Discordance between pain specialists and patients on the perception of dependence on pain medication: A multi-centre cross-sectional study

AIM

Patients with chronic non-cancer pain are referred to pain centres to improve their pain treatment. The discontinuation of pain medications in case of poor efficacy can be difficult to accept for patients, particularly opioid analgesics. Previous research has described that from the patients' perspective, the psychological relief of a negative effect of chronic pain and withdrawal symptoms of prescription opioids represent drivers of persistent use and first stage of opioid use disorder, despite insufficient pain relief. There is no validated tool to investigate this psychological dependence. This study aimed to assess discordance between patients and pain specialists in their perception of dependence on pain medication and investigate associations with characteristics of patients, type of pain and iatrogenic pharmacodependence.

METHODS

Self-administered questionnaires (patients and physicians) were administered in six pain centres in France. A question on perceived dependence on pain medications was addressed to the patient and the physician in a matched pair. Discordance between them was evaluated by the Cohen kappa coefficient. Demographics, pain, anxiety and depression, pain medication withdrawal symptoms, diverted use, and craving represented variables studied in a multivariate model as potentially associated with patient-physician discordance.

RESULTS

According to the 212 pairs of completed questionnaires, a perceived dependence was reported by the majority of patients (65.6%) and physicians (68.4%). However, the concordance was fair (kappa=0.38; CI [95%]: 0.25-0.51). Almost all patients (89.3%) were treated with an opioid analgesic. A higher likelihood of discordance was observed when patients suffered from nociplastic pain (odds ratio [OR]: 2.72, 95% [CI]: 1.29-5.84).

CONCLUSION

Medical shared-decision for changing pain treatment could be improved by taking into account the perception of patient dependence on medications for pain relief and or psychoactive effects, particularly in nociplastic pain for which the treatment is challenging.

Psychosis with use of amphetamine drugs, methylphenidate and atomoxetine in adolescent and adults

BACKGROUND

Use of psychostimulants and relative drugs has increased worldwide in treatment of attention-deficit hyperactivity disorder (ADHD) in adolescents and adults. Recent studies suggest a potential association between use of psychostimulants and psychotic symptoms. The risk may not be the same between different psychostimulants.

OBJECTIVE

To assess whether amphetamine or atomoxetine use is associated with a higher risk of reporting symptoms of psychosis than methylphenidate use in adolescents and adults, particularly in patients with ADHD.

METHODS

Using VigiBase, the WHO's pharmacovigilance database, disproportionality of psychotic symptoms reporting was assessed among adverse drug reactions related to methylphenidate, atomoxetine and amphetamines, from January 2004 to December 2018, in patients aged 13-25 years. The association between psychotic symptoms and psychostimulants was estimated through the calculation of reporting OR (ROR).

FINDINGS

Among 13 863 reports with at least one drug of interest, we found 221 cases of psychosis with methylphenidate use, 115 with atomoxetine use and 169 with a prescription of an amphetamine drug. Compared with methylphenidate use, amphetamine use was associated with an increased risk of reporting psychotic symptoms (ROR 1.61 (95% CI 1.26 to 2.06)]. When we restricted the analysis to ADHD indication, we found a close estimate (ROR 1.94 (95% CI 1.43 to 2.64)). No association was found for atomoxetine.

CONCLUSION

Our study suggests that amphetamine use is associated with a higher reporting of psychotic symptoms, compared with methylphenidate use.

CLINICAL IMPLICATIONS

The prescription of psychostimulants should consider this potential adverse effect when assessing the benefit-risk balance.

Amantadine use in the French prospective NS-Park cohort

OBJECTIVE

To assess amantadine use and associated factors in the patients with Parkinson's disease (PD).

BACKGROUND

Immediate-release amantadine is approved for the treatment of PD and is largely used in clinical practice to treat "levodopa-induced dyskinesia (LIDs). Its use varies according to countries and PD stages. The prospective NS-Park cohort collects features of PD patients followed by 26 French PD Expert Centres.

METHODS

Variables used for the analyses included demographics, motor and non-motor PD symptoms and motor complications [motor fluctuations (MFs), LIDs)], antiparkinsonian pharmacological classes and levodopa equivalent daily dose (LEDD). We evaluated: (i) prevalence of amantadine use and compared clinical features of amantadine users vs. non-users (cross-sectional analysis); (ii) factors associated with amantadine initiation (longitudinal analysis); (iii) amantadine effect on LIDs, MFs, apathy, impulse control disorders and freezing of gait (Fog) (longitudinal analysis).

RESULTS

Amantadine use prevalence was 12.6% (1,585/12,542, median dose = 200 mg). Amantadine users were significantly younger, with longer and more severe PD symptoms, greater LEDD and more frequent use of device-aided/surgical treatment. Factors independently associated with amantadine initiation were younger age, longer PD duration, more frequent LIDs, MFs and FoG, higher LEDD and better cognitive function. 9 of the 658 patients on amantadine had stopped it at the following visit, after 12-18 months (1.3%). New users of amantadine presented a higher improvement in LIDs and MF compared to amantadine never users.

CONCLUSIONS

About 12% of PD patients within the French NS-Park cohort used amantadine, mostly those with younger age and more severe PD. Amantadine initiation was associated with a subsequent reduction in LIDs and MFs.

Trim33 masks a non-transcriptional function of E2f4 in replication fork progression

Replicative stress promotes genomic instability and tumorigenesis but also presents an effective therapeutic endpoint, rationalizing detailed analysis of pathways that control DNA replication. We show here that the transcription factor E2f4 recruits the DNA helicase Recql to facilitate progression of DNA replication forks upon drug- or oncogene-induced replicative stress. In unperturbed cells, the Trim33 ubiquitin ligase targets E2f4 for degradation, limiting its genomic binding and interactions with Recql. Replicative stress blunts Trim33-dependent ubiquitination of E2f4, which stimulates transient Recql recruitment to chromatin and facilitates recovery of DNA synthesis. In contrast, deletion of Trim33 induces chronic genome-wide recruitment of Recql and strongly accelerates DNA replication under stress, compromising checkpoint signaling and DNA repair. Depletion of Trim33 in Myc-overexpressing cells leads to accumulation of replication-associated DNA damage and delays Myc-driven tumorigenesis. We propose that the Trim33-E2f4-Recql axis controls progression of DNA replication forks along transcriptionally active chromatin to maintain genome integrity.

Abstract 69: Blood-brain Barrier Profile Influences Outcome After Mechanical Thrombectomy In The Frame Study

Background and Purpose: The FRAME study demonstrated that even in the early time window (<6hrs) perfusion imaging profiles can influence response to mechanical thrombectomy. Perfusion imaging (PWI) can also be used to measure damage to the blood-brain barrier (BBB) which has been shown to be associated with increased risk of hemorrhagic complications (HC) with treatment. We aimed to determine if BBB profiles in the FRAME study would influence outcome after mechanical thrombectomy (MT).

Methods: This was a post-hoc analysis of the FRAME study which enrolled stroke patients with large vessel occlusion who received MT within 6 hours of stroke onset. Patients with successful pre-treatment MRI PWI were included. We tested the hypothesis that more severe pre-treatment BBB disruption is associated with higher frequency of HC after MT. BBB disruption was measured as the percent of signal change due to gadolinium leakage on the PWI source images. Mean permeability derangement (MPD) was defined as the average of all voxels in the stroke core that are two standard deviations above normal. The outcome of HC was defined as any type of parenchymal hematoma (PH1 or PH2); poor functional outcome was defined as mRS >2 at 90 days. MPD was compared with HC and functional outcome using the Wilcoxon signed-rank test and logistic regression. A prespecified MPD threshold of 20% was tested as a predictor of HC based on prior studies.

Results: There were 164 patients included in the analysis, median age 74 and 48% female. HC occurred in 57 patients. The average MPD was 15.1% for patients with HC and 8.7% for patients without HC. Elevated MPD was significantly associated with HC (p<0.0001) with a 25% increased risk of HC for each 5% increase in MPD (OR 1.25; CI 1.09:1.45; p=0.0018). Increased MPD was also associated with poor functional outcome (p=0.0002). ROC analysis confirmed the prespecified MPD threshold, identifying 19.7% as the optimal cut point for classification. MPD greater than 20% more than tripled the risk of HC (OR 3.37; CI 1.49:7.85; p=0.004).

