Spreading and impact of the World Health Organization's Allergic Rhinitis and its impact on asthma guidelines in everyday medical practice in France. Ernani survey.

OBJECTIVES: The aim of this study was to determine the spreading level of the WHO-ARIA (World Health Organization's Allergic Rhinitis and its Impact on Asthma) guidelines among the medical community and their influence on medical practices. METHODS: A cross-sectional study based on a questionnaire was performed between April and July 2005 on randomly chosen general practitioners (GPs) (943) and ear, nose and throat (ENT) physicians (277). RESULTS: About 54.4% of the physicians claimed to know the WHO-ARIA guidelines and 49.7% said they followed them. These results vary significantly, mainly according to medical specialty (ENT vs. GP). In comparison to those who did not know the guidelines, their patients benefited more frequently (P<0.0001) from allergen search (42.2% vs. 31.7%), a nasal endoscopy (38.3% vs. 26.0%), a follow-up consultation (64.9% vs. 52.6%) and written information on rhinitis (30.7% vs. 14.1%). Paradoxically, they do not search more frequently for asthma and do not provide different first-line treatment strategy and duration.

Venous disease and ergonomics of female employment.

AIM: The aim of this study was to describe the employment conditions of women with chronic venous disorders of the lower limbs. METHODS: Cross sectional study conducted by general practitioners who describe the first 3 women, between 18 and 65 years of age, who were employed and who presented with at least CEAP stage I venous disorders. RESULTS: Occupations held by these women indicate significant departures from the general population with an over representation of industrial workers (18.6% vs 11.9%) and an under representation of intermediate professions (12.5% vs 26.6%), (P<0.001). At work, 78.2% (n=4,143) of the women remained standing for 6.2+/-2.4 hours per day and/or 52.3% (n=2,771) were seated for prolonged periods, 28.9% (n=1 503) were exposed to sources of high heat on the legs and 18.2% (n=947) wore garments that compressed the abdomen Conditions favorable to the ergonomic evolution of their workstation are limited: only 9.2% (n=397) thought it possible to reduce the time they spend standing; 10.1% (n=319) the time they spend sitting; 12.9% (n=189) their exposure to heat. Combating these factors appears difficult: 74.3% (n=3 883) state that they do not have sufficient breaks to rest their legs, 38.9% (n=2,053) that they do not have the opportunity to stretch their legs and 42.5% (n=1,395) that compression stockings would be permitted, but would be a hindrance in their work (85.6%, n=4,503). For 27% (n=1,424) of respondents, these problems significantly increase the arduousness of their work and 73.7% (n=3,870) think their working conditions have worsened their venous distress. CONCLUSIONS: Women who consult for venous problems are employed in work which are characterized by unavoidable conditions constituting undeniable venous risk factors for venous disease and occupational medicine does not pay enough attention to the ''ladies legs'' at work.

Assessment of cetirizine, an antihistamine, to prevent cutaneous reactions to nevirapine therapy: results of the viramune-zyrtec double-blind, placebo-controlled trial.

We conducted a 12-week, multicenter, randomized, double-blind, placebo-controlled trial of cetirizine to assess the ability of antihistamines to prevent nevirapine-associated rash in patients infected with human immunodeficiency virus type 1. Patients initiating treatment with nevirapine were randomized to receive either cetirizine, 10 mg q.d. (104 patients), or placebo (96 patients) during the first 6 weeks of therapy. Rash occurred in 22 (11%) of 200 patients; 10 (9.6%) were in the cetirizine group and 12 (12.5%) were in the placebo group (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.31-1.81; P=.5). Five of 22 rashes were cases of hypersensitivity syndrome. The rate of nevirapine discontinuation due to rash was similar in the 2 groups (7.7% and 6.25% in the cetirizine and placebo groups, respectively; P=.4). Multivariate analysis showed no treatment-group effect but indicated that age >40 years (OR, 3.83; 95% CI, 1.4-10.46; P=.008) was associated with an increased risk of rash. Cetirizine has no preventive effect on nevirapine-associated rash.

Incidence of multiple sclerosis in Dijon, France: a population-based ascertainment.

Incidence of multiple sclerosis (MS) was prospectively determined within the population of the city of Dijon (94,000 inhabitants under 60 years old) at 47 degrees northern latitude, in Burgundy, France. All the incident cases were diagnosed according to the criteria of Poser, associated to the study of cerebrospinal fluid, evoked potentials and cerebral magnetic resonance imaging. Diagnosis was assessed in all the cases by a neurologist working either in the University Hospital (four neurologists) or in private offices (seven neurologists). The ascertainment was performed on a full 5-year period, from 1993 to 1997. Twenty-one cases were diagnosed in the population of 94,000 inhabitants, with an incidence of 6.1/100,000/year in women, 3.3/100,000/year in men and 4.3/100,000/year in both sexes. The sex-ratio female/male was 2.5. Our data are similar to those of the literature, in particular in countries around the Burgundy area. Our data allow evaluation of the burden of MS in our area and allow evaluation of the changes of incidence in the future.

