ABSTRACT
The placebo effect is one of the mechanisms at work in the success of comprehensive care. It relies on psychological, biological and environmental mechanisms. If its effectiveness has been documented, it should be noted that its power of effect remains weak and that it depends on the context. Although real, the placebo effect is remembered to be associated with manipulation concerning the success of a treatment, we pose as an ethical defender of its use. This article aims to recall the psychobiological mechanisms at work and to replace the placebo effect in clinical practice.
L'effet placebo, un phénomène fréquemment évoqué dans la société, est souvent sous-estimé par la communauté médicale. Pourtant, il repose sur des mécanismes psychologiques, biologiques et environnementaux solidement documentés dans la littérature scientifique. Des études ont démontré son efficacité sur une vaste gamme de symptômes et de pathologies. L'objectif de cet article est de rappeler les mécanismes psychobiologiques impliqués, de réintégrer l'effet placebo dans la pratique clinique quotidienne et de fournir un aperçu des études consacrées à ce sujet.
Subject(s)
Neurosciences , Placebo Effect , HumansABSTRACT
In cases of severe bleeding on direct oral anticoagulant (DOAC) therapy, several hemostatic agents can be used with varying levels of evidence, including fresh frozen plasma and prothrombin complex concentrates. Recently, we have seen the emergence of specific antidotes to DOAC, such as idarucizumab and andexanet alfa, effective on anti-II and anti-Xa DOAC respectively. These new molecules have shown excellent biological efficacy, hence supporting their use in clinical practice, however they are not routinely used, mainly due to limited availability and high cost. Ciraparantag, an antagonist of DOAC and heparins currently in phase III trials, could become a key molecule in the future considering encouraging preliminary results.
En cas d'hémorragie sévère sous traitement par un anticoagulant oral direct (ACOD), plusieurs agents hémostatiques peuvent être utilisés avec un niveau d'évidence variable, notamment le plasma frais congelé et les concentrés de complexe prothrombinique. Récemment, nous avons vu l'émergence d'antidotes spécifiques aux ACOD, comme l'idarucizumab et l'andexanet alfa, neutralisant les ACOD anti-II et anti-Xa respectivement. Ces nouvelles molécules ont montré une bonne efficacité biologique justifiant leur utilisation en pratique mais leur administration n'est pas encore systématique, en raison notamment d'une disponibilité restreinte et d'un coût élevé. Le ciraparantag, antagoniste des ACOD et des héparines, en cours d'étude de phase III, pourrait devenir une molécule clé à l'avenir au vu de résultats préliminaires encourageants.
Subject(s)
Anticoagulants , Dabigatran , Administration, Oral , Anticoagulants/pharmacology , Anticoagulants/therapeutic use , Antidotes/therapeutic use , Dabigatran/therapeutic use , Hemorrhage/drug therapy , Heparin, Low-Molecular-Weight/therapeutic use , Humans , Recombinant ProteinsABSTRACT
Lung ultrasonography (LUS) is an accurate method of estimating lung congestion but there is ongoing debate on the optimal number of scanning points. The aim of the present study was to compare the reproducibility (i.e. interobserver agreement) and the feasibility (i.e. time consumption) of the two most practiced protocols in patients hospitalized for acute heart failure (AHF). This prospective trial compared 8- and 28-point LUS protocols. Both were performed by an expert-novice pair of sonographers at admission and after 4 to 6 days on patients admitted for AHF. A structured bio-clinical evaluation was simultaneously carried out by the treating physician. The primary outcome was expert-novice interobserver agreement estimated by kappa statistics. Secondary outcomes included time spent on image acquisition and interpretation. During the study period, 43 patients underwent a total of 319 LUS exams. Expert-novice interobserver agreement was moderate at admission and substantial at follow-up for 8-point protocol (weighted kappa of 0.54 and 0.62, respectively) with no significant difference for 28-point protocol (weighted kappa of 0.51 and 0.41; P value for comparison 0.74 at admission and 0.13 at follow-up). The 8-point protocol required significantly less time for image acquisition at admission (mean time difference - 3.6 min for experts, - 5.1 min for novices) and interpretation (- 6.0 min for experts and - 6.3 min for novices; P value < 0.001 for all time comparisons). Similar differences were observed at follow-up. In conclusion, an 8-point LUS protocol was shown to be timesaving with similar reproducibility when compared with a 28-point protocol. It should be preferred for evaluating lung congestion in AHF inpatients.