Conclusions: Increased pre-treatment BBB disruption has a substantial influence on the risk of HC after MT. Integration of BBB imaging into patient selection algorithms to improve MT outcomes should be tested further.

Location-weighted versus Volume-weighted Mismatch at MRI for Response to Mechanical Thrombectomy in Acute Stroke

Background A target mismatch profile can identify good clinical response to recanalization after acute ischemic stroke, but does not consider region specificities. Purpose To test whether location-weighted infarction core and mismatch, determined from diffusion and perfusion MRI performed in patients with acute stroke, could improve prediction of good clinical response to mechanical thrombectomy compared with a target mismatch profile. Materials and Methods In this secondary analysis, two prospectively collected independent stroke data sets (2012-2015 and 2017-2019) were analyzed. From the brain before stroke (BBS) study data (data set 1), an eloquent map was computed through voxel-wise associations between the infarction core (based on diffusion MRI on days 1-3 following stroke) and National Institutes of Health Stroke Scale (NIHSS) score. The French acute multimodal imaging to select patients for mechanical thrombectomy (FRAME) data (data set 2) consisted of large vessel occlusion-related acute ischemic stroke successfully recanalized. From acute MRI studies (performed on arrival, prior to thrombectomy) in data set 2, target mismatch and eloquent (vs noneloquent) infarction core and mismatch were computed from the intersection of diffusion- and perfusion-detected lesions with the coregistered eloquent map. Associations of these imaging metrics with early neurologic improvement were tested in multivariable regression models, and areas under the receiver operating characteristic curve (AUCs) were compared. Results Data sets 1 and 2 included 321 (median age, 69 years [IQR, 58-80 years]; 207 men) and 173 (median age, 74 years [IQR, 65-82 years]; 90 women) patients, respectively. Eloquent mismatch was positively and independently associated with good clinical response (odds ratio [OR], 1.14; 95% CI: 1.02, 1.27; P = .02) and eloquent infarction core was negatively associated with good response (OR, 0.85; 95% CI: 0.77, 0.95; P = .004), while noneloquent mismatch was not associated with good response (OR, 1.03; 95% CI: 0.98, 1.07; P = .20). Moreover, adding eloquent metrics improved the prediction accuracy (AUC, 0.73; 95% CI: 0.65, 0.81) compared with clinical variables alone (AUC, 0.65; 95% CI: 0.56, 0.73; P = .01) or a target mismatch profile (AUC, 0.67; 95% CI: 0.59, 0.76; P = .03). Conclusion Location-weighted infarction core and mismatch on diffusion and perfusion MRI scans improved the identification of patients with acute stroke who would benefit from mechanical thrombectomy compared with the volume-based target mismatch profile. Clinical trial registration no. NCT03045146 © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Nael in this issue.

Comparative Effects of 30 Antipsychotics on Risk of Catatonia: An Analysis of the WHO Pharmacovigilance Database

Objective: Catatonia is a life-threatening psychomotor syndrome that occurs in approximately 10% of patients with acute psychiatric illnesses. Although some case reports have argued that first generation antipsychotics (FGAs) are more likely to induce catatonia than second generation antipsychotics (SGAs), no large observational study has confirmed this hypothesis. We investigated whether FGAs were associated with an increased risk of reporting catatonia when compared with SGAs. Methods: A pharmacovigilance study was performed within VigiBase to compare the cases of catatonia syndromes reported in patients exposed to FGAs with those reported in patients exposed to SGAs. This approach is similar in concept to case-control study, but adapted to a pharmacovigilance database, and allows the estimation of reporting odds ratios (RORs) with 95% confidence intervals. Results: We identified 60,443 adverse effects reported in patients who received FGAs and 253,067 adverse effects reported in patients treated with SGAs. Compared with SGAs, the use of FGAs was associated with an increased risk of reporting catatonia syndromes (ROR = 2.2; 95% CI, 2.0-2.3). Consistent results were observed when the analysis was restricted to reports generated from physicians, reports from the US, and reports with the highest completeness score. The highest RORs were found for molindone (6.0; 95% CI, 3.1-10.4) and haloperidol (3.8; 95% CI, 3.5-4.0). Conclusions: In this large pharmacovigilance study of patients exposed to antipsychotics, the use of FGAs was associated with an increased risk of reporting catatonia syndromes compared to the use of SGAs. This increased risk is consistent with the pharmacodynamic hypothesis of antipsychotic-induced catatonia. Our results warrant replication in population-based studies.

Personality assessment with Temperament and Character Inventory in Parkinson's disease

INTRODUCTION

There is a growing interest in personality evaluation in Parkinson's disease (PD), following observations of specific temperaments in PD patients. Therefore, our objective was to evaluate personality dimensions from the Temperament and Character Inventory (TCI) in a cohort of fluctuating PD patients considered for deep brain stimulation.

METHODS

Fluctuating PD patients from the PREDISTIM cohort were included. Description of TCI dimensions and comparison with a French normative cohort were performed. Pearson correlations between TCI dimensions and motor, behavioral and cognitive variables were investigated. Structural and internal consistency analysis of the TCI were further assessed.

RESULTS

The 570 PD patients presented significant higher scores in Harm Avoidance, Reward Dependence, Persistence, Self-Directedness and Cooperativeness and significant lower scores in Self-Transcendence compared to the French normative cohort; only Novelty Seeking scores were not different. Harm Avoidance and Self-directedness scores were correlated with PDQ-39 total, HAMD, HAMA scores, and anxiolytic/antidepressant treatment. Novelty Seeking scores were correlated with impulsivity. Pearson correlations between TCI dimensions, principal component analysis of TCI sub-dimensions and Cronbach's alpha coefficients showed adequate psychometric proprieties.

CONCLUSION

The TCI seems to be an adequate tool to evaluate personality dimensions in PD with good structural and internal consistencies. These fluctuating PD patients also have specific personality dimensions compared to normative French population. Moreover, Harm Avoidance and Self-Directedness scores are associated with anxio-depressive state or quality of life and, and Novelty Seeking scores with impulsivity.

Personality Related to Quality-of-Life Improvement After Deep Brain Stimulation in Parkinson's Disease (PSYCHO-STIM II)

BACKGROUND

Deep brain stimulation of the sub-thalamic nucleus (DBS-STN) reduces symptoms in Parkinson's disease (PD) patients with motor fluctuations. However, some patients may not feel ameliorated afterwards, despite an objective motor improvement. It is thus important to find new predictors of patients' quality of life (QoL) amelioration after DBS-STN. We hypothesized that personality dimensions might affect QoL after DBS-STN.

OBJECTIVE

To evaluate associations between personality dimensions and QoL improvement one year after DBS-STN.

METHODS

DBS-STN-PD patients (n = 303) having answered the "Temperament and Character Inventory" (TCI) before surgery and the PDQ-39 before and one year after surgery were included, from the cohort study PREDI-STIM. Linear regression models were used to evaluate associations between TCI dimensions and change in PDQ-39 scores after DBS-STN.

RESULTS

Novelty Seeking and Cooperativeness scores before surgery were positively associated with PDQ-39 scores improvement after DBS-STN (FDR-adjusted p < 0.01). Moreover, paradoxically unimproved patients with deterioration of their PDQ-39 scores after DBS-STN despite improvement of their MDS-UPDRS-IV scores had lower Cooperativeness scores, while paradoxically improved patients with amelioration of their PDQ-39 scores despite deterioration of their MDS-UPDRS-IV scores had higher Reward Dependence scores.

CONCLUSION

Some presurgical personality dimensions were significantly associated with QoL amelioration and discrepancy between motor state and QoL changes after DBS-STN in PD. Educational programs before DBS-STN should take in account patient personality dimensions to better deal with their expectations.

Diagnostic utility of T2*-weighted GRE in migraine with aura attack. The cortical veins sign

OBJECTIVE

To evaluate the frequency, distribution, and clinical associations of the dilated appearance of cerebral cortical veins, termed cortical veins sign on T2*-weighted gradient recalled-echo (T2*-GRE) in the acute setting of migraine with aura attack in adult patients.

