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Persistent pain despite satisfactory disease treatment is frequent in rheumatoid arthritis (RA) and spondyloarthritis (Spa) and may result from specific changes in central pain processing. We assessed these mechanisms further by systematically comparing thermal pain thresholds and conditioned pain modulation (CPM) between patients with active RA or Spa and healthy controls. We included 50 patients with RA and 50 patients with Spa and 100 age-matched and sex-matched controls. Heat and cold pain thresholds (HPT-CPT) were measured on the dominant forearm, and CPM was assessed by applying conditioning stimuli (immersion in a cold-water bath) to one foot and the nondominant hand in 2 successive randomized sequences. Descending pain modulation was assessed as the difference in HPTs (in °C) before and after conditioning. Larger HPT differences (ie, a larger CPM effect) reflected more efficient descending inhibition. Potential associations between changes in CPM and clinical data, including disease activity, pain intensity, and psychological and functional variables, were systematically assessed. Heat pain threshold and cold pain threshold were similar in patients and controls. The mean CPM effect was significantly weaker in patients than that in controls for conditioning applied to either the foot (0.25°C ±2.57 vs 2.79°C ±2.31; P0.001) or the nondominant hand (0.57°C ±2.74 vs 2.68°C ±2.12; P0.001). The smaller CPM effect in patients was correlated with average pain intensity, but not with disease activity or other clinical characteristics, suggesting a significant pathophysiological role for changes in endogenous pain modulation in the mechanisms of chronic pain associated with inflammatory rheumatism.

Background The fear of contracting coronavirus disease 2019 (COVID-19) and the preventive measures taken during the health crisis affected both people’s lifestyles and the health system. This nationwide study aimed to investigate the impact of the first wave of the COVID-19 pandemic on hospitalizations and mortality related to geriatric syndromes (GS) in older adults in France. Methods The French National Health Data System was used to compare hospital admissions (excluding the main diagnosis of COVID-19) and mortality rates (using multiple-cause and initial-cause analyses, and both including or excluding confirmed/probable COVID-19) related to 10 different GS (dementia, other cognitive disorders and symptoms, delirium/disorientation, depression, undernutrition/malnutrition, dehydration, pressure ulcer, incontinence, fall/injury and femoral neck fracture) from January to September 2020 to rates observed in previous years. Analyses were stratified by age, sex, place of residence or place of death, and region. Results Hospitalization rates for all GS decreased during the first lockdown compared to the same periods in 2017-19 (from −59% for incontinence to −13% for femoral neck fractures). A dose–response relationship was observed between reduced hospitalizations and COVID-19-related mortality rates. Conversely, for almost all GS studied, excess mortality without COVID-19 was observed during this lockdown compared to 2015-17 (from +74% for delirium/disorientation to +8% for fall/injury), especially in nursing homes and at home. Conclusions In France, during the first lockdown, a substantial decrease in hospitalizations for GS was accompanied by excess mortality. This decline in the use of services, which persisted beyond lockdown, may have a mid- and long-term impact on older adults’ health.

Background Among patients successfully resuscitated after an out-of-hospital cardiac arrest (OHCA), 10% to 15% evolve toward brain death (BD), thus becoming potential organ donors. Research Question Is it possible to establish a score for early estimation of BD risk after OHCA? Study Design and Methods The BD after cardiac arrest (BDCA) score was developed from data available within 24 hours after OHCA from two OHCA trials: Cyclosporine in Cardiac Arrest Resuscitation and Erythropoietin After OHCA. The BDCA score was then validated in another large prospective multicenter data set. The main outcome was the occurrence of BD. Independent prognostic covariates for BD were identified using a binomial two-stage adaptive least absolute shrinkage and selection operator procedure. Results The development cohort included 569 patients alive 24 hours after OHCA, among whom 84 (14.8%) experienced BD. Independent predictors of BD used to build the BDCA score were being female (4 points), nonshockable rhythm (24 points), cardiac cause of OHCA (−6 points), neurological cause of OHCA (45 points), natremia at 24 hours (natremia in millimoles per liter minus 140 points), and vasoactive drug at admission (4 points) and at 24 hours (6 points). The area under the curve (AUC) of the BDCA score was 0.82 (95% CI, 0.77-0.86), and the discrimination value in the validation cohort (n = 487) was consistent (AUC, 0.81; 95% CI, 0.76-0.86). In the validation cohort, BD occurred in 4.0%, 20.4%, and 67.7% of patients with scores of 50, respectively. Interpretation The BDCA score allows early detection of patients with a high probability of experiencing BD, which may help increase organ donation after OHCA. Clinical Trial Registration ClinicalTrials.gov; No.: NCT01595958, and ClinicalTrials.gov ; No.: NCT00999583; URL: www.clinicaltrials.gov

