Klinische Untersuchung des Hüftgelenkes des Erwachsenen

Complaints in the region of the hips and pelvis are often difficult to classify. This is due to the fact that pain projection and overlapping can occur; therefore, the complete region of the lumbar spine, pelvis and hips must be considered as a single entity in which alterations can result in radiation throughout the whole region. There are many different anatomical structures within the pelvic region so that the function of various muscle components can be impaired and cause pathological alterations to positional relationships of bony structures or even alterations to other soft tissues, such as ligaments, tendons and labra. In terms of differential diagnostics the groin must be seen as the weak point of the peritoneum and vascular system and taken into consideration. Therefore, a detailed and targeted medical history, functional testing and specific examinations and tests are necessary to narrow down the pathology in question and reach a definitive diagnosis. Orthopedic surgeons must know which conspicuous features can lead to which problems and which anatomical structures are likely to be affected by irritation. The results of the clinical examination are the basis for targeted imaging diagnostics and subsequent therapy.     

Effets comportementaux des cannabinoïdes Données animales

Résumé  Deux sous-types de récepteurs cannabino?des (CB-R) sont identifiés à présent, les CB1-R, essentiellement localisés dans le SNC, et les CB2-R, périphériques. Le Δ9-tétrahydrocannabinol (Δ9-THC) est le composé actif essentiel de Cannabis sativa, l’anandamide est un ligand endogène, le WIN 55,212-2, le CP55,940, le HU-210, sont de puissants agonistes synthétiques, mais tous sont non sélectifs CB1/CB2. Chez l’animal, ils induisent l’association caractéristique de quatre sympt?mes: hypothermie, analgésie, hypoactivité et catalepsie, qui sont annulés par le SR 141716, antagoniste sélectif CB1. L’anandamide présente plusieurs différences par rapport aux autres agonistes puisque l’hypothermie, l’analgésie et la catalepsie qu’il induit ne sont pas atténuées par le SR 141716. Un processus cannabino?de semble également intervenir dans la cognition, la mémoire, l’anxiété, le contr?le de l’appétit les vomissements, la pression intra-oculaire, l’inflammation et les réponses immunitaires. Bien que le Cannabis ait un usage récréationnel chez l’Homme, rares sont les études qui indiquent un potentiel appétitif chez l’animal. Au contraire, le Δ9-THC et les autres agonistes ont des effets aversifs dans divers tests. Le SR 141716 altère la perception par les animaux du caractère plaisant de différentes substances appétitives (nourriture, coca?ne, morphine) et réduit la consommation de sucre, de bière et d’alcool, suggérant que des mécanismes dépendant des CB1-R pourraient exercer un contr?le permissif sur les processus motivationnels positifs. Les systèmes cannabino?des ne semblent pas activés dans des conditions basales. Cependant, une étape dépendant d’une activation tonique des CB1-R a été mise en évidence dans le cas de douleurs chroniques et chez des animaux confrontés à des stimuli anxiogènes ou à des renforcements très motivants. Des mécanismes CB1 pourraient également exercer un contr?le tonique sur certains processus cognitifs.      

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.

L’évaluation des pratiques addictives des douloureux chroniques

Résumé  La clinique des pratiques addictives des douloureux chroniques est complexe et a longtemps fait l’objet de publications contradictoires. Une mise au point s’avère d’autant plus nécessaire que le r?le étiopathogénique, de l’abus médicamenteux dans l’aggravation et la chronicité de certains types de douleurs est largement reconnu. Différents auteurs soulignent que l’évaluation des comportements addictifs des patients douloureux chroniques pourrait être améliorée, si l’on utilisait les définitions standardisées appliquées classiquement à la toxicomanie, celle de l’Association Américaine de Psychiatrie (dépendance et abus), et celle de l’Organisation Mondiale de la Santé (dépendance et usage nocif pour la santé). Le recours à des définitions standardisées (abus, dépendance) ne peut rendre que plus lisibles les données recueillies. Les comparaisons deviennent possibles et l’examen des études publiées fournit une approximation de la prévalence de l’abus et de la dépendance médicamenteuse des sujets consultant pour une douleur chronique (entre 10 à 20%). Mais, l’inadaptation partielle de ces définitions lorsqu’elles sont appliquées à la population des douloureux chroniques est discutée. Leur inconvénient principal est que les comportements addictifs de la majorité de ces sujets douloureux chroniques n’entrent pas dans la catégorie de la dépendance ni même de l’abus de médicaments. Cette évaluation, bien qu’utile, s’avère être réductrice face à la complexité de la psychopathologie des conduites addictives et de ses intrications multiples avec la pathologie douloureuse.