METHODS

We conducted a retrospective analysis of 60 consecutive patients admitted for acute neurological symptoms with a final diagnosis of migraine with aura (42%) or probable migraine with aura (58%) who underwent emergency brain magnetic resonance imaging and 60 non-migrainous control adults. The cortical veins sign was defined as a marked hypo-intensity and/or an apparent increased diameter of at least one cortical vein. We examined the prevalence, the spatial distribution, and the associations of cortical veins sign with clinical characteristics of migraine with aura.

RESULTS

We detected the cortical veins sign in 25 patients (42%) with migraine with aura, compared to none in the control group (p < 0.0001). The spatial distribution of cortical veins sign was characterised by the predominantly bilateral and posterior location. Presence of cortical veins sign was associated with increased severity of aura (p = 0.05), and shorter delay to MRI (p = 0.02).

CONCLUSION

In the setting of acute neurological symptoms, the presence of cortical veins sign is frequent in patients with migraine with aura and can be detected with good reliability. This imaging marker may help clinicians identify underlying migraine with aura.

Rebleeding After Aneurysmal Subarachnoid Hemorrhage in Two Centers Using Different Blood Pressure Management Strategies

Background

High systolic blood pressure (SBP) after aneurysmal subarachnoid hemorrhage (aSAH) has been associated with an increased risk of rebleeding. It remains unclear if an SBP lowering strategy before aneurysm treatment decreases this risk without increasing the risk of a delayed cerebral ischemia (DCI). Therefore, we compared the rates of in-hospital rebleeding and DCI among patients with aSAH admitted in two tertiary care centers with different SBP management strategies.

Methods

Retrospective cohort study. Consecutive patients from Utrecht and Toulouse admitted within 24 h after the aSAH onset were enrolled. In Toulouse, the target SBP before aneurysm treatment was ≤140 mm Hg, while, in Utrecht, an increased SBP was only treated in extreme situations. We compared SBP levels, the incidence of rebleeding within 24 h after admission, and DCI during hospitalization.

Results

We enrolled 373 patients in Utrecht and 149 in Toulouse. The mean SBP on admission was similar but lower in Toulouse 4 h after admission (127.3 ± 17.4 vs. 138. ± 25.7 mmHg; p < 0.0001). After a median delay of 3.7 h (IQR, 2.3-7.4) from admission, 4 patients (3%) in Toulouse vs. 29 (8%) in Utrecht experienced a rebleeding. After adjustment for Prognosis on Admission of Aneurysmal Subarachnoid Hemorrhage (PAASH) score, aneurysm size, age, and delay from ictus to admission, the HR was 0.66 (95% CI: 0.23-1.92). Incidence of DCI was 18% in Toulouse and 25% in Utrecht (adjusted OR, 0.68; 95% CI: 0.41-1.11).

Conclusion

Our results suggest that an intensive SBP lowering strategy between admission and aneurysm treatment does not decrease the risk of rebleeding and does not increase the risk of DCI compared to a more conservative strategy.

Low bone mass in Noonan syndrome children correlates with decreased muscle mass and low IGF-1 levels

Although musculoskeletal abnormalities have long been described in patients with Noonan syndrome (NS), only a few studies have investigated the bone status of these patients. The aim of this retrospective observational study was to describe the bone health of children with NS. Thirty-five patients with a genetically confirmed diagnosis of NS were enrolled. We analyzed the axial skeleton (lumbar spine) using dual energy X-ray absorptiometry and the appendicular skeleton (hand) with the BoneXpert system. Bone metabolism markers, including mineral homeostasis parameters, serum 25-hydroxy vitamin D (25-OHD) levels and markers of bone formation and resorption were also reported. Compared to the general population, axial and appendicular bone mass was significantly decreased in children with NS (p < 0.0001). Serum 25-OHD levels were low in about half of the patients and were negatively correlated with age (r = -0.52; p < 0.0001). Patients with NS exhibited reduced bone formation marker levels and increased bone resorption marker levels (p < 0.0001). No gender difference or genotype-phenotype correlations were found for the different bone parameters. Muscle mass and, to a lesser extent, serum insulin-like growth factor 1 (IGF-1) levels were independent predictors of whole-body bone mineral content (p < 0.0001 for both parameters; adjusted R² = 0.97). In conclusion, bone mass is reduced in children with NS and correlates with decreased muscle mass and low serum IGF-1 levels. These data justify addressing all potential threats to bone health including sufficient calcium and vitamin D intake, regular physical exercise, and hormone replacement therapy.

β-adrenoceptor antagonists and nightmares: A pharmacoepidemiological-pharmacodynamic study

AIM

To compare different β-adrenoceptor antagonists for the risk of reporting nightmare.

METHODS

The study involved two approaches: first, we investigated in VigiBase^®, the World Health Organization Individual Case Safety Report (ICSR) database, the disproportionality between exposure to each β-adrenoceptor antagonists and reports of nightmares between 1967 and 2019. Second, in a pharmacoepidemiological-pharmacodynamic analysis, we assessed whether use of β-adrenoceptor antagonists with moderate and high lipid solubility or strong 5-HT_1A affinity were associated with an increased risk of reporting nightmares. We conducted multivariate logistic regression to estimate reporting odds ratios (RORs) of nightmares compared to all other adverse drug reactions.

RESULTS

Of the 126,964 reports recorded with β-adrenoceptor antagonists, 1138 (0.9%) were nightmares. The highest risk of reporting a nightmare was found with exposure of pindolol (adjusted ROR 2.82, 95%CI, 2.19-3.61), metoprolol (1.89, 1.66-2.16), and alprenolol (1.77, 1.06-2.97). Compared to use of low lipid solubility β-adrenoceptor antagonists, use of moderate or high lipid solubility β-adrenoceptor antagonists were significantly more associated with nightmare reports (aROR moderate vs. low 1.72, 95%CI 1.47-2.00 and aROR high vs. low 1.84, 95%CI 1.53-2.22). Use of moderate or high 5-HT_1A affinity of β-adrenoceptor antagonists was associated with an increased ROR of nightmares compared with low 5-HT_1A affinity of β-adrenoceptor antagonists (aROR moderate vs. low 1.22, 95%CI 1.04-1.43 and aROR high vs. low 2.46, 95%CI 1.93-3.13).

CONCLUSION

In our large pharmacovigilance study, nightmares are more frequently reported for pindolol and metoprolol, and among β-adrenoceptor antagonists with high lipid solubility and high 5-HT_1A receptor affinity.

What predicts poor outcome after successful thrombectomy in early time window?

BACKGROUND

Half of the patients with large vessel occlusion (LVO)-related acute ischemic stroke (AIS) who undergo endovascular reperfusion are dead or dependent at 3 months. We hypothesize that in addition to established prognostic factors, baseline imaging profile predicts outcome among reperfusers.

METHODS

Consecutive patients receiving endovascular treatment (EVT) within 6 hours after onset with Thrombolysis In Cerebral Infarction (TICI) 2b, 2c and 3 revascularization were included. Poor outcome was defined by a modified Rankin scale (mRS) 3-6 at 90 days. No mismatch (NoMM) profile was defined as a mismatch (MM) ratio ≤1.2 and/or a volume <10 mL on pretreatment imaging.

RESULTS

187 patients were included, and 81 (43%) had a poor outcome. Median delay from stroke onset to the end of EVT was 259 min (IQR 209-340). After multivariable logistic regression analysis, older age (OR 1.26, 95% CI 1.06 to 1.5; p=0.01), higher National Institutes of Health Stroke Scale (NIHSS) (OR 1.15, 95% CI 1.06 to 1.25; p<0.0001), internal carotid artery (ICA) occlusion (OR 3.02, 95% CI 1.2 to 8.0; p=0.021), and NoMM (OR 4.87, 95% CI 1.09 to 22.8; p=0.004) were associated with poor outcome. In addition, post-EVT hemorrhage (OR 3.64, 95% CI 1.5 to 9.1; p=0.04) was also associated with poor outcome.

CONCLUSIONS

The absence of a penumbra defined by a NoMM profile on baseline imaging appears to be an independent predictor of poor outcome after reperfusion. Strategies aiming to preserve the penumbra may be encouraged to improve these patients' outcomes.

