Methadone Induction in Primary Care for Opioid Dependence: A Pragmatic Randomized Trial (ANRS Methaville)

International audienceObjective: Methadone coverage is poor in many countries due in part to methadone induction being possible only in specialized care (SC). This multicenter pragmatic trial compared the effectiveness of methadone treatment between two induction models: primary care (PC) and SC. Methods: In this study, registered at ClinicalTrials.Gov (NCT00657397), opioid-dependent individuals not on methadone treatment for at least one month or receiving buprenorphine but needing to switch were randomly assigned to start methadone in PC (N = 155) or in SC (N = 66) in 10 sites in France. Visits were scheduled at months M0, M3, M6 and M12. The primary outcome was self-reported abstinence from street-opioids at 12 months (M12) (with an underlying 15% non-inferiority hypothesis for PC). Secondary outcomes were abstinence during follow-up, engagement in treatment (i.e. completing the induction period), retention and satisfaction with the explanations provided by the physician. Primary analysis used intention to treat (ITT). Mixed models and the log-rank test were used to assess the arm effect (PC vs. SC) on the course of abstinence and retention, respectively. Results: In the ITT analysis (n = 155 in PC, 66 in SC), which compared the proportions of street-opioid abstinent participants, 85/155 (55%) and 22/66 (33%) of the participants were classified as street-opioid abstinent at M12 in PC and SC, respectively. This ITT analysis showed the non-inferiority of PC (21.5 [7.7; 35.3]). Engagement in treatment and satisfaction with the explanations provided by the physician were significantly higher in PC than SC. Retention in methadone and abstinence during follow-up were comparable in both arms (p = 0.47, p = 0.39, respectively). Conclusions: Under appropriate conditions, methadone induction in primary care is feasible and acceptable to both physicians and patients. It is as effective as induction in specialized care in reducing street-opioid use and ensuring engagement and retention in treatment for opioid dependence

Management of a complex appendicular wound in a mare

Les plaies cutanées complexes constituent souvent un défi thérapeutique pour le praticien et une source d'inquiétude pour le propriétaire. Des soins relativement simples, une bonne observance des traitements et des grandes règles de prise en charge des plaies permettent d'obtenir des résultats très satisfaisants pour un coût acceptable. A travers l’exemple d’un cas concret, il est rappelé comment une plaie complexe doit être explorée avec minutie, largement drainée, nettoyée et débarrassée de tous corps étrangers lors de sa prise en charge. Son suivi passe par la mise en place de pansements adaptés et la gestion du tissu de granulation. Le traitement peut faire appel à des techniques chirurgicales simples de reconstruction comme la greffe en îlots. Mots clés: Plaie complexe, cheval, greffe, pinch/punch graft, hypergranulation, pansementComplex skin wounds are often a therapeutic challenge for the practitioner and a source of concern for the owner. Relatively simple care, good adherence to treatment and great rules for wound management allow very satisfactory results to be obtained with an acceptable cost. Through the example of a concrete case, it is recalled how a complex wound must be explored with meticulousness, widely drained, cleaned and cleared of all foreign bodies during its treatment. Its monitoring involves the placement of suitable dressings and the management of granulation tissue. Treatment may involve simple surgical reconstruction techniques such as islet transplantation. Keywords: Complex wound, horse, graft, pinch / punch graft, hypergranulation, dressin

Eating at the university canteen. Associations with socioeconomic status and healthier self-reported eating habits in France

International audienceFrench university canteens offer structured meals at a fixed moderate price. We examined whether eating regularly at university canteens was associated with socioeconomic status (SES) or dietary practices. The study data came from a cross-sectional study of a random sample of 1723 students aged 18-24 years, in their first year of university in 2005-2006, enrolled in the universities of southeastern France (response rate = 71%). Self-reported dietary practices were collected with a behavioral questionnaire. Adjusted logistic regressions showed that eating regularly at university canteens was less frequent among students with less than (sic)300 monthly resources and not living with their families (OR = 0.68 [95%CI: 0.49-0.94]). It was also positively associated, regardless of SES, with the consumption of at least five servings of fruit/vegetables daily (OR = 1.42 [1.05-1.92]) and one serving of meat/fish daily (OR = 1.41 [1.13-1.76]) but not with either restricting fatty food (OR = 1.04 [0.81-1.33]) or never/rarely adding salt to food (OR = 1.06 [0.85-1.32]). Eating regularly at university canteens was less frequent among less well-off students and was positively associated with some healthier self-reported dietary habits. Further research is needed to confirm these results in the overall student population in France and to understand the determinants of university canteen utilization. (C) 2010 Elsevier Ltd. All rights reserved

Indicators show differences in antibiotic use between general practitioners and paediatricians.

