The use of uncemented stems in femoral neck fractures in elderly patients: A comparative study of 671 cases

INTRODUCTION

The use of cemented stems in elderly patients is associated with the risk of intraoperative embolic complications. Uncemented stems eliminate this risk, but their use is controversial because of the risk of mechanical complications, with estimated subsidence between 3.6 and 30% and periprosthetic fractures between 2.1 and 11% at 6 weeks. A retrospective multicenter comparative study was conducted using a propensity score analysis to evaluate mechanical performances of uncemented stems in femoral neck fractures in elderly patients to (1) compare the risk of mechanical complications and (2) assess the use of metaphyseal-anchored stems for this indication.

HYPOTHESIS

There is no difference in the risk of mechanical complications, intraoperatively or postoperatively, between these stems.

MATERIALS AND METHODS

We conducted a multicenter retrospective comparative study including 358 uncemented and 313 cemented stems. The mean age was 84.5 years [83.9-85.1]. The inclusion criteria were patients 70 years and older and a follow-up of at least 6 weeks. The primary endpoint was a composite endpoint comprised of stem subsidence≥2mm or periprosthetic fracture (up to 3 months postoperatively). The secondary endpoints were infection, stem subsidence≥2mm, and operative time. These endpoints were analyzed using a propensity score to control confounding factors. A secondary analysis used the same endpoints to compare metaphyseal-anchored (short stems) versus Corail-like stems.

RESULTS

After adjusting for the propensity score, we found 11.17% mechanical complications in the uncemented group (n=40, 5.59% subsidence, and 5.59% fractures) versus 13.42% for the cemented group (n=42, 7.99% subsidence, and 5.43% fractures). There was no statistically significant difference between the 2 values (Odds Ratio [OR]=0.64 [95% Confidence Interval [CI]: 0.14-2.85] [p=0.7]). The mortality rate due to cement embolism was 1%. There was no difference in the rate of subsidence (OR=0.55 [95% CI: 0.02-12.5] [p=0.7]), periprosthetic fracture (OR=0.65 [95% CI: 0.13-3.12] [p=0.7]) or infection (OR=0.71 [95% CI: 0.32-1.55] [p=0.4]). However, the operative times were longer in the cemented group (p=0.03 for hemiarthroplasties [mean additional time 16minutes] and p=0.02 for total hip arthroplasties [mean additional time 22minutes]). No difference was observed between the metaphyseal-anchored (short stems) and Corail-like stems regarding operative time, rate of infection, and rate of stem subsidence or periprosthetic fractures.

DISCUSSION

This is one of the first studies to highlight cemented stem subsidence when used for femoral neck fractures in elderly patients. Using uncemented stems in this indication is still warranted, especially since they do not bring about more mechanical complications in the first few months. Metaphyseal-anchored short stems seem to give the same results as "standard" stems. However, these findings need to be assessed in the longer term.

LEVEL OF EVIDENCE

III; retrospective comparative study.

Assessment of risk factors of treatment discontinuation among patients on paliperidone palmitate and risperidone microspheres in France, Germany and Belgium

BACKGROUND

Long-acting antipsychotics (e.g. 1-monthly (PP1M) / 3-monthly (PP3M) injection forms of paliperidone palmitate) have been developed to improve treatment continuation in schizophrenia patients. We aim to assess risk factors of treatment discontinuation of patients on paliperidone palmitate and risperidone microsphere. Additionally, treatment discontinuation between patients with PP1M and PP3M was compared.

METHODS

The IQVIA Longitudinal Prescription databases were used. Risk factors of treatment discontinuation were identified by a multilevel survival regression using Cox proportional hazards model. Kaplan Meier analyses were performed by identified significant risk factors.

RESULTS

Twenty-five thousand three hundred sixty-one patients (France: 9,720; Germany: 14,461; Belgium: 1,180) were included. Over a one-year follow-up period, a significant lower treatment discontinuation was observed for patients newly initiated on paliperidone palmitate (53.8%) than those on risperidone microspheres (85.4%). Additionally, a significantly lower treatment discontinuation was found for 'stable' PP3M patients (19.2%) than 'stable' PP1M patients (37.1%). Patients were more likely to discontinue when drugs were prescribed by GP only (HR = 1.68, p < 0.001 vs. psychiatrist only) or if they were female (HR = 1.07, p < 0.001), whereas discontinuation decreased with age (31-50 years: HR = 0.95, p = 0.006 and > 50 years: HR = 0.91, p < 0.001 vs. 18-30 years).

CONCLUSIONS

This study demonstrates that patients stay significantly longer on treatment when initiated on paliperidone palmitate as compared to risperidone microspheres. It also indicated a higher treatment continuation of PP3M over PP1M. Treatment continuation is likely to be improved by empowering GPs with mental health knowledge and managing patients by a collaborative primary care-mental health model. Further research is needed to understand why females and younger patients have more treatment discontinuation.

Assessment of risk factors of treatment discontinuation among patients on paliperidone palmitate and risperidone microspheres in france, germany and belgium – a retrospective database study

Introduction

Long-acting antipsychotics (e.g. 1-monthly (PP1M) / 3-monthly (PP3M) injection forms of paliperidone palmitate) have been developed to improve treatment continuation in schizophrenia patients.

Objectives

To assess risk factors of treatment discontinuation in patients on paliperidone palmitate and risperidone microsphere. Additionally, treatment continuation between patients with PP1M and PP3M was compared.

Methods

The IQVIA Longitudinal Prescription databases were used. Risk factors of treatment discontinuation were identified by a multilevel survival regression using Cox proportional hazards model. Kaplan Meier analyses were performed by identified significant risk factors.

Results

25,361 patients (France: 9,720; Germany: 14,461; Belgium: 1,180) were included. Over a one-year follow-up period, a significant higher treatment continuation was observed for patients newly initiated on paliperidone palmitate (46.2%) than those initiated on risperidone microspheres (14.6%). Additionally, a significantly higher treatment continuation was found for ‘stable’ PP3M patients (81.8%) than ‘stable’ PP1M patients (62.9%). Patients were more likely to discontinue when drugs prescribed by GP only (HR = 1.68, p < 0.001 vs. psychiatrist only) or being females (HR = 1.07, p < 0.001), whereas discontinuation rate decreased with age (31-50 years: HR = 0.95, p = 0.006 and > 50 years: HR = 0.91, p < 0.001 vs. 18-30 years).