ASCOD Phenotyping of Stroke With Anterior Large Vessel Occlusion Treated by Mechanical Thrombectomy

BACKGROUND AND PURPOSE

Determining the mechanism of large vessel occlusion related acute ischemic stroke is of major importance to initiate a tailored secondary prevention strategy. We investigated using the atherosclerosis, small vessel disease, cardiac source, other cause, dissection (ASCOD) classification the distribution of the causes of large vessel occlusion related acute ischemic stroke treated by mechanical thrombectomy.

METHODS

This was a predefined substudy of the FRAME (French Acute Multimodal Imaging to Select Patient for Mechanical Thrombectomy). Each patient underwent a systematic etiological workup including brain and vascular imaging, electrocardiogram monitoring lasting at least 24 hours and routine blood tests. Stroke mechanisms were systematically evaluated using the atherosclerosis, small vessel disease, cardiac source, other cause, dissection grading system at 3 months. We defined single potential cause by one cause graded 1 in a single domain, possible cause as a cause graded 1 or 2 regardless of overlap, and no identified cause without grade 1 nor 2 causes.

RESULTS

A total of 215 patients (mean age 70±14; 50% male) were included. A single potential cause was identified in 148 (69%). Cardio-embolism (53%) was the most frequent, followed by atherosclerosis (9%), dissection (5%) and other causes (1%). Atrial fibrillation accounted for 88% of C1. Overlap between grade 1 causes was uncommon (3%). Possible causes were identified in 168 patients (83%) and 16 (7%) had no cause identified after the initial evaluation.

CONCLUSIONS

Cardio-embolism, especially atrial fibrillation, was the major cause of large vessel occlusion related acute ischemic stroke. This finding emphasizes the yield of paroxysmal atrial fibrillation detection in those patients. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03045146.

Personality Dimensions Are Associated with Quality of Life in Fluctuating Parkinson's Disease Patients (PSYCHO-STIM)

BACKGROUND

Parkinson's disease (PD) negatively affects patients' Quality of Life (QoL) which depends on both objective criteria such as physical health and subjective ones such as worries and norms according to personal believes. Therefore, QoL could be also associated to personality dimensions in chronic neurological diseases such as PD.

OBJECTIVE

Our objective was thus to study the potential association between personality dimensions and QoL in PD patients with motor fluctuations before Deep Brain Stimulation of the Sub-Thalamic Nucleus (DBS-STN).

METHODS

Data were obtained from the French multicentric cohort study Predi-Stim. All PD patients awaiting DBS-STN and responding to the inclusion criteria at the time of the study were included. All participants answered the "Temperament and Character Inventory" (TCI) and the PDQ-39 before surgery. Analyses were made using adjusted univariate generalized linear regression models to evaluate a potential association between TCI dimensions and PDQ-39 scores.

RESULTS

Three hundred thirty-three consecutive patients were included. The temperament Harm Avoidance was negatively associated with QoL (p = 1e-4, R2= 0.33), whereas the character Self-Directedness was positively associated with mental component of QoL (p = 2e-4, R2= 0.33) in PD patients with motor fluctuations awaiting DBS-STN.

CONCLUSIONS

PD patients with motor fluctuations, with lower Harm Avoidance and higher Self-Directedness scores have the best QoL mainly at an emotional and social level. Therapeutic education of these PD patients focusing on their personal resources may thus be important to improve their well-being.

Taking the A Train? Limited Consistency of Aβ42 and the Aβ42/40 Ratio in the AT(N) Classification

The consistency of cerebrospinal fluid amyloid-β (Aβ)42/40 ratio and Aβ 42 has not been assessed in the AT(N) classification system. We analyzed the classification changes of the dichotomized amyloid status (A+/A-) in 363 patients tested for Alzheimer's disease biomarkers after Aβ 42 was superseded by the Aβ 42/40 ratio. The consistency of Aβ 42 and the Aβ 42/40 ratio was very low. Notably, the proportions of "false" A+T-patients were considerable (74-91%) and corresponded mostly to patients not clinically diagnosed with Alzheimer's disease. Our results suggest that the interchangeability of Aβ 42/40 ratio and Aβ 42 is limited for classifying patients in clinical setting using the AT(N) scheme.

A French survey on the lockdown consequences of COVID-19 pandemic in Parkinson's disease. The ERCOPARK study

Background

In 2020 the coronavirus disease 19 (COVID-19) pandemic imposed a total and sudden lockdown. We aimed to investigate the consequences of the first COVID-19 lockdown (mid-March – mid-April 2020) on motor and non-motor symptoms (NMS) in a cohort of French people with Parkinson's disease (PwP).

Methods

PwP were enrolled either by an on-line survey sent from the national France Parkinson association (FP) to reach the French community of PwP or as part of outpatients' telemedicine visits followed by an hospital-based Parkinson Expert Center (PEC). All patients were evaluated using the same standardized questionnaire assessing motor and NMS (including a list of most disabling, new or worsened symptoms and Patient's Global Impression-Improvement scales [PGI-I]) psycho-social queries and quality of life.

Results

2653 PwP were included: 441 (16.6%) in the PEC group and 2122 (83.4%) in the community-based group. Physiotherapy was interrupted among 88.6% of the patients. 40.9% referred a clinical modification of their symptoms. Based on the questionnaire, pain (9.3%), rigidity (9.1%) and tremor (8.5%) were the three most frequently new or worsened reported symptoms. Based on the PGI-I, the motor symptoms were the most affected domain, followed by pain and psychic state. PwP in community-based group tended to have more frequent worsening for motor symptoms, motor complications, pain and confusion than those of the PEC group.

Conclusions

The first COVID-19 lockdown had a negative impact on motor and NMS of PwP. Efforts should be allocated to avoid interruption of care, including physiotherapy and physical activities and implement telemedicine. .

Perfusion Imaging and Clinical Outcome in Acute Ischemic Stroke with Large Core

OBJECTIVE

Mechanical thrombectomy (MT) is not recommended for acute stroke with large vessel occlusion (LVO) and a large volume of irreversibly injured tissue ("core"). Perfusion imaging may identify a subset of patients with large core who benefit from MT.

METHODS

We compared two cohorts of LVO-related patients with large core (>50 ml on diffusion-weighted-imaging or CT-perfusion using RAPID), available perfusion imaging, and treated within 6 hours from onset by either MT + Best Medical Management (BMM) in one prospective study, or BMM alone in the pre-MT era from a prospective registry. Primary outcome was 90-day modified Rankin Scale ≤2. We searched for an interaction between treatment group and amount of penumbra as estimated by the mismatch ratio (MMRatio = critical hypoperfusion/core volume).

RESULTS

Overall, 107 patients were included (56 MT + BMM and 51 BMM): Mean age was 68 ± 15 years, median core volume 99 ml (IQR: 72-131) and MMRatio 1.4 (IQR: 1.0-1.9). Baseline clinical and radiological variables were similar between the two groups, except for a higher intravenous thrombolysis rate in the BMM group. The MMRatio strongly modified the clinical outcome following MT (p_interaction  < 0.001 for continuous MMRatio); MT was associated with a higher rate of good outcome in patients with, but not in those without, MMRatio>1.2 (adjusted OR [95% CI] = 6.8 [1.7-27.0] vs 0.7 [0.1-6.2], respectively). Similar findings were present for MMRatio ≥1.8 in the subgroup with core ≥70 ml. Parenchymal hemorrhage on follow-up imaging was more frequent in the MT + BMM group regardless of the MMRatio.

INTERPRETATION

Perfusion imaging may help select which patients with large core should be considered for MT. Randomized studies are warranted. ANN NEUROL 2021.

The Use of Rifaximin in the Prevention of Overt Hepatic Encephalopathy After Transjugular Intrahepatic Portosystemic Shunt : A Randomized Controlled Trial

BACKGROUND

The efficacy of rifaximin in the secondary prevention of overt hepatic encephalopathy (HE) is well documented, but its effectiveness in preventing a first episode in patients after transjugular intrahepatic portosystemic shunt (TIPS) has not been established.

OBJECTIVE

To determine whether rifaximin prevents overt HE after TIPS compared with placebo.

DESIGN

Randomized, double-blind, multicenter, placebo-controlled trial. (ClinicalTrials.gov: NCT02016196).

PARTICIPANTS

197 patients with cirrhosis undergoing TIPS for intractable ascites or prevention of variceal rebleeding.

