Impact of reference panel composition on scores of script concordance test assessing basic nephrology knowledge in undergraduate medical education.

PURPOSE: In the assessment of basic medical knowledge, the composition of the reference panel between specialists and primary care (PC) physicians is a contentious issue. We assessed the effect of panel composition on the scores of undergraduate medical students in a script concordance test (SCT). METHODS: The scale of an SCT on basic nephrology knowledge was set by a panel of nephrologists or a mixed panel of nephrologists and PC physicians. The results of the SCTs were compared with ANOVA for repeated measurements. Concordance was assessed with Bland and Altman plots. RESULTS: Forty-five students completed the SCT. Their scores differed according to panel composition: 65.6 ± 9.73/100 points for nephrologists, and 70.27 ± 8.82 for the mixed panel, p < 0.001. Concordance between the scores was low with a bias of -4.27 ± 2.19 and a 95% limit of agreement of -8.96 to -0.38. Panel composition led to a change in the ranking of 71% of students (mean 3.6 ± 2.6 places). CONCLUSION: The composition of the reference panel, either specialist or mixed, for SCT assessment of basic knowledge has an impact on test results and student rankings.

Profile of patients with type 2 diabetes and glycated haemoglobin ≥ 10% followed in general practice.

OBJECTIVE: To determine whether profiles of patients with unbalanced type 2 diabetes (T2DM) and glycated haemoglobin (HbA1c) ≥ 10% could be identified on the basis of socio-demographic, behavioural, clinical, and biological characteristics. METHODS: Retrospective, cross-sectional, factorial analysis study of patients with T2DM treated for at least 1 year, with HbA1c ≥ 10%. Patients were recruited via medical analysis laboratories, France. Patients were followed up in general practice with possible recourse to specialist consultations. Data were collected by means of self-administered questionnaires sent by post. RESULTS: A total of 104 patients were included: 69 men and 35 women, with a median age of 66 ± 12 years, body mass index 30.7 ± 6.2kg/m2 and 47% in a vulnerable socio-economic situation. Fifty patients (48%) were followed exclusively by their general practitioners and only 30% had no compliance problems. Creatinuria was measured at least once during the year in 92% of patients, but microalbuminuria was measured in only 20%. Age, socio-economic precariousness, insulin treatment, and follow-up by several health professionals had a negative influence on quality of life (QoL). Two patient profiles were defined by factor analysis: (i) young, rural, smoker, socially isolated, precarious patient with poor compliance and QoL; and (ii) elderly, urban, regular physical activity, in a couple, without precariousness and with satisfactory QoL. CONCLUSIONS: Analysis of the characteristics of patients with T2DM and glycaemic imbalance reveals profiles that are useful in clinical practice for a personalized approach to treatment and active prevention of diabetes complications.

Efficacy of local glucocorticoid after local anesthetic in low back pain with lumbosacral transitional vertebra: A randomized placebo-controlled double-blind trial.

OBJECTIVE: The primary objective of this study was to compare the efficacy of local injection of a local anesthetic with a glucocorticoid versus a local anesthetic with saline to treat low back pain due to lumbosacral transitional vertebras (LSTV) with a pseudoarticulation. METHODS: A randomized placebo-controlled double-blind study was conducted in patients with unilateral low back pain ascribed clinically to LSTV. Patients were randomized to lidocaine plus saline (LS group) or lidocaine plus cortivazol (LC group) injected locally under computed tomography guidance. The primary outcome measure was the 24-hour mean visual analog scale (VAS) score for low back pain 4 weeks after the injection. RESULTS: Of 16 randomized patients, 15 were included in the analysis, 8 in the LS group and 7 in the LC group. The mean VAS pain score at week 4 was not significantly different between the two groups. In the two groups pooled, the mean VAS pain score decreased significantly from baseline to week 4, from 5.52±0.99 to 3.86±2.55 (P≤0.05). The difference remained significant at week 12. Significant improvements occurred in the EIFEL disability index and items of the Dallas Pain Questionnaire. No adverse events were recorded. CONCLUSION: In patients with chronic low back pain consistent with a symptomatic LSTV type II or IV in the Castellvi classification, a local injection of lidocaine with or without cortivazol may provide sustained improvements in pain and function. The underlying mechanism is unclear.

Decreased patient exposure to ionizing radiation during interventional rheumatology procedures after optimization of protection.