Multidisciplinary approaches to treating chronic pain have been proven effective. Currently, chronic pain patients face lengthy waitlists in pain medicine departments. To overcome this problem, we developed the "FastSchool" program to educate patients about pain management and treatment. In this study, we evaluated the benefit of a "FastSchool" session on pain and catastrophizing in chronic pain patients.Included patients had chronic non-cancer pain, no more than 2 visits to a pain medicine department. Patients attended a single 3-hour session, conducted by an interprofessional team. Four topics were addressed: chronic pain mechanisms, pharmacological therapies, physical activity, and the management of analgesics. Patients completed questionnaires at baseline and at 3 months post-session to assess pain interference, pain intensity, and catastrophizing.The study population included 88 patients; 71 completed the follow-up questionnaires. Pain interference (p = 0.002), average pain intensity (p = 0.013), and catastrophizing (p 0.001) decreased 3 months after FastSchool. At M3, 35 % of patients felt their pain had improved based on the Patient Global Impression of Change.FastSchool, an innovative short-term educational program inspired by cognitive behavioral therapy, showed positive results in reducing pain impact.Implementation of FastSchool in pain medicine departments would reduce waitlist times for non-pharmacological treatment.

Purpose Adrenocortical carcinoma (ACC) is a rare endocrine malignancy, whose diagnosis is suspected by conventional radiology and hormonal investigations. 18F-fluorodeoxyglucose positron emission tomography ([18F]-FDG PET) could help predict malignancy, but more consistent data are necessary to support future guidelines.MethodsA cohort of 63 patients with histologically proven ACC (n=55) or metastatic ACC with steroid oversecretion (n=8) was assembled. All patients underwent a [18F]-FDG PET and the maximum Standardized Uptake Value (SUVmax) and the adrenal-to-liver SUVmax ratio were calculated. The [18F]-FDG PET parameters were compared with clinical, pathological and outcome data.ResultsA positive correlation between [18F]-FDG PET parameters (SUVmax and adrenal-to-liver SUVmax ratio) and tumor size, ENSAT (European Network for the Study of Adrenal Tumors) staging, total Weiss score and the proliferation marker Ki67 was found. The strong correlation between SUVmax and Ki67 (r=0.47, p=0.0009) suggests a relationship between FDG uptake levels and tumor proliferation. Associations between outcome parameters (progression free or overall survival) and [18F]-FDG PET parameters were weaker. Fifty-six out of 63 patients (89%) had an adrenal-to-liver SUVmax >1.45, a previously defined cutoff value to predict malignancy. Seven ACC (11%) had a lower uptake, with a Ki67 expression level statistically lower compared to other ACC.ConclusionThis large cohort study shows that most ACC demonstrate high [18F]-FDG uptake. However, the positive correlation observed between SUVmax and Ki67 expression levels seems to explain the possibility of identifying some ACC with a low [18F]-FDG uptake and Ki67 ≤ 10%.

Background This study was designed to describe contacts with health services during the year before suicide death in France, and prevalent mental and physical conditions. Methods Data were extracted from the French National Health Data System (SNDS), which comprises comprehensive claims data for inpatient and outpatient care linked to the national causes-of-death registry. Individuals aged ≥15 years who died from suicide in France in 2013-2015 were included. Medical consultations, emergency room visits, and hospitalisations during the year preceding death were collected. Conditions were identified, and standardised prevalence ratios (SPRs) were estimated to compare prevalence rates in suicide decedents with those of the general population. Results The study included 19,144 individuals. Overall, 8.5% of suicide decedents consulted a physician or attended an emergency room on the day of death, 34.1% during the week before death, 60.9% during the month before death. Most contacts involved a general practitioner or an emergency room. During the month preceding suicide, 24.4% of individuals were hospitalised at least once. Mental conditions (36.8% of cases) were 7.9-fold more prevalent in suicide decedents than in the general population. The highest SPRs among physical conditions were for liver/pancreatic diseases (SPR=3.3) and epilepsy (SPR=2.7). Limitations The study population was restricted to national health insurance general scheme beneficiaries (76% of the population living in France). Conclusions Suicide decedents have frequent contacts with general practitioners and emergency departments during the last weeks before death. Improving suicide risk identification and prevention in these somatic healthcare settings is needed.

International audience; AbstractIntroduction : Treatment credibility and patient expectancy of improvement have been increasingly considered in clinical research.Objectives : The objective of this study was to carry out the cross-cultural validation of a French-language version of the credibility/expectancy questionnaire (CEQ), to further document the psychometric properties of the CEQ, and to add to the empirical data concerning the concepts of credibility and expectancy.Methods : The process followed up-to-date guidelines for cross-cultural adaptation and included extensive psychometric validation. Accurate translation and cross-cultural equivalence of the questionnaire's basic concepts were assessed by a multidisciplinary expert committee. Reliability and validity were evaluated in a cohort of 209 consecutive patients referred to health psychologists for psychotherapy for posttraumatic stress disorder.Results : The French CEQ was found to be well understood and acceptable. It demonstrated excellent reproducibility, consistency and factorial validity, confirming the 2-factor model separating credibility from expectancy of the original CEQ. The use of modern measurement methods indicated that the CEQ scales satisfy the important characteristics of unidimensionality and invariance across age and gender.Conclusion : The French CEQ can be used for French-speaking populations in various studies to evaluate both credibility and expectancy for improvement. However, the questionnaire's sensitivity to change should be further confirmed before it can be safely used in longitudinal studies. The study also confirms the close relation between credibility and expectancy but substantiates differences large enough to justify separate measurement of the two components of the questionnaire.

