Management of low back pain in primary care prior to multidisciplinary functional restoration: a retrospective study of 72 patients.

OBJECTIVE: Chronic low back pain is a major socioeconomic health issue, due to the high direct (healthcare) and indirect (sick leave) costs. The aim of the present study was to describe the primary care management of low back pain patients prior to their inclusion in a multidisciplinary functional restoration network. METHODS: A descriptive, retrospective, questionnaire-based survey of the general practitioners dealing with 72 low back pain patients. RESULTS: Patients had been monitored by their general practitioner for an average of four years, with a mean frequency of eight appointments per year per patient. Ninety-three percent and 60% of the patients had been referred to a rheumatologist and a surgeon, respectively. Ninety-eight percent had had lumbar radiographies, 80% had undergone a computed tomography scan and 64% had undergone magnetic resonance imaging. The most commonly prescribed medications were anti-inflammatories and first- or second-line analgesics. Thirty percent had already received morphine analgesics and 50% had taken antidepressants. Thirty-two percent had undergone lumbar surgery. Physiotherapy was frequently reported and, indeed, 6% of patients had participated in over 100 sessions. Total sick leave averaged 8.25 months over the study's follow-up period. CONCLUSION: The time interval before referral to a multidisciplinary care team is long and so GPs should be encouraged and helped to organize this process earlier. It is also essential to determine factors which predict progression to chronic LBP.

What have been the strategies for the registration, positioning and control of medical information for intramuscular artemether?

At the beginning of the 1990s the Chinese Authorities and Rhone-Poulenc Rorer signed an agreement to develop intramuscular (i.m.) artemether (Paluther) and to market the product in the malaria endemic countries. This accord ushered in an exemplary period of co-operation between an international pharmaceutical group and its Chinese partners, the WHO (especially TDR), the Wellcome Trust, and several university research departments. The challenge was to complement the Asian development (to Western standards of Good Manufacturing Practices, Good Laboratory Practices, and Good Clinical Practices) of a molecule which was already used on an everyday basis in East Asia and by Chinese medical missions in Africa. The implementation of Good Manufacturing Practice was the priority for Rhone-Poulenc Rorer in order to ensure the pharmaceutical quality of Paluther. New preclinical and clinical studies confirmed the importance of the drug in the curative treatment of severe malaria due to Plasmodium falciparum, or when resistance to other antimalarial drugs is suspected. The outcome of these new trials was the recognition that i.m. artemether is at least as efficient as quinine. The results of the current development of Paluther have been presented at several international congresses and the latest clinical trials were published in the New England Journal of Medicine in July 1996. The neurotoxicity observed in animals after long term administration of high and repeated dosages has never been reported in human subjects. I.m. artemether was listed in the WHO List of Essential Drugs in December 1995, and the product has now been registered in more than 40 malaria endemic countries. Authorization for use of Paluther in hospitals in France and in several other European countries was granted in 1996.

Preoperative color-Doppler assessment of vascularisation of the rectus abdominis: anatomic basis of breast reconstruction with a transverse rectus abdominis myocutaneous flap--a prospective study.

The unipedicled TRAM flap is an useful alternative to breast reconstruction after mastectomy in patients who refuse mammary implants. There is however the risk of unpredictable partial skin necrosis even after rigorous surgical procedures. Certain authors have proposed color flow doppler assessment before reconstructive surgery better to identify the vascular network and optimise patient selection. We performed a prospective study in 20 outpatients in order to compare preoperative assessment of the blood supply to the abdominal flap with the operative findings. An Ultramark 9 HDI (Advanced Technology Laboratories) equipped with a high frequency (10 Mhz) linear probe was used to measure blood flow and vessel caliber in the epigastric a. and perforating vessels (localisation, number; peak flow). Despite three limiting factors (anatomic, technical, morphologic) the results obtained in this series could be used to determine the indications for a TRAM flap.

The view of the pharmaceutical industry.

Rhône-Poulenc Rorer has committed itself to the development of artemether because we believe the drug will be of considerable benefit to sufferers from severe falciparum malaria, and because it is a stable, effective and economical compound that can be given by intramuscular injection. The quality of the pharmaceutical product meets international regulatory standards. Artemether is unlikely to yield big profits, but we believe that major pharmaceutical companies have a responsibility to develop such much-needed products. To develop this project further, we will need the assistance of academic institutions, research organizations and international bodies.