[SPA therapy for pain of patients with chronic low back pain, knee osteo-arthritis and fibromyalgia]. / Médecines thermals et douleurs des lombalgies chroniques, gonarthrose ou fibromyalgia.

The data of 33 randomized controlled trials suggest that chronic pain of patients with chronic low back pain, knee osteo-arthritis, fibromyalgia is significantly improved by balneotherapy and significantly better improved than by control treatments. For chronic low back pain (10 RCT, 1192 patients) pain was better improved in balneotherapy group and the weighted mean of the differential improvement was 19.66 (95 % CI: 16.6 ; 22.8) and the effect size was 1.1 (95 %CI: 0.82 ; 1.38) favouring balneotherapy. For knee osteo-arthritis pain (17 RCT, 1428 patients) pain was better improved in balneotherapy group and the weighted mean of the differential improvement was 13.24 (95 % CI: 5.52 ; 20.96) and the effect size was 0.72 (95 %CI: 0.51 ; 0.93) favouring balneotherapy. For fibromyalgia (6 RCT, 398 patients) pain was better improved in balneotherapy group and the weighted mean of the differential improvement was 19.32 (95 % CI: 10.62 ; 29.2) and the effect size was 0.79 (95 %CI: 0.27 ; 1.31) favouring balneotherapy. Mineral waters and healing muds appear to have a more powerful analgesic action: 13 RCT (701) patients) compared mineral water bathing to tap water bathing or peloid application to hot-apcks or neutral muds application : the effect size was 0.75 (95 % CI :0.71 ; 0.79) favouring balneotherapy. Balneotherapy is a safe treatment as only 1 % of the patients receiving balneotherapy had to interrupt the treatment. However several methodological biases were observed in many trials, mainly a lack of statistical power due to a limited enrolment of patients, an insufficient duration of follow-up, an inhomogeneity of treatments. The clinical benefit has to be confirmed by stronger data of evidence but these data are sufficient to perform a more complete scientific analysis (meta-analysis) ; but further clinical investigations with a better methodological quality remain necessary.

Frequency and severity of adverse drug reactions due to self-medication: a cross-sectional multicentre survey in emergency departments.

BACKGROUND: Little is known about the relation of adverse drug reactions (ADRs) to self-use of medications. OBJECTIVE: The aim of this study was to determine the frequency and severity of ADRs related to self-medication (ADR-SM) among emergency department (ED) patients and to describe their main characteristics. METHODS: A prospective, cross-sectional, observational study was conducted over a period of 8 weeks (1 March to 20 April 2010), in the ED of 11 French academic hospitals. Adult patients presenting to the ED during randomization periods were included, with the exception of cases of self-drug poisoning, inability to complete self-medication questionnaire, or refusal. Clinical outcomes were assessed as well as history of self-medication behaviours and all drugs taken. All doubtful files and those related to ADR-SM were systematically reviewed by an expert committee. RESULTS: A total of 3,027 of 4,661 patients presenting to the ED met the inclusion criteria. Of these, 84.4 % declared a self-medication behaviour, 63.7 % took at least one non-prescribed drug during the previous 2 weeks and 59.9 % took a prescribed medication. A total of 296 patients experienced an ADR (9.78 %), of which 52 (1.72 %) were related to self-medication. Those ADRs related to self-medication included prescribed drugs (n = 19), non-prescribed drugs (n = 17), treatment discontinuation (n = 14), and interactions between non-prescribed and prescribed drugs (n = 2). The ADRs attributed to non-prescribed drugs represented 1 % of all patients taking non-prescribed drugs (n = 1,927). ADR severity was significantly lower for those related to self-medication (p = .032). CONCLUSION: Self-medication is frequent; its potential toxicity should not be neglected, taking into account the rate of adverse drug reactions in about 1 % of ED patient.

[What therapeutic goals in the aged diabetic patients?]. / Quels enjeux thérapeutiques chez la personne agée diabétique?

