 230 interventions per year. Consequently, the number of interventions performed in the most active hospitals would not be sufficient to make such comparisons. LIMITATIONS AND COUNTER EFFECTS: Some studies have demonstrated that the publication of mortality rates does not have a major influence on patients' decisions nor on physicians' choice of a referral hospital. It would have no effect on improving health care quality of the institutions cited. One the contrary, certain counter effects have been observed: modification in patient recruitment, higher-risk patients being referred to hospitals with unpublished mortality rates. For many authors, procedure indicators are more pertinent than outcome indicators for detecting differences in health care quality between different care structures.

Individual smallest detectable difference in bone mineral density measurements

Bone mineral density (BMD) measurement is a major outcome measure in osteoporosis. The BMD changes observed must exceed the variability inherent in the measurement process to be considered related to disease progression. The objective of the study was to estimate short-term variability of BMD measurement and to propose a cut-off value for the smallest detectable BMD changes for an individual. To estimate the short-term variability, 70 healthy postmenopausal women aged 53 +/- 4 years (group 1) and 57 elderly osteoporotic postmenopausal women aged 80 +/- 6 years (group 2) had two repeated BMD measurements of the lumbar spine (L2-L4) and the proximal femur with dual-energy X-ray absorptiometry, with complete repositioning within 1 h. Cut-offs derived from short-term variability were either estimated from the coefficient of variation (CV) (which is a function of the measured value) or from the standard deviation (SD), and applied to 330 postmenopausal women (group 3) who had BMD measurements at baseline and 2 years later. The short-term intrasubject variability was greater at the lumbar spine in group 2 versus group 1 (0.0123 vs. 0.0059 g/cm2, p < 10-4), whereas it was not at the femoral neck (0.0098 vs. 0.0076 g/cm2, p = 0.28). There was no statistically significant correlation between short-term intrasubject variability (SD) and BMD as demonstrated with an analysis of covariance (p values ranging from 0.17 to 0.90). Cut-offs estimated with SD and CV were individually applied to group 3 patients. Using these two cut-offs, discrepancies in assessment of progression were observed in 1.7-8.6% of cases. Short-term BMD variability is constant in a wide range of BMD values. Consequently, to determine cut-off values for the smallest detectable differences in BMD at the individual level, precision errors should be based on SD (expressed in absolute units) rather than on CV (expressed in percentage).

A large subset of neutrophils expressing membrane proteinase 3 is a risk factor for vasculitis and rheumatoid arthritis

It has been shown previously that proteinase 3 (PR3), a neutrophil intracellular protease that is the main antigen of antineutrophil cytoplasm (ANCA) autoantibodies, is present on the plasma membrane of a subset of freshly isolated neutrophils. This study shows that the size of this subset of membrane PR3-positive (mPR3+) neutrophils is a stable feature of a given individual, most likely genetically controlled. It ranges from 0 to 100% of neutrophils and allows us to define a new polymorphism in the healthy population, with three discrete phenotypes corresponding respectively to less than 20% mPR3 + neutrophils (mPR3low) or to a mean percentage of 47% (mPR3intermediate) and 71.5% (mPR3high) mPR3+ neutrophils. The frequency of the mPR3high phenotype was significantly increased in patients with ANCA-associated vasculitis (85% versus 55% in healthy subjects). The percentage of mPR3+ neutrophils was not affected by disease activity, relapses, or therapy, and did not reflect in vivo cell activation. In addition, mPR3+ phenotypes were normally distributed in cystic fibrosis patients, indicating that infection and/or inflammation per se do not lead to a high percentage of mPR3+ neutrophils. The frequency of the mPR3high phenotype was not related to anti-PR3 autoimmunization, since it was increased in vasculitic patients regardless of the ANCA specificity (anti-PR3, anti-myeloperoxidase, or unknown). Interestingly, the frequency of the mPR3high phenotype was also increased in patients with rheumatoid arthritis. It was normal in type I-diabetes, a T cell-dependent autoimmune disease. It is proposed here that a high proportion of membrane PR3-positive neutrophils could favor the occurrence or the progression of chronic inflammatory diseases.

Arthroscopic evaluation of post-traumatic patellofemoral chondropathy

OBJECTIVE

To evaluate clinically and arthroscopically post-traumatic patellofemoral chondropathy.