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Summary  Addiction in chronic pain patients is a complex topic and the studies published have long been contreversial. Some authors suggested that the use of standardized diagnostic criteria for addiction developped in the population of substance abusers could improve the assessment of addiction in chronic pain patients. Operational diagnostic criteria have been defined by the World Health Organization (for substance dependence and harmful use) and the American Psychiatric Association (for substance dependence and abuse). A review of studies using these criteria indicated that drug dependence or abuse occurred in a minority of chronic pain subjects (10 to 20%). These definitions should be interpreted caustiously when applied to chronic patients and the limitations are discussed. It appeared that the categorical model of substance use disorder could be applied to a subset of chronic pain patients but that clinical observations and quantitative evaluations indicated that a larger subset of addictive behaviors were not captured by this kind of evaluation.

     

La responsabilité médico-légale des médecins des Samu et des Smur

A study on the legal liability of physicians working for the SAMU and SMUR emergency medical services was carried out based on a retrospective assessment of all the accidents involving the intervention of medical staff, recorded between 1994 and 1999 by the Sou Médical. During this period, a total of 15 claims were made concerning physicians who acted either in a transporting capacity (ten claims) or in a regulatory capacity (five claims). In the majority of cases (12 out of 15 cases), the claim followed legal proceedings. In two other cases, it was submitted after a verbal or written complaint, in one case, it was spontaneously submitted by a physician following the accidental death of a patient during transport, without any complaint being made by the victim's family. The medico-legal repercussions of the 15 accidents reported in the study were only known in 11 cases, as in the remaining cases there were ongoing legal proceedings. None of the 11 cases involved conviction for any of the doctors concerned. In particular, the criminal lawsuits brought against three regulators and three transporters led to closure of the file (two instances) or to dismissal of the case (four instances). In contrast to the high ratio of criminal lawsuits initiated by the patients, in this series of 15 accidents the fact that no doctor was sentenced by the court reflects a degree of partiality on the part of the judges towards the doctors involved in emergency medical service activity.     

Facteurs pronostiques des leucémies aiguës et des lymphomes

During the last two decades, striking advances in characterization and risk-adapted treatments of haematological malignancies have led to a substantial improvement in long-term survival rates. Thus, patients admitted in intensive care unit, either at diagnosis or during the first line therapy, should be managed as patients that could be potentially cured. The main prognostic factors are detailed in this review. Most of adult patients with acute leukaemia, despite impressive progress, are not cured by chemotherapy (CT) alone, and allogenic stem cell transplantation (ASCT) as post-remission therapy, remains the most effective treatment. In adult acute myeloid leukaemia (AML), only patients with favourable cytogenetics can be cured by CT in more than two-third of the cases and patients with acute promyelocytic leukaemia (APL), since the use of all-trans retinoic acid (ATRA) in combination with CT, have the most favourable outcome with nearly 75% of cure rates. In contrast, patients with unfavourable cytogenetics and older patients have less than 20% of cure rates. In adult acute lymphoblastic leukaemia (ALL), current CT treatments are associated with cure rates of 30 to 40%. As in AML, patients with unfavourable cytogenetics and older patients have a bad prognosis. Patients with mature B cell and T cell phenotypes have gone from having the least favourable outcome to the most favourable outcome. Lymphomas are among the most curable malignancies. Overall, patients with aggressive NHLs have a 5-year survival rate of 50% and patients with Hodgkin disease (HD) can be cured in nearly 75% of the cases. Patients with indolent non-hodgkin lymphoma (NHL), live with a median survival time of 7-10 years from diagnosis.     

Beugung des Kniegelenks und Aktivitäten des täglichen Lebens

Background

The normal range of motion of the knee joint and the impact of restricted knee flexion on activities of daily living might seem to be trivial; however, relevant data in the medical literature are rare. German speaking textbooks give the normal range of motion as being very broad (5–10/0/120–150°).

Methods and results

This study on 14 volunteers examined what amount of knee flexion allows for different activities of daily living. Some degrees of flexion were added to the mean values calculated from experimental data to give an estimate of flexion which would be sufficient in most cases: descending stairs 79°, climbing stairs 90°; rising from a high seat 90°, from a normal seat 100°, from a low seat 120° and cycling 106°–113° depending on the position of the seat.

Conclusion

This knowledge is not fully implemented in clinical practice or clinical scores. These data can lead to a better understanding of restriction in activities and improve the measurement of clinical outcome.     

