Échographie des fractures de stress

Accurate assessment of bones is essential in every musculoskeletal US examination. Several articles reported the US appearance of SF of knees, legs, ankles and feet. The US hallmarks of a SF at this level are: (1) local soft tissues oedema; (2) hypoechoic thickening of the periosteum; (3) hyperaemia located into the soft tissues, periosteum and frequently inside the bone cortex; (4) normal appearance of other local structures. The US diagnosis of a SF necessitates a careful correlation with clinical findings, since US appearance although suggestive is aspecific. If US indicate a SF, an attending attitude including rest and avoidance of charge and clinical follow-up can be proposed in most patients. If the patient does not improve or in case presenting a discrepancy between US and clinical findings a MRI examination must be obtained.     

Implications pratiques des changements de seuils de sensibilité aux bêtalactamines des entérobactéries

Lowering break-points of beta-lactam antibiotics greatly contributed to optimize their use. This is obvious with the third and fourth generation cephalosporins and aztreonam in relation to the extended spectrum beta-lactamase (ESBL)-producing enterobacteria. Up to 2011, antibiogram interpretation used to consider any ESBL-positive strain as “intermediate” or “resistant” to these antibiotics. Since this date, breakpoints of beta-lactam antibiotics has been lowered, allowing ESBL-positive strains to be considered as susceptible, given that the minimum inhibitory concentration (MIC) (whose measurement is mandatory) is lower than or equal to the lowest break-point. The resistance/susceptibility pattern is sometimes dissociated regarding these antibiotics. Expected benefits of this recent approach include the decrease in carbapenem use in ESBL-positive infections. Administration of third and fourth generation cephalosporins and aztreonam to treat ESBL-producing strains, appearing susceptible based on the disk diffusion test, requires measurement of the exact MIC. Patients with ESBL-positive infections treated using these antibiotics should receive high-dosage regimens and combinations with other classes of antibiotics like aminoglycosids. However, despite a significant decrease, the current break-points of carbapenems (imipenem and meropenem) likely remain too high.     

Prévention des lésions des cartilages de croissance des doigts chez les jeunes grimpeurs

Introduction

Epiphyseal stress fractures of the second phalanx base of the fingers are predominant in young climbers. The objectives of the study were 1) to determine the incidence of these injuries among young French competitive climbers (9–18 years old); 2) to determine injury risk factors during training.

Utilisation des filtres échangeurs de chaleur et d’humidité au cours de la ventilation mécanique des patients de réanimation

Adequate heating and humidifying of inspired gases is required for long-term mechanical ventilation of intensive care unit (ICU) patients. This process can be achieved by either a heated humidifier or by more recent disposable devices called heat and moisture exchangers (HME). The choice to use one method instead of the other depends on both technical and economic considerations. HMEs are more often used nowadays because they are simple to use and cost-effective. Their performances are for several models comparable to those of a heated humidifier. The vast majority of ICU patients can be ventilated with an HME. They are usually changed after 24 h of use. It has recently been shown that some HMEs can be changed only every 48 h and that at least one HME can be changed only once a week in some patients. Using HMEs instead of heated humidifiers has no clear impact on the rate of nosocomial pneumonia but considerably reduces the cost of mechanical ventilation and the number of septic procedures, thus improving quality of care.     

Pourquoi un accueil transculturel au sein des centres de traitement de la douleur?

Résumé  La culture est un élément déterminant de la perception de la douleur et de sa prise en charge. II est néanmoins difficile, pour plusieurs ordres de raisons, de lui faire toute sa place dans les démarches de soins. Ces difficultés, plut?t que de décourager les acteurs du soin, peuvent conduire à un enrichissement de la prise en charge, tant il est vrai que les questions soulevées ont des répercussions éthiques et épistémologiques pour tous les patients, indépendamment de leur nationalité. Alros, en continuité plut?t qu’en rupture de part et d’autre des frontières, il devient possible de traiter chacune des difficultés rencontrées.      

L'évaluation de la satisfaction des patients des services d'urgences est-elle possible?

