Diagnostic validity and triage concordance of a physiotherapist compared to physicians' diagnoses for common knee disorders.

BACKGROUND: Emergence of more autonomous roles for physiotherapists warrants more evidence regarding their diagnostic capabilities. Therefore, we aimed to evaluate diagnostic and surgical triage concordance between a physiotherapist and expert physicians and to assess the diagnostic validity of the physiotherapist's musculoskeletal examination (ME) without imaging. METHODS: This is a prospective diagnostic study where 179 consecutive participants consulting for any knee complaint were independently diagnosed and triaged by two evaluators: a physiotherapist and one expert physician (orthopaedic surgeons or sport medicine physicians). The physiotherapist completed only a ME, while the physicians also had access to imaging to make their diagnosis. Raw agreement proportions and Cohen's kappa (k) were calculated to assess inter-rater agreement. Sensitivity (Se) and specificity (Sp), as well as positive and negative likelihood ratios (LR+/-) were calculated to assess the validity of the ME compared to the physicians' composite diagnosis. RESULTS: Primary knee diagnoses included anterior cruciate ligament injury (n = 8), meniscal injury (n = 36), patellofemoral pain (n = 45) and osteoarthritis (n = 79). Diagnostic inter-rater agreement between the physiotherapist and physicians was high (k = 0.89; 95% CI:0.83-0.94). Inter-rater agreement for triage recommendations of surgical candidates was good (k = 0.73; 95% CI:0.60-0.86). Se and Sp of the physiotherapist's ME ranged from 82.0 to 100.0% and 96.0 to 100.0% respectively and LR+/- ranged from 23.2 to 30.5 and from 0.03 to 0.09 respectively. CONCLUSIONS: There was high diagnostic agreement and good triage concordance between the physiotherapist and physicians. The ME without imaging may be sufficient to diagnose or exclude common knee disorders for a large proportion of patients. Replication in a larger study will be required as well as further assessment of innovative multidisciplinary care trajectories to improve care of patients with common musculoskeletal disorders.

Efficacy of transcutaneous electrical nerve stimulation for rotator cuff tendinopathy: a systematic review.

OBJECTIVE: To perform a systematic review on the efficacy of transcutaneous electrical nerve stimulation (TENS) for the treatment of rotator cuff tendinopathy in adults. METHODS: A literature search was conducted in four databases (CINAHL, Embase, PubMed and PeDRO) for randomised controlled trials published from date of inception until April 2015, comparing the efficacy of TENS for the treatment of rotator cuff tendinopathy with placebo or any other intervention. Risk of bias was evaluated using the Cochrane risk of bias tool. Results were summarised qualitatively. RESULTS: Six studies were included in this review. The mean methodological score was 49% (standard deviation 16%), indicating an overall high risk of bias. One placebo-controlled trial reported that a single TENS session provided immediate pain reduction for patients with rotator cuff tendinopathy, but did not follow the participants in the short, medium or long term. Two trials that compared ultrasound therapy with TENS reported discrepancy and contradictory results in terms of pain reduction and shoulder range of motion. Corticosteroid injections were found to be superior to TENS for pain reduction in the short term, but the differences were not clinically important. Other studies included in this review concluded that TENS was not superior to heat or pulsed radiofrequency. CONCLUSION: Due to the limited number of studies and the overall high risk of bias of the studies included in this review, no conclusions can be drawn on the efficacy of TENS for the treatment of rotator cuff tendinopathy. More methodologically sound studies are needed to document the efficacy of TENS. Until then, clinicians should prefer other evidence-based rehabilitation interventions proven to be efficacious to treat patients with rotator cuff tendinopathy.

[Mood and cognitive disorders, and androgen deprivation]. / Troubles de l'humeur et cognitifs et suppression androgénique.

Prostate cancer has become a chronic disease. In this context, it is important to take into account the quality of life of patients and their family in the therapeutic approach. Recent studies have demonstrated the importance of depression and the risk of suicide in patients with prostate cancer as well as the repercussions of the disease on the spouse and their relationship. The implication of hormonal treatment in the increase in risk of depression is difficult to affirm. Few studies have investigated this subject and they present methodological biases. Some authors report an increased risk of cognitive decline in patients on androgen deprivation. However, even if certain physiopathological hypotheses have been put forward, the imputability of the treatment on the alteration of cognitive functions has not been clearly established. Urologists are at the forefront of diagnosis and treatment of prostate cancer occurring most often in elderly subjects. Therefore, given the prevalence of depression syndromes and/or the alteration of cognitive functions in this population, the urologist must be aware of these different factors, which are potentially aggravated by the introduction of androgen deprivation. Based on a review of the recent literature, the authors suggest using a simple depression screening tool: confirmation of the diagnosis and management is within the competence of the general practitioner. As for the risk of cognitive decline, it seems difficult to imagine, and not necessarily relevant, to systematically propose a battery of neuropsychometric screening tests. On the other hand, giving the patient the G8 screening test can allow the urologist to assess whether the patient needs a geriatric consultation or not.