INTERVENTION

Patients were randomly assigned to receive rifaximin (600 mg twice daily) or placebo, beginning 14 days before TIPS and continuing for 168 days after the procedure.

MEASUREMENTS

The primary efficacy end point was incidence of overt HE within 168 days after the TIPS procedure.

RESULTS

An episode of overt HE occurred in 34% (95% CI, 25% to 44%) of patients in the rifaximin group (n = 93) and 53% (CI, 43% to 63%) in the placebo group (n = 93) during the postprocedure period (odds ratio, 0.48 [CI, 0.27 to 0.87]). Neither the incidence of adverse events nor transplant-free survival was significantly different between the 2 groups.

LIMITATIONS

The study's conclusion applies mainly to patients with alcoholic cirrhosis, who made up the study population. The potential benefit of rifaximin 6 months after TIPS and beyond remains to be investigated.

CONCLUSION

In patients with cirrhosis treated with TIPS, rifaximin was well tolerated and reduced the risk for overt HE. Rifaximin should therefore be considered for prophylaxis of post-TIPS HE.

PRIMARY FUNDING SOURCE

French Public Health Ministry.

Fluoxetine for the Symptomatic Treatment of Multiple System Atrophy: The MSA-FLUO Trial

BACKGROUND

There are no effective treatments for multiple system atrophy (MSA).

OBJECTIVE

The objective of this study was to assess the efficacy and safety of the serotonin reuptake inhibitor fluoxetine (40 mg/d) for the symptomatic treatment of MSA.

METHODS

This was a double-blind, parallel-group, placebo-controlled, randomized trial in patients with "probable" MSA. The primary outcome was the change from baseline to week 12 in the mean total score of the Unified MSA Rating Scale (UMSARS Parts I + II). Secondary outcomes included change from baseline to week 6 in total UMSARS, and change from baseline to week 12 in the Scales for Outcomes in Parkinson Disease-Autonomic Dysfunction, Beck Depression Inventory, and different domains of the MSA-Quality of Life Questionnaire. Exploratory outcomes included change from baseline to week 12 in the UMSARS Parts I and II separately and change from baseline to week 24 in the total UMSARS score.

RESULTS

A total of 81 patients were randomly assigned, with no significant difference in the primary outcome (-2.13 units [95% confidence interval, CI, -4.55 to 0.29]; P = 0.08). There was a greater reduction on fluoxetine in the change from baseline to 12-week in UMSARS Part II (exploratory outcome: -1.41 units [95% CI, -2.84; 0.03]; p = 0.05) and in MSA-QoL emotional/social dimension (secondary outcome: -6.99 units [95% CI, -13.40; -0.56]; p < 0.03). A total of 5 deaths occurred (3 on fluoxetine and 2 on placebo).

CONCLUSION

The MSA-FLUO failed to demonstrate fluoxetine superiority over placebo on the total UMSARS score, whereas trends in motor and emotional secondary/exploratory outcomes deserve further investigation. © 2021 International Parkinson and Movement Disorder Society.

Evolution of medication consumption in a working environment in France: Results of the four waves of the "Drugs and Work" study (1986-2016)

OBJECTIVES

Previous studies in the working environment have underlined the high prevalence of drug consumption. The aim of this study was to present the main characteristics of this consumption in French workers and to identify changes from the 1986, 1996, 2006 and 2016 surveys.

METHODS

The design was a repeated cross-sectional study in 1986, 1996, 2006 and 2016. At each wave, demographic and socio-professional characteristics, self-reported consumption of medications during the week before the occupational medical visit, and perceived difficult working conditions and extraprofessional problems were collected among a sample of workers. Factors associated with consumption of any drug and of main therapeutic classes were investigated through multivariate logistic regression models, using 2016 as the reference for investigating temporal trends.

RESULTS

Prevalence of use of any drug was significantly higher in 2016, with marked changes observed in comparison with 1986: absolute decrease of psychotropic (-5.1%, p < 0.0001), antibiotics (-2.7%, p < 0.0001) and cardiovascular drug use (-3.8%, p < 0.0001), increase of analgesic use (+8.3%, p < 0.0001). Difficult working conditions, age and female gender were independently associated with analgesic drug use, and extraprofessional problems and female gender associated with psychotropic drug use.

CONCLUSIONS

This analysis of self-reported drug use in the working environment illustrates the global patterns of medication use in a French active population over 3 decades. The favorable development in the level of consumption of psychotropic drugs should not underestimate the attention to be paid to the determinants of chronic consumption, or possible transfers to less stigmatized medications.

Botulinum toxin injections as an effective treatment for patients with intertriginous Hailey-Hailey or Darier disease: an open-label 6-month pilot interventional study

BACKGROUND

Patients with Hailey-Hailey and Darier diseases present with disabling inflammatory lesions located in large skin folds, which are often exacerbated or induced by sweating. Quality of life is highly impaired because of pain and recurrent skin infections. An improvement in skin lesions after botulinum toxin A injections has previously been reported in some patients but no prospective interventional studies are available. The aim of this open-label, 6-month, interventional pilot study (NCT02782702) was to evaluate the effectiveness and safety of botulinum toxin A for patients with moderate to very severe skin lesions located in folds.

RESULTS

Thirty patients (26 Hailey-Hailey/4 Darier) were included. Botulinum toxin A proved effective within the first month in two-thirds of patients, taking all study parameters (itchiness, cutaneous pain, sweating and odour, infections, psychosocial impairment and quality of life) into account and persisted during the 6-month follow-up period. No patient was classed as a BtxA non-responder, but 11 (37%) Hailey-Hailey patients (the most severe ones), experienced a relapse during the study. No serious side effects were reported. Mild transient clear fluid discharge at the site of the injections was reported for 27% of patients.

CONCLUSIONS

Botulinic toxin seems to be an effective and safe treatment for Hailey-Hailey and Darier diseases. Nevertheless, it may prove insufficient for the severest of Hailey-Hailey cases and could be considered as supplementary to other conventional treatments. Further studies are required to confirm our results on larger Darier cohorts.

Loss-of-function alleles of P2RX7 and TLR4 fail to affect the response to chemotherapy in non-small cell lung cancer

The success of anticancer chemotherapy relies at least in part on the induction of an immune response against tumor cells. Thus, tumors growing on mice that lack the pattern recognition receptor TLR4 or the purinergic receptor P2RX7 fail to respond to chemotherapy with anthracyclins or oxaliplatin in conditions in which the same neoplasms growing on immunocompetent mice would do so. Similarly, the therapeutic efficacy (measured as progression-free survival) of adjuvant chemotherapy with anthracyclins is reduced in breast cancer patients bearing loss-of-function alleles of TLR4 or P2RX7. TLR4 loss-of-function alleles also have a negative impact on the therapeutic outcome of oxaliplatin in colorectal cancer patients. Here, we report that loss-of-function TLR4 and P2RX7 alleles do not affect overall survival in non-small cell lung cancer (NSCLC) patients, irrespective of the administration and type of chemotherapy. The intrinsic characteristics of NSCLC (which near-to-always is chemoresistant and associated with poor prognosis) and/or the type of therapy that is employed to treat this malignancy (which near-to-always is based on cisplatin) may explain why two genes that affect the immune response to dying cells fail to influence the clinical progression of NSCLC patients.

Tramadol-induced hypoglycemia: A pharmacovigilance study

Several papers have reported that tramadol can induce hypoglycemia. However, in some reports, confounding factors can be found, like coadministration of hypoglycemic drugs. We used the WHO pharmacovigilance database (VigiBase®) to investigate whether tramadol alone could be associated with hypoglycemia. All 2010–2019 ICSRs (Individual Case Safety Reports) with the PT term “hypoglycemia” and tramadol were included. Two disproportionality analyses were performed: 1/after inclusion of all reports, 2/after exclusion of concomitant hypoglycemic drugs. Results are expressed as Reporting Odds Ratios (ROR; 95% CI). Among 10 038 436 ICSRs, 97 639 were included. In comparison with codeine, a significant association was found between tramadol use and reports of hypoglycemia before [ROR = 1.54 (1.43–1.66)] or after [ROR = 1.43 (1.31–1.56)] exclusion of hypoglycemic drugs. Tramadol use is associated with a higher risk of hypoglycemia reports than codeine, the other step 2 analgesic, in the presence as well as in the absence of other hypoglycemic drugs. We concluded that hypoglycemia is an adverse drug reaction of tramadol, which can be observed in diabetic as well as in non-diabetic patients.