The aim of this study was to assess patients' satisfaction in an emergency unit.Methods: French-speaking patients and volunteers that came to the emergency unit between 10:00 am and 12:00 pm were included in the study for a two-week period. In order to obtain reliable responses, the investigators interviewed the patients face to face with the assistance of a specific questionnaire.Results: Fifty-two percent of the 514 interviewed patients agreed to answer the investigators' questions; the major reason for failure to reply was the lack of time. Using the Principal Components Analysis, the data were gathered into six dimensions: reception, waiting room 1, waiting room 2, staff appreciation, communication, and waiting time. Six scores of dissatisfaction were established, ranging from 0 (most satisfied) to 100 (most dissatisfied). The results showed that the most worrying point was the waiting (45 ± 22 min). The perception of the length of waiting time was statistically related (P < 0.0001) to the time spent in the emergency unit, contrary to its tolerance. The second point of dissatisfaction was the location (waiting room 1:30 ± 22; waiting room 2.31 ± 22). Finally, the most motivating point for the staff was the recognition of their work by the patients (28 ± 15).Conclusion: This study found the reasons for the published dissatisfaction. Its intent was to quantify the degree of dissatisfaction and to treat the problems on a hierarchical basis, thus making it possible to better meet the patients' needs. The assessment of patients' satisfaction in an emergency unit is possible but implies a significant deployment of means to obtain a satisfying response rate.     

Évaluation endoscopique des patients atteints de maladie coeliaque

Celiac disease is an autoimmune disorder of the small bowel triggered by the exposure to gliadine, a storage protein of wheat and similar grains, occurring in genetically predisposed patients. The diagnosis of celiac disease typically requires the presence of both anti-tissue transglutaminase antibodies in the serum and specific histological features on small bowel mucosal biopsies, such as villous atrophy. The goals of the endoscopist in the management of patients with known or suspected celiac disease is to obtain contributive histological samples, knowing that mucosal lesions may be patchy among the small bowel, and to diagnose potential complications, such as ulcerative jejunitis, refractory sprue, or enteropathy-associated T lymphoma. We reviewed the respective contribution of the various endoscopic diagnostic tools in the management of patients with celiac disease.     

Utilisation des modulateurs de la voie de la thrombine et de la protéine C dans les CIVD : résultats des essais cliniques

A correlation between acquired antithrombin (AT) and protein C (PC) deficiencies, multiple organ dysfunction and mortality has been demonstrated in various clinical conditions. In addition, the evolution of these deficiencies over time seems to have a more pronounced predictive value. Thrombin and PC pathways modulation in DIC has been evaluated in various clinical trials. This chapter aims at reviewing the clinical situations associated with DIC and in which the effects of these therapies have been evaluated. Congenital PC deficiency and heparin resistance are not considered here. AT and PC therapies are reviewed with regard to their influence on DIC, multiple organ dysfunction and mortality. AT supplementation improves DIC biomarkers and in some situations, organ dysfunction scores. Its effect on mortality remains to be demonstrated. PC concentrates seem to favourably improve coagulation disorders observed in DIC. However, no controlled study has evaluated its effect on mortality. Activated protein C has been demonstrated to improve survival in patients with severe sepsis at increased risk of death and DIC biomarkers but is associated with an increased risk of bleeding. Finally, heparin improves coagulation parameters observed in DIC but has not been demonstrated to improve survival. Its influence on the effects of other DIC therapies has to be evaluated.     

Représentations des médicaments et expérience de la douleur chez des patients souffrant du syndrome de fibromyalgie

Aim

The purpose of this article is to analyse the representations and categorisations of medication constructed by patients with a fibromyalgia syndrome.

Materials and methods

Thirty-five semi-structured interviews were realised with patients. They were analysed according to thematic analysis.

Results

Medicines and pain are co-constructed in the patients’ discourses. Medicines are evaluated and categorised by patients by analogy with pain and its paradoxical representations in the body. Four axes structuring this analogy have been identified: space (local/diffuse), time (permanent/sudden), intensity (soft/hard) and familiarity (usual/new).

Conclusion

To analyse patients’ representations is a way to adjust patient-doctor communication about medicines.