Objectives To estimate the systemic serious adverse event (SAE) rates after colonoscopy and to identify their risk factors. Methods A nationwide cohort study was conducted using the comprehensive French claims databases SNDS (National Health Data System). Patients aged 30 years and over who underwent a first screening or diagnostic colonoscopy in 2010-2015 were included. The rates of cardiovascular and renal SAEs were estimated within 5 days after colonoscopy. The standardized incidence ratios were calculated to compare these incidence rates with those of the same events in the general population, and the associated risk factors were assessed by multilevel logistic regression. Results Among the 4,088,799 included patients (median age, 59 years [interquartile range = 50-67]; 55.2% women; 30.1% with a Charlson index score ≤1), the 5-day SAE incidence rate was 2.8/10,000 procedures for shock, 0.87/10,000 for myocardial infarction, 1.9/10,000 for stroke, 2.9/10,000 for pulmonary embolism, 5.5/10,000 for acute renal failure, and 3.3/10,000 for urolithiasis. These SAEs occurred 3.3 to 15.8 times more often during the first 5 days after colonoscopy than expected in the general population. Thirty-day mortality rates ranged from 2.2/1,000 cases of urolithiasis to 268.1/1,000 cases of shock. Increasing age was associated with an increasing incidence of SAEs. Risks of shock and acute renal failure were associated with a greater number of comorbidities than the other SAEs. Colonoscopies in university hospitals were associated with higher risks, reflecting patient selection processes. Discussion The systemic SAEs can be associated with a substantial mortality. They should be taken into account when deciding colonoscopy, in addition to perforation and bleeding, particularly in elderly patients with multiple comorbidities.

ObjectiveTo evaluate the risk of Guillain-Barré syndrome (GBS) following seasonal influenza vaccination based on French nationwide data.MethodsAll cases of GBS occurring in metropolitan France between September 1 and March 31 from 2010 to 2014 were identified from the French national health data system. Data were analyzed according to the self-controlled case series method. The risk period started 1 day after the patient received vaccine (D1) until 42 days after vaccination (D42). The incidence of GBS during this risk period was compared to that of the control period (D43–March 31). The incidence rate ratio (IRR) was estimated after adjusting for seasonality and presence or not of acute infections.ResultsBetween September and March, of the 2010/2011 to 2013/2014 influenza vaccination seasons, 3,523 cases of GBS occurred in metropolitan France and were included in the study. Among them, 15% (527 patients) had received influenza vaccination. A total of 140 patients developed GBS during the 42 days following influenza vaccination. The crude risk of developing GBS was not significantly increased during the 42 days following influenza vaccination (IRR, 1.02; 95% confidence interval [CI], 0.83–1.25; p = 0.85). This result remained nonsignificant after adjustment for calendar months and the incidence of acute gastrointestinal and respiratory tract infections (IRR, 1.10; 95% CI, 0.89–1.37; p = 0.38). In contrast, the risk of GBS was fourfold higher after acute respiratory tract infection (IRR, 3.89; 95% CI, 3.52–4.30; p < 0.0001) or gastrointestinal infection (IRR, 3.64; 95% CI, 3.01–4.40; p < 0.0001).ConclusionsNo association between seasonal influenza vaccination and GBS was shown during the 42 days following vaccination.

Purpose Fractures are common events, but the exact incidence and severity of fractures have not been clearly determined for most anatomical sites. We estimated the incidence and severity of fractures in France regardless of the anatomical site. Methods Observational cross-sectional study in France in 2016 based on the national health data system. All incident fractures in patients 20 years and older were included. We determined the anatomical fracture site (12 sites) and the severity using a 4-point scale (outpatient care, hospitalization, surgery, and in-hospital death). Results We identified 562,094 incident fractures, predominantly occurring in women (319,858: 56.9%); with a mean age of 63.6 years, and an exponential increase after the age of 70 years. Distal upper limb (172,591: 30.7%), distal lower limb (84,602: 15.1%), and femoral neck (78,766: 14.0%) accounted for more than one-half of all fractures. Sex and age of onset distributions varied widely according to fracture sites, with earlier onset for distal lower limb fractures (mean age: 54.2 years) and distal upper limb fractures (mean age: 55.2 years) with a men predominance for skull fractures. Only 105,165 (18.7%) fractures were treated on an outpatient basis; 11,913 (2.1%) in-hospital deaths occurred in patients with a mean age of 79.5 years. High mortality was observed for skull (12.9%), rib (4.9%), and femoral fractures (femoral neck 4.3% and proximal lower limb 4.2%). Conclusion We estimated the incidence of fractures in France by sex and anatomical site. We also showed that fractures remain common and serious life events, especially in older people.

