General practitioner’s strategy for dealing with the depressed patient

Eric Constant Published in the journal : July 2019 Category : ECU-Congrès de médecine générale

The general practitioner is confronted daily with patients with depressive symptoms. The first step is to establish a correct differential diagnosis and a first-line treatment plan. Often, this first treatment will have to be reviewed, modified and complexified, in order to allow the patient to obtain a substantial symptomatic improvement and to arrive at symptomatic remission, which should be the goal of any management. Key Words

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Transaminases : When should it be considered?

Perrine Vande Berg, Peter Stärkel (1) Published in the journal : July 2019 Category : ECU-Congrès de médecine générale

An elevation in aminotransferases may be of multiple etiologies and should be investigated. In this article, the different etiologies of increased aminotransferase blood levels are being reviewed, with a systematic approach to interpret transaminase alterations proposed. It is essential to establish whether aminotransferase blood levels are either acutely or chronically disturbed. A thorough assessment of personal and family past-medical history and exposure to toxics, medications, and dietary supplements should be obtained. Subsequently, given an acute perturbation, a baseline blood assessment for various viral etiologies must include HBs antigen, anti-HBc antibody, and IgM antibodies for hepatitis A, hepatitis E, EBV, CMV, HSV, VSV, and HIV. A liver Doppler ultrasound should be performed to exclude vascular etiologies.

Concerning chronic disturbances, alcohol consumption must be detailed, and metabolic syndrome sought using physical examination and biological parameters. In addition, one should screen for hepatitis B and C viral infection and for hemochromatosis (ferritin levels and transferrin saturation). In a second step, liver autoimmune and genetic diseases are to be looked for. A Doppler ultrasound of the liver should be performed in the event of chronic perturbation with the aim to assess the presence of steatosis and signs of cirrhosis. Any patient with severe acute hepatic impairment and chronic B or C viral infection or autoimmune, metabolic, and genetic disorders must be referred to a specialized centre.

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Doctor, I have tingling hands

Olivier Barbier, Xavier Libouton (1) Published in the journal : July 2019 Category : ECU-Congrès de médecine générale

Complaints of tingling and numbness in the hands are common. These paresthesias are most often indicative of a compressive neuropathy affecting the nerves of the hand. Compression of the median nerve in the carpal tunnel is the most common, followed by compression of the ulnar nerve in the cubital tunnel at the elbow. More rarely, the median nerve is compressed at the arcade of the pronator teres in the forearm and the ulnar nerve in the Guyon’s canal at the wrist. Other compression sites also affecting the radial nerve, mainly under fibromuscular tunnels (distributed from the thoracic outlet to the distal part of the limb), and cervical root compressions may also cause paresthesias. The diagnosis is mainly clinical, but can be complemented by electromyography and ultrasound. The treatment is usually conservative in early stages, consisting in avoiding stress on the nerve and in corticosteroid infiltrations. If symptoms persist, surgical decompression gives good results and prevents sequelae if performed sufficiently early.

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Doctor, my fingers are curling

Xavier Libouton, Olivier Barbier (1) Published in the journal : July 2019 Category : ECU-Congrès de médecine générale

A patient who consults for curling fingers is a common situation in hand surgery. Based on history taking, it is possible to distinguish between an acute and chronic condition. In acute cases, patients often report a trauma. The differential diagnosis includes tendon injury or osteoarticular involvement, which are not discussed here.

In case of chronic symptoms, two pathological conditions must be considered, namely Dupuytren's disease and trigger finger. The diagnosis is mainly clinical, but can be assisted by ultrasound if necessary. For Dupuytren's disease, the treatment is usually conservative as long as the palm of the hand can be completely laid down on a flat surface. When this is no longer possible, treatment of the symptom, i.e. contracture, may be considered. Collagenase (Xiapex®) injections are the currently preferred treatment option. To date, there is no cure for this disease. Regarding trigger finger, corticosteroid infiltrations are the first-line treatment to be privileged. First-line surgery should only be considered in case of secondary trigger finger, where studies have shown a trend towards recurrence following infiltrations.