Conclusions

Paliperidone palmitate was associated with a significantly higher treatment continuation than risperidone microspheres. Treatment continuation is likely to be improved by targeting young patients (18-30 years), empowering GPs with mental health knowledge and managing patients by a collaborative primary care-mental health model. Further research is needed to understand why females have more treatment discontinuation.

Disclosure

Rui Cai, Flore Decuypere and Pierre Chevalier are IQVIA employees and served as paid consultants to Janssen during the conduct of this study. Antonie Wimmer, Pascal Guillon, Stefan Pype, Annabelle Godet, Valeria Timtschenko are Janssen employees.

Le fardeau des aidants de patients souffrant de schizophrénie en France

Objectif

Étudier la qualité de vie (QdV), les comorbidités liées au stress, l’activité, la productivité et les consommations de soins des aidants de patients schizophrènes par rapport aux non-aidants et aux aidants d’adultes présentant d’autres pathologies (maladie d’Alzheimer, cancers, AVC) en France.

Méthodes

Les données ont été obtenues à partir des enquêtes en ligne santé et bien-être France (2010–2013) dans la population adulte (> 18 ans). Le recueil portait sur la QdV (SF-36v2 : dimensions mentale et physique (MCS, PCS), SF-6d (utilités liées à la santé)), les comorbidités liées au stress (insomnie, troubles du sommeil, douleur, céphalées, anxiété, dépression) au cours des 12 derniers mois, l’activité et la productivité au travail et l’utilisation des soins de santé (consultations, passage aux urgences et hospitalisations dans les 6 derniers mois). Les aidants de patients schizophrènes (n = 73) ont été comparés avec les non-aidants (n = 40 326) et les autres aidants (n = 3814) sur les caractéristiques socio-démographiques et les indicateurs relatifs à la santé pour rechercher des différences significatives entre les groupes.

Résultats

L’âge moyen des aidants de patients schizophrènes était de 51,8 ans (SD = 15,4) ; 64,4 % étaient des femmes ; 45,2 % avaient un emploi ; 53,4 % étaient mariés/en couple ; 76,7 % ont déclaré un revenu < €50 000. Leurs scores de QdV (MCS : 39,7 vs 46,7 ; PCS : 47,2 vs 51,0) et d’utilité (0,63 vs 0,73) étaient significativement plus faibles que chez les non-aidants (p < 0,001) ; ils rapportaient davantage de troubles du sommeil (42,5 % vs 28,0 %), d’insomnie (38,4 % vs 19,4 %), de douleurs (34,2 % vs 22,9 %), de céphalées (45,2 % vs 27,6 %), d’anxiété (46,6 % vs 21,7 %), ou de dépression (20,5 % vs 8,4 %) (p < 0,05) ainsi qu’une moindre activité (34,3 % vs 22,1 %), une augmentation des consultations médicales (9,5 contre 4,9), des passages aux urgences (0,7 vs 0,1) et des hospitalisations (0,8 vs 0,1) (p < 0,001). Des résultats similaires étaient retrouvés par rapport aux autres aidants sur la QdV, l’utilité, les céphalées, l’anxiété et les consommations de soins. Aucune différence significative n’apparaissait sur le score PCS, les autres comorbidités liées au stress, l’activité et la productivité.

Conclusions

Les aidants de patients souffrant de schizophrénie rapportaient une moins bonne QdV, plus de comorbidités liées au stress, de consommation de soins de santé que les non-aidants et les aidants d’autres pathologies.

The clinical and economic impact of three-monthly long-acting formulation of paliperidone palmitate versus the one-monthly formulation in the treatment of schizophrenia in France: A cost-utility study

OBJECTIVES

Schizophrenia entails a considerable humanistic and economic burden. Improved treatment continuity to antipsychotic therapy is paramount to reduce the risk of relapse. The novel three-monthly paliperidone palmitate treatment (PP3M) offers the longest dosing interval currently available in France. This study assesses its cost-effectiveness, versus the currently available one-monthly long-acting treatment (PP1M) in French schizophrenic patients.

METHODS

A Markov model with monthly cycles was developed and adapted. It encompassed [a] administration of PP3M or PP1M in first-line, [b] a period where the patient does not receive any active treatment, and [c] a follow-up treatment line consisting of a treatment mix reflecting French clinical practice. Relapse rates in first-line were based on a pivotal non-inferiority head-to-head trial, and treatment discontinuation rates were based on French real-world data. Accounting for differences in drug exposure, time-dependent monthly relapse rates were applied following discontinuation to first line. The impact of a less frequent injection schedule for PP3M in QoL was accounted for through the application of a utility differential. The collective perspective was adopted throughout a 5-year time horizon. Four percent discount rates were applied on costs and outcomes.

RESULTS

PP3M was dominant when compared to PP1M, featuring an incremental QALY of 0.123 and a cost saving effect (-669€) resulting from reduced therapy costs (drug acquisition, administration and monitoring) and relapse-related costs. Sensitivity analysis supported the robustness of the results.

CONCLUSION

With slightly better QALY outcomes and a cost-saving effect when compared to PP1M, introducing PP3M is an improvement to the current treatment in France.

Comparison of dual mobility total hip arthroplasty and bipolar arthroplasty for femoral neck fractures: A retrospective case-control study of 199 hips

BACKGROUND

The choice between performing total hip arthroplasty (THA) or hemiarthroplasty (HA) is not straightforward in older patients with femoral neck fracture, particularly when co-morbidities are factored in. This led us to carry out a case-control study to determine (1) the rate of mechanical complications for these two types of implants, and (2) the rate of medical complications and mortality.

HYPOTHESIS

THA with dual mobility cup (DM) will result in fewer mechanical complications than HA.

PATIENTS AND METHODS

This was a single-center, retrospective case-control study. Between 2010 and 2015, all patients with a femoral neck fracture treated by HA or DM THA were included. The primary outcome was the occurrence of any type of surgical complication. The Charlson Co-morbidity Index (CCI) and the independence during Activities of Daily Living (ADL) score were calculated for every patient. Two subgroups of patients were made based on whether they met frailty criteria. The effect of covariates on 1-year mortality was controlled using Cox's proportional hazards regression model.

