Abstract Background The entry into dementia is a period of growing interest for clinical trials and public health policies. We described the frequency of medical care use in the 7 years prior to the first dementia identification (index date). Methods All French health insurance general scheme beneficiaries aged 65 or more with an incident dementia in 2016 (identified through long-term disease registry, hospitalization diagnoses, or specific drug delivery), were matched with beneficiaries without dementia of same age, gender, area of residence. The annual cumulative incidences (ACI) of visits (GP and specialists, including outpatient hospital visits) and hospitalizations were estimated over 7 years (Y-7 to Y-1 before index date), by age (65-74, 75-84, 85-89, 90+). Results Among 274166 subjects (median age 84, 65% women), the ACI of GP visit was stable and similar between cases and controls, around 95%. The ACI of neurologist, psychiatrist and internist visit and of hospitalization in a psychiatric unit increased in cases, especially in Y-1. They were higher than in controls in the youngest age classes. The ACI of visits to a dermatologist, a rheumatologist, an ophthalmologist, a dentist and for women a gynecologist, were lower in cases than in controls, with an increasing difference in the last years before dementia care. Similar patterns were observed in the oldest exclusively (generally ≥85 yo) for pneumologist, cardiologist, nephrologist, and in a lesser extent, endocrinologist visit. The ACI of hospitalizations increased with time in both groups, with a peak in Y-1 in cases. They were higher in cases than in controls in the youngest age classes. Conclusions The increase in hospitalization rate in Y-1 suggests a decline in clinical status leading to the diagnosis or a weakening at the time of entry into dementia. The lesser use of a specialist other than neurologist or psychiatrist suggests a focus of care around dementia, possibly to the detriment of the care of comorbidities. Key messages As most patients visit their GP at least yearly, specific GPs training could help to make a timely diagnosis of major neurocognitive disorders. The lesser use of a specialist other than neurologist or psychiatrist suggests a focus of care around dementia, possibly to the detriment of the care of comorbidities.
Abstract Background Although cyclosporin (CyA) has been in use in psoriasis for more than 20 years, there is still controversy regarding treatment strategy, monitoring of kidney function and utility in non‐plaque psoriasis. Objectives To prepare for evidence‐based recommendations concerning the practical use of CyA in psoriasis, we performed a systematic review to better define treatment strategy, risk of kidney toxicity and evidence for use in non‐plaque psoriasis. Methods A systematic search was performed on PubMed, Cochrane and Embase databases, using the key‐words ‘psoriasis’, ‘CyA’, ‘nephrotoxicity’ during the period from 1980 to June 2010. Results The initial literature search identified 428 articles. The final selection included 16 randomized controlled trials (RCT) for treatment strategy, 25 articles (histological studies and RCT) for risk of kidney toxicity and 10 articles (RCT, prospective studies and case series) for use in non‐plaque psoriasis. Higher doses of CyA of 5 mg/kg produced Psoriasis Area Severity Index (PASI) 75 response in between 50 and 97% of patients, whereas lower doses of 2.5 mg/kg yielded PASI 75 in between 28 and 85%. CyA could maintain remission at doses of at least 3 mg/kg/day. Low calory diet in obese patients was shown to improve CyA efficacy. More than 50% of the patients treated with CyA may have an increase in serum creatinin value over 30% of baseline if treatment is prolonged for 2 years. CyA at a dose of 2.5 mg/kg/day was effective for 89% of patients with palmoplantar pustulosis. More than 50% of the patients with erythrodermic psoriasis obtained a significant improvement at doses between 3 and 5 mg/kg/day at 2–4 months. CyA was more effective than etretinate on nail psoriasis. Conclusion Oral CyA is indicated for patients with plaque psoriasis, pustular psoriasis or erythrodermic psoriasis. The starting dose of 5 mg/kg is associated with a higher degree of clearance. The benefit‐risk appears to be better for patients without risk factors for nephrotoxicity: non‐obese patients without hypertension and aged below 60. Although CyA is ideally suited for crisis intervention, continuous maintenance treatment with CyA may be envisaged in some patients provided serum creatinin is regularly monitored and the cumulative treatment duration is preferably limited to 2 years or less.
Abstract Background Treatment adherence has been recognized as an important issue in the management of chronic diseases such as psoriasis. Objective The aim of this work was to analyse data about topical treatment adherence in psoriasis. Methods Systematic literature review (62 references) between 1980 and 2011 (database: PubMed, Embase and Cochrane; Mesh keywords: Patient Compliance [Mesh] OR Medication Adherence [Mesh] AND Psoriasis [Mesh]; limits: date of publication >1980, humans subjects, written in French or English, aged ≥19 years). Two parameters were evaluated: (i) the ratio of number of product applications performed vs. number of applications expected according to physician recommendations, (ii) the ratio of amount of product used vs. amount of product prescribed. Results A total of 22 studies were selected. Nine studies reported on the frequency of topical treatment application in a real world setting. Five studies showed a frequency of applications varying between 50% and 60% of those expected. Because of the high variability in medication adherence assessment methods, the data could not be combined. Twelve articles reported on the frequency of topical treatment application in randomized controlled trials with adherence varying between 55% and 100%. Concerning the amount of product use, four studies showed patients applied between 35% and 72% of the recommended dose during a treatment period of 14 days to 8 weeks. The most frequently mentioned reasons for non‐adherence to topical treatment were low efficacy, time consumption and poor cosmetic characteristics of topical agents. Patients experiencing adherence issues were significant younger, were men, had younger age at onset of psoriasis and had a higher self‐assessed severity. To improve adherence, the following strategies were suggested: to give patients information about psoriasis, to recognize social impact, to give written instructions for use such as a care plan, to explain side effects of topical therapies, to choose treatment and its cosmetic properties in agreement with the patient. Conclusions Literature data about topical treatment adherence are heterogeneous and scarce. They confirm the limited topical treatment adherence in psoriasis in real life, much lower than what is reported in randomized controlled trials. Therapeutic education and clear instructions on the use of topical agents are necessary to improve adherence. Studies are needed to identify predictors of limited adherence and to identify interventions improving adherence to topical medications in psoriasis.
Administrative data are used in the field of Alzheimer's Disease and Related Syndromes (ADRS), however their performance to identify ADRS is unknown.i) To develop and validate a model to identify ADRS prevalent cases in French administrative data (SNDS), ii) to identify factors associated with false negatives.Retrospective cohort of subjects ≥ 65 years, living in South-Western France, who attended a memory clinic between April and December 2013. Gold standard for ADRS diagnosis was the memory clinic specialized diagnosis. Memory clinics' data were matched to administrative data (drug reimbursements, diagnoses during hospitalizations, registration with costly chronic conditions). Prediction models were developed for 1-year and 3-year periods of administrative data using multivariable logistic regression models. Overall model performance, discrimination, and calibration were estimated and corrected for optimism by resampling. Youden index was used to define ADRS positivity and to estimate sensitivity, specificity, positive predictive and negative probabilities. Factors associated with false negatives were identified using multivariable logistic regressions.3360 subjects were studied, 52% diagnosed with ADRS by memory clinics. Prediction model based on age, all-cause hospitalization, registration with ADRS as a chronic condition, number of anti-dementia drugs, mention of ADRS during hospitalizations had good discriminative performance (c-statistic: 0.814, sensitivity: 76.0%, specificity: 74.2% for 2013 data). 419 false negatives (24.0%) were younger, had more often ADRS types other than Alzheimer's disease, moderate forms of ADRS, recent diagnosis, and suffered from other comorbidities than true positives.Administrative data presented acceptable performance for detecting ADRS. External validation studies should be encouraged.
