Quel bilan pour une gonarthrose avant prothèse

National audienceWork up before a total knee arthroplasty for knee osteoarthritis is part of a clinical care pathway which should be patient-centered, needing a best interdisciplinary communication and collaboration to inform patients about the balance benefits/risk linked to the knee arthroplasty and to obtain an agreement between patient and health's professionals, essential feature of the shared decision-making process or patient’ preferences sensitive. This decision-making is based on the patient's history, search of general risk factors, comorbidities, physical examination, measure of knee function, radiographs, work up for infection sources, assessment of risk linked to anesthesia and orthopedic surgery, and delivering information to patients.Le bilan avant prothèse de genou pour une gonarthrose fait partie d’un parcours de soins qui devrait être centré sur le patient, nécessitant une meilleure concertation interdisciplinaire pour informer le patient de la balance bénéfices/risques liés à la pose d’une prothèse de genou et obtenir un accord mutuel entre le patient et les professionnels de santé, caractéristique essentielle du processus de « décision partagée » ou de « révélation des préférences des patients ». Cette décision repose sur les données de l’interrogatoire, la recherche des facteurs de risques généraux et des comorbidités, l’examen physique, l’évaluation de la gêne fonctionnelle, le bilan radiologique, la recherche de foyers infectieux, l’évaluation des risques liés à l’anesthésie et à la chirurgie orthopédique, et l’information au patient

Traitement de l'ostéoporose/Osteoporosis treatment

International audienc

Pathologies du genou : de l’enfant à l’adulte ; de la physiopathologie à la clinique et la médecine fondée sur les preuves [Knee disorders: From childhood to adulthood, and from pathophysiology to clinical practice and evidence-based medicine]

National audiencePourquoi une nouvelle monographie sur le genou ?.

Prise en charge de la crise de goutte en soins primaires en Polynésie Française (questionnaire auprès de médecins généralistes et état des lieux des connaissances )

La goutte est la pathologie rhumatismale inflammatoire la plus fréquente chez l'homme. Cette étude évaluait la prise en charge de la crises de goutte en soins primaires en Polynésie Française. Elle a été réalisée de Mars à Juillet 2011 à Tahiti, via un questionnaire par mail adressé aux 68 médecins généralistes (MG) libéraux de Tahiti inclus. Le pourcentage de réponse était de 33,8 %. La colchicine et les anti-inflammatoires non stéroïdiens (AINS) étaient prescrits dans plus de la moitié des cas par respectivement 86,9 % et 56,5 % des MG. 60,8 % et 52,2 % des MG étaient confrontés respectivement à une demande expresse et à une automédication par AINS chez plus de la moitié de leur patientèle. 65,2 % d'entre eux ont constaté une inobservance du traitement de fond chez plus de la moitié de leurs patients. Avec une prévalence de l'hyperuricémie à 21 % en 1995, la goutte est un problème de santé publique en Polynésie Française et le polynésien est un goutteux difficile à traiter. La fréquence des comorbidités associées rend délicate l'utilisation des thérapeutiques usuelles, de nouvelles thérapeutiques étant parfois une alternative. L'éducation est la clé du traitement et doit concerner les règles hygiéno-diététiques, l'observance, l'automédication, les comorbidités et le suivi biologique. Certains aspects socioculturels pourraient expliquer l'échec des campagnes de prévention.Gout is the most common inflammatory joint disease in men. The aim of this study was to evaluate the management of goût in primary care in French Polynesia. This study was conducted from March to July 2011 in Tahiti through a questionnaire sent by mail to Gps of Tahiti. Of 68 Gps included, the response rate was 33.8 %. Colchicine and non-steroidal anti-inflammatory drugs (NSAIDs) were prescribed in more than half the cases by respectively 86.9 % and 56.5 % of physicians. 60.8 % and 52.2 % of prescribers were respectively confronted with a specific request and with a self-medication with NSAIDs in more than half of their patients. The prevalence of hyperuricemia was 21 % in 1995. goût is a public health problem in French Polynesia and the Polynesian population has a difficult-to-treat gout. The frequency of comorbidities makes it difficult to use conventional therapies, new therapies are sometimes and alternative. Education is the key to treatment and should involve lifestyle and dietary advice, compliance, self-medication, comorbidities, biological monitoring. Some sociocultural aspects could explain the failure of prevention campaigns.RENNES1-BU Santé (352382103) / SudocSudocFranceF