Vanilloïdes, cannabinoïdes et nociception: aspects anatomiques

Résumé  Les vanillo?des et les cannabino?des, deux substances extraites respectivement du piment du Chili et du cannabis, sont impliqués dans la douleur. Nous verrons ici comment la localisation des récepteurs cannabino?des CB1 et CB2 et des récepteurs vanillo?des VR1 peut apporter des renseignements précieux pour comprendre leu r?le. Les récepteurs VR1 sont localisés dans quatre populations cellulaires de fibres sensorielles impliquées dans la douleur aigu? et chronique. Un contr?le noradrénergique central de la nociception à partir du locus coeruleus par les vanillo?des est aussi vraisemblable. Les cannabino?des sont impliqués dans la modulation de la douleur aigu? ou chronique au niveau spinal par l’intermédiaire de récepteurs CB1 présents sur des afférences primaires, des interneurones inhibiteurs et des astrocytes. Au niveau supraspinal, les cannabino?des sont impliqués dans les contr?les monoaminergiques, sérotoninergiques ou noradrénergiques. Ils pourraient jouer un r?le également dans les régulations centrales du système autonome par la douleur et les aspects psychoaffectifs de la douleur. Les données synthétisées ici suggèrent aussi l’existence de nouveaux types ou sous-types de récepteurs aussi bien pour les cannabino?des que pour les vanillo?des. Enfin, la coexistence, au moins régionale, des récepteurs CB1 et VR1 renforce l’hypothèse récente d’une interaction entre ces deux systèmes.      

Diagnostik des Rückenschmerzes

Many different diagnostic procedures are used in patients with low back pain. Medical history and clinical examination, X-rays, computed tomography (CT)-scan, magnetic resonance imaging (MRI), diagnostic nerve root blocks and facet injections, functional tests in physiotherapy, strength tests of trunk muscles and work-related performance, and psychological and social evaluation including psychometric tests are only some of them. Despite this large number of procedures available, the scientific literature has not changed its conclusion that in about 80% of all back pain episodes the cause remains unknown. During the course of back pain episodes the relevant factors may change. The cause of the problem or the triggering factor of the pain episode may no longer be important during subacute stages, while others may be decisive for the transition to chronic stages. Thus, assessment of the cause is different from that of prognostic factors. There seems to be no consistent distribution of causes or ongoing factors in the population(s) of patients. While individual social factors may be the one important factor in one patient, functional and structural factors may be significant in another patient. Clinical examination is important, but several problems occur in the evaluation of patients with low back pain. Due to their anatomical location, important bony structures of the lumbar spine, e.g., disks or facet joints, are difficult to access by clinical examination. Additionally, there are only few diagnostic tests during clinical examination that do not rely on the patient's cooperation or communication. The term "unspecific back pain" for the majority of patients is scientifically sound, because it reflects the fact that the cause is unknown. It must be taken into consideration that this term enjoys only limited acceptance by both patients and physicians. Physicians are in charge of certifying work disability by assessing the interference of the patient's illness/disease with the specific requirements of his daily life or job. However, in clinical practice both the job tasks and the patient's abilities to perform these tasks with the given symptoms and signs is still difficult to evaluate and requires further definition.     

Impingement des Hüftgelenks

Introduction

According to the technical development in hip arthroscopy in recent years there is an increasing demand for joint preserving treatment of hip impingement pathologies. It is important to detect those pathologies and to differentiate them from non-impingement pathologies with similar symptoms.

Methods

A thorough evaluation of the patient’s history should always be the first step. Pain in standing position and at rest may indicate a concomitant degenerative joint disease. Further diagnostic evaluation should be supported by a standard radiography and magnetic resonance imaging (MRI). At the physical examination the active and passive range of motion (ROM) is documented for both hips. Painful mechanical hip impingement has to be assessed and reproduced. A sterile diagnostic intra- or extraarticular infiltration with a local anesthetic may help in differential diagnosis.     

Implementierung des Querschnittsbereichs 13

Background

In 2013 palliative medicine (PM) will be integrated into the undergraduate curriculum as part of the mandatory education in German medical universities. The aim of this study is to determine the current state of implementation at German medical faculties (MF).

Methods

All German MFs were contacted using a written postal survey in June 2012.

Results

A total of 32 out of 36 MFs participated. Teaching staff consists of 15 or more lecturers in 8 MFs (30?%) and includes psychologists in 24 MFs (75?%) and also nurses in 18 MFs (56?%). Participating physicians are specialized in anesthesiology, internal medicine and general medicine. Teaching staff include palliative outpatient (20 MFs, 63?%) and consultation services (22 MFs, 69?%). Bedside teaching is provided in 15 MFs (47?%). Multiple choice tests are the major form of assessment (29 MFs, 84?%). The total number of teaching units in PM is between 12 and 43 and is usually provided at the end of medical school education. Nurses are employed in the education significantly more in MFs with a chair in PM. General practitioners were engaged only by faculties without a chair in PM.

Conclusions

The implementation of the mandatory training in PM at MFs in Germany is inhomogeneous. Further steps include in particular the development of a competence-based curriculum and assessment.