Personality dimensions of patients can change during the course of parkinson's disease

BACKGROUND

Studies assessing personality dimensions by the "Temperament and Character Inventory" (TCI) have previously found an association between Parkinson's disease (PD) and lower Novelty Seeking and higher Harm Avoidance scores. Here, we aimed to describe personality dimensions of PD patients with motor fluctuations and compare them to a normative population and other PD populations.

METHODS

All PD patients awaiting Deep Brain Stimulation (DBS) answered the TCI before neurosurgery. Their results were compared to those of historical cohorts (a French normative population, a de novo PD population, and a PD population with motor fluctuations).

RESULTS

Most personality dimensions of our 333 included PD patients with motor fluctuations who are candidates for DBS were different from those of the normative population and some were also different from those of the De Novo PD population, whereas they were similar to those of another population of PD patients with motor fluctuations.

CONCLUSIONS

During the course of PD, personality dimensions can change in parallel with the development of motor fluctuations, either due to the evolution of the disease and/or dopaminergic treatments.

Drug-Induced Hearing Loss in Children: An Analysis of Spontaneous Reports in the French PharmacoVigilance Database

INTRODUCTION

Hearing loss can have a negative impact on communication, with significant vocational, educational, and social consequences. Drugs are one of the causes of hearing loss in children.

OBJECTIVES

The objective of our study was to describe drug-induced hearing loss in the pediatric population.

METHODS

Reports of hearing loss from 1985 to December 2019 in the pediatric population (< 18 years) were extracted from the French PharmacoVigilance Database (FPVD). We performed a retrospective and descriptive analysis of adverse drug reaction (ADR) reports.

RESULTS

A total of 70 ADR reports were identified among the 51,216 reports registered in the FPVD, 37 involving adolescents (12-17 years, 52.9%), 28 children (2-11 years, 40.0%), and 5 infants (28 days-23 months, 7.1%). Overall, 40 reports (57.1%) involved girls. A total of 56 reports (80.0%) were "serious." The most frequent hearing disorders were deafness (n = 31, 44.3%) and hypoacusis (n = 22, 31.4%). Suspected drugs (ATC 5th level) were amikacin (n = 11, 15.7%), cisplatin (n = 11, 15.7%), doxorubicin (n = 4, 5.7%), vincristine (n = 4, 5.7%), clarithromycin (n = 4, 5.7%), ceftriaxone (n = 3, 4.3%), isotretinoin (n = 3, 4.3%), and vancomycin (n = 3, 4.3%).

CONCLUSIONS

This study shows that about three out of four cases of drug-induced hearing loss in the pediatric population were "serious". It also underlines the under-reporting of these ADRs and the importance of strengthening hearing monitoring in children during and long after drug exposure.

Mismatch Profile Influences Outcome After Mechanical Thrombectomy

BACKGROUND AND PURPOSE

Mechanical thrombectomy (MT) is the recommended treatment for acute ischemic stroke caused by anterior circulation large vessel occlusion. However, despite a high rate of reperfusion, the clinical response to successful MT remains highly variable in the early time window where optimal imaging selection criteria have not been established. We hypothesize that the baseline perfusion imaging profile may help forecast the clinical response to MT in this setting.

METHODS

We conducted a prospective multicenter cohort study of patients with large vessel occlusion-related acute ischemic stroke treated by MT within 6 hours. Treatment decisions and the modified Rankin Scale evaluation at 3 months were performed blinded to the results of baseline perfusion imaging. Study groups were defined a posteriori based on predefined imaging profiles: target mismatch (TMM; core volume <70 mL/mismatch ratio >1.2 and mismatch volume >10 mL) versus no TMM or mismatch (MM; mismatch ratio >1.2 and volume >10 mL) versus no MM. Functional recovery (modified Rankin Scale, 0-2) at 3 months was compared based on imaging profile at baseline and whether reperfusion (modified Thrombolysis in Cerebral Infarction 2bc3) was achieved.

RESULTS

Two hundred eighteen patients (mean age, 71±15 years; median National Institutes of Health Stroke Scale score, 17 [interquartile range, 12-21]) were enrolled. Perfusion imaging profiles were 71% TMM and 82% MM. The rate of functional recovery was 54% overall. Both TMM and MM profiles were independently associated with a higher rate on functional recovery at 3 months Adjusted odds ratios were 3.3 (95% CI, 1.4-7.9) for TMM and 5.9 (95% CI, 1.8-19.6) for MM. Reperfusion (modified Thrombolysis in Cerebral Infarction 2bc3) was achieved in 86% and was more frequent in TMM and MM patients. Reperfusion was associated with a higher rate of functional recovery in MM and TMM patients but not among those with no MM.

CONCLUSIONS

In this cohort study, about 80% of the patients with a large vessel occlusion-related acute ischemic stroke had evidence of penumbra, regardless of infarction volume. Perfusion imaging profiles predict the clinical response to MT.

Psychiatric Disorders and Hydroxychloroquine for Coronavirus Disease 2019 (COVID-19): A VigiBase Study

INTRODUCTION

In the stressful context of the coronavirus disease 2019 (COVID-19) pandemic, some reports have raised concerns regarding psychiatric disorders with the use of hydroxychloroquine. In this study, we reviewed all psychiatric adverse effects with hydroxychloroquine in COVID-19 patients, as well as in other indications, reported in VigiBase, the World Health Organization's (WHO) global database of individual case safety reports.

METHODS

First, we analyzed all psychiatric adverse effects, including suicide, of hydroxychloroquine in COVID-19 patients reported to 16 June 2020. We also performed disproportionality analysis to investigate the risk of reporting psychiatric disorders with hydroxychloroquine compared with remdesivir, tocilizumab, or lopinavir/ritonavir prescribed in COVID-19 patients. We used reporting odds ratios (RORs) and their 95% confidence intervals (CIs) to calculate disproportionality. Second, we sought to examine the psychiatric safety profile of hydroxychloroquine in other indications (before 2020).

RESULTS

Among the 1754 reports with hydroxychloroquine in COVID-19 patients, we found 56 psychiatric adverse effects. Half of these adverse effects were serious, including four completed suicides, three cases of intentional self-injury, and 12 cases of psychotic disorders with hallucinations. Compared with remdesivir, tocilizumab, or lopinavir/ritonavir, the use of hydroxychloroquine was associated with an increased risk of reporting psychiatric disorders (ROR 6.27, 95% CI 2.74-14.35). Before 2020, suicide was the main cause of death among all adverse drug reactions reported with hydroxychloroquine, followed by cardiac adverse effects (cardiomyopathy) and respiratory failure.

CONCLUSIONS

This pharmacovigilance analysis suggests that COVID-19 patients exposed to hydroxychloroquine experienced serious psychiatric disorders, and, among these patients, some committed suicide. Further real-world studies are needed to quantify the psychiatric risk associated with hydroxychloroquine during the COVID-19 pandemic.

Drug-induced tics: An observational postmarketing study

OBJECTIVES

While drug-induced tics have been described, in particular with neuroleptics, psychostimulants, or anti-epileptics, the strength and the direction of these associations are still debated. The aim of this study was to investigate the association between tics and drug exposure through a two-step analysis in two pharmacovigilance databases.

METHODS

We first performed a descriptive clinical analysis of cases registered in the French pharmacovigilance database (FPVD) from January 1985 to December 2018. We then performed a disproportionality analysis in VigiBase®, the WHO pharmacovigilance database, from January 1967 to June 2019, through the calculation of reporting odds ratio (ROR).

RESULTS

The drugs most frequently associated with tics in the FPVD were methylphenidate, lamotrigine, montelukast, tramadol, mirtazapine, venlafaxine, aripiprazole, and risperidone. In VigiBase®, we found a significant ROR with methylphenidate (ROR 37.54, 95% confidence interval [CI] 34.81-40.48), montelukast (ROR 12.18, 95% CI 10.29-14.41), aripiprazole (ROR 7.40, 95% CI 6.35-8.62), risperidone (ROR 4.40, 95% CI 3.72-5.21), and venlafaxine (ROR 1.52, 95% CI 1.14-2.03).

