Les infiltrations de corticoïdes en cabinet de médecine générale (pratiques, réticences et souhaits)

CONTEXTE : Les pathologies rhumatologiques sont rencontrées quotidiennement en médecine ambulatoire. Leur fréquence risque de s accroître devant le vieillissement de la population et l augmentation des troubles musculo-squelettiques. Il est donc important de connaître les fondements des pratiques d infiltration du médecin généraliste, premier acteur de santé consulté. OBJECTIF : Appréhender le vécu, le ressenti des généralistes, pour mieux comprendre leurs pratiques, réticences et désirs sur les infiltrations de corticoïdes pratiquées au cabinet. METHODE : Une recherche qualitative a été effectuée par 14 entretiens individuels semi-structurés auprès de médecins généralistes de Savoie. L échantillonnage était varié. Une analyse thématique des verbatim fut conduite par triangulation des chercheurs après retranscription intégrale des entretiens. RESULTATS : L analyse des résultats a permis de faire émerger 6 thèmes. La pratique était détaillée avec le choix des pathologies infiltrées, les techniques d asepsie et le ressenti des médecins. Les non pratiquants exprimaient leurs réticences comme le manque de preuve scientifique, le manque de moyens, le manque de formation, le faible coût de revient d une infiltration. Nous avons pu identifier les barrières à cette pratique comme les nouvelles technologies, le coût élevé, le manque de pratique, les difficultés d asepsie du cabinet, la difficulté de gérer les comorbidités et les limites du médecin lui-même. Les médecins ont détaillé les formations reçues ainsi qu une formation idéale qui les aiderait à pratiquer. Les complications conduisaient à un changement de comportement. Les médecins ont exprimé leurs pensées sur la pratique de leurs confrères et les relations entre médecins et avec les patients. CONCLUSION : Cette étude nous a permis de percevoir les fondements de la pratique des infiltrations en médecine générale. Il est important d adapter la formation des médecins généralistes et revoir le coût lié aux infiltrations, avant que les autres spécialités médicales et chirurgicales ne soient débordées.BACKGROUND: Musculoskeletal disorders are daily encountered in outpatient medicine. Their frequency is likely to increase due to the aging population and the increase in musculoskeletal disorders. Therefore, it is important to know the basics corticosteroid injections practice by General Practitioner (GP), first health care provider. OBJECTIVE: To understand the experiences, the feelings of GPs, to better understand their practices, reluctances and desires on corticosteroid injections performed in the office. METHODS: A qualitative research was conducted by 14 individual semi-structured interviews with GPs from Savoy. The sample was varied. A thematic analysis of verbatim triangulation was conducted by researchers after full retranscription of the interviews. RESULTS: Analysis of the results led to six themes. The practice was detailed with the choice of infiltrated diseases, aseptic techniques and the feelings of doctors. Non-practitioners expressed their reservations as the lack of scientific evidence, the lack of resources, the lack of training, the low cost of infiltrations. We were able to identify barriers to the practice as new technologies, high cost, lack of practical, difficulties for asepsis in the office, the difficulty of managing comorbidities and limitations of the doctor himself. The doctors detailed the training received and an ideal one to help them to practice. Complications led to a change in behavior. Doctors have expressed their thoughts on the practice of their colleagues and the relationships between doctors and patients. CONCLUSION: This study allowed us to see the foundations of the practice of infiltration in general practice. It is important to adapt the training of general practitioners, review the cost to infiltration before other medical and surgical specialties are overwhelmed.GRENOBLE1-BU Médecine pharm. (385162101) / SudocSudocFranceF

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IA évolutionniste pour la détection de comportements déviants dans les SI

