Épidémiologie bactérienne,réalité de la surinfection bactérienne au cours de la bronchite aiguë de l'adulte sans pathologie respiratoire préexistante

The diagnostic of lower respiratory tract infections is still as difficult as in 1991, year of the previous consensus conference. Viral etiology remains dominant in acute bronchitis, especially rhinovirus. Among bacteria, only the implication of Mycoplasma pneumoniae and Chlamydia pneumoniae has been demonstrated in this disease, with incidence varying according to geographical localization, age of patients, and epidemics. Rare observations of pneumonia following viral infection may account for a possible bacterial superinfection. The scarcity of documentation may be explained by methodological problems or just because superinfection is so rare.     

Diagnosis and management of Alzheimer disease.

BACKGROUND: Alzheimer disease afflicts millions of older Americans, with an estimated cost to society approaching $100 million annually. Family physicians will care for an increasing number of patients with Alzheimer disease as well as their caregivers and families. METHODS: A comprehensive and systematic review of the literature published between 1985 and 1998 about diagnosing and treating Alzheimer disease was conducted, using "dementia," "Alzheimer's disease," and "treatment" as search strategy key words. Data and information that reported significant conclusions were critically reviewed. Potentially important new data about new agents that might be of benefit when caring for patients with Alzheimer disease are discussed. RESULTS AND CONCLUSIONS: The primary goals when treating Alzheimer disease patients are enhancing autonomy and functional abilities and maintaining quality of life for patients and caregivers. In addition to diagnostic and pharmacologic treatment, primary care physicians will be called upon to provide nonpharmacologic support to assist with behavioral, social, and living environment problems faced by these patients and their families. The most common pharmacologic treatment is cholinesterase inhibition. Two cholinesterase inhibitors, tacrine and donepezil, are effective in treating cognitive and global function. Newer cholinesterase inhibitors should soon be available that might offer safety advantages as well as efficacy in treating behavioral and psychiatric symptoms related to Alzheimer disease. Other agents, including vitamin E, nonsteroidal anti-inflammatory drugs, estrogen, and Ginkgo biloba, are under investigation. Nonpharmacologic measures are important components in the management of Alzheimer disease. Support groups can help to diminish behavioral problems, maintain the patient's independence, and provide relief for caregivers and families.     

Diagnostic research on routine care data: prospects and problems

A diagnosis in practice is a sequential process starting with a patient with a particular set of signs and symptoms. To serve practice, diagnostic research should aim to quantify the added value of a test to clinical information that is commonly available before the test will be applied. Routine care databases commonly include all documented patient information, and therefore seem to be suitable to quantify a tests' added value to prior information. It is well known, however, that retrospective use of routine care data in diagnostic research may cause various methodologic problems. But, given the increased attention of electronic patient records including data from routine patient care, we believe it is time to reconsider these problems. We discuss four problems related to routine care databases. First, most databases do not label patients by their symptoms or signs but by their final diagnosis. Second, in routine care the diagnostic workup of a patient is by definition determined by previous diagnostic (test) results. Therefore, routinely documented data are subject to so-called workup bias. Third, in practice, the reference test is always interpreted with knowledge of the preceding test information, such that in scientific studies using routine data the diagnostic value of a test under evaluation is commonly overestimated. Fourth, routinely documented databases are likely to suffer from missing data. Per problem we discuss methods that are presently available and may (partly) overcome each problem. All this could contribute to more frequent and appropriate use of routine care data in diagnostic research. The discussed methods to overcome the above problems may well be similarly useful to prospective diagnostic studies.     

Chronic pelvic pain

Chronic pelvic pain is one of the most challenging gynecologic problems seen in primary care practice. Important causes of this problem include endometriosis, pelvic adhesions, chronic pelvic inflammatory disease, and the syndrome of chronic pelvic pain without obvious pathology. The diagnostic approach to chronic pelvic pain begins with a careful medical history and physical examination in conjunction with a comprehensive psychosocial assessment. Laboratory evaluation may include pelvic ultrasonography, psychometric testing, and diagnostic laparoscopy. Optimal management of these patients may require a multidisciplinary approach, integrating chronic pain management techniques with specific therapy.     