OBJECTIVES: To decrease radiation exposure of patients undergoing interventional rheumatology procedures, without adversely affecting quality of care. METHODS: The radiation dose received, assessed by the dose-area product (DAP), was measured during 283 intraarticular injections performed under fluoroscopic guidance between May and July 2013. Then, three steps were taken to decrease patients' radiation exposure: a copper filter was added, the anti-scatter grid was removed, and exposure cell sensitivity was set at the highest value. DAP was measured during 158 intraarticular injections performed in 2014 with these measures in place. RESULTS: Mean DAP before optimization was 175µGray·m2 during facet joint injections (n=4) and 43µGray·m2 during hip injections but was less than 20µGray·m2 for injections into the shoulders (15.7µGray·m2), ankles (7.7µGray·m2), wrists (3.7µGray·m2), and fingers (3.3µGray·m2). After optimization, DAP decreased markedly for all injection sites, by 52% (shoulders) to 87% (facet joints, 22.7µGray·m2). Decreases occurred at all three steps of the procedure, i.e., patient installation, injection, and last image hold. Exposure during facet joint injections varied from 84 (54.5-108.5) µGray·m2 when body mass index (BMI) was <25kg/m2 to 228.9 (161.3-340.4)µGray·m2 when BMI was>30kg/m2. CONCLUSION: Simple technical changes translate into large decreases in patient radiation exposure during fluoroscopically-guided injections, particularly at the facet joints and in obese patients.

Patient education in chronic heart failure in primary care (ETIC) and its impact on patient quality of life: design of a cluster randomised trial.

BACKGROUND: Chronic heart failure, is increasing due to the aging population and improvements in heart disease detection and management. The prevalence is estimated at ~10% of the French general practice patient population over 59 years old. The primary objective of this study is to improve the quality of life for heart failure patients though a complex intervention involving patient and general practitioner (GP) education in primary care. METHODS: A randomised, cluster controlled trial, stratified over 4 areas of the Auvergne region in France comparing intervention and control groups. The inclusion criteria are: patients older than 50 years with New York Heart Association (NYHA) stage I, II, or III heart failure, with reduced ejection fraction or with preserved ejection fraction. Heart failure should be confirmed by the patient's cardiologist according to the European Society of Cardiology guidelines criteria. The exclusion criteria include: severe cognitive disorders, living in an institution, participating in another clinical trial, having NYHA stage IV heart failure, or a lack of French language skills. The complex intervention consists of training at the GP practice with an interactive 2-day workshop to provide a patient's education programme. GPs are trained to perform case management, lifestyle counselling and motivational interviewing, to educate patients on the main topics including clinical alarm signs, physical activity, diet and cardiovascular risk factors. The patients' education sessions are scheduled at 1, 4, 7, 10, 13 and 19 months following the start of the trial. The primary outcome to be assessed is the impact on the quality of life as determined using two questionnaires: the Minnesota Living with Heart Failure Questionnaire and SF-36. To detect a difference in the mean quality of life at 19 months, we anticipate studying a minimum of 400 patients from 80 GPs. DISCUSSION: This trial will provide insight into the effectiveness of a complex intervention to educate patients with heart failure including a 2-day GP workshop and patients' education programme in the setting of a GP consultation to improve the quality of life in patients with chronic heart failure. This complex intervention tool could be used during initial and further medical training. TRIAL REGISTRATION: ETIC is a cluster-randomised, controlled trial registered on ClinicalTrials.gov [ NCT01065142 , 2010, Feb 8] and the French drug agency [Agence Nationale de Sécurité du Médicament et des produits de santé; registration number: 2009-A01142-55, on March 5th, 2010].

CANABIC: CANnabis and Adolescents: effect of a Brief Intervention on their Consumption--study protocol for a randomized controlled trial.