Obésité, hyperuricémie et goutte

National audienceLes associations entre hyperuricémie et comorbidités comme l’hypertension (HTA), l’obésité et le syndrome métabolique (SM) ont été démontrées dans de nombreuses études épidémiologiques. Les interactions entre l’uricémie et les autres comorbidités métaboliques augmentent le risque de goutte. L’IMC est associé à une augmentation du risque de goutte selon un effet « dose-dépendant ». La prévalence du SM est remarquablement élevée chez les sujets goutteux et augmente substantiellement avec l’importance du taux d’uricémie. On a montré que plusieurs composantes du SM étaient des facteurs de risque indépendants pour la survenue de la goutte. L’obésité et l’hypertriglycéridémie peuvent potentialiser l’effet de l’uricémie dans le développement de la goutte. La goutte est associée à une augmentation du risque de développer un diabète de type 2 (DT2) : l’insulinorésistance joue un rôle clé potentiel dans la relation causale entre SM, DT2 et hyperuricémie. On a montré que l’HTA est un facteur de risque indépendant de goutte dans plusieurs études. L’hyperuricémie pourrait aussi prédire la survenue de l’obésité, du SM et du DT2, de l’HTA et des maladies cardiovasculaires. La perte de poids a un effet bénéfique chez les obèses hyperuricémiques et chez les goutteux, et améliore les comorbidités associées à l’obésité, comme le fait la chirurgie bariatrique. Le niveau de preuve démontrant le bénéfice thérapeutique des modifications diététiques chez les patients goutteux est faible. Les règles hygiéno-diététiques peuvent réduire le risque de goutte récurrente, mais contribueraient aussi à améliorer la santé globale en diminuant le risque de maladies cardiovasculaires. Il faut privilégier les mesures pharmacologiques et hygiéno-diététiques qui peuvent améliorer à la fois l’uricémie et les comorbidités. Abstract The associations between hyperuricemia and comorbidities, such as hypertension, obesity, and metabolic syndrome (MS), have been shown in many epidemiologic studies. The interactions between serum uric acid (sUA) and other metabolic comorbidities increase the risk of gout. BMI is associated with increased risk of gout according to a dose-dependent effect. The prevalence of MS is remarkably high among individuals with gout and increases substantially with increasing levels of serum uric acid. Several components of the metabolic syndrome have been shown to be independent risk factors for the development of gout. Obesity and hypertriglyceridemia may potentiate a sUA effect for gout development. Gout is associated with an increased risk of developing Diabetes Mellitus: insulin resistance plays a potentially key role in the causal relationship between metabolic syndrome, type 2 diabetes and hyperuricemia. Hypertension was found to be an independent risk factor for gout in several studies. Hyperuricemia also could predict the development of obesity, metabolic syndrome and diabetes, hypertension and cardiovascular diseases. Weight loss has urate-lowering benefits in obese hyperuricaemic or gout patients, and improves comorbidities associated with obesity, as bariatric surgery did. Evidence regarding the therapeutic benefit of dietary modification in patients with gout is low. Lifestyle modification can reduce the risk of recurrent gout, but would also contribute to improve major health in decreasing the risk of cardiovascular disease. The lifestyle and pharmacologic measures that can improve serum urate level and comorbidities together should be preferre

Apprentissage en binôme collaboratif dans l'enseignement pratique de la formation initiale des pédicures-podologues : une enquête de terrain