CONCLUSION

This postmarketing study confirmed a potential harmful association with methylphenidate (the highest association, as expected), aripiprazole, risperidone, lamotrigine, and venlafaxine and, interestingly, found a strong signal with montelukast, which, to our knowledge, had never been published before.

Can tramadol really induce hyponatraemia? A pharmacovigilance study

Several papers have described hyponatraemia with tramadol. However, in most reports, several confounding factors can be found. We used the WHO pharmacovigilance database (VigiBase®) to investigate if tramadol alone could be associated with hyponatraemia. All 1992-2019 ICSRs (individual case safety reports) with the preferred term (PT) "hyponatraemia" and tramadol were included. Two disproportionality analyses were performed: (1) after inclusion of all reports, and (2) after exclusion of concomitant hyponatraemic drugs. Results are expressed as reporting odds ratios (ROR; 95% CI) and information component (IC). Of 19 747 604 ICSRs, 225 575 were included. A significant association was found between tramadol use and reports of hyponatraemia (ROR = 1.49 [1.39-1.60], IC = 0.57 [IC₀₂₅ = 0.47]). After exclusion of hyponatraemic drugs, the previously found association disappeared. The study failed to find any pharmacovigilance signal of hyponatraemia with tramadol alone. We suggest that reports of hyponatraemia with tramadol can be explained principally by other underlying causes of hyponatraemia, especially other concomitant hyponatraemic drugs.

OP0314 FACTORS ASSOCIATED WITH 5-YEAR DRUG-FREE REMISSION IN EARLY ONSET AXIAL SPONDYLOARTHRITIS PATIENTS: DATA FROM DESIR COHORT

Background:

It is recommended to target remission when treating a patient with a chronic inflammatory rheumatism. To date, drug-free (DF) remission has been poorly investigated in axial Spondyloarthritis (axSpA).

Objectives:

1/To estimate the frequency of patients in DF remission after 5 years of follow-up in a cohort of early axSpA and 2/to assess the factors associated with 5-year DF Remission.

Methods:

Patients: All patients included in DESIR (DEvenir des Spondyloarthrites Indifférenciées Récentes) cohort were selected for this analysis.Definition of 5-year DF Remission: 1/all patients in ASAS partial remission and/or ASDAS<1.3 at 5 year visit and 2/ taking no disease modifying anti-rheumatic drugs (DMARDs, including synthetic and biologics) only at 5-year visit (patients could have received DMARD before the 5-year visit) and 3/ with a NSAIDs score ≤ 25 at the 5-year visit.Covariates analysed: age, gender, smoking status, body mass index, disease classification criteria (ASAS, Amor, ESSG, New York), presentation at onset (peripheral or extra-articular features), disease activity at onset (BASDAI, ASDAS-CRP, CRP, MASES, TJC or SJC), functional impairment at baseline (BASFI, HAQ-AS, BASMI), comorbidities, baseline imaging data (radiographic sacroiliitis, mSASSS, MRI sacroiliitis, spine MRI Berlin score), NSAID intake within 6 months before baseline visit and 5-year treatment intake (including DMARDs, corticoids and NSAIDs).Statistical analysis: The associations between each of these clinical factors and the 5-year DF remission were tested by logistic regression. A multivariate model was built, stepwise procedure, to identify the independent variables associated with 5-year DF remission.

Results:

Of the 708 patients included in DESIR cohort, 419 were seen at the 5-year visit and 72 (17.0%) were in DF remission (50% of males, aged of 33.08 years (SD:8.0), disease duration: 1.26 years (SD: 0.72), HLA-B27 in 71%, 26.4% had a MRI sacroiliitis). Patients in 5-year DF remission had lower symptom duration (1.3 year versus 1.6 year, p=0.01) had lower disease activity (BASDAI at baseline: 30.1 versus 46.1, p<0.0001, ASDAS-CRP: 1.96 versus 2.75, p<0.0001, CRP: 3.9 versus 8.6, p=0.01) had less peripheral involvement (at least 1 enthesitis at baseline: n=33 (45.8%) versus n=226 (65.1%), p=0.002; at least 1 painful joint at baseline: n=24 (33.3%) versus n=196 (56.5%), p=0.0006) less functional impairment (HAQ-AS: 0.32 versus 0.69, p< 0.0001, BASFI: 14.3 versus 32.1, p<0.0001, BASMI: 1.98 versus 2.51, p<0.0001), and had lower NSAIDs intake at baseline (NSAIDs score: 28.2 versus 48.1, p=0.0001). Interestingly, there was no difference in sacroiliac bone marrow oedema on MRI while Berlin scores on spine MRI were lower in patients in 5-year DF remission (Berlin score mean: 0.41 versus 1.24, p=0.03). During the 5 years of follow-up, patients in 5-year DF remission received less often analgesics (n=46 (63.9%) versus n=297 (85.3%), p<0.0001) and anti-TNF (n=1 (1.4%) versus n=182 (52.5%), p<0.0001), but there was no difference in NSAID or csDMARD intake between groups until the 4-year visit. After multivariate analysis, the variables that remained associated with 5-year DF remission were lower symptom duration (OR[95%CI]=0.58[0.36-0.88], p=0.01), lower baseline ASDAS-CRP (OR[95%CI]=0.50[0.32-0.76], p=0.002) or NSAIDs score (OR[95%CI]=0.54[0.34-0.81], p=0.004) and not initiating an anti-TNF during the 5 years of follow-up (OR[95%CI]=0.029[0.00-0.14], p=0.0005).

Conclusion:

DF remission is rare, 5 years after onset of axSpA. Patients with longer symptom duration, higher baseline ASDAS-CRP and NSAIDs scores were less often in DF remission, while imaging and biological data did not predict DF remission.

Disclosure of Interests:

Adeline Ruyssen-Witrand Grant/research support from: Abbvie, Pfizer, Consultant of: Abbvie, BMS, Lilly, Mylan, Novartis, Pfizer, Sandoz, Sanofi-Genzyme, Vanessa Rousseau: None declared, Agnès Sommet: None declared, Philippe Goupille Grant/research support from: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Lilly, Janssen, Medac, MSD France, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Consultant of: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Lilly, Janssen, Medac, MSD France, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Speakers bureau: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Lilly, Janssen, Medac, MSD France, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Yannick Degboe: None declared, Arnaud Constantin: None declared

Are potentially inappropriate and anticholinergic medications being prescribed for institutionalized elderly subjects?

The PAAPI project (Optimising Inappropriate Prescriptions in the Elderly) is a multi-disciplinary approach put in place by the Toulouse Pharmacovigilance Centre (CRPV) in order to improve drug prescribing practice in nursing homes. The aim of this study was to analyse the association between polypharmacy, frequency of prescriptions for potentially inappropriate medications (PIMs) and the anticholinergic burden of prescriptions in elderly patients from the PAAPI cohort. We carried out a retrospective study on residents of 24 nursing homes (EHPAD) participating in the PAAPI programme between 1er January 2017 and 31 December. Resident's Data were collected in a single review in a random day. Drug prescriptions were analysed quantitatively and qualitatively. PIMs and anticholinergic drugs were identified by the list EU(7)PIM and the Duran scale, respectively. The total anticholinergic burden was calculated by adding the anticholinergic scores of each drug. We classified the drugs into three categories: no anticholinergic burden (burden = 0), low anticholinergic burden (≥1 ≤ 3) or high anticholinergic burden (burden > 3). A total of 1191 residents living were included, and we analysed 8869 drug prescription lines. The average age of the residents was 87.0 ± 8.3 years, and the majority (71.5%) were female. Nearly half of the residents (49.6%, n = 67) having a prescription with a high anticholinergic burden were taking more than 9 drugs (Fisher exact test P < 0.05). All the prescriptions with more than 5 PIMs (n = 23) had an anticholinergic burden > 0, with the majority (65.2%, n = 15) having a high anticholinergic burden (Kruskal-Wallis test, P < 0.0001). In this cohort, 88% (n = 539) of prescriptions with a low anticholinergic burden and 100% (n = 135) of prescriptions with a high anticholinergic burden included at least one PIM. According to our study, the anticholinergic burden of prescriptions given to residents in the PAAPI cohort is associated with the prescription of PIMs and with polypharmacy. Optimizing the use of medicines remains essential in this population, given the harmful properties of these drugs. It would also be useful for the list of anticholinergic drugs to be updated as new medicines come onto the market.

