La Revue du praticien最新文献

METHODS OF CEREBRAL STIMULATION IN PSYCHIATRY. Psychiatric disorders are a frequent reason for consultation, accounting for 15% of general medical visits. Some patients have severe disorders, meaning they have a significant impact on their daily functioning. Others have treatment-resistant disorders, defined as an insufficient response to at least two antidepressant treatments prescribed at an adequate dosage for a sufficient length of time. Some symptoms are inacessible to pharmacological treatment. Because of their systemic action, pharmacological therapies may expose patients to adverse metabolic or neurological effects. Brain stimulation is a new therapeutic approach that helps mitigate systemic adverse effects through its focal action. Various brain stimulation techniques are used in routine clinical practice in France (electroconvulsive therapy) or within the research field (rTMS: repetitive transcranial magnetic stimulation, TDCS: transcranial direct-current stimulation, DBS: deep brain stimulation, and VNS: vagus nerve stimulation).

NEW TECHNIQUES OF PROSTATE IRRADIATION. Radiotherapy is a leading treatment in the management of prostate cancer. Technological developments and experience have made it possible to develop innovative techniques, to carry out shorter treatments, with fewer sessions and similar effectiveness, with a good control of toxicity. Historical treatments involving 40 sessions have been replaced by much shorter cycles of 20 sessions and even as few as 5 sessions in carefully selected cases. The hindsight seems sufficient, and ongoing studies suggest the installation of new treatment standards, and in the goal for the future is one session treatments.

THROMBOTIC MICROANGIOPATHIES. The syndrome of thrombotic microangiopathy (TMA) is defined by the combination of mechanical hemolytic anemia, consumptive thrombocytopenia, and organ failure secondary to microvascular obstruction by microthrombi. TMAs include thrombotic thrombocytopenic purpura and atypical hemolytic uremic syndrome and require specific therapies that have significantly improved the prognosis ; post-infectious HUS (including shigatoxin-associated HUS), and secondary TMAs that occur in specific contexts (infection, neoplasia, transplantation, autoimmune disease, medication or toxin exposure, severe hypertension, etc.). The main etiological entities, their pathophysiology, clinical phenotypes, and appropriate management, are reviewed below, with a focus on situations requiring specific and urgent treatment.

WHAT ARE THE KEY TAKEAWAYS FROM THE HAS RECOMMENDATIONS REGARDING SPECIAL POPULATIONS (ELDERLY POPULATIONS AND PREGNANCY OR PLANNING TO BECOME PREGNANT) ? Type 2 diabetes in elderly patients is a common reason for consultation in general practice. Its management is challenging due to the heterogeneity of this particular population, which often combines age-related and diabetes-related complications. A geriatric assessment is necessary to set glycemic targets and define the therapeutic strategy. Therapeutic means are based on lifestyle modifications combined with medical treatment with particular attention to the risk of hypoglycemia and malnutrition. The indications for cardio- and nephroprotective treatments are the same as for younger subjects. Regular reassessment of health status is necessary and therapeutic deintensification should be considered when appropriate.

PHARMACOLOGICAL MANAGEMENT OF NON-INSULIN-TREATED TYPE 2 DIABETES: PRACTICAL IMPLEMENTATION OF HAS GUIDELINES. French health authorities' guidelines for type 2 diabetes were updated in May 2024. These guidelines provide a framework for the appropriate positioning of various therapeutic options in the management of type 2 diabetes. Lifestyle modifications and metformin remain the first-line treatment. A paradigm shift introduced by these new recommendations emphasizes the need to prioritize cardiovascular and renal status over glycemic control when initiating therapy. Consequently, these guidelines recommend early use of SGLT2 inhibitors (sodium-glucose co-transporter 2 inhibitors) or GLP-1 receptor agonists in patients requiring secondary cardiovascular prevention. In cases of chronic kidney disease or heart failure, SGLT2 inhibitors are preferred, followed by GLP-1 receptor agonists.

Sarcoma: A PLURAL ENTITY. Sarcoma are a heterogeneous group of 150 different histopathological entities, developed from soft tissues or bone of any anatomical location.Their estimated incidence is around 70 cases for 100 000 people. They can occur in patients of any age, including children, the median age of onset being around 60 years. Most sarcomas are sporadic, since predisposing factors are rare. In France, the treatment of patiens with sarcomas must be carried out, within a center belonging to Netsarc+ networt as soon as a diagnosis is suspected, to offer them a better prognosis, mostly explained by the quality of the surgery, a major prognostic factor in these diseases.

LIFESTYLE MODIFICATIONS IN TYPE 2 DIABETES: YES, BUT HOW ? Management of type 2 diabetes relies above all on sustainable lifestyle changes, including physical activity, diet, therapeutic education and psychological support. These approaches must be personalized and integrated into a comprehensive treatment plan. Adapted physical activity, a real treatment, requires prior assessment and can be prescribed within a structured framework. Dieticians must provide individualized support for diets, avoiding restrictive diets. Therapeutic patient education, although sometimes difficult to access, encourages autonomy and commitment. Digital tools, local resources and professionals trained in education can make this possible. Psychological support, though often neglected, is essential. To be effective, this strategy requires going beyond theoretical discourse and proposing concrete solutions, adapted to the realities of each patient, by mobilizing available local resources.

THE DIAGNOSIS OF SARCOMA REQUIRES TEAM EXPERTISE. Sarcoma is the prototype of the "rare cancer" which suff ers from a sometimes complicated diagnostic pathway. This is all the truer for soft tissue sarcomas for which the clinical signs are not very specific or even falsely reassuring. The key message is that any patient with a suspected sarcoma must be referred as soon as possible to an expert "sarcoma" center belonging to the NetSarc+ network to benefit from the expertise both diagnostically and therapeutically. In the centers of this expert network, the diagnostic phase begins with radiological expertise both on the analysis of tumor semiology and on the taking of specific samples for diagnostic purposes. This precious sample allows the expert pathologist to apply the most accurate techniques to off er a precise diagnosis and determine the grade of malignancy, paving the way for personalized treatment.