National audienceContext: In France, podiatry students work in pairs (near-peer: two students from different cohorts) during clinical practice training sessions organized by the podiatry teaching institute. Aim: To evaluate the collaborative work from a peer-perspective (degree of satisfaction, scheme experience and anticipated training progress). Method: An online questionnaire that included ten closed and one open question was designed. It was first handed out in class and then through Facebook to young graduates. Results: The percentage of positive opinions for all closed questions was over 50%. The quality of practice training sessions was considered adequate or very adequate. The strong points identified by students on closed questions related to the significance of peer-work learning in the care center, the lack of discomfort in asking questions, the ability to explain the links between diseases, morphologies and environment on the one hand and the therapeutic approach on the other. On the whole, students mention that they were satisfied with the pairing. Conclusion: Students seem to appreciate the educational scheme. However, its organization would deserve to be better institutionalized and recognized in order for students to see it as an opportunity rather than an obligation in their training as professional practitioners. For tutor competencies to be recognized, a tutoring course could be recommended to students as early as the first year of training.Contexte : En France, les étudiants en pédicurie podologie se forment en binôme de pairs sur les compétences techniques lors des stages pratiques dans les instituts de formation. But : Évaluer le vécu des étudiants lors de cette formation collaborative en binômes : degré de satisfaction, vécu du dispositif et évolution souhaitée de la formation. Méthode : Un questionnaire en ligne combinant dix questions fermées et une question ouverte a été conçu. Il a été diffusé, d’une part, en présentiel et, d’autre part, via le réseau social Facebook pour les jeunes diplômés. Résultats : Le pourcentage d’opinions positives pour l’ensemble des questions fermées était supérieur à 50 %. La qualité du stage était jugée satisfaisante et très satisfaisante. Les points forts identifiés par les étudiants dans les questions fermées concernaient l’importance du travail en binôme dans leur apprentissage au pôle de soin, l’absence de gêne pour poser des questions, la capacité d’expliquer simplement, d’une part, les liens entre pathologies, morphologies et environnement, d’autre part, la démarche thérapeutique. De manière générale, les étudiants notent qu’ils sont à l’aise avec leur binôme. Conclusion : Ce dispositif pédagogique semble être apprécié des étudiants. Toutefois, l’organisation mériterait d’être mieux institutionnalisée et reconnue, afin que les étudiants le voient d’abord comme une chance pour leur formation de clinicien et non comme une obligation imposée par l’institution. Pour reconnaître les compétences de tuteur des étudiants, une formation au tutorat pourrait être proposée aux étudiants dès la première année de formation

Reproducibility of CT-based bone texture parameters of cancellous calf bone samples: Influence of slice thickness.

International audienceBone microarchitecture is an important determinant of the fracture risk, independently of bone mineral density. At present, bone biopsy is required for microarchitecture assessment, and accessible non-invasive techniques are needed. In this study, we tested the short-term reproducibility and parameter changes of a non-invasive method for microarchitecture assessment with a medical computed tomography. Texture parameters (run lengths and co-occurrence) were extracted from bone sample images. Reproducibility and the influence of slice thickness (1, 3, 5 and 8mm) were also studied. After five repositionings, short-term reproducibility was found to be good. All run length parameters but one fell significantly with increasing slice thickness. Co-occurrence parameters showed different patterns of change. Short-term coefficients of variation of texture parameters used to assess bone microarchitecture were similar to those obtained elsewhere with other techniques. The results were influenced by slice thicknesses, emphasizing the importance of the conditions of acquisition

Concordance between fresh joint fluid analysis by the rheumatologist and joint fluid analysis at the laboratory: Prospective single-center study of 180 samples