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Doctor, I have an ache in my hand

Olivier Barbier, Xavier Libouton (1) Published in the journal : July 2019 Category : ECU-Congrès de médecine générale

Hand and wrist osteoarticular pain usually results from osteoarthritis-related degenerative alterations. Osteoarthritis has two main causes: age-related spontaneous degeneration and post-traumatic degeneration. Traumas lead to direct osteoarticular lesions or instability secondary to bone deformities and ligamentous lesions. The treatment of primary osteoarthritis, dominated by rhizarthrosis (base of the thumb), is initially conservative, using anti-inflammatory drugs (per os and by local massages) and resting splints. Corticosteroid or hyaluronic acid infiltrations can be used as second-line treatment. Finally, surgical prosthetic or non-prosthetic arthroplasty usually yields good results in more severe cases. In post-traumatic situations, early recognition of instability may allow surgical stabilization to be performed so as to prevent pain and secondary degenerative lesions. Radiography, CT-arthrography and MR-arthrography are the examinations of choice to complete the clinical examination.

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Endometriosis: When should it be considered?

Jean Squifflet, Vassiliki Samartzi 1 Published in the journal : July 2019 Category : ECU-Congrès de médecine générale

Three steps play a key role when assessing patients with suspected endometriosis.

First step: Patient’s clinical history and symptoms (dysmenorrhea, dyspareunia, dyschesia and chronic pelvic pain). Although there is no evidence of a relationship between patient’s symptoms and the presence and severity of endometriotic lesions, the implemented or proposed medical / surgical treatment depends on the context in which endometriosis is observed.

The second step is the physical examination, including evaluation of the posterior vaginal fornix and of the Douglas pouch, which detects more lesions that are missed on ultrasonography and magnetic resonance imaging.

The third step is imaging. A recent meta-analysis found no difference in the detection of endometriotic lesions between ultrasound and magnetic resonance imaging, but these examinations should be performed by a radiologist with expertise in this field.

To date, the final diagnosis of endometriosis is made by laparoscopy with biopsies of the lesions.

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Immunotherapy: successes and prospects

Jean-Francois Baurain Published in the journal : May 2019 Category : ECU-Congrès de médecine générale

Immune checkpoint inhibitors, such as anti-PD1/PD-L1 antibodies, have changed the treatment of several cancers.The survival of cancer patients has drastically improved, with some of them showing complete and durable responses. A number of patients are likely to be cured of their metastatic cancer. This should encourage further research from academic or pharmaceutical teams in an effort to increase the efficacy of modern immunotherapy.

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Monoclonal gammopathy of undetermined significance

Julien Depaus Published in the journal : May 2019 Category : ECU-Congrès de médecine générale

Monoclonal gammopathy of undetermined significance (MGUS) is commonly diagnozed in the general population, particularly the elderly. The condition carries a risk of progression to myeloma or other lymphoproliferative disorders and, thus, warrants regular follow-up. MGUS patients can be risk-stratified based on both the amount and type of the monoclonal protein and light-chain ratio.

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Cardiac stress test: For whom? Why? How?

Agnès Pasquet Published in the journal : May 2019 Category : ECU-Congrès de médecine générale

This article reviews the main indications for stress testing and the different kinds of stress tests that can be performed in patients in the cardiological setting.

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Direct oral anticoagulants: How to choose?

Christophe Scavée Published in the journal : May 2019 Category : ECU-Congrès de médecine générale

Atrial fibrillation (AF) is a major cause of stroke. To prevent this devastating complication, anticoagulants are recommended in some patients. Two classes of oral anticoagulants can be used for this indication: anti-vitamin K (AVK) agents, such as warfarin, and direct-acting non-vitamin K oral anticoagulants, also called new oral anticoagulants (NOACs). NOACs include agents with two distinct modes of action: direct factor Xa inhibitors (apixaban, rivaroxaban, edoxaban) on the one hand and direct thrombin inhibitors (dabigatran) on the other hand. These molecules have been compared individually to warfarin: While showing similar efficacy, they had a better safety profile in terms of bleeding, with a lower risk of hemorrhagic stroke and intracranial hemorrhage. They are therefore preferred over AVKs.

The choice of the anticoagulant is made on a case-by-case basis, always taking into account the risk of stroke (using anticoagulants in patients without thromboembolic risk factors is currently not recommended) and bleeding (dosage!). These two aspects should be assessed prior to any prescription. When choosing an anticoagulant agent, the physician should also consider the presence of coronary artery disease (concomitant use of antiplatelet therapy), the patient's age and weight (dose adjustment!), renal function (important for dabigatran), the patient’s preference (once daily vs twice daily administration), and the patient’s understanding of the treatment, which is decisive for therapeutic compliance. It should be noted that dabigatran is currently the only NOAC for which a specific reversal agent is available that can be used in some cases when emergency surgery is required or major bleeding has to be controlled.

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