Showing papers in "La Revue du praticien in 2005"

[Guillain-Barré syndrome].

Abstract: L'incidence annuelle du syndrome de Guillain-Barre est de 1,5/100000 habitants La mortalite actuelle est estimee a environ 5 % d'apres des essais therapeutiques recents, bien conduits Dix pour cent des malades gardent des sequelles motrices tres invalidantes un an apres le debut des premiers signes neurologiques La prise en charge de ces malades necessite des equipes entrainees, multidisciplinaires, pouvant pratiquer l'ensemble des therapeutiques specifiques La corticotherapie per os'ou par voie intraveineuse est inefficace Les echanges plasmatiques sont le premier traitement dont l'efficacite a ete demontree par rapport a un groupe controle Les indications sont maintenant mieux connues Les formes benignes (marche possible) beneficient de 2 echanges plasmatiques; 2 echanges supplementaires sont realises en cas d'aggravation Dans les formes intermediaires (marche impossible) et les formes severes (recours a la ventilation mecanique), 4 echanges plasmatiques sont conseilles Il n'est pas utile d'augmenter leur nombre dans les formes severes ou en cas d'absence d'amelioration De fortes doses d'immunoglobulines donnees par voie intraveineuse (lq IV) [0,4 g/kg/j pendant 5 jours] sont aussi efficaces que les echanges plasmatiques dans les formes intermediaires et severes Dans ces formes, le choix entre Ig IV et echanges plasmatiques depend des contre-indications respectives de ces traitements et de leur faisabilite Les travaux en cours ont comme objectif de mieux preciser les indications respectives des echanges plasmatiques et des lq IV dans des formes de gravite differente, leur morbidite comparee, la dose optimale des lq IV

Epidemiology and natural history of hepatitis B

Abstract: La transmission du virus de l'hepatite B (VHB) se fait par voie parenterale, sexuelle et materno-fœtale. Si une hepatite fulminante peut compliquer environ 1 % des hepatites aigues B symptomatiques, le probleme principal de l'infection virale B est celui du portage chronique de l'antigene HBs, classiquement defini par la persistance de l'Ag HBs 6 mois apres l'hepatite aigue. Il survient dans 0,5 a 3 % des cas chez l'adulte immunocompetent, mais plus frequemment chez les enfants infectes tot dans la vie (jusqu'a 90 %) ou chez les immunodeprimes (30 a 100 %). Son evolution peut etre marquee par des modifications parfois bruyantes de la replication virale avec l'existence d'arrets spontanes de la multiplication virale et de reactivations. Sa physiopathogenie principalement immunomediee, resultant des interactions hote-virus mais aussi de la complexite de ce virus (integration, mutations, replication residuelle), explique le polymorphisme de presentation de l'infection chronique par le VHB; elle va de l'immunotolerance au portage inactif de l'antigene HBs, en passant par une phase d'immuno-elimination ou l'hepatite chronique active peut aboutir a la cirrhose (incidence annuelle de 1,3 a 5,9 %). La cirrhose, avec ses complications propres d'hypertension portale et d'insuffisance hepatocellulaire ou de carcinome hepatocellulaire, est responsable de 80 % de la morbidite et de la mortalite liees a cette infection: en cas de cirrhose constituee, la survie a 5 ans varie de 52 a 82 %. En plus des facteurs epidemiologiques. les principaux parametres modifiant l'histoire naturelle de l'infection B sont l'immunosuppression et les cofacteurs incluant l'infection associee par le VHD et la surconsommation d'alcool. Ainsi, l'infection virale B est un probleme majeur de sante publique, particulierement dans les pays en voie de developpement (qui sont souvent des zones de haute endemie) rendant necessaires l'intensification et l'universalisation de la vaccination.