A systematic review of interventions promoting clinical information retrieval technology (CIRT) adoption by healthcare professionals.

PURPOSE: This paper presents the evidence on the effectiveness of interventions promoting the use of clinical information retrieval technologies (CIRTs) by healthcare professionals. METHODS: We electronically searched articles published between January 1990 and March 2008 using following inclusion criteria: (1) participants were healthcare professionals; (2) specific intervention promoted CIRT adoption; (3) studies were randomised controlled trials, controlled clinical trials, controlled before and after studies or interrupted time series analyses; and (4) they objectively reporting measured outcomes on CIRT use. RESULTS: We found nine studies focusing on CIRT use. Main outcomes measured were searching skills and/or frequency of use of electronic databases by healthcare professionals. Three studies reported a positive effect of the intervention on CIRT use, one showed a positive impact post-intervention, and four studies failed to demonstrate significant intervention effect. The ninth study examined financial disincentives, and found a significant negative effect of introducing user fees for searching MEDLINE in clinical settings. A meta-analysis showed that educational meetings were the only type of interventions reporting consistent positive effects on CIRT adoption. CONCLUSION: CIRT is an information and communication technology commonly used in healthcare settings. Interventions promoting CIRT adoption by healthcare professionals have shown some success in improving searching skills and use of electronic databases. However, the effectiveness of these interventions remains uncertain and more rigorous studies are needed.

[The therapeutic alliance in the initial stages of the management of depression by the general practitioner]. / L'alliance thérapeutique au début d'une prise en charge pour dépression par le généraliste.

In the field of depression, good initial management is crucial for the subsequent treatment. A relationship based on trust is essential. This can be of various types: there is no consensus on what is the "best" type of relationship. General practitioners diagnose more than two-thirds of depression and write out more than one third of prescriptions for antidepressors. Physicians are faced with various problems in the management of depressed patients: lack of time during the consultation, insufficient training in depression and its treatment, absence of somatic markers, fear of suicide risks... To specify the problems and elaborate responses, this survey assessed, mirror-wise, the point of view of the patient and that of the physician, the feelings regarding the pathology and its treatment, during consultations when the physician is confronted with a depression syndrome. Patient anonymousness was guaranteed by the use of a ballot box and sealed envelopes. In both parties, the survey explored the perception and experience of the pathology, the patient-physician relationship, and the history and perception of the initial consultations. Eligible patients were those who had been diagnosed with depression by the general practitioner and who had been informed of this during the past three months. Based on this information, and other than the data regarding the pathology, the procedure for establishing the diagnosis, the conditions in which the diagnosis was announced and the treatment measures, a characterisation of the alliance between the patient and the physician was established based on the combination of the patients' and physicians' data. Homogenous patient-physician groups were thus identified using multiple component factorial analysis followed by mixed classification. This methodology identified types of patient-physician binomials according to the nature of their alliance (independent of any "doctor effect"): a clinical alliance, a united alliance, an alliance based on sense, and a difficult alliance.

Meeting the challenges of neurosurgery. The 2006 presidential address.

The challenges faced by neurosurgery in 2006 are many. There are five principal challenges that have received a great deal of attention from the Board of Directors of the American Association of Neurological Surgeons this past year. These are the challenge of maintaining a modern, efficient, and responsive educational program for neurosurgery; the challenge of maintaining the boundaries of neurosurgical practice and preventing the incursion of subspecialty groups into the performance of neurosurgical procedures; the challenge of responding to the changing demands of society; the challenge of influencing increased reimbursement; and the challenge of creating meaningful medical liability reform. Each of these issues are discussed.

[Cognitive aging in chronic psychotic patients]. / Vieillissement cognitif des psychotiques chroniques.

