Potentially inappropriate drug prescription in the elderly in France: a population-based study from the French National Insurance Healthcare system.

BACKGROUND: Inappropriate prescribing is a known risk factor for adverse drug event occurrence in the elderly. In various countries, several studies have used insurance healthcare databases to estimate the national prevalence of potentially inappropriate medications (PIM) in the elderly, as defined by explicit PIM lists. Recently, a representative sample of the French National Insurance Healthcare database, known as the "Echantillon Généraliste des Bénéficiaires" (EGB), was created, making it possible to assess the quality of drug prescription in France. Our objective was to evaluate the prevalence and the regional distribution of PIM prescription in the elderly aged 75 years and over in France, using the French PIM list and the EGB database. METHODS: The list of drugs reimbursed to patients aged 75 years and over from 1 March 2007 to 29 February 2008 was extracted from the EGB. Drugs were classified as inappropriate using the French PIM list. A PIM user was defined as a person receiving at least one PIM reimbursement during the study period. Interregion variability was estimated from logistic regression. RESULTS: In 53.6% (95% CI: 53.0-54.1) of the elderly aged 75 years and over, at least one PIM was given during the study period. The three main drug groups identified were cerebral vasodilators (19.4%), drugs with antimuscarinic properties (19.3%), and long half-life benzodiazepines (17.8%). There was an important disparity in PIM prescription among the French regions. In 14 out of 22 regions, the risk of PIM prescription was significantly elevated. This geographical variation differed for the different drug groups. CONCLUSION: PIM prescription in the elderly is a major and worrying problem in France. As in other countries, recent accessibility of the National Insurance Healthcare database makes it possible to create local indicators that the regional health agencies could use to manage public health policy in closer alignment to the needs of the patients within each French region.

New growth charts for Libyan preschool children.

To draw up new growth charts for Libyan children under 5 years of age, a cross-sectional survey was carried out in urban and rural areas in 2 regions of the Libyan Arab Jamahiriya from June 1999 to February 2000. Using WHO cluster sampling methodology, 1473 infants and children of both sexes aged between 0 and 59 months were selected from residential areas, maternal and child health centres, kindergartens and the delivery section of hospitals. Growth charts for weight-for-age, height-for-age and weight-for-height were plotted and smoothed, to provide reference curves for clinical, epidemiological and research purposes. In addition, mean Z-scores were analysed by sociodemographic variables collected from interviews with parents. Factors with a strong influence on childhood growth patterns were child's age, mother's education level and sex.

Determinants of arterial stiffness in an apparently healthy population over 60 years.

Arterial stiffness assessed by the pulse wave velocity (PWV), a non-invasive and reproducible method, predicts cardiovascular morbidity and mortality. The main determinants of arterial stiffness are well established in younger and middle-aged populations, but much less in the elderly. The aim of this study was to describe the determinants of arterial stiffness in elderly apparently healthy subjects. The study included 221 voluntary subjects born before 1944 (mean age 67.4+/-5.0 years), who had a standard health check-up at the 'Centre de Médecine Préventive' of Nancy. Arterial stiffness was evaluated by measuring the carotid-femoral PWV with the PulsePen automatic device. Clinical and biological parameters were evaluated at the same day. Measurements were valid and analysed in 207 subjects (94 women). Mean PWV was 9.39+/-2.64 m/s. Men showed higher PWV values than women (9.99+/-2.56 vs 8.66+/-2.56, P<0.001). In univariate analysis, PWV was correlated with age (r=0.26, P<0.001) and mean arterial pressure (MAP) (r=0.40, P<0.001), and these relationships were similar in men and women. Subjects with hypertension (P<0.001), diabetes mellitus (P<0.001) and obesity (P<0.01) had higher values of PWV. In multiple regression analysis, PWV correlated positively and independently with age, male gender, MAP and diabetes mellitus. In conclusion, in an apparently healthy elderly population, the main determinants of arterial stiffness are the age, MAP, diabetes and gender. Our study also shows that the gender-related differences in arterial stiffness observed in middle-aged subjects are maintained in the elderly.