Epidemiology and natural history of hepatitis C

Abstract: La prevalence de l'infection par le virus de l'hepatite C en France est estimee actuellement a 0,86 % chez l'adulte. L'usage de drogues par voie intraveineuse est actuellement le principal mode de contamination et serait responsable de 4 400 nouvelles infections par an en France. L'infection aigue par le virus de l'hepatite C passe le plus souvent inapercue, et le risque de passage a la chronicite varie de 55 a 85 %. Cette infection chronique expose au risque de cirrhose a long terme. Les facteurs influencant la progression vers la cirrhose sont l'âge lors de la contamination, la consommation d'alcool et le sexe masculin. La progression de la fibrose semble lineaire dans le temps, mais elle pourrait s'accelerer considerablement apres l'âge de 50 ans. Le virus de l'hepatite C est la 2 e cause de cirrhose et de carcinome hepatocellulaire en France.

Epidemiology of malaria

Abstract: Four parasite species, among which one lethal, at least 20 efficient vectors, spread on the most crowded and underdeveloped continents, where first antimalarials and insecticides were so extensively used for decades that they are now inefficient after resistances. It is today the sad medium on which malaria raged, spring of 1 million deaths and 300 millions cases a year, of which 90% in sub-Saharan Africa. In Africa, epidemiological patterns are widely different some to others, which explain unique control strategy failure and vanity. Waiting vaccines and new drugs, control must be centred on vectors control and multidrug therapy. France is the industrialised country with the highest number of imported cases (approximately equal to 7000 cases yearly), linked mainly to P. falciparum coming from sub-Saharan Africa and recurring in nearly 3/4 of cases in immigrants.

[Therapeutic strategies for Parkinson's disease].

Abstract: Le traitement de la maladie de Parkinson est symptomatique. La prise de L-dopa initialement efficace entraine, secondairement, des complications motrices tres handicapantes liees au caractere pulsatile de la stimulation dopaminergique, ce qui impose d'en retarder la prescription chez le sujet jeune et de viser a stabiliser cette stimulation a toutes les etapes du traitement. La remarquable efficacite de la L-dopa sur l'akinesie, le tremblement et la rigidite de la maladie de Parkinson est incontestable. Elle explique l'amelioration fonctionnelle, la qualite de vie retrouvee. Apres cette desormais classique « lune de miel » apparaissent malheureusement les « complications motrices de la dopatherapie », fluctuations motrices et dyskinesies. D'autant plus frequentes et severes que le malade est jeune, elles compromettent son autonomie. Certes, la manipulation de la L-dopa, la modification de son metabolisme, l'association d'un agoniste permettent une amelioration, mais elle est inconstante, imparfaite et breve. La pulsatilite de la stimulation dopaminergique est l'element physiopathologique determinant dans la genese des complications motrices de la dopatherapie. Les nouvelles strategies du traitement antiparkinsonien trouvent la leur justification. Certaines ont pour but de retarder, attenuer sinon prevenir ces complications: c'est l'emploi d'un agoniste en monotherapie de premiere intention chez le sujet jeune, l'association L-dopa/agoniste de principe... D'autres ont pour but de traiter les complications: la stimulation electrique a haute frequence du noyau sous-thalamique en est l'exemple le plus recent. Son efficacite ne doit cependant pas faire oublier la necessite d'en respecter les criteres de selection, gage de reussite. Ces traitements symptomatiques n'ont cependant pas d'influence sur le cours evolutif de la maladie et (ou) l'atteinte des systemes autres que dopaminergiques. C'est dire l'espoir place dans la neuroprotection.

Understanding rheumatoid arthritis

Abstract: Rheumatoid arthritis is a common and severe inflammatory rheumatic disease, for which the immune mechanisms are being decoded little by little. The pathogenic ncludes significant cellular actors of innate immunity (fibroblastic synoviocytes, macrophages, mastocytes...) and adaptive immunity (T and B lymphocytes). These actors interact through the production of and response to specific (cytokines, chemokines and auto-antibodies) and non-specific (prostaglandins, nitrous oxide [NO], complement, proteases) mediators. The chronology of this rheumatoid synovitis is becoming progressively clearer. Its initiation could be the consequence of a precocious activation of the innate immunity, induced by bacterial agents or debris (PAMP). The activation of the synoviocytes and the macrophages via specific receptors (PPR) unleashes an intense inflammatory reaction that triggers a cascade of events. The ongoing nature of this synovitis leads to the intra-articular recruitment of different cells of immunity. This cellular afflux amplifies the macrophagic and synoviocytic activation and proliferation. All of these interactive phenomena end in the production of large quantities of pro-inflammatory cytokines (TNFa, IL1, IL6, IL15, IL17, IL18) but also other pathogenic mediators (auto-antibodies, complement, prostaglandins, nitrous oxide...). This synovitis persists, as it is no longer regulated by a sufficient production of physiological regulators (soluble receptors and inhibitors of cytokines). The consequence of this intense inflammation and synovial proliferation leads to osteo-articular destruction by the production of proteases and the activation of osteoclasts by the RANK/RANK-ligand pathway under the effect of cytokines (TNFa, IL5, IL1, IL6, IL17) and other mediators (prostaglandins) liberated by synoviocytes, macrophages and lymphocytes. The decryption of this puzzle has already created new therapeutic orientations. The identification of new targets is one of the major consequences of this progress in immuno-rheumatology.