Diabetes in the elderly is a growing public health problem, impacting both quality of life and autonomy. In the absence of prospective studies, the therapeutic goal will depend both on classical diabetes-related criteria and on geriatric assessment to determine the degree of frailty. The glycemic goal for elderly diabetic patients in good general health is roughly the same as for younger patients, while the target should be less strict for frail patients, in order to avoid both hypoglycemia and excessive treatment constraints that have no direct benefit. As elderly diabetic patients have more frequent severe degenerative disorders and other cardiovascular risk factors, the treatment goals must take into account not only diabetes itself but also the consequences of aging. This clinical assessment, which is crucial for individually tailored treatment, must be undertaken by a multidisciplinary team.

Effectiveness of a lumbar belt in subacute low back pain: an open, multicentric, and randomized clinical study.

STUDY DESIGN: Multicentric, randomized, and controlled study of clinical evaluation of medical device in subacute low back pain. OBJECTIVE: To evaluate the effects of an elastic lumbar belt on functional capacity, pain intensity in low back pain treatment, and the benefice on medical cost. SUMMARY OF BACKGROUND DATA: There is limited evidence of efficiency of lumbar supports for treatment of low back pain. There is also a lack of the methodology in the studies reported on the efficiency of this device. METHODS: This study is randomized, multicentric, and controlled with 2 groups: a patient group treated with a lumbar belt (BWG) and a control group (CG). The main criteria of clinical evaluation were the physical restoration assessed with the EIFEL scale, the pain assessed by a visual analogic scale, the main economical criteria was the overall cost of associated medical treatments. RESULTS: One hundred ninety-seven patients have participated. The results show a higher decrease in EIFEL score in BWG than CG between days 0 and 90 (7.6 +/- 4.4 vs. de 6.1 +/- 4.7;P = 0.023). Respectively significant reduction in visual analogic scale was also noticed (41.5 +/- 21.4 vs. 32.0 +/- 20; P = 0.002). Pharmacologic consumption decreased at D90 (the proportion of patients who did not take any medication in BWG is 60.8% vs. 40% in CG;P = 0.029). CONCLUSION: Lumbar belt wearing is consequent in subacute low back pain to improve significantly the functional status, the pain level, and the pharmacologic consumption. This study may be useful to underline the interest of lumbar support as a complementary and nonpharmacologic treatment beside the classic medication use in low back pain treatment.

[Crenobalneotherapy: a medical and scientific update]. / Médecine thermale: actualités médicales et scientifiques.

The PubMed database contains about eighty scientific papers on crenobalneotherapy (i.e., medical balneology or spa therapy) published in the last three years, mostly in journals with an impact factor. These studies focus on the actions of thermomineral products (waters, muds, gases, steam) on biological systems (immune system, antioxidant system, cytokine networks, nociception, etc.). Hot mineral waters can have an action on the circulatory system. Ingested mineral water can act on carbohydrate, lipid and mineral metabolism. Dermocosmetologic mineral products have shown real benefits. Medical benefits of thermal treatment have been observed in patients with rheumatic conditions, psoriasis, venous insufficiency, ENT conditions, gynecolgical disorders, and anxiety. Unfortunately, many publications in this area suffer from methodological flaws. Clinical investigations of thermal medicine encounter dificulties of a methodological and financial nature, and problems of patient recruitment. The aim of the French thermal research institute is to provide support and advice for teams wishing to conduct well-designed controlled trials.

[When "deprescribing" drugs can improve the elderly patient's health]. / Quand "déprescrire" les médicaments chez les personnes âgées pour améliorer leur santé?

Elderly people are frequently prescribed unnecessary and/or dangerous medications. The resulting polymedication carries four types of risk : an increased risk of adverse drug events (ADEs), decreased benefits of appropriate drugs, decreased compliance with appropriate treatments, and increased cost. Physicians should thus, when possible, deprescribe, reduce, replace or withdraw inappropriate medications. This article examines the following questions: Which medications can be stopped? What are the risks? How best to withdraw undesirable drugs? What are the potential health benefits for elderly people? When should drugs not be deprescribed? How to promote controlled trials aimed at optimizing the duration of treatments, especially in elderly people? and How to educate prescribers, pharmacists and patients in deprescription?