Correlation between inter-ictal regional cerebral blood flow and sphenoidal electrodes--recorded inter-ictal spikes in mesial temporal lobe epilepsy.

The objective of this study was to assess the reliability of the diagnosis of mesial temporal lobe epilepsy using EEG and sphenoidal electrodes. Inter-ictal 99 m Tc-HMPAO SPECT scans were registered in 21 patients with confirmed mesial temporal lobe epilepsy identified by scalp EEG and sphenoidal electrodes. Visual and quantitative SPECT analysis was performed blind to EEG data. An asymmetry index (AI) was measured from the ratio of two symmetrical regions of interest. A temporal lobe hypoperfusion was defined as an uptake reduced by 5% with respect to the contralateral region. Inter-ictal SPECT abnormalities were observed in 12 out of 21 patients (57%) from both visual and quantitative analysis (focal hypoperfusion in 11 cases, focal hyperperfusion in one case). In seven patients (33%) both visual and quantitative scintigraphy were normal. Abnormal AI was found in 11/15 patients with a high frequency of seizures and in 1/6 patients with a low frequency of seizures. The major data is that the probability to have an abnormal SPECT is statistically correlated to the frequency of the epileptic fits. The couple EEG recordings with sphenoidal electrodes and SPECT is sensitive and reliable in the diagnosis of mesial temporal lobe epilepsy.

Stroke patterns in cardio-embolic infarction in a population-based study.

The study demonstrates that clinical-radiological causes and outcome of cardio-embolic infarcts in a population-based study correspond to a well-identified stroke pattern. Cardio-embolic infarcts was diagnosed in 882 cases (37.9%) of 2,330 consecutive first-ever stroke patients included in a prospective population-based stroke registry over a 14-year period (1985-1997). Thirty-three criteria out of 98 were introduced into a monovariate analysis and the significant variable were introduced into a multivariate analysis to identify significant criteria to define stroke patterns in cardio-embolic infarction. Cardiac sources of embolus included atrial arrhythmia, valvular heart disease (19%), and cardiac failure (18%). Patients with cardio-embolic infarction showed a significantly higher rate of female predominance (p < 0.001), history of ischemic heart disease (p < 0.001), acute stroke onset (p < 0.05), headache (p < 0.05), previous treatment by anti-platelets and anti-K-vitamin (p < 0.001), Wernicke aphasia (p < 0.001), severe deficit (p < 0.001) and death (p < 0.001). After a logistic procedure, female gender and ischemic heart disease were the two independent risk factors associated with cardio-embolic stroke. Cardio-embolic stroke is a specific subtype of stroke with its own clinical, radiological, etiological and prognostic characteristics. In the acute stage, it is necessary to identify quickly this type of stroke because of severe prognosis and appropriate treatment.

Acute low back pain: predictive index of chronicity from a cohort of 2487 subjects. Spine Group of the Société Française de Rhumatologie.

UNLABELLED: Low back pain (LBP)-related disability involves patients with chronic outcome. OBJECTIVE: To identify the factors predictive of chronic evolution of acute LBP and to develop a predictive clinical index. PATIENTS AND METHODS: Prospective investigation of 2487 employed patients referred for their first consultation with acute LBP (less than eight days). Chronic evolution defined by persistence of symptoms, unchanged or worse, at seven weeks. A predictive index was developed according to a logistic regression model. RESULTS: One hundred fifty-five patients (6.2%) were considered to have unchanged or worsened LBP at the time of final evaluation, which was carried out on average 42 +/- 15 days after the initial visit, and were thus regarded as having a chronic outcome. When comparing patients with chronic outcome and the others, there were 25 elementary characteristics for which the degree of significance of the bilateral test was less than 0.01. They were introduced into a logistic regression model. Five parameters appeared to be related to chronic outcome: characteristics of current episode (isolated acute low back pain, acute exacerbation of chronic low back pain, sciatica), two daily living activity items, duration of certificate to remain off work and taking part in a sport. They were used to develop an easily applied index providing identification, as of the initial consultation, of the risk of chronic evolution. CONCLUSION: The early recognition of patients with LBP with high risk of chronic outcome can be achieved with an easily applied clinical index.

[Medico-economic aspects of the management of perennial allergic rhinitis in general medicine]. / Aspects médico-économiques de la prise encharge des rhinites allergiques perannuelles en médecine générale.