[Pathogenesis of bipolar disorders: genetic vulnerability and environmental factors].

Abstract: It is now well-established that there is a genetic vulnerability for developing bipolar disorders. For instance, the rate of bipolar disorders in first degree relatives of bipolar probands (19%) is higher than in the general population (1%); monozygote twins have higher concordance rates for bipolar diseases (67%) than dizygote (19%); finally affective disorders are more frequent in biological parents than in adoptive parents in adopted bipolar patients. However, currently genes predisposing for the disease are not known, in part because bipolar disorders are very heterogeneous. New research strategies should be developed based on more homogeneous groups of patients defined by the presence of "candidate symptoms" or by the evidence of endophenotypes in healthy relatives. However, it is clear now that there is an interaction between the genetic vulnerability and environmental factors in the aetiology and course of the disorder. Environmental factors have been neglected for a long time because bipolar disorder was considered an endogenous disease. Thus, very recently, studies have shown that early trauma could contribute to the occurrence or the severity of the disease. During a lifetime, many environmental components (stressful life events, changes in daily schedules, drug abuse, some medications) could also trigger the onset of the pathology or the occurrence of new episodes. It is very important to recognize these factors in order to develop preventive strategies for limiting their impact.

Epidemiology and natural history of cirrhosis

Abstract: The cirrhosis prevalence in the whole French population can be estimated between 2000 and 3300 cases/million of individuals. Alcoholism, hepatitis C virus and non alcoholic fatty liver disease are the three most common causes of cirrhosis in France. About 40% of patients with cirrhosis have compensated cirrhosis and are asymptomatic over long period of 1 to 10 years. Decompensation of cirrhosis was considered when a patient first developed one of the mayor complications of the disease (ascites, jaundice, encephalopathy or gastrointestinal haemorrhage). After the first decompensation, the incidence of death is about 10% by year, in the absence of hepatic transplantation. The mortality of patients with cirrhosis and acute varicose bleeding has greatly decreased over the past 2 decades in concurrence with an early and combined use of pharmacological and endoscopic therapy, but hepatocellular carcinoma is the most frequent life threatening complication.

Adverse effects of marijuana

Abstract: When admitted in an emergency unit, young patients often present acute neurological effects of smoked marijuana. Other chronic adverse effects of marijuana are probably underestimated: postural syncope, arteritis, chronic bronchitis, amnesia. Marijuana may trigger a myocardial infarction and have a vasospastic effect. Marijuana has impairing effects on driving ability. Smoked marijuana is a potential respiratory tract carcinogen.

How to deal with teenagers in general practice

Abstract: Meeting a teenager as a general practitioner is not straightforward. Such a consultation has its own specific characteristics, and what is at stake goes beyond the apparent reason for the consultation. In order to avoid missing something by adopting a "wait and see" attitude in front of the uninsured teenagers, the author suggests the simplest ways of sticking to the four major objectives: ensuring self-expression, easing the relationship, improving body image and self esteem and increasing the range of possible solutions. A first series aims to expand the contents of all the consultations starting from the alleged reasons, the presence of a third party, the clinical examination and the investigative questions. A second series aims to create the conditions that help to get over a hurdle when a malaise has been diagnosed: confronting points of view, setting an appointment, strengthening the links thanks to relational tools and possibly directing towards the relevant health system.