OBJECTIVE: The cognitive aging of psychotic patients is still poorly apprehended and sometimes wrongly compared with demential or pseudo-demential deterioration. We studied the impact of chronic psychosis on cognitive performance in the elderly. PATIENTS AND METHODS: We estimated cognitive performance in two groups of 15 patients each among persons on old-age pensions or living in geriatric nursing homes. One group included patients who had already showed dissociative or non-dissociative chronic psychosis and the other group persons with no previous psychotic signs. Cognitive estimations were made on the basis of Folstein's Mini Mental State (MMS) score and Signoret's Battery of Cognitive Efficacy (BEC 96). Results obtained in the two groups were compared with the Mann and Whitney non-parametric test. RESULTS: The psychiatric patients showed a significant deficiency compared with the others for memory and executive functions and also a much broader range of scores on the BEC96 that demonstrated deficiency among the psychiatric patients. DISCUSSION: Though these findings must be interpreted with caution, they do demonstrate a trend similar to that observed in young schizophrenics and also to that of the cognitive performances observed in older schizophrenics and demented subjects. Patients with dissociated or non-dissociated psychotic disorders show an apparent relative cognitive deficiency irrespective of age. The psychotic elderly appear to exhibit a cognitive clash much more than a simple pseudo-demential deficiency.

[Typology of elderly patients hospitalized in psychiatry: evaluation of psychiatric antecedents before age 60]. / Typologie des patients âgés hospitalisés en psychiatrie: importance des antécédents psychiatriques avant l'âge de 60 ans.

To take care of elderly patients in psychiatric hospital sets specific problems. It is interesting to know the mode, the frequency, and the reasons of these hospitalizations, to improve the medical care given to these subjects. We made a prospective study with elderly patients hospitalized in a psychiatric institution. The results were completed in discussions with the medical care staff. During the study (January and February 1997), 112 elderly patients, about more than 60 years old, were hospitalized in Villejuif' specialized hospital (inpsychiatric units). Informations about social facts, main psychiatric previous, reasons of the hospitalization, the caring and the evolution of these subjects were collected. The main important reflexion we did observe was the significant difference between elderly patients hospitalized in psychiatric units, with or without psychiatric previous before the age of 60. Those who were hospitalized at the first time in psychiatric units before 60, presented a medium aged population, younger than the other group. They also presented more delusion with psychosis, were more frequently hospitalized longly in psychiatric units, took neuroleptics, and their somatic associate pathologies were less difficult to take care of. In the second group including the elderly patients without psychiatric previous before 60, we did observe very different characteristics: the diagnosis of most of the patients is dementia; these elderly subjects leaved mostly at home, they presented more sadness, aggression, or social inappropriate behaviour. Depression is a more frequent diagnosis. This study of all the elderly patients admitted in a psychiatric hospital confirmed the population's heterogeneity. The existence of an hospitalisation in psychiatric unit before sixty represented a pertinent test to a major and simple approach of these differences. The psychiatric unit which receives more and more elderly patients take care of their differences to the organisation of care needs between the gerontopsychiatric patients types. The patients with a late gerontopsychiatric's disease could need a specific hospitalization in gerontopsychiatric units, especially organised to deliver psychiatric cares and somatic cares, including medical geriatric practicer and medical care staff formed to the dependence need care.

[Evaluation of medical web sites. Interobserver and intraobserver reliability of an evaluation tool]. / Evaluation des sites web médicaux. Fidélité interobservateur et intraobservateur d'un outil d'évaluation.

OBJECTIVE: To develop and test the reliability of a tool for rating websites that provide information on evidence-based medicine. DESIGN: For each site, 60% of the score was given for content (eight criteria) and 40% was given for organization and presentation (nine criteria). Five of 10 randomly selected sites met the inclusion criteria and were used by three observers to test the accuracy of the tool. Each site was rated twice by each observer, with a 3-week interval between ratings. SETTING: Laval University, Quebec city. PARTICIPANTS: Three observers. MAIN OUTCOME MEASURES: The intraclass correlation coefficient (ICC) was used to rate the reliability of the tool. RESULTS: Average overall scores for the five sites were 40%, 79%, 83%, 88%, and 89%. All three observers rated the same two sites in fourth and fifth place and gave the top three ratings to the other three sites. The overall rating of the five sites by the three observers yielded an ICC of 0.93 to 0.97. An ICC of 0.87 was obtained for the two overall ratings conducted 3 weeks apart. CONCLUSION: This new tool offers excellent intraobserver and interobserver measurement reliability and is an excellent means of distinguishing between medical websites of varying quality. For best results, we recommend that the tool be used simultaneously by two observers and that differences be resolved by consensus.

[Alzheimer type dementia: is early diagnosis significant?]. / Démence d'Alzheimer: le diagnostic précoce a-t-il un intérêt?