Resume L’avenement de l’ere numerique a permis la construction de larges bases de donnees en sante. La France dispose depuis 1999 d’un Systeme National d’Information Inter-Regime (SNIIRAM) permettant l’enregistrement exhaustif et systematique des activites de soins remboursees par l’Assurance Maladie. Celui-ci a ete progressivement ameliore et elargi pour conduire a la construction du Systeme National des Donnees de Sante (SNDS). De nombreux travaux ont deja ete publies et ont montre la pertinence et la qualite de ces donnees. L’objectif de ce travail est de montrer l’interet des donnees du SNDS appliquees a la recherche en orthopedie et d’en expliquer le fonctionnement.

Background Robust public health and health system response to the increasing burden of multimorbidity worldwide requires detailed epidemiological examination of its key sociodemographic and geographic determinants. We investigated the role of gender, age and socioeconomic and geographic factors on multimorbidity (i.e., having two or more conditions) in the adult population in France and examined implications for surveillance and prevention. Methods We used data from two large nationwide representative surveys with cross-sectional and longitudinal health and socio-demographic indicators, conducted in France between 2008 and 2014. Morbidity counts and frequent dyads/triads of conditions independently impacting mortality, activity limitations, and perceived health were investigated with regard to differences in gender, age, socioeconomic (education, occupation and income) and geography (size of the urban unit and region). Results The component conditions of multimorbidity varied with gender and age. Women experienced multimorbidity 23–31% more frequently and at a younger age (5–15 years earlier) than men. Multimorbidity increased with age while its associations with most health indicators weakened with it. Multimorbidity was strongly and independently associated with socioeconomic indicators, with a strong inverse dose-response relationship with education, but less consistently with geographic factors. Conclusions Multimorbidity has diverse and variable components and impacts across gender and age. It is strongly associated with socioeconomic factors, notably educational level, for which causality appears likely. Consideration of this diversity and variability, its common occurrence in dyads and triads, and its impact on health outcomes according to age and gender may contribute to efficient surveillance and support the identification of prevention strategies targeting middle-aged men and women.

Background The Patient Reported Outcome Measurement Information System profile instruments include “high information” items drawn from large item banks following the application of modern psychometric criteria. The shortest adult profile, PROMIS-29, looks set to replace existing short-form instruments in research and clinical practice. The objective of this study was to undertake the first psychometric evaluation of the Norwegian PROMIS-29, following a postal survey of a random sample of 12,790 Norwegians identified through the National Registry of the Norwegian Tax Administration. Confirmatory factor analysis was used to assess structural validity. Fit to the Rasch partial credit model and differential item functioning (DIF) were assessed in relation to age, gender, and education. PROMIS-29 scores were compared to those for the EQ-5D-5L and the Self-assessed Comorbidity Questionnaire (SCQ), for purposes of assessing validity based on a priori hypotheses. Results There were 3200 (25.9%) respondents with a mean age (SD) of 51 (20.7, range 18 to 97 years) and 55% were female. The PROMIS-29 showed satisfactory structural validity and acceptable fit to Rasch model including unidimensionality, and measurement invariance across age and education levels. One pain interference item had uniform DIF for gender but splitting gave satisfactory fit. Domain reliability estimates ranged from 0.85 to 0.95. Correlations between PROMIS-29 domain, SCQ and EQ-5D scores were largely as expected, the largest being for scores assessing very similar aspects of health. Conclusions The Norwegian version of the PROMIS-29 is a reliable and valid generic self-reported measure of health in the Norwegian general population. The instrument is recommended for further application, but the analysis should be replicated and responsiveness to change assessed in future studies before it can be recommended for clinical and health services evaluation in Norway.

We aimed to explore the relationship between comorbidities and the structural progression in symptomatic knee and/or hip osteoarthritis (OA) patients. We analyzed the 5-year outcome of non-obese participants (body mass index (BMI) &lt, 30 kg/m2) from the KHOALA cohort having symptomatic hip and/or knee OA (Kellgren and Lawrence (KL) ≥ 2). The primary endpoint was radiological progression, defined as ΔKL ≥ 1 of the target joint at 5 years. The secondary outcome was the incidence of total knee or hip replacement over 5 years. Dichotomous logistic regression models assessed the relationship of comorbidities with KL progression and joint replacement while controlling for gender, age and BMI. Data from 384 non-obese participants were analyzed, 151 with hip OA and 254 with knee OA. At 5 years, cardiovascular diseases (CVD) were significantly associated with the 5-year KL change in both knee (OR = 2.56 (1.14–5.78), p = 0.02) and hip OA (OR = 3.45 (1.06–11.17), p = 0.04). No significant relationship was found between any type of comorbidities and knee or hip arthroplasty. This 5-year association between CVD and radiological progression of knee and hip OA in non-obese participants argue for an integrated management of CVD in knee and hip OA non-obese patients.