Epidemiology and risk factors of inflammatory bowel diseases

Abstract: Inflammatory bowel diseases (IBD) are a public health problem in developed countries as 1 per 1000 people suffers from these diseases Most of affected people are young adults The incidence of IBD has increased considerably in western countries since the Second World War and it is beginning to level off On the other hand, incidence is still rising in low incidence areas such as Eastern Europe, Asia and developing countries Differences in incidence across age, time, and geographic areas suggest that environmental factors are acting in IBD but so far cigarette smoking and appendectomy are the only risk factors which have been consistently demonstrated An important role for genetic factors in IBD was first suggested by epidemiological studies showing familial aggregation of IBD and by twin studies In 2001, the first CD susceptibility gene, NOD2/CARD15 on chromosome 16, has been characterized Other susceptibility genes have been localized Their identification should help to understand the complex interaction between the environment and the intestinal immune system from which IBD are originating

Cancer de l'estomac

Abstract: Malgre une baisse de son incidence dans les pays developpes, le cancer de l'estomac est le deuxieme cancer digestif en France et reste la deuxieme cause de mortalite par cancer dans le monde. La gastrite favorisee par H. pylori et l'alimentation sont les facteurs preneoplasiques les plus frequents; toutefois, l'efficacite d'un depistage de masse et d'une eradication systematique de H. pylori n'est pas encore prouvee. Dans l'attente d'un vaccin anti-H. pylori efficace, seules des indications ciblees sont recommandees chez les sujets a haut risque de cancer. L'enjeu a venir est d'identifier en routine le risque de cancer des patients infectes, dependant de l'interaction entre la virulence de la souche bacterienne et la reponse genetiquement determinee de l'hote. Le cancer de l'estomac est frequemment peu symptomatique, d'ou un diagnostic endoscopique souvent trop tardif a un stade avance. Le pronostic est mediocre, avec une survie globale a 5 ans de moins de 20 %. Le traitement standard est la resection chirurgicale avec curage ganglionnaire D1. Un traitement adjuvant postoperatoire associant radiotherapie et chimiotherapie est indique chez les patients a risque eleve de recidive. Les cancers gastriques sont chimiosensibles mais le benefice sur la survie des polychimiotherapies actuelles (5-FU ± cisplatine ± epirubicine) reste faible (mediane de 9 mois); neanmoins, l'efficacite prometteuse de nouveaux agents (irinotecan, docetaxel, oxaliplatine, capecitabine, biotherapies ciblees) fait esperer un allongement de la duree de la survie. Plusieurs entites, linite, lymphome de type MALT et tumeurs stromales, ne doivent pas etre meconnues, car elles requierent une prise en charge therapeutique differente.

Thirty years later

Abstract: precise—the first pumps supplying water coolant stopped functioning at Unit 2 of the Three Mile Island nuclear power plant near Harrisburg, Pennsylvania. This began a chain of events that lead to a partial core meltdown and the release of radiation into the atmosphere, the full extent of which remains unknown to this day. Inside the plant, station manager Gary Miller stated, “Radiation was all over the place. Everything was off scale.” Nearby cancer rates increased in the years following, but the official story blames the increase on “stress.”

Medical and legal problems of death certificates

Abstract: Les objectifs du present article consistent a clarifier les notions de mort violente, suspecte et naturelle, et de definir les situations ou l'obstacle medico-legal doit etre signale, en se referant aux recommandations de l'Ordre national des medecins et a la recommandation europeenne n° R (99) 3 relative a l'harmonisation des regles en matiere d'autopsie medico-legale. En pratique, les situations requerant l'obstacle medico-legal sont les suivantes: homicide ou suspicion d'homicide, suicide ou suspicion de suicide, violation des droits de l'homme, deces en detention ou potentiellement associe a des actions de police ou militaires, mort engageant une responsabilite eventuelle, mort mettant en jeu une legislation particuliere, catastrophe collective, mort subite inattendue, corps non identifies ou restes squelettiques. Un principe de base est qu'une mort non attendue reste non naturelle jusqu'a preuve medico-legale du contraire!