ADVANTAGES OF EARLY DIAGNOSIS: Better prognosis and quality of life for patients with Alzheimer's disease and their caregivers depends on early diagnosis as specific treatment (anticholinesterase drugs) early in the disease process can have a beneficial effect on cognition and psychiatric or behavioral disorders. In addition early diagnosis gives the physician the opportunity to provide adapted advice for the patient and caregivers especially important in preventing complications and helping the family cope with the inevitable disruption of the family pattern caused by the disease, a situation which is particularly for the "designated caregiver". PREDEMENTIA STATES: The question of early diagnosis raises several types of problems. Defining the limits of the disease is particularly difficult: when does Alzheimer type dementia start? what is the definition of predementia? A growing body of work suggests that it is warranted to identify patients at risk of developing Alzheimer type dementia since, according to certain authors, they can benefit from specific treatment. RISK FACTORS: The only fully recognized risk factors are age, family history of dementia and presence of the allele epsilon 4 of the apolipoprotein E gene. There are probably several other risk factors. Their identification is a current subject of debate. TOOLS FOR EARLY DIAGNOSIS: Psychometric tests have been shown to provide specific information useful for interpreting the clinical assessment which must focus on detecting early signs and exploring even minimal memory deficiencies.

[Management of patients and their families]. / Prise en charge des patients et des familles.

The management of Alzheimer's disease is currently undergoing profound upheavals. The advent of specific treatments for the disease is largely responsible for those changes. Psychiatrists are directly involved in that approach. They play a very important role in the pluridisciplinary approach to patients and their families. The management of the disease shows, in fact, that management consists in long-term accompaniment of the patient, of course, but also of the family, qualified as the "natural caregiver", and that the two are indissociable. A review of the natural course of the disease enables restitution of the concomitant progress of the entourage's experience and the problems encountered by the family. The various studies on caregivers stress the importance of the psychological burden, the risk of depression and, above all, the position of behavioral symptoms in their quality of life. WHO has formulated recommendations concerning caregivers, and while they are simply common sense, they deserve to be restated: carefully evaluating their capacities and work load and informing them on the disease may enable them to benefit from support and, above all, enable periods of respite to be arranged. Lastly, the resources available for management need to be understood, even though the list is far from complete and a certain number of resources have yet to be fully evaluated and defined.

[Drug use in the elderly. Use of psychotropic drugs in the elderly: overuse or underuse?]. / Médicaments et sujets âgés. L'utilisation des psychotropes chez le sujet âgé: trop ou trop peu?

POORLY DEFINED USE: The first of three leading problems in the use of psychotropic drugs in elderly subjects is related to the overall situation of their use, often tainted by an ìideologicalî point of view. Prescribers are ìforî or ìagainstî psychotropic and justify their prescription by the need to take into account the general situation rather than strictly clinical arguments. Some prescriptions are written for the family or institutions. Even the definition of the elderly subject is extremely vague and is generally taken to include subjects over 65, a very heterogeneous group. Too few studies have been devoted to subjects over 80. NEED FOR GOOD CLINICAL ANALYSIS: The second type of problem is raised by the clinical expression of psychotic disorders in the elderly, too often considered to be limited to the classical signs of depression, dementia, and confusion. A careful clinical analysis is essential before prescription, with an adapted therapeutic response to each pathological situation. In addition, good clinical analysis would allow better diagnosis of depression, a condition largely underestimated and undertreated. BY THERAPEUTIC CLASS: It is now classical to denounce inappropriate use of neuroleptics and question their efficacy in controlling behavioral disorders in dementia. This attitude results from the impact of the adverse effects. Several authors have emphasized the contribution of new antipsychotic drugs but very few controlled studies have been reported. For antidepressors, the current consensus would suggest that prescription doses are generally insufficient and treatment durations too short. Finally, though it is widely accepted that use of benzodiazepines should be limited in dose and duration, data on drug use however show the contrary, emphasizing the difficulty in changing habits. New compounds including thymoregulators are increasingly used for elderly subjects but here again, like for antipsychotic drugs, too few studies have been published and many points remain to be elucidated.

Faculty evaluation in departments of family medicine: do our universities measure up?

Family medicine programmes at Canadian universities have expanded dramatically over the past several years. The development of effective means of faculty evaluation is a real concern for these departments as they strive to maintain the high quality of their teaching programmes in the face of rapid change. The literature on faculty evaluation, including reviews and articles discussing the application of faculty evaluations, is reviewed. The current state of faculty evaluation at three Canadian family medicine department has also been surveyed. Student evaluations were found to be valid, accurate and well studied. They are not perfect, however, and require the use of additional methods such as peer review or video review in conjunction in order to provide a comprehensive evaluation of all areas of faculty activity. Faculty evaluation in family medicine teaching units and community-based settings has not been well studied. Our survey of faculty evaluation at three Canadian universities shows much room for improvement, particularly in community-based settings where evaluation is almost non-existent. Expanding the use of faculty evaluations for formative means and linking evaluation to faculty development opportunities are essential if improvements to the currently used systems are to be successful and accepted by faculty. Special consideration must be given to community-based settings where systems designed for use in larger university settings will need to be modified substantially before they can be used effectively. Further research is required in this area.