METHODS

Fifty-nine patients with post-traumatic patellofemoral chondropathy were included in a cross sectional study and 46 of them completed a 6 month longitudinal study. Evaluation of the disease, performed once in the cross sectional study and twice (at entry and after 6 months) in the longitudinal study, included clinical and arthroscopic variables evaluating disease activity and severity. Arthroscopy was performed under local anesthesia in an outpatient procedure using a small arthroscope. Chondropathy was evaluated by the overall assessment of the investigator using a visual analog scale, and by the Société Française d'Arthroscopie (SFA) scoring system (SFA score: 0-100). Synovitis was assessed by the "synovitis score," which represents a composite index taking into account intensity, extent and location of synovial abnormalities.

RESULTS

In the cross sectional study, severity of chondropathy correlated with age, body mass index, disease duration, functional impairment (Lequesne's index and maximum number of steps descended), patellofemoral crepitus on active motion, limitation of flexion, and presence and amount of synovitis. Knee effusion correlated with the presence of synovitis, but no correlation was found between pain or functional impairment and presence or amount of synovitis. In the longitudinal study, no statistically significant change in chondropathy was observed after 6 months followup despite a statistically significant improvement in pain, function, and knee effusion after this period. However, a statistically significant correlation was found between the progression of patellofemoral chondropathy and the presence and amount of synovitis at baseline. Synovitis was present at baseline in 10 patients. Changes in SFA scores were 1.2 +/- 1.6 and -0.1 +/- 1.0 in the groups of patients with and without synovitis, respectively (p = 0.0062).

CONCLUSION

These data suggest that synovitis might have a deleterious effect on the evolution of post-traumatic patellofemoral chondropathy or might be a marker for active cartilage breakdown.

Are radiological joint space widths of normal hips asymmetrical?

BACKGROUND

To be certain that the joint space width is abnormal in the case of hip joint pain when compared with the contralateral hip requires knowledge of physiological dissymmetry.

AIM OF THE STUDY

To assess interindividual variability and dissymmetry in pelvic radiological joint space width.

METHODS

Pelvic radiographs of subjects without hip joint disease. Measurement with a 0.1 mm graduated magnifying glass and 0.5 mm graduated flat ruler at the hip superointermediate site (vertical going through the femoral head centre). After randomisation of the side to measure, analysis of nine groups of 19 plain films by one investigator blind for the result of the contralateral side.

RESULTS

The difference between the left and right hip was plotted against the corresponding mean for all 171 normal subjects. This shows the frequency and the limits of the asymmetry at each measurement site. The asymmetry is independent of interindividual variability of the joint space width and greater than the measurement error in most subjects.

CONCLUSION

This study confirms the interindividual variability of hip joint space width, shows the frequency of hip joint space asymmetry and defines its limit.

[Does continuing medical education improve the way physicians conduct their practice?]

OBJECTIVES

Physicians practicing in France are required to participate in continuing education programs in accordance with the code of deontology and the official decree on controlling medical expenditures. We reviewed the literature to analyze the efficacy of such training on the way physicians conduct their practice.

METHODS

We examined the following educational methodologies: diffusion of educational documents or guidelines, conferences and presentations, interventions by opinion leaders, direct visits at the physician's office. The analysis was based solely on publications issuing from work considered to be valid in accordance with the Cochrane collaboration: intervention trials, chronological series, before-after studies with control group.

RESULTS

The diffusion of educational material or more formal continuing education programs do not appear to have an effect on the way physicians conduct their practice. Interventions by opinion leaders have a demonstrated impact but are rarely judged clinically significant. Visits to the physician's office by specially trained health care workers have an effect but this mode of education is costly.

CONCLUSIONS

The conventional strategies, such as simple information diffusion and continuing education programs, developed to promote an evolution of clinical practices appear to be the least effective methodologies.

Effects of joint lavage and steroid injection in patients with osteoarthritis of the knee: results of a multicenter, randomized, controlled trial

OBJECTIVE

To evaluate the efficacy of joint lavage and intraarticular steroid injection, alone and in combination, in the treatment of patients with symptomatic knee osteoarthritis (OA).