RESULTS

The cohort consisted of 101 HA and 98 THA procedures in 193 patients (139 women, 54 men) with a mean age of 80.6years (range, 76-101). The mean follow-up was 24.2months (range, 0-83) with a median of 14.5months. Fifteen of the HA hips (15%) had surgical complication, of which 10 were posterior dislocations (10%). Ten patients in the HA cohort had a serious medical complication (10%). Ten of the THA hips (10%) had a mechanical complication, including three posterior dislocations (3%) and four infections (4%). Nine patients in the THA cohort had a medical complication (9%). There were significantly fewer posterior dislocations in the THA hips (p = 0.05). In the subgroup analysis, the 117 patients (58%) who met the frailty criteria had a significantly lower dislocation rate after undergoing THA (p = 0.048). After adjusting on age, ADL and CCI score, the dislocation rate no longer differed significantly between the two groups (p = 0.1). The dislocation rate was lower in the THA hips only in the "frail" patients (Odds ratio = 0.137, 95% CI: [0.003-0.97] (p = 0.04)). There was no difference in the dislocation rate in the "non-frail" patients. The overall 1-year mortality was 85% [95% CI: 78-94%]. It was 78% [95% CI: 69-86%] for the HA hips and 88% [95% CI: 82-95%] for the THA hips (p = 0.01). After factoring in the impact of age, CCI and ADL, the differences in the 1-year mortality between HA and THA were no longer present (p = 0.42). Thus, there is no increased risk of mortality in THA patients.

DISCUSSION

When the CCI and independence level are taken into consideration, the frailest patients can undergo DM THA to reduce the dislocation risk, without increasing the mortality rate at 1year. Patients who are not frail will benefit equally from undergoing HA or THA.

LEVEL OF EVIDENCE

III, case-control study.

Targeting human respiratory syncytial virus transcription anti-termination factor M2-1 to inhibit in vivo viral replication

Human respiratory syncytial virus (hRSV) is a leading cause of acute lower respiratory tract infection in infants, elderly and immunocompromised individuals. To date, no specific antiviral drug is available to treat or prevent this disease. Here, we report that the Smoothened receptor (Smo) antagonist cyclopamine acts as a potent and selective inhibitor of in vitro and in vivo hRSV replication. Cyclopamine inhibits hRSV through a novel, Smo-independent mechanism. It specifically impairs the function of the hRSV RNA-dependent RNA polymerase complex notably by reducing expression levels of the viral anti-termination factor M2-1. The relevance of these findings is corroborated by the demonstration that a single R151K mutation in M2-1 is sufficient to confer virus resistance to cyclopamine in vitro and that cyclopamine is able to reduce virus titers in a mouse model of hRSV infection. The results of our study open a novel avenue for the development of future therapies against hRSV infection.

Cost Effectiveness of Paliperidone Long-Acting Injectable Versus Other Antipsychotics for the Maintenance Treatment of Schizophrenia in France

BACKGROUND

French clinical recommendations suggest prescribing long-acting injectable (LAI) antipsychotics to patients with a maintenance treatment indication in schizophrenia. Despite this, and due to their relatively high acquisition and administration costs, LAIs are still underused in clinical practice in France, thus highlighting the need for pharmacoeconomic evaluations.

OBJECTIVE

Our objective was to estimate the cost effectiveness of paliperidone LAI (or paliperidone palmitate), a once-monthly second-generation LAI antipsychotic, compared with the most common antipsychotic medications for the maintenance treatment of schizophrenia in France.

METHODS

A Markov model was developed to simulate the progression of a cohort of schizophrenic patients through four health states (stable treated, stable non-treated, relapse and death) and to consider up to three lines of treatment to account for changes in treatment management. Paliperidone LAI was compared with risperidone LAI, aripiprazole LAI, olanzapine LAI, haloperidol LAI (or haloperidol decanoate) and oral olanzapine. Costs, quality-adjusted life-years (QALYs) and number of relapses were assessed over 5 years based on 3-month cycles with a discount rate of 4% and from a French health insurance perspective. Patients were considered to be stabilised after a schizophrenic episode and would enter the model at an initiation phase, followed by a prevention of relapse phase if successful. Data (e.g. relapse or discontinuation rates) for the initiation phase came from randomised clinical trials, whereas relapse rates in the prevention phase were derived from hospitalisation risks based on real-life French data to capture adherence effects. Safety and utility data were derived from international publications. Additionally, costs were retrieved from French health insurance databases and publications. Finally, expert opinion was used for validation purposes or in case of gaps in data. The robustness of results was assessed through deterministic and probabilistic sensitivity analyses.

RESULTS

All LAI antipsychotics were found to have similar costs over 5 years: approximatively €55,000, except for paliperidone LAI which had a discounted cost of €50,880. Oral olanzapine was less costly than LAIs (i.e. €50,379 after 5 years) but was associated with fewer QALYs gained and relapses avoided. Paliperidone LAI dominated aripiprazole LAI, olanzapine LAI and haloperidol LAI in terms of costs per QALY, and it was associated with slightly fewer QALYs when compared with risperidone LAI (i.e. 3.763 vs 3.764). This resulted in a high incremental cost-effectiveness ratio (ICER) (i.e. €4,770,018 per QALY gained) for risperidone LAI compared with paliperidone LAI. Paliperidone LAI was more costly than olanzapine oral but associated with more QALYs (i.e. ICER of €2411 per QALY gained for paliperidone LAI compared with oral olanzapine). Paliperidone LAI had a probability of being the optimal strategy in more than 50% of cases for a willingness-to-pay threshold of €8000 per QALY gained.

CONCLUSION

This analysis, to the best of our knowledge, is the first of its kind to assess the cost effectiveness of antipsychotics based on French observational data. Paliperidone LAI appeared to be a cost-effective option in the treatment of schizophrenia from the French health insurance perspective.