[4 years using clozapine in community psychiatry]. / Quatre ans d'utilisation de la clozapine en psychiatrie de secteur.

This study report clinical experience of Clozapine treatment in 48 chronic schizophrenic patients. At the study time, 35 patients are still under this treatment while 13 patients have stopped it. These two populations and their differences are presented. Clozapine experience is positive as testifies quality of life and social situation improvement in numerous cases.

Carbonic anhydrase in mouse skeletal muscle and its influence on contractility.

Carbonic anhydrase III (EC 4.2.1.1) is the most abundant cytosolic protein in type I skeletal muscle fibers. Investigations of its physiological role have mostly been conducted with rat muscles, which sometimes are unsuitable for in vitro studies. The objective of the present study was to characterize the carbonic anhydrase in the mouse soleus muscle to verify if this muscle can be used as a model to further study the enzyme's function. Total carbonic anhydrase specific activity in the mouse soleus was comparable to the value for rat. However, 60% of the total carbonic anhydrase activity in the mouse was of the sulfonamide-sensitive type and, therefore, not related to carbonic anhydrase III. Electrophoretic analysis revealed the presence of a 29-kDa protein in total and cytosolic extracts of the mouse soleus. Immunoblotting with an antibody developed against rat carbonic anhydrase III showed that it was also specific for this 29-kDa peptide, which presumably is the mouse carbonic anhydrase III. Inhibition of the sulfonamide-sensitive activity had no effect on contractile and fatigue characteristics, whereas inhibition of the sulfonamide-resistant carbonic anhydrase III activity led to a significant increase in resistance to fatigue. We conclude that the mouse soleus may represent an excellent model to understand the contribution of different carbonic anhydrase isoforms to muscle physiology.

Effect of carbonic anhydrase III inhibition on substrate utilization and fatigue in rat soleus.

Carbonic anhydrase III (CA III; EC 4.2.1.1) is the most abundant cytosolic enzyme in type I skeletal muscle fibers. We have previously shown that inhibiting the CA III activity of type I muscle can influence fatigability. Our goal was to test the hypothesis that the influence on fatigability of CA III inhibition is linked to an increased utilization of carbohydrates. Rat soleus muscles were incubated in vitro in a physiological solution with or without CA inhibitor (methazolamide, 1 mM) and submitted to a fatigue protocol. When the bathing solution contained glucose, the muscles incubated with methazolamide maintained a higher level of tension production than control muscles for the first 55-60 min of the test compared with 35-40 min when glucose was not added. Measurement of muscle glycogen content revealed that muscles incubated with CA inhibitor were utilizing their glycogen at a higher rate than control muscles over the first 45 min of the fatigue protocol. When glycolysis was inhibited with sodium iodoacetate, fatigability was not influenced by the addition of a CA inhibitor. These results further support the existence of a link between CA III activity and energy metabolism in type I skeletal muscle fibers.

In vitro regulation of the innervation pattern of quail muscle fibers by quail and mouse neurons.

Myoblasts from rudiments of slow and fast muscle, anterior latissimus dorsi (ALD) and posterior latissimus dorsi (PLD) respectively, of 9-day-old quail embryos were cultured in vitro for a period of up to 60 days in order to give rise to well-differentiated muscle fibres. These fibres were innervated by neurons from either quail or mouse embryo spinal cord and their innervation pattern was examined by the visualization of acetylcholine receptors (ACh-R) and of acetylcholinesterase (ACh-E) activity at the neuromuscular contacts. In the culture system used, quail neurons always innervated muscle fibres at several sites and only when a fast-type activity was imposed on these neurons did a reduction in the number of the previously established neuromuscular contacts take place. In contrast, in the muscle fibres innervated by mouse neurons, a spontaneous reduction in the number of the previously established neuromuscular contacts occurred but this spontaneous reduction depended upon the level of differentiation reached by the muscle fibres in vitro. In the cultures of muscle fibres previously innervated by mouse neurons, the addition of quail neurons did not provoke any modification in the initial innervation pattern, and no quail ACh-R cluster was observed. In contrast, in the muscle fibres previously innervated by quail neurons, the mouse neurons contacted these fibres, resulting in a decrease in the number of quail ACh-R clusters. These results emphasize the part played by neurons in the establishment of the innervation pattern when muscle fibres have reached a high level of differentiation. In vitro, the slow and fast characteristics of the muscle fibres do not influence this pattern.