The practice guideline 'Influenza and influenza vaccination' (first revision) from the Dutch College of General Practitioners; a response from the perspective of general practice

The first revision of the guideline 'Influenza and influenza vaccination' from the Dutch College of General Practitioners illustrates that influenza has evolved from a supposedly harmless condition to a disease against which growing numbers of patients and healthcare professionals are vaccinated. Although recent studies support its effectiveness, it is still believed that vaccination may prevent serious health problems in the vulnerable patients, notably in homes for the elderly and nursing homes. In order to streamline diagnostic triage in cases of flu-like symptoms, general practitioners must keep abreast of the actual influenza figures, but also be aware that not all patients with flu-like symptoms have influenza. Pneumonia should always be present in the differential diagnosis of influenza.     

New directions in the understanding and management of pain

Control of pain and the suffering that it causes still eludes us. Despite impressive progress in the prevention and cure of disease and in care of the trauma victim, pain is still a frontier in medical research. It accompanies surgery, various diagnostic procedures and dental care as well as acute injury and disease. For a significant number of patients it persists after injury or illness into a chronic state. Chronic pain is recognized to be the most frequent cause of disability in the United States and many industrialized nations today, and is a major cost to society in both work hours lost and medical expenses. In addition to its social importance, pain is an intimate cause of personal concern for every human being throughout life. The progress, or lack of progress, achieved by medical research in pain control is of interest to us all. Pain disorders may be usefully classified in two categories: acute and chronic. The etiology, physiopathology, symptomatology, diagnosis and therapy of these two types of pain are quite different and require separate consideration. Acute pain is that which arises from an acute injury or disease process and persists only as long as the tissue pathology itself. If acute pain problems are not effectively treated, they may progress to chronic states. Chronic pain is that: (1) associated with chronic tissue pathology; or (2) which persists beyond the normal healing period for an acute injury or disease. There are unique challenges for health care providers associated with each of these two categories of problems, and failure to distinguish between these types of pain has led to a widespread, ongoing mismanagement of patients that can be prevented if strong efforts are made to better educate health care professionals about pain and its therapy. This paper presents an overview of current understanding about the nature of pain and its management. The physiology and psychology of pain are reviewed against a background of the concepts and information taught 25 years ago. Some common acute and chronic pain problems are reviewed and discussed. Finally, several new directions in pain control are described.     

Clinical manifestations of HIV infections

The wide clinical spectrum of HIV infection is reflected in the new CDC classification. Presentations range from acute infection, asymptomatic carriage and persistent lymphadenopathy through constitutional upset and neurological disease to the opportunistic infections and cancers of AIDS. AIDS is an enigmatic disease which presents special clinical diagnostic and management problems. Although any system may be affected the lungs and the brain are the most important target organs. Though the underlying disease is currently untreatable, many of the complications of AIDS are amenable to prompt therapy. Seropositive patients should be monitored to detect early signs of significant HIV disease. Skilled counselling about the avoidance of co-factors which may potentiate HIV infection, is important.     

The bone scan in primary care: diagnostic pitfalls.

Skeletal scintigraphy (bone scanning) is a useful adjunct in the diagnosis of disease states, such as osteomyelitis, and in the evaluation of occult fractures. Certain conditions can alter the appearance of bone scans, such as age of the patient, prior use of antibiotics, concomitant diseases, and disruption of the vascular supply. Three patients whose clinical problems highlight diagnostic problems with bone scans are discussed.     

A global sensitivity analysis of performance of a medical diagnostic test when verification bias is present

Current advances in technology provide less invasive or less expensive diagnostic tests for identifying disease status. When a diagnostic test is evaluated against an invasive or expensive gold standard test, one often finds that not all patients undergo the gold standard test. The sensitivity and specificity estimates based only on the patients with verified disease are often biased. This bias is called verification bias. Many authors have examined the consequences of verification bias and have proposed bias correction methods based on the assumption of independence between disease status and election for verification conditionally on the test result, or equivalently on the assumption that the disease status is missing at random using missing data terminology. This assumption may not be valid and one may need to consider adjustment for a possible non-ignorable verification bias resulting from the non-ignorable missing data mechanism. Such an adjustment involves ultimately uncheckable assumptions and requires sensitivity analysis. The sensitivity analysis is most often accomplished by perturbing parameters in the chosen model for the missing data mechanism, and it has a local flavour because perturbations are around the fitted model. In this paper we propose a global sensitivity analysis for assessing performance of a diagnostic test in the presence of verification bias. We derive a region of all sensitivity and specificity values consistent with the observed data and call this region a test ignorance region (TIR). The term 'ignorance' refers to the lack of knowledge due to the missing disease status for the not verified patients. The methodology is illustrated with two clinical examples.     