Radial nerve palsy in surgical revision of total elbow arthroplasties: A study of 4 cases and anatomical study, possible aetiologies and prevention

BACKGROUND

Damage to the radial nerve in the arm during revision of total elbow arthroplasty is a serious complication; which is still not well documented. The aim of this study was to define a way on how to avoid this complication and to prevent it.

PATIENTS AND METHODS

Four patients underwent radial palsy after revision of total elbow arthroplasty. An anatomical study on 20 upper limbs was performed to define landmarks for the radial nerve in the arm and elbow.

RESULTS

Radial nerve damage occurred near the proximal tip of the stem in all four patients, due to cement seepage caused by cortical effraction in two patients, and to damage caused by the retractors in the two other patients. The anatomical study made it possible to specify landmarks for the radial nerve in relation to the humerus. A high-risk area located 14cm away from the tip of the olecranon fossa, and 15.5cm from the medial epicondyle, was identified.

CONCLUSION

A high-risk area for the radial nerve was defined and suggested targeted landmarks with a posterior proximal counter-incision situated at about 14cm above the olecranon fossa.

LEVEL OF EVIDENCE

IV.

Analyse coût-efficacité du palmitate de palipéridone par rapport aux autres antipsychotiques indiqués dans le traitement de la schizophrénie en France

Objectif

Évaluer l’efficience du palmitate de palipéridone (PP) par rapport aux antipsychotiques les plus communément utilisés en France.

Méthodes

Un modèle médico-économique a été développé afin de simuler la progression d’une cohorte de patients atteints de schizophrénie à travers quatre états de santé (« Stable-traité », « Stable-non-traité », « En-rechute », « Décédé »). PP a été comparé à rispéridone injectable à libération prolongée (ILP), aripiprazole ILP, olanzapine ILP, halopéridol décanoate et olanzapine orale (OO). Les coûts, les années de vie pondérées par la qualité de vie (« Quality-adjusted-life-year » ; QALY) et le nombre de rechutes ont été estimés sur cinq ans selon une perspective tous payeurs. Supposés stabilisés suite à une décompensation clinique, les patients initiaient un antipsychotique et passaient en phase de prévention de la rechute en cas de succès après trois mois. Ils/elles pouvaient arrêter leur traitement après une rechute, un manque de tolérance ou par choix, et passer sur la ligne de traitement suivante jusqu’à la troisième ligne (c.-à.-d. clozapine). Afin de prendre en compte l’observance, les probabilités de rechute en phase de prévention ont été calculées à partir de taux d’hospitalisation sur des données françaises en vie réelle. Les données de tolérance et d’utilité ont été dérivées d’études internationales, et les coûts de sources françaises. La robustesse des résultats a été testée via des analyses de sensibilité.

Résultats

À 5 ans, PP est le moins coûteux des ILP et est associé à un surcoût de 249 € par rapport à OO. Rispéridone ILP et PP sont associés aux plus grands nombres de QALY. PP domine tous les autres ILP en termes de rechute évitée hormis olanzapine ILP.

Conclusion

PP est le moins coûteux des antipsychotiques ILP en France. OO est l’antipsychotique le moins coûteux, mais est associée à un nombre plus faible de QALY gagnées et de rechutes évitées comparé aux antipsychotiques ILP.

Prospective evaluation of venous access difficulty and a near-infrared vein visualizer at four French haemophilia treatment centres

Although a serious impediment in haemophilia patients, difficulty accessing peripheral veins has received little attention in clinical studies. New peripheral vein visualization devices could potentially ameliorate difficult venous access (DVA), but their utility remains unproved. The study aim was to survey the frequency, causes and clinical manifestations of DVA and evaluate the clinical utility of a near-infrared (NIR) vein visualizer. In this multicentre prospective study, methods, difficulties and outcomes of venous access were assessed for a single venipuncture in consecutive patients. The impact of an NIR vein visualizer on vein localization, the number of venipuncture attempts and patient stress and pain was determined. Among 450 total patients enrolled, venous access was judged to be difficult in 165 (36.7%), most often because of poor vein condition, young patient age, overweight and difficulty in finding veins. Of the patients with DVA, difficulty in locating veins was encountered in 82.4%, and more than one venipuncture attempt was required in 24.8%. Veins were difficult to locate in significantly fewer DVA patients (P = 0.002) when the NIR vein visualizer was used (76.0%) than not used (92.3%). Pain during venipuncture in DVA patients was also significantly less common (P = 0.019) with use of the NIR vein visualizer (34.0% vs. 55.4%). No effect was observed on venipuncture attempts. DVA affects more than one-third of patients at haemophilia treatment centres. An NIR vein visualizer showed significant promise for facilitating vein location and mitigating patient pain in those patients.

[Posteromedial dislocation of the elbow with lateral condyle and coronoid process fractures: a case report]

We report the occurrence of a rare injury in a teenager not yet described in the literature: the association of posteromedial elbow dislocation, lateral condyle and coronoid process fractures. The treatment required fixation of lateral condyle and coronoid process thanks to lateral and medial approaches and capsular fixation. This lesion is unstable, such as the terrible triad described in adults. It requires external and anterior stabilization of the elbow. The management of such injuries of the elbow is complex. It must consider both bone and ligament instability, and risk of injury to growth plates.

CT evaluation of torsional malalignment after intertrochanteric fracture fixation

INTRODUCTION

Trochanteric fractures are commonly stabilized either by intramedullary nailing or plate and screw fixation after reduction on the orthopaedic surgical table under radiological guidance.

HYPOTHESIS

Closed trochanteric fracture anatomic reduction is difficult in the transversal plane.

OBJECTIVES

The objective of this prospective study was to assess the rotational malalignment induced after reduction and osteosynthesis of trochanteric fractures.

PATIENTS AND METHODS

Prospective study including 40 patients (mean age, 78 years; range, 51-90 years) operated for a trochanteric fracture between January 2007 and September 2008. Fourteen fractures were treated using DHS™ (Synthes™) plate and screw fixation and 26 with intramedullary nailing (trochanteric nail™, Stryker™). All these patients underwent postoperative CT of the pelvis during their hospitalization with measurement of anteversion of the operated and healthy femoral necks at the posterior condyles. The evaluation criterion was whether or not there was malalignment greater than 15° on the operated side compared to the healthy side.