Emergency department visits caused by adverse drug events: results of a French survey.

BACKGROUND: Adverse drug events (ADEs) are a substantial cause of hospital admissions. However, little is known about the incidence, preventability and severity of ADEs resulting in emergency department visits. To address this issue, we conducted a prospective survey in emergency departments of French public hospitals. METHODS: This study was performed over two periods of 1 week each, one in June 1999 and one in December 1999, in emergency departments of five university hospitals and five general hospitals throughout France. All patients aged>or=15 years presenting with medical complaints were included in the study. Trauma patients, those with gynaecological conditions and those with alcohol intoxication or intentional drug poisoning were excluded from the study. Each patient was assessed by two local emergency physicians to determine whether the visit was the result of an ADE. All medical records were subsequently validated by an independent group of medical lecturers in iatrogenic disorders. RESULTS: Out of a total of 1937 patients consulting, 1562 were taking at least one drug during the previous week and were included for analysis; 328 (21%; 95% CI 19, 23) of these patients consulted an emergency physician because of an ADE. Patients with ADEs were older than those without (mean age 63.5 vs 54.8 years; p<0.0001). Furthermore, ADE patients were more likely to have a higher severity presentation than the non-ADE group (p=0.019). The number of drug exposures was significantly higher in patients with an ADE than in those without (mean number of medications 5.17 vs 3.82; p<0.0001). On multivariate analysis, only age and the number of medications taken were significantly associated with adverse events. In total, 410 drugs were incriminated in the occurrence of 328 ADEs. The most frequently incriminated drug classes were: (i) psychotropic agents (n=84; 20.5%); (ii) diuretics (n=48; 11.7%), anticoagulants (n=38; 9.3%) and other cardiovascular drugs (n=63; 15.4%); and (iii) analgesics, including NSAIDs (n=57; 13.9%). Preventability could be assessed in 280 of the 328 cases. In 106 cases (37.9%), the ADE was judged to be preventable. CONCLUSION: ADEs leading to emergency department visits are frequent, and many are preventable, confirming that there is a need to develop prevention strategies.

[Admissions of elderly to French emergency departments related to adverse drug events]. / Admissions des sujets âgés aux Services d'Accueil des Urgences pour effets indésirables médicamenteux.

AIMS: To investigate the characteristics of adverse drug events (ADE) causing emergency medical admissions in the elderly. METHODS: Data were obtained from two prospective cross sectional studies with similar experimental design which were carried out in seven French emergency departments in 1999 and 2003. The proportion of ADE leading to admission, their severity and preventability were assessed in patients aged > or =70 (group A) and compared to those of patients < 70 years (group B). RESULTS: Out of a total of 2907 patients, 1158 (39.8%) were > or =70 years of age. Among these, 17.1% were admitted as a result of an ADE vs. 13.2% in group B (p = 0.004). ADE appeared to be more severe in group A than in group B. The part of preventable ADE did not significantly differ between the two groups (48.9% vs. 43.7%, respectively). CONCLUSION: ADE are a common preventable cause of unplanned admissions, especially in the elderly.

[Not Available]. / Admissions des sujets âgés aux Services d'Accueil des Urgences pour effets indésirables médicamenteux.

AIMS: To investigate the characteristics of adverse drug events (ADE) causing emergency medical admissions in the elderly. METHODS: Data were obtained from two prospective cross sectional studies with similar experimental design which were carried out in seven French emergency departments in 1999 and 2003. The proportion of ADE leading to admission, their severity and preventability were assessed in patients aged ≥70 (group A) and compared to those of patients <70years (group B). RESULTS: Out of a total of 2907 patients, 1158 (39.8%) were ≥70years of age. Among these, 17.1% were admitted as a result of an ADE vs. 13.2% in group B (p=0.004). ADE appeared to be more severe in group A than in group B. The part of preventable ADE did not significantly differ between the two groups (48.9% vs. 43.7%, respectively). CONCLUSION: ADE are a common preventable cause of unplanned admissions, especially in the elderly.