Background Acute kidney injury (AKI) is frequent in patients resuscitated from cardiac arrest (CA) and may worsen outcome. Experimental data suggest a renoprotective effect by treating these patients with a high dose of erythropoietin (Epo) analogues. We aimed to evaluate the efficacy of epoetin alpha treatment on renal outcome after CA. Methods We did a post hoc analysis of the Epo-ACR-02 trial, which randomized patients with a persistent coma after a witnessed out-of-hospital CA. Only patients admitted in one intensive care unit were analysed. In the intervention group, patients received five intravenous injections of Epo spaced 12 h apart during the first 48 h, started as soon as possible after resuscitation. In the control group, patients received standard care without Epo. The main endpoint was the proportion of patients with persistent AKI defined by Kidney Disease: Improving Global Outcomes criteria at Day 2. Secondary endpoints included the occurrence of AKI through Day 7, estimated glomerular filtration rate (eGFR) at Day 28, haematological indices and adverse events. Results A total of 162 patients were included in the primary analysis (74 in the Epo group, 88 in the control group). Baseline characteristics were similar in the two groups. At Day 2, 52.8% of the patients (38/72) in the intervention group had an AKI, as compared with 54.4% of the patients (46/83) in the control group (P = 0.74). There was no significant difference between the two groups regarding the proportion of patients with AKI through Day 7. Among patients with persistent AKI at Day 2, 33% (4/12) in the intervention group had an eGFR

Summary Background CT‐P13, a biosimilar of the reference product infliximab, has been approved for the treatment of ulcerative colitis on the basis of the results of trials conducted in patients with spondyloarthritis and rheumatoid arthritis. Aim To compare the effectiveness and safety of CT‐P13 and the reference product in infliximab‐naive patients with ulcerative colitis Methods A comparative real‐life equivalence cohort study was conducted using the French nationwide health administrative database. Infliximab‐naive patients with ulcerative colitis over 15 years of age who started infliximab with no other indications for infliximab were included. The primary outcome was a composite endpoint (death, ulcerative colitis‐related surgery, all‐cause hospitalisation and reimbursement for other biologics). Equivalence was defined as a 95% CI of the hazard ratio (HR) of CT‐P13 vs the reference product, in a multivariable marginal Cox model situated within prespecified margins of (0.80‐1.25). Results A total of 3112 patients were included between 1 January 2015 and 30 June 2017: 1434 received the reference product, 1678 received CT‐P13. Overall, 710 patients in the reference product group and 743 patients in the CT‐P13 group met the composite endpoint. In multivariable analysis of the primary outcome, CT‐P13 was equivalent to the reference product (HR 1.04; 95% CI: 0.94‐1.15). The number of serious infections was lower in the CT‐P13 group (HR 0.65; 95% CI: 0.48‐0.88). There was no difference in the incidence of solid or haematologic malignancy (HR 0.81; 95% CI: 0.41‐1.60). Conclusions The effectiveness of CT‐P13 is equivalent and the risk of serious infections could be lower than that of the reference product for infliximab‐naive patients with ulcerative colitis.

Context There has been concern that GH treatment of children might increase meningioma risk. Results of published studies have been inconsistent and limited. Objective To examine meningioma risks in relation to GH treatment. Design Cohort study with follow-up via cancer registries and other registers. Setting Population-based. Patients A cohort of 10,403 patients treated in childhood with recombinant GH in five European countries since this treatment was first used in 1984. Expected rates from national cancer registration statistics. Main Outcome Measures Risk of meningioma incidence. Results During follow-up, 38 meningiomas occurred. Meningioma risk was greatly raised in the cohort overall [standardized incidence ratio (SIR) = 75.4; 95% CI: 54.9 to 103.6], as a consequence of high risk in subjects who had received radiotherapy for underlying malignancy (SIR = 658.4; 95% CI: 460.4 to 941.7). Risk was not significantly raised in patients who did not receive radiotherapy. Risk in radiotherapy-treated patients was not significantly related to mean daily dose of GH, duration of GH treatment, or cumulative dose of GH. Conclusions Our data add to evidence of very high risk of meningioma in patients treated in childhood with GH after cranial radiotherapy, but suggest that GH may not affect radiotherapy-related risk, and that there is no material raised risk of meningioma in GH-treated patients who did not receive radiotherapy., In a five-country cohort of 10,403 patients treated with recombinant growth hormone, meningioma risk was greatly raised in relation to radiotherapy, but not apparently related to growth hormone.