RESULTS

The mean anteversion was 14.2° for the healthy side and 23° for the operated side. The mean rotational malalignment was 15.3°. Forty percent of the rotational malalignments were greater than 15°, with a majority of cases showing excess internal rotation (35%) of the distal fragment.

CONCLUSION AND DISCUSSION

The rate of internal rotational malalignment of the distal fragment greater than 15° was high (40% of this series). This should encourage surgeons to reduce the excess internal rotation that tends to be attributed to the distal fragment during preoperative reduction of these fractures.

LEVEL OF EVIDENCE

Level III. Prospective diagnostic study with no control group.

Patient resources in the therapeutic education of haemophiliacs in France: their skills and roles as defined by consensus of a working group

The activities of 'expert patients' or 'patient tutors', who help educate their peers, are gaining recognition in the health care system. This study investigates the role played by such patients in therapeutic education programmes organized by caregivers to validate the role of patients in implementing the therapeutic education of haemophilic patients and to define the skills required for such activities. This study employs the consensus methodology recommended by France's National Authority for Health. The working group includes seven caregivers from Hemophiliac Treatment Centers (HTCs) and three patients from the French Association of Hemophiliacs (FAH). The role of patients in haemophilia education is recognized. Patients participating in the education of their peers are referred to as 'patient resources'. A patient resource should be an adult, a volunteer and live in the same region as his peers. Candidates are chosen by the FAH and the HTCs to serve based on their motivation to facilitate the education of other patients as well as on their psychological and pedagogical aptitudes. A patient resource participates in the conception and administration of therapeutic education programmes. He also mediates between the caregivers and the patients. He ensures that the patients understand the material and are able to apply their knowledge in daily life. His activities are governed by professional ethics. Seven categories of skills were defined, permitting the group to determine precisely which skills are required to function as a patient resource. Supervision of the patients is planned to reinforce reflexive practices in the patients. Evolution of the health care system has led patients to become involved in therapeutic education. This phenomenon calls for a framework to be developed and an evaluation of its eventual effects.

Modelling the budget impact of darunavir in the treatment of highly treatment-experienced, HIV-infected adults in France

BACKGROUND

A key element for payers in the assessment of the economic profile of a medication is its anticipated impact on the evolution of healthcare budgets.

OBJECTIVES

To forecast the impact of the use of darunavir with low-dose ritonavir 600/100 mg twice a day (bid) in highly treatment-experienced, HIV-infected adults who have failed one or more protease inhibitor (PI)-containing regimen on the budget of the French Sickness Fund (French healthcare system) over a 3-year time horizon.

METHODS

A transition state model based on disease severity was developed that compared the evolution of antiretroviral and non-antiretroviral-related direct costs of care in the target population over 3 years (2007-2009) under two scenarios: (1) darunavir enters the French market in year 1; (2) darunavir is not available to the target population during 2007-2009. Model inputs were derived from a targeted analysis of the French hospital database in HIV, the darunavir POWER 1 and 2 trials and other relevant clinical studies.

RESULTS

In the scenario where darunavir was available from year 1, the proportion of patients in the lower, more costly CD4 cell count strata (≤ 100 cells per mm³) was consistently lower than in the scenario without darunavir in each year of the model (17.0% vs 19.2%, 13.9% vs 18.3% and 10.8% vs 16.8% for years 1, 2 and 3, respectively). As a result, over the entire 3-year period, the net increase of antiretroviral drug costs (+ 5.6 million Euros; €), resulting from the substitution of older, cheaper PIs by darunavir, is expected to be fully compensated by savings in hospitalization costs (€-9.7 million) and expenditures for other HIV-related (non-antiretroviral) medications (€-7.3 million), leading to a net saving of €11.4 million or 2.9% of the total budget in the scenario without darunavir. Various sensitivity analyses confirmed these projected savings.

CONCLUSION

The use of darunavir/ritonavir (DRV/r) 600/100 mg bid, in combination with other antiretroviral agents, in highly pre-treated, HIV-infected adults who have failed one or more PI-containing highly active antiretroviral therapy regimen is not expected to increase the budget of the French healthcare system, in comparison with a scenario without darunavir. Further research is needed to estimate the budget impact of the use of DRV/r in less treatment-experienced, HIV-infected individuals in France.

The cost of managing HIV infection in highly treatment-experienced, HIV-infected adults in France

BACKGROUND

Highly active antiretroviral therapy (HAART) has greatly enhanced HIV management, lowering the risk of clinical disease progression and death by substantially improving HIV-induced immune deficiency. Lower CD4 cell counts have consistently been associated with higher direct costs of HIV patient care. The aim of this study was to analyze HIV costs of care in France at different levels of HIV-induced immune deficiency (as measured by the CD4 cell count) using recent data from treatment-experienced patients.

METHODS

This analysis used data from the French Hospital Database in HIV, containing data on approximately 50% of the French HIV population. Patients were included in the analysis if they had visited a participating centre from 2003 to 2005, had CD4 cell counts determined at least twice during the study period, and had been prescribed at least two nucleoside reverse transcriptase inhibitors, one non-nucleoside reverse transcriptase inhibitor and two protease inhibitors since their first consultation. Resources consumed were counted and aggregated according to the CD4 cell count level. Standard costs were applied.

RESULTS

Periods with the lowest CD4 cell counts were associated with increased prescription rates of antiviral agents (other than anti-HIV agents), antiparasitic drugs and antimycobacterial agents. Antiretroviral treatments accounted for 80% of all medications prescribed during the study period. Hospitalization rates decreased with increasing CD4 cell counts, with 0.72 hospitalizations per patient-year for those with CD4 cell counts of 50 cells/mm³ or less compared with 0.05 per patient-year for patients with CD4 cell counts greater than 500 cells/mm³. There was a clear trend towards lower mean healthcare costs per patient-year with decreasing immune deficiency; from €34,286 to €12,361.

CONCLUSIONS

Our study showed an association between the degree of HIV-induced immune deficiency (measured by CD4 cell count) and the costs of managing HIV infection among highly pre-treated, HIV-infected individuals in France in the HAART era.