Psychological assessment and treatment of somatization: adolescents with medically unexplained neurologic symptoms

Adolescent patients who report physical symptoms that are unexplained by physical disease or pathophysiologic processes are prevalent in health care settings. Physical symptoms with no notable physical pathology are often referred to as medically unexplained symptoms (MUS). Common MUS found in adolescent populations include headaches, abdominal pain, back pain, fatigue, dizziness, numbness and tingling sensations in the limbs, and gastrointestinal symptoms. The most important diagnostic concern is the exclusion of neurologic and other general medical conditions. Failure to diagnose real physical pathology appropriately can have serious, deleterious consequences. However, it is also important for physicians to address psychological and other psychosocial factors that may play a role in the etiology or maintenance of MUS. The onus often falls on the primary care physician to screen for such problems and to make cost-effective and appropriate referrals. This article reviews some alternative treatment guidelines for physicians to assist in the assessment, intervention, and referral process for adolescent patients with MUS. The advantages of integrating psychological screening practices into the evaluation process and present recommendations regarding the management of such patients are discussed.     

Vagally mediated atrial fibrillation in a young man

Atrial fibrillation may be provoked by either vagal or sympathetic stimulation. Sympathetic effects are common in middle-aged and elderly patients with underlying heart disease. However, in the young, non-diseased heart, vagal influences are more likely to predominate. Recognition of vagally mediated atrial fibrillation in young adults as a unique clinical entity has diagnostic and therapeutic implications.     

Alzheimer’s disease therapeutic trials: EU/US task force report on recruitment, retention, and methodology

While we may not be able to find a cure for Alzheimer's disease (AD) in the near future, several drugs presently in trials have shown promise as possible modifiers of disease progression. However, we may not be able to demonstrate efficacy due to issues of recruitment, retention, site-to-site variability, and other methodological issues. It is thus incumbent on the scientific community to find solutions to these problems, particularly as the field moves toward preventing illness or treating the disease in its prodromal stages, where these methodological issues will become even more critical. We need to better understand why participants agree or refuse to enter drug trials, and why both primary care physicians and Alzheimer's specialists agree or refuse to involve their patients. We also need to quantify the impact of requiring imaging studies, extensive questionnaires, cognitive testing, and lumbar punctures on recruitment and retention. With these concerns in mind, an international task force meeting of experts from academia and industry in the United States, European Union, and Japan in San Diego, California on November 2, 2011 to focus on recruitment, retention and other methodological issues related to clinical trials for AD. Based on the recommendations of this Task force meeting, this Perspectives article critically reflects on the most critical and timely methodological issues related to recruitment and retention in prevention and therapeutic trials in AD, which are paralleled by a paradigm shift in the diagnostic conceptualization of this disease, as reflected by recently new proposed diagnostic criteria involving preclinical stages of the disease.     

医用仿真乳房教具模型结合PBL教学法在乳腺外科临床教学中的应用

乳腺外科的特点是患者群体以女性为主、疾病所在部位是女性的第二性征部位,如何处理好保护患者隐私权与临床学习、工作之间的关系也是问题之一。以问题为基础的教学法（Problem—basedlearning,PBL）是一种以自我学习为主,教师引导的新型教学方法。采用PBL教学法实施乳腺外科临床教学,应用医用仿真乳房教具模型,可以锻炼并提高学生的检诊技巧,减少患者隐私部位暴露时间,启迪学生关注人文,提高医患沟通能力,处理好患者隐私权与临床教学需要的矛盾。     