[Blood pressure control by antihypertensive agents in people older than 60]. / Contrôle de la pression artérielle par le traitement antihypertenseur chez le sujet âgé de 60 ans et plus.

PURPOSE: The prevalence or hypertension increases with aging, reaching more than 50% in people aged 60 years and older. The increase of systolic blood pressure is a major risk of cardiovascular event. METHODS: With the aim of assessing risk factors in old people "in apparent good health", we analysed blood pressure and treatments in people aged 60 years and older who had a periodic check-up that was adapted to older people. RESULTS: This check-up concerned, between April and December 2003, 1638 people with a mean age of 68 years (SD 5.7): 815 men and 823 women. Fourty percent had a systolic blood pressure (SBP) >or=140 mmHg (44% of men, 36% of women); 6% (8% of men, 4% of women) had a diastolic blood pressure (DBP) >or=90 mmHg. A treatment for hypertension was followed by 473 people: 31% of men and 26% of women. Fifty percent were controlled for the SBP and the DBP. Fourty-two percent were not controlled for the SBP, but were controlled for the DBP. Seven percent were not controlled for the SBP nor the DBP. Only 3 subjects (<1%) were not controlled for the DBP, whereas they were controlled for SBP. CONCLUSION: These results, combined with data of literature on the predominant role of SBP in cardio-vascular risk, as compared with DBP, underline the need for a better treatment of systolic hypertension in older people.

[Epidemiological study of oral dental health of 4-year-old children in french nursery schools]. / Enquête épidémiologique sur la santé buccodentaire d'enfants âgés de 4 ans scolarisés en école maternelle.

UNLABELLED: The departmental service of maternal and infantile protection (PMI) of Moselle (Lorraine region), together with the Paediatric Dentistry Department from Nancy University, organized a study of the dental health of 4-year-old children. AIMS OF THE STUDY: To assess the children dental health; to evaluate parental knowledge of dental health; to identify the factors associated with caries amongst children. MATERIAL AND METHODS: The study was a cross sectional observation. A random sample of 4-year-old children was selected among 11 586 children in nursery schools. The study was based on a clinical examination performed by a dentist and a structured questionnaire completed by parents. RESULTS: The overall proportion of children affected by caries was 37.5%. The mean dmft score was 1.51 (sd = 2.82) and 11.6% of the children had caries which affected their upper incisors, a sign of early childhood caries. Only 6.2% had received dental treatment on at least 1 occasion. There was a clear disparity in dental health: 1 child out of 3 suffered from caries but 1 out of 2 children in priority education districts was affected, compared with only 1 out of 4 children coming from a rural area. The questionnaires completed by parents showed a lack of knowledge of dental health and inadequate use of current prevention facilities. The multivariate logistic regression analysis showed that the variables that were significantly associated with caries in 4 year-old children were the mother's education, the low social background, the level of consumption of drinks containing sugar by both children and parents, the consumption of fluoride, and the level of knowledge about fluoride. CONCLUSION: Preventive measures must be developed in close relationship between pediatricians and dentists. Initial training of health care professionals has to be reinforced. Health care professionals in paediatrics are far more likely to meet mothers and young children than are dentists.

[Comparison of the individual deprivation index of the French Health Examination Centres and the administrative definition of deprivation]. / Comparaison du score individuel de précarité des centres d'examens de santé, EPICES, à la définition socio- administrative de la précarité.

In French Health Examination Centres, populations in deprived situation were usually defined by administrative criteria The aim of the study was to investigate whether EPICES, a new individual index of deprivation, was more strongly related to health status than an administrative classification. The EPICES score was calculated on the basis of 11 weighted questions related to material and social deprivation. Participants were 197, 389 men and women, aged over 18, encountered in 2002 in French Health Examination Centres. Relationships between health status, health-related behaviours, access to health care, EPICES and the administrative classification of deprivation were analyzed by logistic regression. The associations between EPICES and the study variables were stronger than those observed for the administrative definition. The comparison also showed socially disadvantaged people with poor health identified by the EPICES score who were not by the administrative classification. These results showed that the EPICES score can be a useful tool to improve the identification of deprived people having health problems associated to deprivation.