[Adverse drug reactions in the elderly]. / Effets indésirables des medicaments chez les sujets âgés.

Adverse drug reactions (ADRs) are more frequent and more serious in elderly patients (>65 years). Signs and symptoms of ADRs are varied and sometimes atypical. The culprit drugs are mainly cardiovascular and psychotropic agents, anticoagulants, and nonsteroidal antiinflammatory drugs. Some risk factors for ADRs are inherently due to aging, while others can he corrected. These preventable risk factors are related both to drugs themselves and to the behavior of doctors and patients. Given the major human and economic costs of ADRs in the elderly, a proactive prevention policy is urgently needed. This will involve more specific drug evaluation in the elderly, and better information for healthcare professionals and patients alike.

[Adverse drug effects observed at French admissions departments and emergency services (Prospective study of the National Educational Association for Teaching Therapeutics and proposals for preventive measures]. / Effets indésirables médicamenteux observés dans des Services d'Accueil et d'Urgences français (Etude prospective de l'APNET et propositions pour des mesures préventives).

Various studies have shown that adverse drug events (ADE) are a substantial cause of hospital admissions. However, little is known about the incidence and severity of ADE resulting in hospital visits. To address this issue, we conducted a prospective survey in 10 primary care and emergency departments of French public hospitals. This study was performed over two periods of one week, one in June 1999 and one in December 1999, in primary care and emergency departments of five university hospitals and five general hospitals throughout France. Out of a total of 1,937 patients consulting, 1,562 were taking at least one drug during the previous week and were included for analysis according to the protocol. Altogether, 328 (21%; 95% confidence interval 19% to 23%) of these patients receiving at least one drug consulted because of an ADE. The sex ratio (M/F) was the same in both groups with or without ADE (1.04 vs 1.02, respectively, P = 0.83). Patients with ADE were older than those without (63.5 vs 54.8 years, P < 0.0001). Furthermore, ADR patients were more likely to have a higher severity score than no-ADE group (P = 0.019). The outcome seemed to be worse in patients with an ADE. The percentage of patients treated with 2 or more drugs and the number of drug exposures were significantly higher in patients with ADE than in those without (90.9% vs 75.0%, P < 0.0001, and 5.17 vs 3.82, P < 0.0001, respectively). The most frequent causes of visits for ADE-patients were digestive (n = 53, 16.2%), neurological (n = 52, 15.9%), cardiovascular (n = 49, 14.9%) and malaise (n = 49, 14.9%) events. In total, 410 drugs were incriminated in the occurrence of 328 ADE. The most frequently incriminated drug classes were (1) psychotropic agents, including anxiolytics and/or hypnotics, antidepressants and antipsychotics (n = 84, 20.5%), (2) diuretics (n = 48, 11.7%), (3) anticoagulants (n = 38, 9.3%), (4) other cardiovascular drugs (n = 63, 15.4%), and (5) analgesics, including non steroidal antiinflammatory agents (n = 57, 13.9%). The avoidability of ADE could be estimated by an external expert panel in 280 of the 328 cases. In 106 cases (37.9%), ADE was considered to be preventable because a contra-indication or a warning about drug use had not been respected.

Pulse pressure: an important tool in cardiovascular pharmacology and therapeutics.

Epidemiological studies in the past decade have stressed the importance of pulse pressure (PP) as an independent risk factor for cardiovascular morbidity and mortality. We briefly review the epidemiological evidence and discuss the pathophysiological mechanisms which involve arterial stiffness and wave reflections in older patients. We discuss the therapeutic consequences of targeting PP rather than systolic (S) or diastolic (D) blood pressure (BP) when using antihypertensive agents. With this line of evidence it is important, first, to determine what minimal PP level indicates cardiovascular risk and, second, to note that an increasing number of clinical studies indicate that PP is poorly sensitive to placebo, while SBP and DBP are conversely highly sensitive. Finally, on the basis of large-scale intervention trials, PP seems to be an appropriate tool for studies of clinical pharmacology and therapeutics in the fields of hypertension, congestive heart failure and other cardiovascular diseases.