Rheumatoid Arthritis

Rheumatoid arthritis is a common inflammatory joint disorder, with a prevalence of about 1% in the general population. It shows high variability with respect to its course and prognosis. In typical cases an insidious onset of symmetrical synovitis of the small joints of the hands and feet occurs, accompanied by symptoms such as morning stiffness, weakness and fatigue. Besides clinical findings, laboratory tests and imaging techniques are other cornerstones for diagnosis of rheumatoid arthritis.Rheumatoid arthritis is anything but a benign disease, potentially leading to disability, chronic pain, morbidity and even early death. Recent studies provide strong evidence that early diagnosis and treatment are crucial for the prognosis of the disease. In recent years, great efforts have been made to detect and establish diagnostic, as well as prognostic, parameters for rheumatoid arthritis. Whereas the reliability of new diagnostic parameters has not been proven conclusively, reliable prognostic factors have been established that may help in identifying patients at high risk for progressive, disabling disease. These risk factors include: high number of joints involved at onset, marked disability, elevated acute phase reactants, a positive finding for rheumatoid factor, female gender, advanced age, presence of certain HLA class II antigens, early x-ray changes, low bone mineral density and job-related physical requirements.As the established classification criteria cover longstanding disease, but not the early stages, it appears necessary to establish a new set of diagnostic criteria for early rheumatoid arthritis. In the case of newly diagnosed rheumatoid arthritis, more attention should be paid to well-known risk factors. This allows a risk profile to be established for individual patients, which may facilitate decisions regarding therapy. A better outcome of rheumatoid arthritis would not only be advantageous for individual patients, but would also result in reduced costs for healthcare systems.     

医用仿真乳房教具模型结合PBL教学法在乳腺外科临床教学中的应用

乳腺外科的特点是患者群体以女性为主、疾病所在部位是女性的第二性征部位,如何处理好保护患者隐私权与临床学习、工作之间的关系也是问题之一。以问题为基础的教学法(Problem-based learning,PBL)是一种以自我学习为主,教师引导的新型教学方法。采用PBL教学法实施乳腺外科临床教学,应用医用仿真乳房教具模型,可以锻炼并提高学生的检诊技巧,减少患者隐私部位暴露时间,启迪学生关注人文,提高医患沟通能力,处理好患者隐私权与临床教学需要的矛盾。     

A simple decision analytic solution to the comparison of two binary diagnostic tests

One of the most basic biostatistical problems is the comparison of two binary diagnostic tests. Commonly, one test will have greater sensitivity, and the other greater specificity. In this case, the choice of the optimal test generally requires a qualitative judgment as to whether gains in sensitivity are offset by losses in specificity. Here, we propose a simple decision analytic solution in which sensitivity and specificity are weighted by an intuitive parameter, the threshold probability of disease at which a patient will opt for treatment. This gives a net benefit that can be used to determine which of two diagnostic tests will give better clinical results at a given threshold probability and whether either is superior to the strategy of assuming that all or no patients have disease. We derive a simple formula for the relative diagnostic value, which is the difference in sensitivities of two tests divided by the difference in the specificities. We show that multiplying relative diagnostic value by the odds at the prevalence gives the odds of the threshold probability below which the more sensitive test is preferable and above which the more specific test should be chosen. The methodology is easily extended to incorporate combinations of tests and the risk or side effects of a test. Copyright © 2012 John Wiley & Sons, Ltd.     

Diagnostic significance of cold provocation test at 12°C

In Germany, vibration-induced white finger (VWF) disease is accepted as an occupational disease (BK No. 2104 BKV), for which compensation may be paid provided that the sociolegal requirements are met in accordance with the list of occupational diseases that is valid at the time. A cold provocation test (thermometry, infrared thermography) is helpful in the diagnosis of VWF and we believe that it could contribute to the standardization of vascular assessment methods. In Germany, the approved degree of the decrease in earning power is downgraded as disease symptoms improve with time; therefore, insured individuals suffering from VWF are regularly reassessed every 1–3 years. In the context of such follow-up examinations and the assessment of reversibility of this disease, a standardized cold provocation test is of central importance. Currently, there is a lack of data that confirm the diagnostic value of this test. Further investigations on VWF patients to validate the use of the cold provocation test in obtaining sufficient data for determining the satisfactory diagnostic value of this test are required.     

Problems with Psychodiagnostics at “Environmental Patients”

The classification of environmental illnesses (e. i.) as a somatic disease is related to several problems with regard to the proof of chemical agents causing the syndrome. Also the understanding of those disorders as a mental illness interferes with some problems. One problem is the fact that in literature there are some dozen different terms for e. i. Nobody knows if the various authors talk about the same group of patients or if there are subgroups of patients etc. Furtheron there are quite marked differences at the symptom profiles which have to be explained.For those reasons a more sophisticated measurement and analysis of symptoms of environmental patients is necessary.If e. i. is supposed to be a psychopathological phenomenon the pecularities of the criteria of the various diagnostic categories must be carefully considered. For instance, the classification according to somatization disorders does not fit well into clinical experience and also therapeutically seems to be not very fruitful.