METHODS

Ninety-eight patients with painful tibiofemoral OA were enrolled in a prospective, randomized, controlled, 2 x 2 factorial-design trial of 6 months' duration. The 4 treatment groups consisted of 1) intraarticular placebo (1.5 ml of 0.9% normal saline), 2) intraarticular corticosteroids (3.75 mg of cortivazol in 1.5 ml), 3) joint lavage and intraarticular placebo, and 4) joint lavage and intraarticular corticosteroid. Outcome measures evaluated at baseline, week 1, week 4, week 12, and week 24 included severity of pain (100-mm visual analog scale [VAS]), global status (100-mm VAS), and Lequesne's functional index.

RESULTS

No interaction between steroid injection and joint lavage was demonstrated. Patients who had undergone joint lavage had significantly improved pain VAS scores at week 24 (P = 0.020). In contrast, corticosteroid injection had no long-term effect (P = 0.313); corticosteroid injection was associated with a decrease in pain only at week 1 (P = 0.003) and week 4 (P = 0.020). After week 4, Lequesne's functional index was not significantly improved regardless of the assigned treatment.

CONCLUSION

Compared with placebo, both treatments significantly relieved pain but did not improve functional impairment. The effects of the 2 treatments were additive. Cortivazol provided short-term relief of pain (up to week 4). The effects of joint lavage persisted up to week 24.

Efficacy of epidural steroids in low back pain and sciatica. A critical appraisal by a French Task Force of randomized trials. Critical Analysis Group of the French Society for Rheumatology

OBJECTIVE

Several randomized trials have suggested recently that epidural steroid injections may not be a valid treatment in common low back pain and sciatica. To clarify this issue, we conducted a critical appraisal of relevant randomized trials published up to 1997. Attention was directed to methodological quality, results, and clinical implications.

METHOD

A Medline search identified 13 trials published between 1966 and 1997. Trial methodology was evaluated using a 100-point grid based on four groups of items, namely study population, therapeutic intervention, evaluation method, and data presentation and analysis.

RESULTS

Methodology quality scores ranged from 12 to 84 and were unrelated to the results of epidural steroid therapy. Five trials demonstrated greater pain relief within the first month in the steroid group as compared to the control group. Eight trials found no measurable benefits. Obstacles to meaningful comparisons across studies included differences in the patient populations, steroid used, volume injected, and number of injections. None of the published studies used the injection modalities that are standard practice in France.

CONCLUSION

Whether epidural steroids are effective in common low back pain and sciatica cannot be determined based on our review.

Accuracy and precision of 62 bone densitometers using a European Spine Phantom

Dual-energy absorptiometry (DXA) is widely used for bone mineral density measurements. Different types of devices are available. Differences between devices from either the same manufacturer or different manufacturers can lead to difficulties in clinical practice when patients are followed on different machines. We calculated the accuracy and precision of 62 DXA devices from two manufacturers (51 Hologic, 11 Lunar) using a European Spine Phantom (ESP, semi-anthropomorphic). The ESP was measured 5 times on each device without repositioning. Accuracy was assessed by comparing bone mineral density (BMD, g/cm(2)) values measured on each device with the actual value of the phantom. Precision was assessed by the coefficient of variation (CVsd), using the root mean square average. The limits of agreement were estimated from the differences between each replicate measurement of BMD and the estimated true value for a particular manufacturer, according to Bland and Altman. The results confirm the difference between devices from different manufacturers (18.5%). Mean CVsd values were 0.57% and 0.64% for Hologic and Lunar respectively. The limits of agreement among devices from the same manufacturer were 0.026 g/cm(2) and 0.025 g/cm(2) for Hologic and Lunar respectively. Differences in extreme results between devices from the same manufacturer were on average 5.4% and 3.6% for Hologic and Lunar respectively. Results of different devices from the same manufacturer are highly comparable, although unpredictable differences exist that may be clinically relevant.

Piroxicam therapy: a double blind, randomized, multicenter study comparing 2 versus 4 week treatment in patients with painful knee osteoarthritis with effusion

OBJECTIVE

To compare the efficacy and safety of piroxicam 20 mg once a day for 14 or 28 days in patients with knee osteoarthritis (OA) and synovial effusion.