Resume Introduction et methodes La fibromyalgie (FM) a souvent un impact important au quotidien. Un auto-questionnaire en ligne (103 questions) a ete propose en 2014 pour connaitre le ressenti des patients. Resultats Au total, 4516 personnes ont repondu : femmes (93 %), âge moyen 48 ans, souffrant depuis 5 ans en moyenne avec un diagnostic porte par un rhumatologue (54 %). Pres de 77 % des patients recevaient des medicaments : paracetamol seul (52 %), associe aux opioides faibles (64 %), opioides forts (20 %), antidepresseurs (82 %), antiepileptiques (55 %), anti-inflammatoires non steroidiens (AINS) (54 %), anxiolytiques (52 %) et steroides (13 %). L’osteopathie (41 %) occupait une place importante, suivie de la sophrologie-relaxation (22 %), de l’acupuncture (21 %) et de l’homeopathie (19 %). Les patients rapportaient un sentiment d’injustice (77 %), des troubles cognitifs (62 %), des troubles anxieux (52 %) une depression (48 %) et des facteurs favorisant (73 %). Des traitements etaient prescrits par des medecins generalistes (85 %), kinesitherapeutes (63 %), rhumatologues (54 %). Pres de la moitie (45 %) n’etait pas en activite professionnelle, 22 % a temps partiel therapeutique et 28 % sans emploi. Malgre un score d’impact de la FM modere (Questionnaire d’Impact de la Fibromyalgie–QIF a 51/100), les participants declaraient beaucoup de recours aux soins et d’arrets de travail. Les variations du QIF etaient impactees par l’existence d’un sentiment d’injustice (+ 4,5 points), un travail a temps partiel (+ 2,4 points) et des revenus faibles dans le foyer ( Conclusion Cette enquete francaise sur la fibromyalgie de grande envergure (n = 4516) montre que l’impact professionnel de la FM est considerable, avec des determinants socio-economiques importants.

La fibromyalgie (FM), pathologie douloureuse chronique fréquente, nécessite une prise en charge globale incluant les comorbidités psychologiques (CP) selon les recommandations internationales. Afin d’évaluer le retentissement de ces CP, nous avons étudié les données d’une enquête en ligne menée auprès de 4 516 patients en 2014. Notre objectif principal était d’évaluer la prévalence du sentiment d’injustice perçu (SIP) et son impact chez le sujet fibromyalgique. Il s’agit d’une étude déclarative descriptive fondée sur un autoquestionnaire comprenant 103 questions dont deux concernant précisément le SIP, réalisé sur une plateforme Internet dédiée (Association française de lutte antirhumatismale et fibromyalgie SOS). Parmi les répondants, 76 % rapportent un SIP. Il est lié à la FM pour 71,3 % d’entre eux. Il est significativement plus fréquent chez les patients souffrant de dépression (p < 0,0001) sans corrélation avec la préexistence de la dépression. Il est plus fréquent en cas d’envies suicidaires (p < 0,0001) sans différence avec le passage à l’acte. La fréquence du SIP est plus importante en cas de demande de prestations sociales (p < 0,0001), de dépenses liées à la FM (p < 0,0001) et en cas de non-reconnaissance par l’employeur (< 0,0001). Le SIP est plus important en cas de retentissement sur la vie quotidienne (p < 0,0001), et ce, dans tous les domaines. Aucune caractéristique démographique n’est associée au SIP (p = 0,1). La prévalence du SIP est importante chez les patients fibromyalgiques de notre enquête et a un fort impact. Il est donc nécessaire d’évaluer les comorbidités psychologiques et de les prendre en charge.

Background: Patients with fibromyalgia (FM) frequently resort to osteopathic or chiropractic treatment, despite very weak supporting evidence. We aimed to assess the efficacy of osteopathic manipulation in FM in a properly controlled and powered randomized clinical trial. Methods: Patients were randomized to osteopathic or sham treatment. Treatment was administered by experienced physical medicine physicians, and consisted of six sessions per patient, over 6 weeks. Treatment credibility and expectancy were repeatedly evaluated. Patients completed standardized questionnaires at baseline, during treatment, and at 6, 12, 24, and 52 weeks after randomization. The primary outcome was pain intensity (100-mm visual analog scale) during the treatment period. Secondary outcomes included fatigue, functioning, and health-related quality of life. We performed primarily intention-to-treat analyses adjusted for credibility, using multiple imputation for missing data. Results: In total, 101 patients (94% women) were included. Osteopathic treatment did not significantly decrease pain relative to sham treatment (mean difference during treatment: −2.2 mm; 95% confidence interval, −9.1 to 4.6 mm). No significant differences were observed for secondary outcomes. No serious adverse events were observed, despite a likely rebound in pain and altered functioning at week 12 in patients treated by osteopathy. Patient expectancy was predictive of pain during treatment, with a decrease of 12.9 mm (4.4–21.5 mm) per 10 points on the 0–30 scale. Treatment credibility and expectancy were also predictive of several secondary outcomes. Conclusion: Osteopathy conferred no benefit over sham treatment for pain, fatigue, functioning, and quality of life in patients with FM. These findings do not support the use of osteopathy to treat these patients. More attention should be paid to the expectancy of patients in FM management.