Quality of life and clinical correlates in patients with diabetic foot ulcers

OBJECTIVE

To compare the Health Related Quality of Life (HRQL) of French diabetic patients with and without foot ulcers and to determine the factors influencing disease-specific HRQL for those with foot ulcers.

METHODS

355 diabetic patients, including 239 with foot ulcers (group 1) and 116 without foot ulcers (group 2) were studied in a cross-sectional setting. Socio-demographic and clinical variables were recorded and HRQL was evaluated using a generic HRQL questionnaire (SF-36) for all subjects. For group 1, the severity of foot ulcers was assessed according to Wagner's classification, and disease-specific HRQL assessed using the Diabetes Foot Ulcer Scale (DFS).

RESULTS

HRQL was found to be significantly lower (P = 0.0001) in group 1 than in group 2 for all domains of the SF-36. Independent inverse relationships were found between good HRQL in the DFS domain of Leisure and Wagner grade (OR = 0.136 [0.029-0.467]) as well as the number of foot ulcers (OR = 0.365 [0.191-0.678]). Age was significantly associated with several DFS domains including Daily Activities, Physical Health and Dependence.

CONCLUSION

Our findings suggest that the number and severity of foot ulcers are associated with patient HRQL, especially in terms of leisure activity disruption and constraints due to treatment. These findings have implications for the evaluation, planning and management of patient care in diabetic foot disease.

Analyse coût-efficacité des stratégies de prise en charge des patients schizophrènes : place d’un antipsychotique atypique sous forme injectable à libération prolongée

Schizophrenia is a disease affecting the young adults and amounts to approximately 300,000 people in France. The French public psychiatric sector takes care of approximately 150,000 adults schizophrenics: 50% benefit from ambulatory care, 50% are in partial or full-time hospitalization care. Schizophrenia represents the first diagnosis that psychiatric sectors take in charge. The costs associated with schizophrenia, mainly hospital costs, are important and were estimated at 2% of the total medical costs in France. In the French social welfare system, the social costs (pensions, allowances, managements of custody or guardianship by social workers) are also to be taken into account: it amounts to a third of the global direct cost. Schizophrenia also generates indirect costs (losses of productivity and premature deaths) which would be at least equal, or even more important, than direct medical costs. The non-compliance to the antipsychotic treatment is a major problem with people suffering from schizophrenia. Indeed the lack of compliance to the treatment, estimated at 20 to 40%, is a major handicap for schizophrenic patient stabilization. The poor level of compliance is due to many various causes: adverse effects that are considered unbearable, medicine viewed as persecutory, negation of the disease, nostalgia for the productive phases of the disease, lack of social support, complexity of the prescription, relapse itself. Compliance is thus influenced by the patient's clinical features, local provision of health care and the specific nature of the drug (adverse effects, pharmaceutical formulation). The atypical antipsychotics present fewer extrapyramidal side effects and reduce the cognitive deficits associated with the disease, which results in improved compliance. Long-acting injectable antipsychotics allow a better therapeutic compliance and thus better efficacy of the treatment. Several studies have shown a significant improvement in compliance related to the pharmaceutical formulation of antipsychotics. Hospitalization and relapse risks are lower in compliant than in non-compliant patients.

OBJECTIVES

The main objective of this pharmacoeconomic analysis is to evaluate the impact in terms of medical benefits and costs of the following strategies: 1. Risperidone long-acting injection: first long-acting injectable atypical antipsychotic; 2. Haloperidol depot: long-acting injectable conventional neuroleptic; 3. Olanzapine: atypical antipsychotic available commercially in oral formulation.

METHODS

The target population defined for the study are young schizophrenic patients treated for at least 1 year and whose disorder has not been diagnosed for longer than 5 years. The time horizon is 2 years. A cost-effectiveness analysis is performed. The perspective adopted is the French Health System. The main hypothesis of the model is that an increase in compliance linked to the use of long-acting injectable formulation could lead to an increased efficacy and a modification of the cost-effectiveness ratio. A decision tree was built. Six periods of follow-up are identified with a duration of 4-months per period. The tree contains 3 principal arms, each one corresponding to a specific treatment: risperidone LA injection, haloperidol decanoate and olanzapine. For each arm, at the chance node, two health states are identified: either the patient responds favourably to the treatment or does not respond favourably and requires a switch to another drug treatment. After a period of response, the patient can either remain in the same state or experiences a clinical deterioration. If the patient presents a clinical deterioration, he can either go back to a positive response state after a period of intensive follow-up or remain in an insufficient response state; in this case, a change of antipsychotic treatment is necessary. In the model, a patient should receive four different treatments before a long-term hospitalization takes put in place. According to the market authorization labelling, clozapine is proposed only as a 2nd or 3rd line therapeutic option, so when at least one or two successive neuroleptics have failed. The efficacy data used in the model are provided by clinical research recently published. These studies estimate the efficacy of oral risperidone, LA risperidone, olanzapine, and treatment by haloperidol. When available data in the literature were insufficient, the opinion of experts was sought. The effectiveness criteria is the rate of patients treated successfully: patients responding to the initial treatment with the possibility of experiencing one or two episodes of clinical deterioration but without requiring a switch to another drug during 2 years of follow-up. The base case is as follows: efficacy for oral risperidone is used for the LA risperidone strategy, increased by 10% within the first 4 months of follow-up; efficacy for oral haloperidol is used for haloperidol depot, increased by 5% within the first 4 months of follow-up; for olanzapine, observed data in clinical trials were applied. The hypotheses for long acting forms are rather conservative because the increase of efficacy which can be expected for the long-acting injectable formulations varies between 5% to more than 30% according to the literature data. The analysis of sensibility includes three scenarios: scenario 1: for LA risperidone, 5% of patients treated successfully improvement in regard to oral risperidone instead of 10% in the base case; scenario 2: for haloperidol depot, 10% of patients treated successfully improvement in regard of oral haloperidol instead of 5% in the base case; scenario 3: the results of an open trial conducted within the framework of the LA risperidone license are used, leading to an increase of up to 13,3% of the rate of successfully treated patients, compared to oral risperidone literature data. As for the side effects, only extrapyramidal symptoms were considered. Other side effects are described in the literature such as the obesity or the occurrence of a diabetes; these effects were not taken into account in the model, their impact on the cove-rage of schizophrenic patients and on resources utilisation being poorly known. Only direct medical costs were considered in the pharmaco-economic analysis. Two types of costs were identified: hospital costs and community care costs. The stays in overnight hospitalisation and day hospitalisation were derived from the Disease Related Groups (DRG) and valued from the data of the National Cost Study (Etude Nationale de Coûts; 1999). The DRGs corresponding to the diagnosis of schizophrenia are the DRG 627 (complete hospitalization) and DRG 819 (day hospitalisation). Ambulatory care: procedures and visits, were valued in euros in reference with the tariffs for reimbursement issued in the Naming General of the Professional Acts (NGAP) and published by the French National Health Insurance (Year 2001). Medication consumption was quantified by using the daily dosage specified in the the MAA and the French prescription database IMS-Dorema. The cost of medicines was valued from tariffs 2001 (SEMPEX). LA risperidone price being not fixed to date, the reserved hypothesis is a 141,62 Euro retail price. As schizophrenia is listed among the diseases reimbursed at a 100% rate by the Health insurance, out of pocket expenses by patient are not considered in the analysis. The cost for the extrapyramidal effects was attributed to all the strategies. This cost was calculated according to the rates of extrapyramidal effects occurrence collected in the literature. Globally, in the published studies, the incidence of the side effects for the patients treated by olanzapine or risperidone is similar. It was thus decided by the experts to use the same rate of occurrence for extrapyramidal effects for olanzapine and risperidone (20%). This rate is 40% for haloperidol decanoate, 10% for oral clozapine. For the cost estimation, the expenses for treating a schizophrenic patient for two years were taken into account.