METHODS

We conducted a multicenter, randomized, double blind study in 1905 outpatients. Efficacy was assessed by changes in synovial effusion, pain on a 100 mm visual analog scale (VAS), and impairment using Lequesne's functional index. Patients were classified at Day 28 as improved (defined as VAS and Lequesne index decrease of at least 30% from Day 14), worsened (defined as VAS and Lequesne index increase of at least 30% from Day 14), or unchanged. Safety was assessed on the basis of adverse events reported by the patients.

RESULTS

After 14 days, changes in pain, synovial effusion, and functional impairment significantly decreased from baseline within each group (p < 0.001, respectively), but did not differ between the groups. Between 14 and 28 days, outcome measure changes were significantly better in the 28 day group, p = 0.01, 0.0001, and 0.0001, respectively. In the 28 day and 14 day groups, improvement with regard to pain was observed for 339 (52.4%) and 280 (29.4%) patients, respectively, (p < 0.0001), and with regard to functional impairment for 298 (31.5%) and 233 (24.3%) patients (p < 0.0001). Adverse events accounted for 7.5 and 6.7% of withdrawals in the 28 day and 14 day groups, respectively.

CONCLUSION

When administration of piroxicam 20 mg is prolonged to 28 days, continuing benefit is observed for some patients with knee OA with painful synovial effusion without a significant difference in safety.

High-dose therapy and autologous peripheral blood stem cell transplantation in multiple myeloma: up-front or rescue treatment? Results of a multicenter sequential randomized clinical trial

Results to date indicate that high-dose therapy (HDT) with autologous stem cell support improves survival of patients with symptomatic multiple myeloma (MM). We performed a multicenter, sequential, randomized trial designed to assess the optimal timing of HDT and autotransplantation. Among 202 enrolled patients who were up to 56 years old, 185 were randomly assigned to receive HDT and peripheral blood stem cell (PBSC) autotransplantation (early HDT group, n = 91) or a conventional-dose chemotherapy (CCT) regimen (late HDT group, n = 94). In the late HDT group, HDT and transplantation were performed as rescue treament, in case of primary resistance to CCT or at relapse in responders. PBSC were collected before randomization, after mobilization by chemotherapy, and, in the two groups, HDT was preceded by three or four treatments with vincristine, doxorubicin, and methylprednisolone. Data were analyzed on an intent-to-treat basis using a sequential design. Within a median follow-up of 58 months, estimated median overall survival (OS) was 64.6 months in the early HDT group and 64 months in the late group. Survival curves were not different (P = .92, log-rank test). Median event-free survival (EFS) was 39 months in the early HDT group whereas median time between randomization and CCT failure was 13 months in the late group. Average time without symptoms, treatment, and treatment toxicity (TWiSTT) were 27.8 months (95% confidence interval [CI]; range, 23.8 to 31.8) and 22.3 months (range, 16.0 to 28.6) in the two groups, respectively. HDT with PBSC transplantation obtained a median OS exceeding 5 years in young patients with symptomatic MM, whether performed early, as first-line therapy, or late, as rescue treatment. Early HDT may be preferred because it is associated with a shorter period of chemotherapy.

Variability in knee radiographing: implication for definition of radiological progression in medial knee osteoarthritis

OBJECTIVES

(1) To assess reproducibility of medial knee joint space width (JSW) measurement in healthy subjects and osteoarthritic (OA) patients. (2) To define minimal relevant radiological change in knee JSW based on the reproducibility of its measurement.

PATIENTS AND METHODS

(1) Healthy volunteers: in the first part of the study, 20 knees of healthy adult volunteers were radiographed in the weightbearing, anteroposterior extended view, twice, two weeks apart, using three different radiographic procedures: (a) without guidelines, (b) with guidelines and without fluoroscopy, (c) with guidelines and fluoroscopy. (2) Knee OA patients: in the second part of the study, 36 knees of OA patients were radiographed twice with guidelines and without fluoroscopy. JSW was measured blindly using a graduated magnifying glass. Based on the Bland and Altman graphic approach, cut off points defining minimal relevant radiological change are proposed.