Wine, beer, and mortality in middle-aged men from eastern France.

OBJECTIVE: To evaluate prospectively the health risk of wine and beer drinking in middle-aged men in the area of Nancy, France. DESIGN: Prospective cohort study. SUBJECTS: A total of 36 250 healthy men who underwent comprehensive health appraisals in a center of preventive medicine between January 1, 1978, and December 31, 1983. MAIN OUTCOME MEASURES: Education, professional and leisure activities, and smoking and drinking habits were evaluated using a questionnaire. Blood pressure and mean corpuscular volume and gamma-glutamyltransferase, glucose, and serum cholesterol levels were routinely measured, and electrocardiography was routinely performed. We recorded mortality from all causes and specific causes during a 12- to 18-year follow-up across categories of baseline alcohol consumption. RESULTS: Of the subjects, 28% drank beer, 61% drank wine but no beer, and 11% were abstainers; there was not much difference between social classes. During the follow-up, 3617 subjects died. The relative risk of death was estimated by the Cox proportional hazards model using nondrinkers as the reference and adjusting for 4 or 5 covariables. Moderate intake of both wine and beer was associated with lower relative risk for cardiovascular diseases; the risk was more significant with the intake of wine. For all-cause mortality, only daily wine intake (22-32 g of alcohol) was associated with a lower risk (0.67; 95% confidence interval, 0.58-0.77; P<.001) due to a lower incidence of cardiovascular diseases, cancers, violent deaths, and other causes. CONCLUSION: In eastern France, moderately drinking only wine was associated with a lower all-cause mortality, although drinking both wine and beer reduced the risk of cardiovascular death.

[Determination of glucose, proteins, blood and leucocytes in urines: evaluation of automated analyzer Aution Max AX 4280]. / Détermination urinaire du glucose, des protéines, du sang et des leucocytes avec l'analyseur automatique Aution Max AX-4280.

The aim of this study was to evaluate the automated urine test strip analyzer Aution Max AX 4280 which uses strips able to measure 12 urinary parameters. For precision study, we considered glucose, protein, blood, leukocytes, nitrite, and pH and the four first were compared with usual methods: chemical measurement or microscopic examination. Reproducibility of the semi quantitative results was determined as the proportion of results falling into the same concentration range. Within-run reproducibility assessed using urine specimens were between 83% and 96%. Between day on quality controlled materials, it was higher (96%), and leukocytes were shared between two classes 250 and 500 cells/microL. For glucose and proteins, linearity was good and comparison with quantitative methods yielded high correlation. The false negative fraction was low and there was no false positive results. For blood, fraction of false positive was 7.5% for 0.3 mg/L of hemoglobin compared with microscopic analysis and false negative fraction was 1.3%. For leukocytes, false positive fraction was 4%, false negative one was 7.8%. These results, values for sensitivity, specificity, predictive positive value, predictive negative value permitted to determine the cut-off values to realize second levels analysis: proteins are measured from 0.30 g/L, glucose from 2.8 mmol/L, microscopic urinalysis was performed from hemoglobin more than 0.3 mg/L and leukocytes more than 25 cells/microL.

Segregation analysis and variance components analysis of bone mineral density in healthy families.

Bone mineral density (BMD) was measured in 1992-93 in 129 nuclear families, including 258 parents and 183 children, and was analyzed for familial resemblance factors. BMD measurements were adjusted on weight and age. Segregation analysis rejected the monogenic hypothesis and exhibited a strong polygenic component. Variance components analysis was then used to estimate the parameters of a multivariate normal model including an additive polygenic component, a common environment factor, and a residual specific to each individual. The genetic component was independent of sex and age. The common environmental factor was not significant. The variance of the residual specific factor appeared to be a quadratic function of age, reaching its minimum value at 26.4 years. Consequently, the maximum value for heritability (ratio of genetic variance to total variance) is observed at this age (h2 = 0.84). According to this model, the correlation between two relatives is a function of the ages of each individual in the pair.

Multivariate genetic analysis of high density lipoprotein particles.