RESULTS

The results show that in two years, LA risperidone is more effective than the two other antipsychotics. After 2 years, the rate of patients treated successfully is 82,7% for LA risperidone, 74,8% for olanzapine and 57,3% for haloperidol depot. The 2 year-cost per patient treated by LA risperidone is 14,055 Euro. This cost is 14,351 Euro and 17,203 Euro respectively for the strategies olanzapine and haloperidol depot. The cost-efficacy ratios per patient successfully treated are 16,995 Euro for the strategy LA risperidone, 19,186 Euro for olanzapine and 30,023 Euro for haloperidol depot. LA risperidone is a dominant strategy compared with both olanzapine and haloperidol depot. Scenario 1 shows that LA risperidone strategy remains the most effective. Indeed, this strategy allows a response increase of 3,5% regarding olanzapine strategy and of 21% regarding haloperidol depot strategy. Under the hypothesis tested in scenario 1, LA risperidone is a partial dominant strategy against olanzapine and a total dominant strategy against haloperidol depot. In scenario 2, as efficacy is improved for haloperidol decanoate (61,10%), a decrease of 1,763 Euro in the cost per patient treated is observed for this strategy. Cost per patient treated successfully and efficacy for LA risperidone and olanzapine are the same than in the base case. LA risperidone is a total dominant strategy against olanzapine and haloperidol decanoate. In scenario 3, the rate of patients treated successfully at 2 years is 88,6% for LA risperidone with a cost per patient of 12,347 Euro. LA risperidone is dominant against olanzapine and haloperidol depot.

DISCUSSION AND CONCLUSION

The schizophrenia is a relatively frequent disease. (ABSTRACT TRUNCATED)

Real-time RT-PCR for norovirus screening in shellfish

Real-time RT-PCR, combining amplification and detection of virus-specific amplicons, is a promising tool for norovirus detection in environmental or food samples such as shellfish. We developed a real-time RT-PCR assay based on one-step detection using single primer sets and probes for norovirus genogroups I and II. Seventy and seven RT-PCR units of genogroup I and II reference norovirus strains, respectively, were detected in artificially contaminated oysters. Validation of the new method on 150 archived naturally contaminated shellfish confirmed the utility of the genogroup II primer set to detect a large range of different strains circulating in France since 1995, but genogroup I strains were detected infrequently.

An economic evaluation of the cost of diabetic foot ulcers: results of a retrospective study on 239 patients

OBJECTIVE

To evaluate the cost of foot ulcers in diabetic patients.

METHODS

Retrospective pharmacoeconomic study using direct and indirect costs (sick leave days) from the perspective of French social security system.

RESULTS

239 patients were included in the study by 80 physicians who treat diabetic patients suffering from foot ulcers. Initially identified by telephone survey, these physicians were primarily endocrinologists/diabetologists, general practitioners and surgeons. Average monthly costs in the treatment of foot ulcers were 697 euro; for outpatient care, 1556.20 euro; for hospital care (day treatment and short stays), and 34.76 euro; for sick leaves. When hospitalization was required, it represented approximately 70% of the average cost for foot ulcers. The portion of outpatient costs was principally generated by medical and paramedical treatments, and interventions carried out by healthcare personnel. On the other hand, medication only represented 10% of total costs. The initial severity of the pathology was a determinant clinical factor of high healthcare costs. In addition, the more recent the lesion was, the higher the cost of treatment. Amputation and follow-up by specialists were correlated to high costs as well, a logical result of these clinical factors.

CONCLUSION

This analysis is the first to evaluate the cost of treating foot ulcers in such a large population of diabetic patients. The economic outcomes should help direct public authorities in their choices, particularly as regards the interest of treating these diabetes-related complications as early as possible.

[Evolution of medical practice in the care of anemia amd the use of erythropoietin in chronic renal insufficiency hemodialysis in the past six years]

In order to analyze changes in anemia management in the hemodialysis patients, a retrospective survey was performed in 1999 on a representative French sample of patients in hemodialysis treated by EPO since 1992, 1994, 1996, and 1998 respectively. 368 patients were enrolled in 97 centres. At treatment initiation, some patients characteristics have significantly changed: the percentage of type 2 diabetic patients has increased marquedly from 4.5% in 1992 to 22.1% in 1998. The mean time lag between dialysis and EPO treatment initiation has decreased from 3.3 years to 0.9 on the 6-year period. Lastly, the mean hemoglobin level has increased from 73.7 to 78.5 g/l. No significant evolution in the EPO protocol was observed at the initiation as well as in the maintenance phase. An average percentage of 33.7% of patients were treated in i.v. route at initiation with a mean posology of 105.2 IU/kg (respectively 91.4 in s.c.). In the first year of follow-up, the overall mean posology was 84 IU/kg. In conclusion, this survey suggests that anemia management has been optimized over the last 6 years follow-up, including an earlier initiation of EPO treatment and a higher target of hemoglobin while EPO needs were reduced in the same time.