Background: Data from death certificates have been studied to explore causal associations between diseases. However, these analyses are subject to collider and reporting biases (selection and information biases, respectively). Methods: We aimed to assess to what extent associations of causes of death estimated from individual mortality data can be extrapolated to the general population. We used a multistate model to generate populations of individuals and simulate their health states up to death from national health statistics and artificially replicate collider bias. Associations between health states can then be estimated from such simulated deaths by logistic regression and the magnitude of collider bias assessed. Reporting bias can be approximated by comparing the estimates obtained from the observed death certificates (subject to collider and reporting biases) with those obtained from the simulated deaths (subject to collider bias only). Results: As an illustrative example, we estimated the association between cancer and suicide in French death certificates, and found that cancer was negatively associated with suicide. Collider bias, due to conditioning inclusion in the study population on death, increasingly downwarded the associations with cancer site lethality. Reporting bias was much stronger than collider bias and depended on the cancer site, but not prognosis. Conclusions: These results argue for an assessment of the magnitude of both collider and reporting biases before performing analyses of cause of death associations exclusively from death certificates. If these biases cannot be corrected, results from these analyses should not be extrapolated to the general population.

Current management of moderate-to-severe psoriasis may be heterogeneous between European countries, probably due to differences in the organization of care. The aim of this study was to compare the utilization of systemic treatments for psoriasis between 2 countries. All adults with psoriasis who were registered in the French (SNDS) and the Dutch (VEKTIS) national health insurance databases between 2012 and 2016 were eligible for inclusion. In France, 105,035 (15%) of 684,156 patients and, in the Netherlands, 37,405 (28.6%) of 130,822 patients received at least a systemic agent. In France, the proportion of patients treated with systemic agents was constant, while the type of drugs dispensed shifted from non-biological to biological agents. In the Netherlands, the first systemic treatment was methotrexate and, in France, acitretin. In France, the choice of the first biologic was much more variable than it was in the Netherlands, where a large proportion of patients were dispensed ustekinumab. This study highlights discrepancies between France and the Netherlands concerning the choice of first non-biologic agent and first biologic agent for patients with psoriasis. These discrepancies may be due to differences in the healthcare systems between the 2 countries.

Objective To assess the risk of meningioma associated with use of high dose cyproterone acetate, a progestogen indicated for clinical hyperandrogenism. Design Observational cohort study. Setting Data from SNDS, the French administrative healthcare database, between 2007 and 2015. Participants 253 777 girls and women aged 7-70 years living in France who started cyproterone acetate between 2007 and 2014. Participants had at least one reimbursement for high dose cyproterone acetate and no history of meningioma or benign brain tumour, or long term disease status. Participants were considered to be exposed when they had received a cumulative dose of at least 3 g during the first six months (139 222 participants) and very slightly exposed (control group) when they had received a cumulative dose of less than 3 g (114 555 participants). 10 876 transgender participants (male to female) were included in an additional analysis. Main outcome measure Surgery (resection or decompression) or radiotherapy for one or more intracranial meningiomas. Results Overall, 69 meningiomas in the exposed group (during 289 544 person years of follow-up) and 20 meningiomas in the control group (during 439 949 person years of follow-up) were treated by surgery or radiotherapy. The incidence of meningioma in the two groups was 23.8 and 4.5 per 100 000 person years, respectively (crude relative risk 5.2, 95% confidence interval 3.2 to 8.6; adjusted hazard ratio 6.6, 95% confidence interval 4.0 to 11.1). The adjusted hazard ratio for a cumulative dose of cyproterone acetate of more than 60 g was 21.7 (10.8 to 43.5). After discontinuation of cyproterone acetate for one year, the risk of meningioma in the exposed group was 1.8-fold higher (1.0 to 3.2) than in the control group. In a complementary analysis, 463 women with meningioma were observed among 123 997 already using cyproterone acetate in 2006 (risk of 383 per 100 000 person years in the group with the highest exposure in terms of cumulative dose). Meningiomas located in the anterior skull base and middle skull base, particularly the medial third of the middle skull base, involving the spheno-orbital region, appeared to be specific to cyproterone acetate. An additional analysis of transgender participants showed a high risk of meningioma (three per 14 460 person years; 20.7 per 100 000 person years). Conclusions A strong dose-effect relation was observed between use of cyproterone acetate and risk of intracranial meningiomas. A noticeable reduction in risk was observed after discontinuation of treatment.