The aim of this study was to investigate the effect of genetic factors on three components of plasma high density lipoproteins, HDL-cholesterol (HDL-C), apolipoprotein A-I (apo A-I) and lipoprotein particle Lp A-I (Lp A-I), which contains apo A-I but not apo A-II. These analyses were carried out on 106 nuclear families with one or more children (407 subjects) who volunteered for health screening at the Center for Preventive Medicine, Vandoeuvre, France. After adjustment by stepwise multiple linear regression analysis for age, gender, weight, height, ponderosity, alcohol consumption, smoking habits, and hormonal treatment in females, a multifactorial model (considering the effect of polygenes, individual, specific, environmental and common household factors) was fitted to each variable separately. The hypothesis of no common household effects was accepted for each of the traits. The contribution of genetic factors to inter-individual variance was larger than the contribution of environmental factors for apo A-I (h2 = 0.81) and Lp A-I (h2 = 0.63) but not for HDL-C (h2 = 0.44). Bivariate analyses were carried out by parameterizing covariance components between traits. The genetic correlations were always significantly different from zero. They were estimated to be 0.73 between HDL-C and apo A-I, 0.40 between HDL-C and Lp A-I, 0.51 between apo A-I and Lp A-I. These results suggest that HDL-C, apo A-I and Lp A-I are only in part affected by the same genes and that the measurement of lipids as well as the apo A-I and Lp A-I gives complementary and different information on the metabolic and genetic aspects.

Apo B signal peptide insertion/deletion polymorphism is involved in postprandial lipoparticles' responses.

The changes in postprandial concentrations of five lipoparticles (LpC-III, LpC-III:B, LpC-IIInoB, LpA-I and LpA-I:A-II) were studied on 144 apparently healthy (71 male and 73 female) subjects during the 4 h following the ingestion of a 1.260 kJ milkshake. The influence of apo B signal peptide polymorphisms, apo E polymorphism, and other factors including age, gender, BMI, tobacco and alcohol consumption on the postprandial responses of lipoparticles was investigated. Apo-A-I-containing lipoparticles were not influenced during the 4 h following the test meal except for LpA-I:A-II, which decreased in women. LpA-I:A-II is the only particle that showed a gender-dependent change in postprandial concentration. Apo-CIII-containing lipoparticles showed significant postprandial variations. Particles containing both apo B and apo C-III (total LpC-III and LpC-III:B), mainly present in VLDL fraction, had significantly different postprandial responses among the genotypes of the apo B signal peptide polymorphism. Homozygotes for Del allele showed a decrease of LpC-III:B concentrations over the 4 h, whereas Ins/Ins homozygotes and Ins/Del heterozygotes had a peak in concentration at 2 h. The apo B signal peptide polymorphism explained 2.3% of the variance of LpCIII:B, whereas apo E polymorphism did not influence the postprandial concentrations of any lipoparticles.

Population genetics of hypervariable loci: analysis of PCR based VNTR polymorphism within a population.

Using a polymerase chain reaction (PCR) based method, genotypes at two hypervariable loci (3' to the Apo-B-structural gene and at the ApoC-II gene) were determined by size classification of alleles. Genotype data at the Apo-B locus (Apo-B VNTR) were obtained on 240 French Caucasians; the sample size for the ApoC-II VNTR was 162. For 160 individuals two-locus genotype data were available. Applications of some recently developed statistical methods to these data indicate that both of these loci are at Hardy-Weinberg equilibrium (HWE) and there is no indication of allelic associations between these two unlinked loci. In addition, the observed numbers of alleles (12 for the Apo-B and 11 for the ApoC-II VNTR loci) are also consistent with their respective expectations based on the observed heterozygosities (76.9% for the Apo-B and 85.9% for the ApoC-II loci) suggesting genetic homogeneity of this population-based sample. The multimodal distribution of allele sizes observed for both loci indicate that the production of new alleles at such VNTR loci may be caused by more than one molecular mechanism. The utility of such highly polymorphic loci for human genetic research and forensic applications are discussed in the context of these findings.

The French paradox and wine drinking.