De nombreuses méthodes IA supervisées ou non supervisées sont utilisées pour la détection d'anomalies et d'attaques. Pour apporter davantage de contexte et d'interprétabilitéà l'analyste SOC, cet article introduit une nouvelle approche d'apprentissage continu de la normalité et de détection de comportement anormal (nouveau ou déviant) avec la production d'une synthèse facilement interprétable par un analyste SOC. Cette approche s'appuie sur des stratégies IAévolutionnistes, des fonctions d'attentions auto paramétrables et des motivations intrinsèques de développement de connaissances comportementales. Dans un esprit d'accroissement de la confiance des analystes envers les algorithmes IA, ce modèle démontre de bonnes capacités de découverte de règles comportementales interprétables et de détection de comportements anormaux dans des logs applicatifs générés par un nouveau simulateur de Système d'Information (SI)

Severity of COVID-19 and survival in patients with rheumatic and inflammatory diseases: data from the French RMD COVID-19 cohort of 694 patients

International audienceObjectives: There is little known about the impact of SARS-CoV-2 on patients with inflammatory rheumatic and musculoskeletal diseases (iRMD). We examined epidemiological characteristics associated with severe disease, then with death. We also compared mortality between patients hospitalised for COVID-19 with and without iRMD.Methods: Individuals with suspected iRMD-COVID-19 were included in this French cohort. Logistic regression models adjusted for age and sex were used to estimate adjusted ORs and 95% CIs of severe COVID-19. The most significant clinically relevant factors were analysed by multivariable penalised logistic regression models, using a forward selection method. The death rate of hospitalised patients with iRMD-COVID-19 (moderate-severe) was compared with a subset of patients with non-iRMD-COVID-19 from a French hospital matched for age, sex, and comorbidities.Results: Of 694 adults, 438 (63%) developed mild (not hospitalised), 169 (24%) moderate (hospitalised out of the intensive care unit (ICU) and 87 (13%) severe (patients in ICU/deceased) disease. In multivariable imputed analyses, the variables associated with severe infection were age (OR=1.08, 95% CI: 1.05-1.10), female gender (OR=0.45, 95% CI: 0.25-0.80), body mass index (OR=1.07, 95% CI: 1.02-1.12), hypertension (OR=1.86, 95% CI: 1.01-3.42), and use of corticosteroids (OR=1.97, 95% CI: 1.09-3.54), mycophenolate mofetil (OR=6.6, 95% CI: 1.47-29.62) and rituximab (OR=4.21, 95% CI: 1.61-10.98). Fifty-eight patients died (8% (total) and 23% (hospitalised)). Compared with 175 matched hospitalised patients with non-iRMD-COVID-19, the OR of mortality associated with hospitalised patients with iRMD-COVID-19 was 1.45 (95% CI: 0.87-2.42) (n=175 each group).Conclusions: In the French RMD COVID-19 cohort, as already identified in the general population, older age, male gender, obesity, and hypertension were found to be associated with severe COVID-19. Patients with iRMD on corticosteroids, but not methotrexate, or tumour necrosis factor alpha and interleukin-6 inhibitors, should be considered as more likely to develop severe COVID-19. Unlike common comorbidities such as obesity, and cardiovascular or lung diseases, the risk of death is not significantly increased in patients with iRMD

COVID-19 outcomes in patients with inflammatory rheumatic and musculoskeletal diseases treated with rituximab: a cohort study