[Pharmaco-epidemiological study on antipsychotic drug prescription in French Psychiatry: Patient characteristics, antipsychotic treatment, and care management for schizophrenia]

In 2000, a one week national survey was conducted among 202 psychiatrists (129 participants) in France, from hospitals and clinics, private or public. The first 20 inpatients and 10 outpatients prescribed at least one antipsychotic drug (age range 18-65), were included. The diagnostic procedure was standardized with a structured interview: the Mini International Neuropsychiatric Interview (MINI). A total 2 068 patients were included, among whom 892 (43.1%) reached the criteria of schizophrenia according ICD-10. We present here data on these latter patients. Mean age was 38.8 years; with 38.8% females. Median duration of current antipsychotic treatment was 0.5 year in inpatients and 2 years in outpatients. Median duration of any antipsychotic treatment was 10 years, without difference between groups. Comorbid situations (anxiety disorder, depression and suicidal risk) were found in 33.1% of schizophrenic patients, with higher frequency among inpatients in private hospitals (54.8%) than in other groups. 46.8% patients were prescribed at least 2 neuroleptics, and 73.6% at least one non-neuroleptic drugs. Cyamemazine accounted for 16.6% of all neuroleptics drugs, and 56% of patients were prescribed an atypical antipsychotic (risperidone, olanzapine, amisulpride or clozapine). Atypical drugs accounted for 59.4% of patients who were prescribed only one neuroleptic drug. Inpatients had more neuroleptics coprescription than outpatients (mean 1.8 vs 1.4 drugs), with higher daily dose. In addition, inpatients had more other psychotropics prescribed (mean 1.5 vs 1.1 drugs). Overall, more other psychotropic drugs were prescribed among patients with -, than those without - comorbid situations (1.7 vs 1.2 drugs). Median time since admission, at the time of the study, were similar in private and public hospitals (107 vs 99 days) but maximal time since admission was respectively 2.8 and 48.9 years. Visit frequency for outpatients was more than one every two weeks for 43.1% in private and 24.7% in public clinics. Among inpatients only we found a difference between private and public hospitals for polypharmacy of non neuroleptics psychotropics, (mean 1.9 vs 1.5). In outpatients, long acting depot accounted for 26.6% of neuroleptics treatments in public clinics and 15.4% in private clinics. Finally, we found that polypharmacy among outpatients increased with duration of antipsychotic treatment.

CONCLUSION

in France, important differences are reported in antipsychotic prescription for schizophrenia between in- and outpatients. Current antipsychotic prescription is more recent in inpatients than in outpatients, with similar duration of overall antipsychotic treatment. Inpatients have more drug prescription, antipsychotics and other psychotropics, than outpatients. Differences are less important between private and public providers. Inpatients in private hospitals receive more non neuroleptic drugs than in public hospitals, and depot antipsychotics are more used among patients of public clinics. Long term inpatients are found in public hospitals only. Outpatients follow up is more intensive in private than in public clinics.

Analysis of the rutile-ring method of frequency-temperature compensating a high-Q whispering gallery sapphire resonator

The rutile-ring method of dielectrically frequency-temperature compensating a high-Q whispering gallery (WG) sapphire resonator is presented. Two and three-dimensional finite element (FE) analysis has been implemented to design and analyze the performance of such resonators, with excellent agreement between theory and experiment. A high-Q factor of 30 million at 13 GHz and compensation temperature of 56 K was obtained. It is shown the frequency-temperature compensation can occur either because the rutile adds a small perturbation to the sapphire resonator or because of a mode interaction with a resonant mode in the rutile. The characteristics of both of these methods are described, and it is shown that for high frequency stability, it is best to compensate perturbatively.

High-Q whispering gallery traveling wave resonators for oscillator frequency stabilization

Usually a frequency-stabilized standing wave resonator-oscillator incorporating a resonator as a frequency discriminator requires a circulator to separate the injected and reflected wave, A ferrite circulator is a noisy device and can limit the phase noise or frequency stability. Moreover, we show that the noise in a circulator varies, and detailed low noise measurements are necessary to choose an appropriate quiet circulator. Thus, by realizing a configuration that does not require a circulator, an improvement in performance and reliability can be obtained. A solution to this problem is to design a high-Q whispering gallery traveling wave (WGTW) resonator. This device naturally separates the injected and reflected wave in the same way as a ring cavity at optical frequencies, without degrading the frequency discrimination. Q-factor measurements of a WGTW sapphire resonator are presented, along with a derivation of critical parameters to maximize the frequency discrimination. New measurements of noise in ferrite circulators and isolators have also been made, which is followed with a discussion on oscillator design.

[A rare complication of cholelithiasis. Ulceration of the cystic artery associated with cholecystoduodenal fistula]

We observed a rare complication of gall stones revealed by a paroxysmal digestive haemorrhage. Ulceration of the cystic artery occurred due to a stone trapped in the neck associated with a cholecystoduodenal fistula. This is an exceptional cause of major digestive tract haemorrhage. Treatment is undertaken with that of the gall stone. Most often haemorrhages originating in the bile tract are occult.

[Seasonal, weekly and lunar cycles of birth. Statistical study of 12,035,680 births]

The authors have studied the seasonal, weekly and lunar rhythms which could characterize deliveries, based on 12,035,680 french births, between January 1, 1968 and December 31, 1982. The seasonal rhythm is the most remarkable. It is characterized by a maximum of newborn in May and a minimum in November; there is an increased number of births during the month of September. The weekly rhythm is characterized by a drop in the number of births especially on Sundays, but also on Saturdays, with a maximum on Tuesday. The number of births also fluctuate according to the lunar cycle. Their amplitude is low. They are however significant. From that standpoint, these results confirm other studies already conducted in France and the USA, in a much smaller scale.