International audienceOBJECTIVES: To assess the diagnosis usefulness of fresh joint fluid analysis by the rheumatologist. METHODS: Prospective single-center 1-year study at a university hospital in Rennes, France. A rheumatologist determined whether the freshly collected fluid suggested a mechanical or inflammatory condition and contained monosodium urate (MSU) and/or calcium pyrophosphate (CCP) microcrystals. Agreement between the rheumatologist results and laboratory results was assessed based on the kappa coefficient (κ). We then determined the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of joint fluid analysis by the rheumatologist and by the laboratory, using the final diagnosis based on the full set of clinical, laboratory, and imaging findings as the reference standard. RESULTS: We included 180 joint fluid samples. The κ values were 0.80 for mechanical or inflammatory fluid, 0.97 for presence of MSU microcrystals, and 0.69 for presence of CCP microcrystals. The rheumatologist findings had 94.2% sensitivity and 84.6% specificity for inflammation; corresponding values were 80.7% and 100% for MSU microcrystals and 66.7% and 93.2% for CCP microcrystals. CONCLUSION: Fresh joint fluid examination by the rheumatologist shows good to excellent agreement with the laboratory analysis for determination of the mechanical or inflammatory nature of the fluid and for detection of MSU and CCP microcrystals

Usefulness and limitations of rapid urine dipstick testing for joint-fluid analysis. Prospective single-center study of 98 specimens

International audienceOBJECTIVE: To evaluate the diagnostic performance of rapid urine reagent strip testing of joint fluid in separating mechanical from inflammatory disease. METHODS: In a prospective single-center 12-month study of joint fluid specimens, leukocyte esterase reagent strip testing (LERST) was compared to leukocyte counts used as the reference standard. Leukocyte counts greater than 2000/mm(3) were taken to indicate inflammation. Reproducibility of LERST was evaluated by testing 73 specimens twice and computing Cohen's kappa coefficient. RESULTS: Ninety-eight joint fluid specimens (26 with mechanical and 72 with inflammatory characteristics) were evaluated. LERST had 79.2% sensitivity, 92.3% specificity, 96.6% positive predictive value, 61.5% negative predictive value, a positive likelihood ratio of 10.3, and a negative likelihood ratio of 0.23. The kappa coefficient was 0.70 (0.53-0.87). Two negative LERSTs a few minutes apart had 80% negative predictive value and a negative likelihood ratio of 0.08. CONCLUSION: LERST of joint fluid is a rapid means of satisfactorily separating mechanical from inflammatory joint fluids

Risk of cutaneous adverse events with febuxostat treatment in patients with skin reaction to allopurinol. A retrospective, hospital-based study of 101 patients with consecutive allopurinol and febuxostat treatment

International audienceObjective To investigate the cutaneous tolerance of febuxostat in gouty patients with skin intolerance to allopurinol. Methods We identified all gouty patients who had sequentially received allopurinol and febuxostat in the rheumatology departments of 4 university hospitals in France and collected data from hospital files using a predefined protocol. Patients who had not visited the prescribing physician during at least 2 months after febuxostat prescription were excluded. The odds ratio (OR) for skin reaction to febuxostat in patients with a cutaneous reaction to allopurinol versus no reaction was calculated. For estimating the 95% confidence interval (95% CI), we used the usual Wald method and a bootstrap method. Results In total, 113 gouty patients had sequentially received allopurinol and febuxostat; 12 did not visit the prescribing physician after febuxostat prescription and were excluded. Among 101 patients (86 males, mean age 61 ± 13.9 years), 2/22 (9.1%) with a history of cutaneous reactions to allopurinol showed skin reactions to febuxostat. Two of 79 patients (2.5%) without a skin reaction to allopurinol showed skin intolerance to febuxostat. The ORs were not statistically significant with the usual Wald method (3.85 [95% CI 0.51–29.04]) or bootstrap method (3.86 [95% CI 0.80–18.74]). Conclusion The risk of skin reaction with febuxostat seems moderately increased in patients with a history of cutaneous adverse events with allopurinol. This moderate increase does not support the cross-reactivity of the two drug