Epidemiology of cannabis use

Abstract: Cannabis is the most consumed illicit drug in France. Its use concerns especially men, in all social groups. It is mainly consumed by young adults and teenagers. Over the last ten years the consumption of cannabis strongly increased amongst French young people, the rise has been even stronger for regular use. Prevalence use in France has now reached the highest European levels. Cannabis use can lead to a treatment demand and a research will soon allow to screen problematic users in general population in France. The part of the cannabis in the activity of specialised centres for drug addicts progresses. Due to a lack of indicators, the sanitary impact is not well-informed; nevertheless there are presumptions that cannabis is involved in road accidents, cancers and psychiatric pathologies. The cannabis constitutes the main part of the arrests for drug use.

Accueil des adolescents en médecine générale : validation de l'usage d'un référentiel

Abstract: Contexte : la consultation de l'adolescent en medecine generale a des caracteristiques propres et un enjeu qui depasse largement le motif evoque. Pour optimiser cette rencontre plutot frequente, les auteurs ont construit un referentiel d'attitudes simples visant a elargir systematiquement le contenu des consultations et a aider l'adolescent pour passer un cap en cas de probleme. Objectif : analyser les modifications de comportements de 39 medecins generalistes, tires au sort, a qui le referentiel a ete propose, et apprecier l'evolution de leurs attitudes sur 4 temps d'investigations portant au total sur 1794 consultations sur 20 mois. Resultats : cette etude a mis en evidence une amelioration possible des attitudes des generalistes dans leur mode d'accueil des adolescents, surtout dans leur abord psychologique, et, en cas de probleme depiste, dans l'amorce d'un accompagnement pour le passage d'un cap difficile.

Troubles psychiatriques liés, induits ou associés au cannabis : Cannabis

Abstract: Les troubles psychiatriques du cannabis recouvrent, selon les classifications internationales, la categorie diagnostique des troubles lies au cannabis (intoxication, abus et dependance) et les troubles induits (troubles anxieux, psychotiques et confusionnels). L'existence d'un syndrome de sevrage n'est pas formellement reconnue, et les syndromes amotivationnels sont mal references. Les comorbidites psychiatriques du cannabis sont l'association d'un trouble lie a son usage a un autre trouble caracterise, anxieux, depressif ou schizophrenique. La forte co-occurrence avec le trouble schizophrenique pose des questions etiopathologiques, en particulier neurobiologiques specifiques. Le cannabis est, comme toutes les substances psychoactives, un facteur de gravite de la morbidite et de resistance aux soins.

Acute and chronic cognitive disorders caused by cannabis use

Abstract: Cannabis is currently the most commonly used illegal psychoactive substance amongst young people aged between 15 and 24, and it seems that 5% of this age group is addicted to it. Many research teams focused particularly on the cognitive disorders caused by cannabis use. Amongst the cognitive functions considered, memory-related, attention-related, psychomotor and motivation-related functions were proved deteriorated by acute and chronic cannabis use; a very important point, especially among teenagers, as possible alteration at the social and academic level could be the outcome. However studies on long-term and persistent cognitive effects haven't provided convergent conclusions. Methodological differences could partly affect these observations. Therefore it seems necessary to develop studies with larger samples.

Screening and diagnosis of hepatitis B and C

Abstract: Le diagnostic virologique des hepatites virales repose sur l'etude de marqueurs directs (antigenes viraux ou genome viral) et de marqueurs indirects (anticorps specifiques). Le diagnostic des hepatites B est fonde sur l'interpretation des profils serologiques associant antigenes et anticorps specifiques et, pour les hepatites chroniques B, sur la quantification de l'ADN du VHB. La reponse therapeutique est evaluee par la mise en evidence de la seroconversion HBe chez les malades ayant un antigene HBe positif et par la mesure de la reduction de la charge virale chez les malades traites. Le diagnostic des hepatites C repose sur la detection des anticorps specifiques et de l'ARN du VHC par technique moleculaire. La determination du genotype permet d'adapter l'indication therapeutique, et l'efficacite du traitement est etudiee a l'aide de techniques moleculaires permettant de demontrer l'elimination progressive et definitive de la replication virale.