ADInternational audienceThe purpose of this investigation was to adapt to an individual physician level and to the paediatric context a set of drug-specific indicators of outpatient antibiotic use developed by the European Surveillance of Antimicrobial Consumption (ESAC) project, and to describe the differences in antibiotic prescriptions between general practitioners (GPs) and paediatricians. We conducted a retrospective cross-sectional study analysing antibiotic prescriptions in 2009 for children below 16 years of age in south-eastern France, using the National Health Insurance (NHI) outpatient reimbursement database. A generalised linear model adjusted on physicians' characteristics and patient population characteristics was used to compare indicators between GPs and paediatricians. We included 4,921 self-employed GPs and 301 paediatricians. Penicillins accounted for 47% and 45% of all antibiotics prescribed by GPs and paediatricians, respectively, followed by cephalosporins (33% and 39%) and macrolides (14% and 9%). In both specialties, there were around 70% more antibiotic prescriptions during the winter quarters compared to the summer quarters. The 13 indicators we calculated showed wide variations in antibiotic prescriptions among GPs, among paediatricians, and between GPs and paediatricians. In an adjusted econometric model, GPs were found to issue 54% more antibiotic prescriptions than paediatricians, whereas paediatricians used a significantly higher proportion of co-amoxiclav (18% vs. 12%) and cephalosporins (39% vs. 33%) and a significantly lower proportion of macrolides (9% vs. 14%) compared to GPs. A set of 13 indicators may be calculated using reimbursement data to describe outpatient antibiotic use at the physician level. We observed very different prescribing profiles between GPs and paediatricians

Approaching the quality of antibiotic prescriptions in primary care using reimbursement data.

ADInternational audienceOur objectives for this investigation were: (i) to design quality measures of outpatient antibiotic use that could be calculated at the individual general practitioner (GP) level using reimbursement data only; and (ii) to analyse the variability in antibiotic prescriptions between GPs regarding these measures in south-eastern France. Based on the literature and international therapeutic guidelines, we designed a set of quality measures in an exploratory attempt to assess the quality of antibiotic prescriptions. We performed a cross-sectional study of antibiotic prescriptions in adults in south-eastern France in 2009, using data from the outpatient reimbursement database of the French National Health Insurance (NHI). We carried out a cluster analysis to group GPs according to their antibiotic prescribing behaviour. Six quality measures were calculated at the GP level, with wide variations in practice regarding all these measures. A six-cluster solution was identified, with one cluster grouping 56 % of the sample and made up of GPs having the most homogeneous pattern of prescription for all six quality measures, probably reflecting better antibiotic prescribing. Total pharmaceutical expenses (per patient), penicillin combinations use, quinolone use and seasonal variation of quinolone use were all positively associated with a more heterogeneous and possibly less appropriate use of antibiotics in a multivariate analysis. These quality measures could be useful to assess GPs' antibiotic prescribing behaviour in countries where no information system provides easy access to data linking drug use to a clinical condition

The parting of the endothelium: miracle, or simply a junctional affair?

Leukocyte extravasation from the blood across the endothelium is vital for the functioning of the immune system. Our understanding of the early steps of this process has developed rapidly. However, it is still unclear how leukocytes undergo the final step, migrating through the junctions that mediate adhesion between adjacent endothelial cells, while preserving the barrier function of the endothelium. The first stage of transmigration - tethering and rolling - is mediated by interactions between selectins on the surface of leukocytes and glycosylated proteins such as GlyCAM-1 on the surface of endothelial cells. Stimulation of the leukocyte by chemokines then induces tight adhesion, which involves binding of activated leukocyte integrins to endothelial ICAM-1/VCAM-1 molecules. Passage of the leukocyte across the endothelium appears to require delocalization of certain endothelial cell molecules and proteolytic degradation of junctional complexes

Drug-specific quality indicators assessing outpatient antibiotic use among French general practitioners.

ACL-3International audienceQuality indicators assessing the use of antibiotics among general practitioners (GPs) would be useful to target antibiotic stewardship interventions. We adapted to an individual GP level a set of 12 drug-specific quality indicators of outpatient antibiotic use in Europe developed by the European surveillance of antimicrobial consumption project. We performed a cross-sectional study analysing reimbursement data on outpatient antibiotic prescriptions in adults in south-eastern France in 2009. Substantial heterogeneity in antibiotic prescribing among French GPs was observed, and opportunity to improve antibiotic prescribing can be identified

Haemangiomas are formed by cells expressing high levels of alphavbeta3 integrin and lacking acetylated LDL uptake

Haemangiomas are benign tumours occurring in up to 12% of Caucasians, particularly in infancy and childhood. In the present study, two variant cell lines were isolated from murine endothelioma cells. One variant, named t.End.1V(high), represented 16.9% of the parental cell population and was selected by virtue of high expression levels of integrin alphavbeta3 and reduced capacity to endocytose acetylated low-density lipoproteins (Ac-LDLs). A second variant, named t.End.1V(low), represented 38.8% of the parental endothelioma cell line, expressed low levels of alphavbeta3 integrin, and was able to endocytose Ac-LDL. These phenotypic modifications were stable and correlated with specific morphological and functional properties of the two variant cell lines. While the t.End.1V(high) cells induced the formation of large haemangiomas when injected subcutaneously into mice, the t.End.1V(low) cells formed haemangiocytomas. When compared with t.End.1V(low) cells, the t.End.1V(high) cells showed increased migratory capacity, lacked an inflammatory response, and formed cord-like structures in fibrin gels. In contrast, the t.End.1V(low) cells organized into cysts with a lumen in fibrin gels. They rarely formed blood-filled haemangiomas in vivo and recruited host smooth muscle cells, a phenomenon typical for vessel wall maturation of resting cells. These data suggest that Ac-LDL uptake and the level of alphavbeta3 integrin expression are linked to the ability of endothelial cells to form large haemangiomas in vivo