RESULTS

Standard deviation (SD) of differences in JSW measurement between two sets of knee radiographs in healthy subjects were 0.66 mm for radiography performed without guidelines, 0.37 mm for radiography performed with guidelines and without fluoroscopy, and 0.31 mm for radiography with guidelines and fluoroscopy. SD of differences in JSW measurement in OA patients were 0.32 mm for radiography performed with guidelines and without fluoroscopy. A minimal relevant change in JSW between two radiographs performed in healthy subjects can be defined by a change of at least 1.29 or 0.59 mm when radiographs are taken without guidelines, and with guidelines and fluoroscopy, respectively. When radiographs are taken with guidelines and without fluoroscopy, the change must be at least 0.73 mm. A similar figure, 0.64 mm was observed in knee OA patients.

CONCLUSION

Definition of radiological progression varies greatly according to the radiographic procedure chosen. Use of guidelines reduces the threshold of progression required to consider that change between two measures is relevant.

Osteoarthritis of the hip: agreement between joint space width measurements on standing and supine conventional radiographs

OBJECTIVE

To assess the effect of standing position on joint space width (JSW) measurements of the hips with and without osteoarthritis (OA) on pelvic radiographs.

METHODS

Adult patients aged 18 or more had pelvic anteroposterior conventional radiographs standing and supine performed by a single radiologist in the same radiology unit according to standardised guidelines. JSW measurements in mm were made by a single reader blind to patients' identity and type of view, using a 0.1 mm graduated magnifying glass directly laid over the radiograph, at the narrowest point for OA hips or at the vertical joint space for non-OA hips. Agreement of JSW between both views was assessed using the Bland and Altman graphical analysis.

RESULTS

JSW was greater on standing than supine radiographs, for example, 7.1% for OA hips. Mean (SD) differences and limits of agreement (mm) between both views were 0.08 (0.27) and -0.46 to 0.62 for the 70 non-OA hips, 0.02 (0.31) and -0.60 to 0.64 for the 46 OA hips. Corresponding 95% confidence intervals of mean difference were 0.02, -0.14 mm and -0.07, -0.11 mm.

CONCLUSIONS

Measurements of JSW of the hip on pelvic standing and supine radiographs are concordant. Changes less than or equal to 0.64 mm between the two views are similar or inferior to radiological progression of OA.

Validation of the Ottawa ankle rules in France: a study in the surgical emergency department of a teaching hospital

STUDY OBJECTIVE

To validate the Ottawa ankle rules to predict fractures in a French clinical setting when they are used by physicians not involved in their development.

METHODS

We used a prospective patient survey by emergency physicians in a surgical emergency department of a university teaching hospital of the Assistance Publique-Hôpitaux de Paris. The study group consisted of 416 consecutive patients aged 18 years and older who presented with acute ankle or midfoot injuries in the surgical ED during a 4-month period. Radiography was performed in each patient after clinical evaluation findings were recorded.

RESULTS

Forty-nine ankle and 22 midfoot fractures were diagnosed. The decision rules had a sensitivity of .98, a specificity of .45, and a negative predictive value of .99 in detecting ankle fractures, a sensitivity of 1.0, a specificity of .29, and a negative predictive value of 1.0 in detecting midfoot fractures. The rules failed to predict one avulsion fracture in the ankle group. Application of these rules by emergency physicians would have reduced ankle or midfoot radiography requests by 33%.

CONCLUSION

Use of the Ottawa ankle rules by French emergency physicians not involved in the rules' development resulted in 99% sensitivity and had a potential of reducing radiography requests by 33%.

Treatment of skeletal involvement in neoplastic bone diseases

Skeletal complications are frequent and increase morbidity dramatically in patients with malignancies. The role of bone resorption has been stressed leading to a key role for osteoclasts in the bone lesions. Specific and sensitive markers of bone resorption are now available. Bisphosphonates, powerful inhibitors of osteoclasts, can benefit patients with neoplastic bone diseases.

Implementation of the Ottawa ankle rules in France. A multicenter randomized controlled trial

OBJECTIVES

To assess the impact of the implementation of the Ottawa ankle rules on radiography requests in French hospitals during a 5-month intervention period and the impact of using posters alone to sustain the effect of the rules during a 5-month postintervention period.

DESIGN

Multicenter randomized controlled trial preceded and followed by observational studies of radiological practices.

SETTING

The emergency departments of 5 Paris university teaching hospitals of the Assistance Publique-Hôpitaux de Paris.