Despite a high level of risk factors such as cholesterol, diabetes, hypertension and a high intake of saturated fat, French males display the lowest mortality rate from ischaemic heart disease and cardiovascular diseases in Western industrialized nations (36% lower than the USA and 39% lower than the UK). By contrast, mortality from all causes is only 8% lower than in the USA and 6% than in the UK, owing to a high level of cancer and violent deaths. In a recent study of 34,000 middle-aged men from Eastern France with a follow-up of 12 years we have observed that for 48 g of alcohol (mostly wine) per day as the mean intake, mortality from cardiovascular diseases was lower by 30%, all-cause mortality was reduced by 20%, but mortality by cancer and violent death was increased compared with abstainers. Thus the so-called 'French Paradox' (a low mortality rate specifically from cardiovascular diseases) may be due mainly to the regular consumption of wine.

Effects of apo B and apo E gene polymorphisms on lipid and apolipoprotein concentrations after a test meal.

The role of apo B signal peptide and apo E polymorphisms, and individual factors (age, sex, etc.) have been investigated on the interindividual variability of the postprandial response of 274 subjects ingesting a 1.260-KJ milkshake. The mean postprandial response, observed during 4 h, is significantly positive for total cholesterol (P < 0.005), LDL-cholesterol (P < 0.0001), triglycerides (P < 0.001), apo E (P < 0.0001) and glucose (P < 0.0001), whereas HDL-cholesterol, apo A-I and apo B do not present mean postprandial variation. Independently of the mean response, some parameters present a large interindividual variability of response, which is significantly influenced by cofactors, such as weight or BMI, for total and LDL-cholesterol, apo B and apo E or tobacco use for HDL-cholesterol. Sex has no effect on any lipid levels. Total, LDL-cholesterol and apo E responses are correlated with their corresponding fasting values. ApoB signal peptide polymorphism is not involved in the postprandial responses, whereas apo E polymorphism explains a significant part of the variability of HDL-cholesterol and apo A-I responses.

Family resemblance in breakfast energy intake: the Stanislas Family Study.

BACKGROUND: There seems to be a consensus that family influences on dietary habits are important. However, no data relative to breakfast have been published yet. OBJECTIVE: To investigate whether and how breakfast energy intake aggregates within French families. DESIGN: A total of 398 families of the Stanislas Family Study who filled in a 3 day food consumption diary were selected. Absolute and relative breakfast energy intakes (BEI in kcal/day and RBEI in percentage of daily intake, respectively) were both studied. RESULTS: By using a variance component analysis, no genetic influence was shown in family aggregation of both BEI and RBEI. Intra-generation common environmental contribution to total phenotypic variance of BEI and RBEI was higher than inter-generation; both were increased with frequency of sharing breakfast. Furthermore frequency of sharing breakfast contributed to increase family resemblance in breakfast energy intake, particularly in offspring for BEI and RBEI, and in spouses for RBEI. Smoking habits, alcohol consumption, BMI or physical activity were related to family resemblance, but after adjustment on each factor degrees of resemblance were almost unchanged. CONCLUSION: General findings of this study were that family aggregation in breakfast absolute and relative energy intakes was significant within Stanislas families. Family resemblance depended on inter- and intra-generation components and was modified by the number of shared breakfasts. Our study confirmed that familial habits act on family resemblance in both absolute and relative breakfast energy intakes, so that family should be a favorite unit for health and diet promotion programs. SPONSORSHIP: Kellogg's PA, France.

Determinants of hormonal replacement therapy in recently postmenopausal women.

Although the efficacy of hormonal replacement therapy (HRT) on the consequences of the menopause is not questioned, it appears that in Europe and in the USA only a small proportion of women are users of HRT. In this study, we examined the prevalence and the determinants of HRT among 1986 French menopausal women, aged 45 to 55 years, presenting to a preventive medicine centre. Overall, 8.1% of women reported current use of HRT. The estrogen preparation most commonly reported was transcutaneous 17 beta-oestradiol. The first determinant of current HRT was birth-place. Women born in France were nearly four times more likely to be on treatment than foreign-born women. A surgical menopause multiplied the probability of current HRT by 2, as did a high level of education. An age at first pregnancy of more than 20 and less than 4 children were also positively linked with HRT use. Even in this population of recently menopausal women, volunteering to undergo health evaluation, the prevalence of HRT was low. The reservations towards HRT may be partly due to the women themselves, and partly due to the physicians. It seems very important to inform the medical profession about the risks and benefits of HRT, and to understand more precisely the reasons why so few women use HRT.