What is a mild cognitive impairment

Abstract: The concept of mild cognitive impairment (MCI) has been proposed by Petersen et al. (1997, 1999) as a nosologic entity referring to elderly persons with mild cognitive deficit without dementia. MCI is being widely used in studies as an intermediate stage between cognitive normalcy and dementia. However, MCI appears to be a heterogeneous clinical entity. Multiple sources of heterogeneity have been described: heterogeneity in aetiological factors (various types of degenerative lesions, vascular risk factors, psychiatric features, association of pathological conditions), heterogeneity in clinical symptoms, and heterogeneity in clinical course with decliners and non decliners presenting stable or reversible cognitive impairment. Thus new criteria of MCI are proposed for use in research but also in clinical practice. MCI may henceforth correspond to the following: (1.) Cognitive complaint emanating from the patient and/or his/her family; (2.) the subject and/or notifying party report a decline in cognitive and/or functional performance relative to previous abilities; (3.) cognitive disorders evidenced by clinical evaluation: impairment in memory and/or another cognitive domain; (4.) cognitive impairment does not have any repercussions on daily life, the subject may report difficulties concerning complex day-to-day activities; (5.) no dementia.

Psychopathology of the cannabis user teenager

Abstract: Over the past 10 years, cannabis use among adolescents has considerably increased. It became a major issue in public health. Today, the cannabis adolescents smoke is more concentrated in tetrahydroxycannabinol. Most of young people are using cannabis to deal with their psychological problems. In a way, cannabis use is more therapeutic than recreative. Substance abuse undercovers adolescent identity fragility. This fragility could lead to depression. The adolescent, by trying to manage this depression with cannabis use, jeopardize his individualisation process. Addiction has a specific function in adolescent psyche. It regulates the interpersonal relationship which is been considered as a treat by the adolescent. By this way, he's trying to avoid intrusion and abandonment anxiety.

Epidemiology of chronic renal failure in the elderly

Abstract: La prevalence de l'insuffisance renale chronique augmente, en particulier chez les personnes âgees. Elle concerne entre 7 et 55 % des plus de 60 ans, selon les pays. En France, l'incidence annuelle de l'insuffisance renale chronique terminale est estimee a 400 pmh chez les plus de 65 ans, avec des variations regionales. Parmi les patients ayant une maladie renale chronique, le nombre de ceux qui evoluent vers l'insuffisance renale terminale diminue avec l'âge; il est 2 a 3 fois plus faible chez les 61-74 ans que chez les 20-60 ans. Cela est lie a une morbidite cardiaque et vasculaire et a une mortalite accrues, en rapport avec l'insuffisance renale chronique. Pour les personnes âgees, on estime que 18 a 20 pour 100 patients-annees ayant une maladie renale chronique decedent avant d'atteindre le stade terminal et 30 a 50 pour 100 patients-annees ont une maladie cardiovasculaire. Les nephropathies diabetiques et hypertensives sont responsables de 48 a 73 % des cas d'insuffisance renale terminale chez les plus de 65 ans, selon les regions et les pays, quand les glomerulonephrites ne concernent plus que 10 % des cas. En Europe, entre 1990 et 1999, l'incidence de l'insuffisance renale terminale due aux nephropathies diabetique, hypertensive et vasculaire a augmente de plus de 10 % par an chez les plus de 65 ans. L'insuffisance renale chronique est frequente et grave chez les personnes âgees en particulier, du fait d'une morbidite cardiovasculaire et d'une mortalite elevees. Le risque d'evolution vers l'insuffisance renale est egalement accru.

How to improve estimation of renal function in the elderly

Abstract: Kidney function is defined by the glomerular filtration rate (GFR). It has been clearly established that serum creatinine should not be used alone to estimate GFR, and that estimated GFR should be calculated using formulas that take into account various parameters including serum creatinine. In adults, two formulas are mostly used to estimate GFR: the Cockcroft-Gault formula and the MDRD formula. In elderly, GFR should only be estimated using the MDRD formula, since the Cockcroft-Gault formula systematically underestimates GFR. GFR tends to decrease with age, but it should be 60 mL/min/1,73 m2 or higher in all subjects who do not suffer from kidney disease, regardless of age.