Which Method for Diagnosing Small Fiber Neuropathy?

Introduction: Small fiber neuropathies (SFN) induce pain and/or autonomic symptoms. The diagnosis of SFN poses a challenge because the role of skin biopsy as a reference method and of each neurophysiological test remain to be discussed. This study compares six methods evaluating small sensory and autonomic nerve fibers: skin biopsy, Quantitative Sensory Testing (QST), quantitative sweat measurement system (Q-Sweat), Laser Evoked Potentials (LEP), Electrochemical Skin Conductance (ESC) measurement and Autonomic CardioVascular Tests (ACVT). Methods: This is a single center, retrospective study including patients tested for symptoms compatible with SFN between 2013 and 2016 using the afore-mentioned tests. Patients were ultimately classified according to the results and clinical features as "definite SFN," "possible SFN" or "no SFN." The sensitivity (Se) and specificity (Sp) of each test were calculated based on the final diagnosis and the best diagnostic strategy was then evaluated. Results: Two hundred and forty-five patients were enrolled (164 females (66.9%), age: 50.4 ± 15 years). The results are as follows: skin biopsy: Se = 58%, Sp = 91%; QST: Se = 72%, Sp = 39%; Q-Sweat: Se = 53%, Sp = 69%; LEP: Se = 66%, Sp = 89%; ESC: Se = 60%, Sp = 89%; Cardiovascular tests: Se = 15%, Sp = 99%. The combination of skin biopsy, LEP, QST and ESC has a Se of 90% and a Sp of 87%. Conclusion: Our study outlines the benefits of combining skin biopsy, ESC, LEP and QST in the diagnosis of SFN.

Interest of a general practitioner pharmacovigilance network to provide drug information: A comparative study in France

INTRODUCTION

Since 2015, Toulouse University PharmacoVigilance Center (TUPVC) set up a pharmacovigilance (PV) general practitioner (GP) network, called PharmacoMIP-MG. A clinical research assistant (CRA) moves to the office of GPs included in the PharmacoMIP-MG network (PMIP-GPs). There, he collects the adverse drug reaction (ADR) reports and drug-related questions. This additional support is not available to GPs not included in the PV network (NoPMIP-GPs) who have to ask drug questions spontaneously to the TUPVC.

OBJECTIVE

The objective of this study was to compare the number and characteristics of drug questions between PMIP-GPs and NoPMIP-GPs.

METHODS

All questions asked by GPs to the TUPVC from 01 Jan 2015 to 31 Dec 2017 were reviewed. Questions were classified into two groups: "general" and "related to a patient". The "related to a patient" category was divided in three subgroups: "ADRs", Drug-Drug Interactions and "Drug Management". Drugs were classified according to anatomical therapeutic chemical (ATC) classification. For comparisons, Wilcoxon test, Chi² test or Fisher test were used.

RESULTS

During the study period, the CRA collected 293 questions from the 165 PMIP-GPs. TUPVC received 333 questions asked spontaneously by the 3400 NoPMIP-GPs. PMIP-GPs asked significantly 3 times more questions than NoPMIP-GPs. Most of the GP questions were classified in the "related to a patient" category (74.9%). When we compared the proportion of "related to a patient" to "general" questions, there was no statistically significant difference between PMIP-GPs and NoPMIP-GPs. PMIP-GPs asked more questions about "ADRs", but less on "Drug Management" and or "Drug-Drug Interactions". The drugs most frequently involved were amiodarone, rivaroxaban and levothyroxine.

CONCLUSION

This is the first study about GPs' drug-related questions asked to a PV center. We found that an organization, such as a CRA-GP "face to face" visit, increased the number of drug questions. This kind of organization should be developed in order to improve independent drug information outreach.

The Cost of Potentially Inappropriate Medications in Nursing Homes in West Occitanie

Introduction: As of 2019, people older than 65 years represent 20% of the French population. Despite several guidelines suggesting to avoid potentially inappropriate medication (PIM) use in elderly, the prevalence of their prescription remains high (25%). Furthermore, PIM could lead to preventable adverse drug reactions (ADRs). The main objective of this study was to determine the direct cost of PIM in older persons living in residential care homes for the elderly (nursing homes). A secondary objective was to assess the potential impact of PIM deprescribing on drug-related health care costs. Methods: We undertook a multicenter, retrospective study in 19 care homes for the elderly including 1240 residents. The analysis of prescriptions was carried out according to the European EU(7) PIM list. The cost of each drug was estimated according to the French Medication Insurance database. Furthermore, patient’s comorbidities were studied using Charlson’s comorbidity index. In order to estimate the economic impact of PIM, we used the list of alternative appropriate drugs suggested by EU(7) PIM list and French National Health Authority. An incremental cost per patient was calculated by the difference in costs between PIMs and alternative drugs. Results: A total of 7768 lines of drug prescriptions were analyzed. The mean age was 87.6 ± 7.6 years. About 70% (n = 872) of residents received more than five drugs. We identified 959 residents (77.3%) with at least one PIM. The mean cost of PIM was 0.58 euros versus 0.48 euros for alternatives. PIM substitution by alternatives led to save 12 centimes/resident/day. The mean cost of prescription with PIM was 2.8 euros per resident per day (28% of the overall cost of prescription). According to these results, more than 25 million euros can be overall saved for aged persons living in nursing homes for the older people in France per year. Conclusion: The prevalence of PIMs among the elderly in nursing homes is high and leads to a significant cost. Deprescribing of these medications could decrease both drug misuse and cost of drug prescription. Further research is needed to estimate the overall cost of PIM exposure outcomes, taking into account the ADRs leading to hospitalization.

Abstract 2: French Acute Cerebral Multimodal Imaging to Select Patients for Mechanical Thrombectomy Final Results

Introduction: Target mismatch (TMM) identifies salvageable penumbra independent of time from stroke onset. Current guidelines do not recommend advanced imaging to select patients for mechanical thrombectomy (MT) within 6 hours after onset but indicate that more research is needed. To address this question, we designed a prospective multicenter cohort study to compare the rate of functional neurological recovery (mRS ≤2 @ 3 months) in patients treated by MT for ICA/M1/M2 occlusions within 6 hours after onset according to the presence of a TMM on baseline imaging.

Hypothesis: 60% of patients with TMM vs. 35% of no TMM, would achieve an mRS≤2 at 3 months. Sample size calculation: 200 patients.

Methods: Consecutive patients eligible for MT within 6 hrs after onset, who underwent CTP or DWI/PWI imaging before treatment were enrolled. No NIHSS or ASPECTS restrictions were applied. Treating teams were blinded of CTP/DWI/PWI maps. mRS at 3 months was rated by an investigator blinded to clinical/imaging/treatment information. Automatically processed maps by RAPID software were reviewed after the end of follow-up. TMM definition followed EXTEND-IA criteria: MM volume >10mL, MM ratio>1.2, Core volume <70 mL. Mismatch (MM) was defined by MM ratio>1.2 and MM volume>10 mL. Imaging-based subgroups (TMM vs. No TMM) were defined after the end of follow-up.

Results: 218 patients were enrolled. Baseline imaging profile distribution was 71% TMM, 29% no TMM, (in the no TMM group, 76% had a core volume > 70 mL); 82% MM and 18% no MM. Reperfusion(TICI 2B-3) was achieved in 86% of the patients after a median delay of 4.4 hrs (95%CI 3.6-5.9). 61% of the patients in the TMM group vs. 35% in the no TMM group had an mRS ≤2 @ 3 months, p<0.001 (adjustment for age, onset to reperfusion, NIHSS, reperfusion and baseline imbalances). Reperfusion vs. no reperfusion was associated with an increased rate of good outcome in the TMM and MM groups (61% vs. 38% p=0.039 and 60% vs. 32%, p=0.016) but not in the no TMM or No MM groups (35% vs. 33%, NS; 35 vs. 45%., NS).

Conclusion: Patients with salvageable penumbra on advanced imaging experienced a larger benefit from MT than those without. Patients with no penumbra did not appear to benefit from reperfusion.