International audienceBackground: Various observations have suggested that the course of COVID-19 might be less favourable in patients with inflammatory rheumatic and musculoskeletal diseases receiving rituximab compared with those not receiving rituximab. We aimed to investigate whether treatment with rituximab is associated with severe COVID-19 outcomes in patients with inflammatory rheumatic and musculoskeletal diseases.Methods: In this cohort study, we analysed data from the French RMD COVID-19 cohort, which included patients aged 18 years or older with inflammatory rheumatic and musculoskeletal diseases and highly suspected or confirmed COVID-19. The primary endpoint was the severity of COVID-19 in patients treated with rituximab (rituximab group) compared with patients who did not receive rituximab (no rituximab group). Severe disease was defined as that requiring admission to an intensive care unit or leading to death. Secondary objectives were to analyse deaths and duration of hospital stay. The inverse probability of treatment weighting propensity score method was used to adjust for potential confounding factors (age, sex, arterial hypertension, diabetes, smoking status, body-mass index, interstitial lung disease, cardiovascular diseases, cancer, corticosteroid use, chronic renal failure, and the underlying disease [rheumatoid arthritis vs others]). Odds ratios and hazard ratios and their 95% CIs were calculated as effect size, by dividing the two population mean differences by their SD. This study is registered with ClinicalTrials.gov, NCT04353609.Findings: Between April 15, 2020, and Nov 20, 2020, data were collected for 1090 patients (mean age 55·2 years [SD 16·4]); 734 (67%) were female and 356 (33%) were male. Of the 1090 patients, 137 (13%) developed severe COVID-19 and 89 (8%) died. After adjusting for potential confounding factors, severe disease was observed more frequently (effect size 3·26, 95% CI 1·66-6·40, p=0·0006) and the duration of hospital stay was markedly longer (0·62, 0·46-0·85, p=0·0024) in the 63 patients in the rituximab group than in the 1027 patients in the no rituximab group. 13 (21%) of 63 patients in the rituximab group died compared with 76 (7%) of 1027 patients in the no rituximab group, but the adjusted risk of death was not significantly increased in the rituximab group (effect size 1·32, 95% CI 0·55-3·19, p=0·53).Interpretation: Rituximab therapy is associated with more severe COVID-19. Rituximab will have to be prescribed with particular caution in patients with inflammatory rheumatic and musculoskeletal diseases

Severity of COVID-19 and survival in patients with rheumatic and inflammatory diseases: data from the French RMD COVID-19 cohort of 694 patients

International audienceObjectives: There is little known about the impact of SARS-CoV-2 on patients with inflammatory rheumatic and musculoskeletal diseases (iRMD). We examined epidemiological characteristics associated with severe disease, then with death. We also compared mortality between patients hospitalised for COVID-19 with and without iRMD.Methods: Individuals with suspected iRMD-COVID-19 were included in this French cohort. Logistic regression models adjusted for age and sex were used to estimate adjusted ORs and 95% CIs of severe COVID-19. The most significant clinically relevant factors were analysed by multivariable penalised logistic regression models, using a forward selection method. The death rate of hospitalised patients with iRMD-COVID-19 (moderate-severe) was compared with a subset of patients with non-iRMD-COVID-19 from a French hospital matched for age, sex, and comorbidities.Results: Of 694 adults, 438 (63%) developed mild (not hospitalised), 169 (24%) moderate (hospitalised out of the intensive care unit (ICU) and 87 (13%) severe (patients in ICU/deceased) disease. In multivariable imputed analyses, the variables associated with severe infection were age (OR=1.08, 95% CI: 1.05-1.10), female gender (OR=0.45, 95% CI: 0.25-0.80), body mass index (OR=1.07, 95% CI: 1.02-1.12), hypertension (OR=1.86, 95% CI: 1.01-3.42), and use of corticosteroids (OR=1.97, 95% CI: 1.09-3.54), mycophenolate mofetil (OR=6.6, 95% CI: 1.47-29.62) and rituximab (OR=4.21, 95% CI: 1.61-10.98). Fifty-eight patients died (8% (total) and 23% (hospitalised)). Compared with 175 matched hospitalised patients with non-iRMD-COVID-19, the OR of mortality associated with hospitalised patients with iRMD-COVID-19 was 1.45 (95% CI: 0.87-2.42) (n=175 each group).Conclusions: In the French RMD COVID-19 cohort, as already identified in the general population, older age, male gender, obesity, and hypertension were found to be associated with severe COVID-19. Patients with iRMD on corticosteroids, but not methotrexate, or tumour necrosis factor alpha and interleukin-6 inhibitors, should be considered as more likely to develop severe COVID-19. Unlike common comorbidities such as obesity, and cardiovascular or lung diseases, the risk of death is not significantly increased in patients with iRMD