A cross sectorial epidemiologic study was conducted in daily medical practice on the cost of perannual rhinitis. This study on 2033 patients shows per consultation the following costs. Medical fees: 130 +/- 45 francs, pharmaceutical expenses: 141 +/- 59 francs, biological and imaging: 109 +/- 174 francs. The indirect costs link to the absent days are evaluated at 776 francs. This rhinitis costs 1156 francs or 380 francs according the fact that the patient stops working or not. The extrapolation of these results to the french population shows 3.42 billions francs for the direct costs and 6 billions for the indirect costs. By comparison to this total amount, medical and pharmaceutical expenses represent only 11.7% and 12.7%.

ARIA (Allergic Rhinitis and Its Impact on Asthma) classification of allergic rhinitis severity in clinical practice in France.

BACKGROUND: The Allergic Rhinitis and Its Impact on Asthma (ARIA) workshop proposes a classification of allergic rhinitis severity. It does not take into account impairment in quality of life and treatment should be adapted accordingly. METHODS: Two cross-sectional surveys were designed:a spring survey, for which 1,321 practitioners enrolled 3,026 patients consulting for seasonal allergic rhinitis and an autumn-winter survey, for which 1,346 practitioners enrolled 3,507 patients consulting for perennial allergic rhinitis. Simple quality of life parameters were included and logistic regressions were performed in order to assess the impairment of quality of life. RESULTS: The majority of the patients were experiencing an impairment on their quality of life (92.2%). Except for cough, these patients had significantly more nasal, lung and ocular symptoms. In a multivariate analysis, rhinorrhea, nasal itching, red eyes, dyspnea, change in voice, fatigue and headache were correlated to impairment of quality of life. Persistent rhinitis was associated only with subjects who expressed difficulties in reading, and intermittent rhinitis with those who had to blow their nose and who expressed an impact on their professional activities. CONCLUSIONS: The proposal of the ARIA expert panel defining the severity of allergic rhinitis based on quality of life parameters is likely to simplify daily physician practice.

Suppression and recovery of adrenal response after short-term, high-dose glucocorticoid treatment.

BACKGROUND: Suppression of the adrenal response is an unpredictable consequence of glucocorticoid treatment. To investigate the kinetics of the adrenal response after short-term, high-dose glucocorticoid treatment, we measured the adrenal response to the low-dose (1 microg) corticotropin stimulation test. METHODS: We studied 75 patients who received the equivalent of at least 25 mg prednisone daily for between 5 days and 30 days. After discontinuation of glucocorticoid treatment, 1 microg corticotropin was administered intravenously, and stimulated plasma cortisol concentrations were measured 30 min later. In patients with a suppressed response to 1 microg corticotropin, the test was repeated until stimulated plasma cortisol concentrations reached the normal range. FINDINGS: The adrenal response to 1 microg corticotropin was suppressed in 34 patients and normal in 41. Subsequent low-dose corticotropin tests showed a steady recovery of the adrenal response within 14 days. In two patients, the adrenal response remained suppressed for several months. There was no correlation between plasma cortisol concentrations and the duration or dose of glucocorticoid treatment. INTERPRETATION: Suppression of the adrenal response is common after short-term, high-dose glucocorticoid treatment. The low-dose corticotropin test is a sensitive and simple test to assess the adrenal response after such treatment.

Combined hormone replacement therapy and risk of breast cancer in a French cohort study of 3175 women.

The largest-to-date randomized trial (Women's Health Initiative) comparing the effects of hormone replacement therapy (HRT) and a placebo concluded that the continuous use of an oral combination of conjugated equine estrogens (CEE) and medroxy-progesterone acetate (MPA) increases the risk of breast cancer. This conclusion may not apply to women taking other estrogen and progestin formulations, as suggested by discrepancies in the findings of in vitro studies, epidemiological surveys and, mostly, in vivo studies of human breast epithelial cell proliferation showing opposite effects of HRT combining CEE plus MPA or estradiol plus progesterone. To evaluate the risk of breast cancer associated with the use of the latter combination, commonly prescribed in France, a cohort including 3175 postmenopausal women was followed for a mean of 8.9 years (28 367 woman-years). In total, 1739 (55%) of these women were users of one type of estrogen replacement with systemic effect during at least 12 months, any time after the menopause, and were classified as HRT users. Among them, 83% were receiving exclusively or mostly a combination of a transdermal estradiol gel and a progestin other than MPA. Some 105 cases of breast cancer occurred during the follow-up period, corresponding to a mean of 37 new cases per 10 000 women/year. Using multivariate analysis adjusted for the calendar period of treatment, date of birth and age at menopause, we were unable to detect an increase in the relative risk (RR) of breast cancer (RR 0.98, 95% confidence interval (CI): 0.65-1.5) in the HRT users. The RR of breast cancer per year of use of HRT was 1.005 (95% CI 0.97-1.05). These results do not justify early interruption of such a type of HRT, which is beneficial for quality of life, prevention of bone loss and cardiovascular risk profile, without the activation of coagulation and inflammatory protein synthesis measured in users of oral estrogens.