Background This study was designed to describe contacts with health services during the year before suicide death in France, and to compare the prevalent mental and physical conditions in these people to those of the general population. Methods Data were extracted from the French National Health Data System (SNDS), which comprises comprehensive claims data for inpatient and outpatient care linked to the national causes-of-death registry. Individuals, national health insurance general scheme beneficiaries (i.e. 76% of the population living in France), aged 15 years or older, who died from suicide in France in 2013-2015 were included. Medical consultations, emergency room visits, and hospitalisations during the year preceding death were collected. Conditions were identified, and standardised prevalence ratios (SPRs) were estimated to compare prevalence rates in suicide decedents with those of the general population. Results The study included 19,144 suicide decedents. Overall, 8.5% of suicide decedents consulted a physician or attended an emergency room on the day of death, 34.1% during the week before death, 60.9% during the month before death. Most contacts involved a general practitioner or an emergency room (46.2% of suicide decedents consulted a general practitioner during the month before death, 16.7% attended an emergency room). During the month preceding suicide, 24.4% of individuals were hospitalised at least once. Mental conditions (36.8% of cases) were 7.9-fold (SPR 95% CI: 7.7-8.1) more prevalent in suicide decedents than in the general population. The highest SPRs among physical conditions were for liver/pancreatic diseases (SPR=3.3, 95% CI: 3.1-3.6) and epilepsy (SPR=2.7, 95% CI: 2.4-3.0). Conclusions General practitioners and emergency departments have frequent contacts with suicide decedents during the last weeks before death and are at the forefront of suicide risk identification and prevention in individuals with mental, but also physical conditions. Key messages Mental and physical conditions are more common among suicide decedents than in the general population, and contacts with primary care services are frequent in the last weeks prior to suicide. Primary care services (general practitioners and emergency rooms) should be targeted for suicide preventive interventions.

Objectives The aims of this study were to identify homogeneous subgroups of knee and/or hip OA patients with distinct trajectories of the combination of pain and physical function (PF) over time and to determine the baseline factors associated with these trajectories. Methods We used data from the Knee and Hip Osteoarthritis Long-term Assessment (KHOALA) cohort, a French population-based cohort of 878 patients with symptomatic knee and/or hip OA. Pain and PF were measured annually over 5 years with the Medical Outcomes Study Short Form 36 questionnaire. First, trajectory models were estimated with varying numbers of groups for each of the outcomes separately then fitted into a multi-trajectory model. We used multinomial logistic regression to determine the baseline characteristics associated with each trajectory. Results Univariate four-class models were identified as most appropriate for pain and PF. Comparison of separate trajectories showed that 41% of patients included in the severe functional limitations trajectory did not belong to the more severe pain trajectory (Cramér’s V statistic = 0.45). Group-based multi-trajectory modelling revealed four distinct trajectories of pain and PF. On multivariate analyses, female sex, older age, high Kellgren grade, low physical activity intensity, low psychosocial distress score (high distress) and low vitality score were associated with the more severe symptoms trajectory. Conclusion Over 5 years, we identified four distinct trajectories combining pain and PF. Management of weight, fatigue and psychosocial distress and the practice of physical activity seem important to maintain function and limit pain in patients with lower-limb OA.

ObjectivesTo assess the association between prenatal exposure to monotherapy with the antiepileptic drugs (AEDs) most commonly used during pregnancy and the risk of various neurodevelopmental outcomes compared with lamotrigine.DesignNationwide population-based cohort study.SettingFrench national healthcare databases.ParticipantsChildren born alive between 2011 and 2014 and prenatally exposed to AED monotherapy.Primary and secondary outcome measuresOutcomes included neurodevelopmental disorders (NDD), defined by International Classification of Diseases, 10th Revision codes F70-F98—pervasive developmental disorders (PDD, F84) and mental retardation (MR, F70-F79) were studied separately—and visits to speech therapists. The reference group comprised children prenatally exposed to lamotrigine. Children were followed until outcome, loss to follow-up, death or 31 December 2016. We performed inverse probability of treatment weighting analyses using the propensity score, which included maternal and infant characteristics. Hazard ratios (HRs) were calculated using Cox models.ResultsThe cohort comprised 9034 children, 2916 of which were exposed to lamotrigine, 1627 to pregabalin, 1246 to clonazepam, 991 to valproic acid (VPA), 621 to levetiracetam, 502 to carbamazepine, 477 to topiramate, 378 to gabapentin and 143 to oxcarbazepine. None of these AEDs, except VPA, was associated with an increased risk of any of the four neurodevelopmental outcomes investigated. Exposure to VPA was associated with increased risks of NDDs (HR=2.7, 95% CI (1.8 to 4.0)), PDD (HR=4.4 (2.1 to 9.3)), MR (HR=3.1 (1.5 to 6.2)) and visits to speech therapists (HR=1.5 (1.1 to 1.9)), with a dose-response relationship.ConclusionsNo increased risk of any of the neurodevelopmental outcomes investigated in this study was observed with prenatal exposure to levetiracetam, pregabalin, oxcarbazepine, topiramate, gabapentin, clonazepam or carbamazepine, compared with lamotrigine. However, this study corroborates the well-known association between maternal use of VPA during pregnancy and the risk of neurodevelopmental disorders in the offspring. Longer follow-up is necessary to confirm these findings.