The role of genetics in defining reference values and health status.

Since its establishment, the Center for Preventive Medicine in Vandoeuvre-les-Nancy, France, performed specific studies on healthy humans, and its approach was very useful for defining reference values. Prevention should extend its interest to chronic diseases. The majority of important adult disorders are partially genetically determined. Genetic markers are also useful as exclusion or as partition criteria in the production of reference values. Results are presented that were obtained for apolipoproteins E, B and AIV, frequencies of these polymorphisms in the Lorraine population, and relationships between these polymorphisms and lipid metabolism-related parameters. Health checkup centers, in particular those involved in family screening, are well suited for resembling many data concerning environmental factors: tobacco consumption, alimentation habits, or alcohol and drug consumption. Simultaneous determination of genetic markers could allow the determination of an individual's susceptibility or resistance to developing a disease and to prepare a preventive action.

[Serum carotenoids and vitamin A in melanodermic and albino subjects in Cameroon]. / Caroténoïdes et vitamine A sériques au Cameroun chez des sujets mélanodermes et albinos.

Vitamin A nutritional status as assessed by carotenoid and vitamin A assays in sera collected in various parts of Cameroon prooved to be of good value. Palm oil rich diets lead to high seric carotenoid concentrations and tissular accumulation which is particularly visible on the palms and soles of melanodermic and albinos subjects.

[Future of blood pressure in young adults during a 15-year follow-up]. / Devenir de la pression artérielle chez de jeunes adultes après un suivi de 15 ans.

Tracking of BP and their determinants were investigated among 2,752 young adults, aged 20-35 years (1,209 men and 1,543 women) in a longitudinal study conducted since 1974 at the Center for Preventive Medicine in Nancy-Vandoeuvre. Prevalence of hypertension (BP > 160/95 mmHg or hypertensive drugs) rose over 15 years from 2.1% to 6.8%. Subjects with antihypertensive drugs were about 3.5% after 15 years of follow up (mean age at the fourth examination: 44 years). Coefficients correlation between initial BP and BP at 5, 10 and 15 years were 0.43, 0.38 and 0.35 for systolic BP, 0.28, 0.24 and 0.26 for diastolic BP in population without antihypertensive drugs. The part of variance for BP at the fourth examination explained by variables from previous examinations was low (27% for systolic BP and 13 or 17% according to sex for diastolic BP). The main variable in the regression was always the BP at the third examination; 69.3% of subjects with high BP (> 140/90 mmHg or treated for hypertension) were well classified in a discriminant analysis. These results underline the difficulty to predict BP and hypertension in a general population, suggest to take into account pathogenic predictors in further studies and allow us to propose selective prevention of future hypertensive.

[Familial aggregation of blood pressure]. / Etude de l'agrégation familiale de la pression artérielle.

Familial aggregation of blood pressure (BP) was studied in 545 families, of which 370 included natural children only, 24 adopted children only and 175 both natural and adopted children. Mean values of four Automatic BP measurements (Dinamap 845) were converted into age (adult) or height (children) and sex adjusted scores. One comparison per family between parents and randomly chosen index children were made. A significant resemblance of blood pressure is observed between natural children and their parents: Systolic BP r = 0.24. Diastolic BP r = 0.29. N = 272 p less than 0.05. Adopted children did not have BP resemblances to the mean BP values of their parents but a significant resemblance was found between children and their mothers for a small sample (N = 46). Weight, heart rate, age and duration of cohabitation do not influence the results. A familial influence on BP can be detected in children. However, estimating the relative contribution of genetic and common environmental factors to BP correlations between family members is difficult. Nevertheless, the BP of children whose parents have high BP should be monitored.