PATIENTS

A total of 2218, 1911, and 851 patients-all aged 18 years and older-who were seen for acute ankle or midfoot injuries in emergency departments during preintervention, intervention, and postintervention periods, respectively.

INTERVENTION

Implementation of the Ottawa ankle rules by emergency department physicians in the intervention hospitals (using meetings, posters, pocket cards, and data forms). During the postintervention period, posters alone were used to sustain the intervention effect.

MAIN OUTCOME MEASURE

Percentage of patients for whom radiography was requested.

RESULTS

During the preintervention period, 98% and 98.5% of patients were referred for radiography in the intervention and control groups, respectively. During the intervention period, the mean proportions of patients referred for radiography by physicians was 78.9% in the intervention group and 99% in the control group (P=.03). Between preintervention and intervention periods, a relative reduction of 22.4% (95% confidence interval [CI], 19.8%-24.9%) in radiography requests was observed in the intervention group, while requests increased by 0.5% (95% CI, 0%-1.4%) in the control group. During the postintervention period, the proportion of radiography requests in the intervention hospitals was lower than the proportion observed in the preintervention period (83.1% vs 98%).

CONCLUSIONS

Implementation of the Ottawa ankle rules significantly reduced radiography requests in French hospitals. Using a minimal postintervention implementation strategy, the effect of this intervention decreased but persisted after it was discontinued.

From clinical guidelines to quality assurance: the experience of Assistance Publique-Hôpitaux de Paris

OBJECTIVES

The objectives of this study are: to present the history of the development of clinical guidelines in France. to present the implementation of a program of clinical guidelines in Assistance Publique-Hôpitaux de Paris (AP-HP), the regional public hospital system of the Paris metropolitan area, and to discuss the lessons learned from this program, which provide a basis for a better policy of guidelines at a national level.

CONTENT

The objective of the AP-HP program is to promote the appropriate use of clinical guidelines and to evaluate their impact on quality of care and/or costs. Experiments such as controlled trials are used to test the effectiveness of some implementation strategies, to verify that guidelines do improve the process of care and to improve physician compliance with clinical guidelines. Guidelines are developed in a context of budget constraint, and the general aim of the program is to promote the more efficient use of available health resources.

RESULTS

In a context of health care inflation, the desire of public authorities is to use guidelines as a tool for cost control strategy, either for ambulatory care or for hospitals. AP-HP experience shows that it is very difficult to develop a national program of clinical guidelines and to implement it in every hospital, as was done in France (but not clearly evaluated) in ambulatory care (under the name 'references médicales'). Guidelines need to be locally adapted, and the best implementation strategies depend on local resources, for example the existence of a pertinent information system. The role of financial incentives is present in French policies, and the role of the drug industry needs to be evaluated.

[Treatment of myeloma: role of intensive treatments]

CURRENT SITUATION

Since the introduction of melphalan, little progress has be obtained in the treatment of multiple myeloma. Complete remission is rarely achieved with classical single-drug or combined chemotherapy protocols: median survival remains low at 2 to 3 years. A NEW APPROACH: High-dose melphalan therapy with hemopoietic stem cell support it a new approach providing promising results. There is a dose effect and 70 to 80% of naive patients, at the cost of severe prolonged aplasia, respond to high-dose melphalan. HEMATOPOIETIC SUPPORT: Allogeneic or autologous bone marrow or blood stem cell grafts are used. Peripheral blood autographs can be used in most patients; contamination with tumoural cells is generally lower. The period of aplasia after chemotherapy and hematopoietic autograft is relatively short. MAIN INDICATIONS: For most authors, high-dose melphalan should be reserved for younger patients with active myeloma: complete remission is achieved in 20 to 30% of cases although relapse still occurs. Other techniques under study (several sequences of high-dose sessions, reduction of graft contamination) should help improve results.

Radiographic assessment in osteoarthritis

Plain film radiographs are widely used to quantify disease progression in osteoarthritis. Various methods proposed for assessing radiological progression include individual radiographic features (e.g., osteophytes), composite indices (e.g., Kellgren and Lawrence grading), and quantitative measures (e.g., joint space width measurement). We discuss the metrologic properties of these methods and suggest means for improving the quality of radiography in clinical trials.