La Revue du praticien最新文献

The "Assessment - Acute Treatment - Reassessment - Relay" approach is still the basis of acute pain management for adults in the emergency department, and intravenous morphine titration remains the cornerstone of severe pain management. However, new recommendations, incorporating all the latest scientific and contextual developments, have led to challenge its place, and to modify the treatment approach. As a general rule, an initial protocol at triage should be followed by multimodal, individualized management for each patient, taking into account the possibility of induced pain, and analgesic relays after the emergency stay should be adapted to the new benefit/risk balance of opioids (from all classes) especially for ambulatory patients.

Vascular diseases of the liver include damage to arterial and venous vessels, both hepatic and perihepatic. The main venous forms are Budd-Chiari syndrome (BCS), portal vein thrombosis (PVT) and porto-sinusoidal vascular disease (PSVD), defined by the location of the thrombotic obstruction. BCS corresponds to an obstruction of the hepatic veins, PVT to an obstruction of the portal vein with a risk of cavernoma, and PSVD to damage the intrahepatic microcirculation without cirrhosis. These rare diseases mainly affect young adults and cause portal hypertension in the absence of underlying liver disease. Myeloproliferative neoplasms are a common risk factor, among other systemic causes (coagulation disorders, antiphospholipid antibodies, infections, pregnancy) or local causes (inflammation, surgery).

The World Tourism Organization estimates that between 195 and 375 million people traveled to high altitudes in 2019. The high prevalence of cardiorespiratory diseases in the general population, combined with the increasing number of elderly travelers, suggests that a significant proportion of these individuals may have underlying health conditions. Hypoxia, the main physiological challenge at high altitude, requires adaptive responses from the cardiorespiratory system, which are often impaired in patients with cardiac or pulmonary diseases. This population is at particular risk of decompensation and altitude intolerance symptoms. Therefore, a thorough medical assessment, including evaluation of comorbidities and consultation with a mountain medicine specialist, may be essential prior to high-altitude travel or long-haul flights.

Chronic kidney disease (CKD) in children has an epidemiology that differs significantly from that in adults. Its main causes vary with age with a predominance of congenital anomalies of the kidney and the urinary tract. Early diagnosis is essential to prevent complications affecting growth, cognition, and long-term cardiovascular health, and to avoid, or at least to slow, progression to end-stage renal disease. Specific clinical contexts warrant targeted screening: family history, perinatal abnormalities, at-risk conditions, or suggestive clinical signs. Screening relies on simple tools such as growth charts, dipstick urinalysis, blood pressure measurement, glomerular filtration rate estimation, and renal ultrasound. The general practitioner plays a key role in the early detection of CKD, and in ensuring early referral to pediatric nephrology, helping to preserve nephron mass and improve long-term outcomes.

Borderline Personality Disorder (BPD) is common, affecting 2 to 6 % of the general population, with a high prevalence in psychiatric settings. It is characterized by emotional, relational instability and impulsivity, often associated with suicidal behaviors and comorbid disorders (anxiety, depression, addictions). Understanding BPD relies on the concept of relational hypersensitivity, rooted in an altered self-concept. The biopsychosocial approach explains its origins through the interaction between genetic vulnerability and emotional invalidation during childhood, exacerbated by trauma. Treatment primarily involves cognitive-behavioral therapies (CBT), such as Dialectical Behavior Therapy (DBT), which promote emotional regulation and reduce self-harming behaviors. Management should include thorough evaluation and education focused on relational hypersensitivity. Although limited, pharmacological treatments can address specific dimensions of BPD but require cautious prescription.

Vascular liver diseases (VLD) are rare and their diagnosis can be difficult and late, leading to a delay in treatment. Diagnosis is most often multidisciplinary, involving primarily the clinician but also the radiologist and pathologist. In all cases, attention should be drawn to the absence of the usual causes of liver disease; conversely, a context of pathology associated with VLD may be a suggestive factor. The two main ways in which porto-sinusoidal vascular disease is discovered are unexplained abnormal liver tests and portal hypertension (PHT) without cirrhosis. In the case of acute splanchnic thrombosis (mainly portal), the main symptom is abdominal pain. The intensity of symptoms varies greatly, and the diagnosis may be overlooked and established late, at the stage of portal cavernoma and possibly complications of PHT. Budd-Chiari syndrome can mimic any acute or chronic liver disease, with the most common presentation being ascites/hepatomegaly/abdominal pain. Many clinical situations should raise the suspicion of VLD, which is based on dialogue between the clinician, radiologist, and pathologist. Early diagnosis allows for optimal patient management, particularly through anticoagulant therapy and treatment of PHT.