La Revue du praticien最新文献

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.

SYSTEMIC TREATMENT OF BONE SARCOMA, SOFT TISSUE SARCOMA, GIST. In osteosarcomas and Ewing sarcomas, the interest of systemic treatments is established in neo-adjuvant and adjuvant setting. Effective molecules are doxorubicin, alkyls, vinca-alkaloids and etoposide in Ewing's sarcomas, and methotrexate, doxorubicin, cisplatin, ifosfamide and etoposide in osteosarcoma. Several ongoing clinical studies raise the question of the value of maintenance treatment, including anti-angiogenic tyrosine kinase inhibitors. In soft tissue sarcomas, anthracyclines remain the reference molecules, either in the adjuvant (neo) or metastatic setting. Other anti-angiogenic chemotherapy molecules or tyrosine kinase inhibitors are authorized whose effectiveness differs depending on the histological subtype. In the adjuvant setting, many questions remain about the optimal use of chemotherapy and the selection of patients who could benefit from such a strategy. In high-risk gastro intestinal stromal tumor (GIST), the standard is 3 years adjuvant treatment with imatinib; a recent study asks whether treatment should continue for up to 6 years. In metastatic GIST, patients are treated with 4 successive lines of more or less specific tyrosine kinase inhibitors: imatinib, sunitinib, regorafenib, riprenib.

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.