BACKGROUND: Cannabis is the most consumed illegal substance in France. General practitioners (GPs) are the health professionals who are most consulted by adolescents. Brief intervention (BI) is a promising care initiative for the consumption of cannabis, and could be a tool for GPs in caring for adolescents who consume cannabis. The aim of the CANABIC study is to measure the impact of a BI carried out by a GP on the consumption of cannabis by adolescents of 15 to 25 years of age. METHODS: A randomized clustered controlled trial, stratified over three areas (Auvergne, Languedoc-Roussillon, and Rhône - Alpes), comparing an intervention group, which carries out the BI in consultation, and a control group, which ensures routine medical care. The main assessment criterion is the consumption of cannabis by amount of joints per month, at 12 months. The amount necessary to highlight a significant difference between the two groups of 30% of consumption at 12 months is 250 patients (50 GPs, 5 patients per GP; risk α = 5%; power = 90%; intra-cluster correlation coefficient ρ = 0.2; Hawthorne effect = 15%; lost to follow-up rates for GPs = 10% and for patients = 20%). This plan is replicated for the three areas, and therefore a total of 750 patients are expected.The secondary criteria for judgment are the associated consumption of tobacco and alcohol, the perception of the consequences of consumption, and the driving of a vehicle following consumption. DISCUSSION: Research about BI for young cannabis users is underway. The aim of the CANABIC study is to validate a BI suited to adolescents who consume cannabis, which may be performed in the general practice. This would provide a tool for their treatment by a GP, which could be widely distributed during initial or further medical training. TRIAL REGISTRATION: CANABIC is a randomized clustered trial (NCT01433692, registered 2011 Sept 12), PHRC funded: Clinical Research Hospital Program (Governmental Fund, Health Ministry). Date first patient randomized: March 2012.

[Quality of life of women GPs in Auvergne]. / Qualité de vie des femmes médecins généralistes en Auvergne.

BACKGROUND: The medical profession is feminising. In parallel, the importance of quality of life (QOL) must be addressed. Family practice needs personal investment and availability. This profession can have repercussions on womens' QOL. The objective of the study was to compare female GPs QOL to other women with the comparable socioprofessional status. The secondary objective was to study the influence of factors, such as workplace and work methods. METHOD: Comparative cross-sectional study. A self-assessed questionnaire, sent by post to 394 female general practitioners in Auvergne, each was asked to recruit one woman (non-GP), with similar age and socioprofessional status. RESULTS: A total of 148 female GPs (37.6%) and 122 non-GPs responded. The global score of QOL was lower in the GP group, noticeably showing a poorer QOL in the relational and material areas. The professional QOL was similar between the 2 groups. The study did not find a significant difference concerning the QOL in its physical and psychological dimensions. The main negative factors influencing the QOL were: age; isolation of the occupation; living alone; and liberal occupation. Working in a rural area did not influence the QOL. CONCLUSION: The profession of GPs remains demanding, and the female GP feels a poorer QOL. Nevertheless, they seem to like their job and they feel fulfilled. The uneasiness comes essentially from the lack of free time, and from low financial income. Working in association seems to be a first step to improve the QOL of female GPs.

Hairy-cell leukemia with inaugural joint manifestations.

Hairy-cell leukemia is a chronic B-cell malignancy seen in adults. The presenting manifestations consist of splenomegaly, pancytopenia, and characteristic monocyte depletion. The presence in peripheral blood or bone marrow of hairy cells exhibiting the CD19(+) CD20(+) CD25(+) CD11c(+) phenotype establishes the diagnosis. Rarely, patients present with inaugural joint manifestations related either to the hematological malignancy or to immune dysfunction. The resulting polymorphic polyarticular symptoms may cause diagnostic wanderings. Monocytopenia is a valuable diagnostic clue. The identification of hairy cells in the joint fluid establishes the diagnosis of leukemia-related arthritis. The treatment rests on purine analogs. One of the main differential diagnoses is Felty's syndrome, which combines rheumatoid arthritis, splenomegaly, and neutropenia. Felty's syndrome is usually caused by T-cell lymphoproliferative disorders. Among 27 patients with hairy-cell leukemia managed at our institution, 1 presented with joint manifestations. We describe this case.

Chronic, eventually fatal, Kawasaki-like disease in an adult with spondylarthropathy responding to IVIG therapy.

We report on an unusual case of a 40-year-old Caucasian male displaying severe Kawasaki-like symptoms. The disease lasted for seven years before diffuse coronary aneurysms occurred, leading to the patient's death, despite ongoing treatment by intravenous immunoglobulins (IVIGs). The patient had also been suffering from a disabling inflammation of the spine, which was reported to have started at the onset of the disorder. Whereas neither NSAIDS, nor high doses corticosteroids, or anti-TNF drugs had a clear effect, the clinical features of spinal inflammation were highly sensitive to IVIGs, and were attributed definitively to HLA-B27-negative axial spondylarthropathy after bone scan and magnetic resonance imaging disclosed typical enthesitis of both heels and bilateral sacroiliitis.