Subject(s)
Heart Failure , Pulmonary Edema , Heart Failure/diagnostic imaging , Heart Failure/therapy , Humans , Lung/diagnostic imaging , Prospective Studies , Pulmonary Edema/diagnostic imaging , Reproducibility of Results , Ultrasonography/methodsABSTRACT
Acute kidney injury (AKI) is frequent and can lead to serious complications. It is classified according to the degree of renal function impairment and classically divided into three categories: pre-renal, intrinsic and post-renal. Identification of risk factors and wise use of additional tests are crucial to the diagnosis, as there are numerous causes of AKI. Identification and specific treatment of the underlying mechanism are essential, all while protecting the kidney. Resorting to a nephrologist is systematic when there are red flags. Follow-up after resolution of AKI is important as the risk of developing a chronic kidney disease is increased.
L'insuffisance rénale aiguë (IRA) est un problème fréquemment rencontré dans la pratique clinique et grevé de complications potentiellement graves. Elle est classée selon l'importance de la diminution de la fonction rénale et divisée en trois catégories : fonctionnelle, parenchymateuse et obstructive. Une attention particulière doit être prêtée au diagnostic en identifiant les facteurs de risque et en utilisant judicieusement les examens complémentaires, tant les étiologies de l'IRA sont nombreuses. Le traitement spécifique de la cause sous-jacente est essentiel tout en limitant les agressions sur le rein. Le recours au néphrologue est systématique en présence de facteurs de gravité. Le suivi après résolution de l'IRA est important, la probabilité de survenue d'une insuffisance rénale chronique(IRC) étant augmentée.
Subject(s)
Acute Kidney Injury , Renal Insufficiency, Chronic , Secondary Care , Acute Kidney Injury/complications , Acute Kidney Injury/therapy , Humans , Renal Insufficiency, Chronic/etiology , Renal Insufficiency, Chronic/therapy , Risk FactorsABSTRACT
INTRODUCTION: Alteplase and tenecteplase are two widely used thrombolytic agents and are both approved for the treatment of acute myocardial infarction. These two molecules have increased fibrin specificity compared with older thrombolytics but distinct pharmacokinetic properties and may differ in terms of risks and benefits. We decided to review the available evidence comparing the safety and efficacy of these two molecules in acute coronary syndrome (ACS) or pulmonary embolism (PE). MATERIAL AND METHODS: To compare the efficacy and safety profile of alteplase and tenecteplase, we systematically searched PubMed, Cochrane and Embase for randomized studies comparing weight-adjusted alteplase to weight-adjusted tenecteplase in patients with ACS or PE. The primary endpoint was the risk of major bleeding, and secondary endpoints were risk of intracranial haemorrhage (ICH), vessel recanalization and 30-day mortality. RESULTS: Three studies including 17,325 patients with ACS were included in a quantitative meta-analysis. No study compared alteplase to tenecteplase in acute PE. Tenecteplase was associated with a statistically significant reduction of the risk of major bleeding compared to alteplase (RR = 0.79; 95% CI: 0.69-0.90, p = 0.0002). The risk of intracranial haemorrhage (RR = 0.96; 95% CI: 0.71-1.31, p = 0.82) and 30-day mortality (RR = 1.02; 95% CI: 0.9-1.15) were similar in patients treated with alteplase or tenecteplase. No difference was observed in the rate of vessel recanalization. CONCLUSIONS: The available evidence suggests that tenecteplase is associated with a reduced risk of major bleeding compared to alteplase in ACS without evidence of reduced efficacy. These results are however mainly dependent on a single study.
