Is Positive Communication Sufficient to Modulate Procedural Pain and Anxiety in the Emergency Department? A Randomized Controlled Trial.

OBJECTIVE: Research suggests that therapeutic communication could enhance patient comfort during medical procedures. Few studies have been conducted in clinical settings, with adequate blinding. Our hypothesis was that a positive message could lead to analgesia and anxiolysis, and that this effect would be enhanced by an empathetic interaction with the nurse performing the procedure, compared with an audio-taped message. This study aimed to modulate the contents and delivery vector of a message regarding peripheral intravenous catheter (PIC) placement in the emergency department (ED). METHODS: This study was a 2 + 2 randomized controlled trial registered on ClinicalTrials.gov (NCT03502655). A positive versus standard message was delivered through audio tape (double-blind) in the first phase ( N = 131) and through the nurse placing the catheter (single-blind) in the second phase ( N = 120). RESULTS: By design, low practitioner empathic behavior was observed in the first phase (median, 1 of 5 points). In the second phase, higher empathic behavior was observed in the positive than in the standard message (median, 2 versus 3, p < .001). Contrary to our hypothesis, the intervention did not affect pain or anxiety reports due to PIC placement in either phase (all p values > .2). CONCLUSIONS: The positive communication intervention did not impact pain or anxiety reports after PIC. There might have been a floor effect, with low PIC pain ratings in a context of moderate pain due to the presenting condition. Hence, such a therapeutic communication intervention might not be sufficient to modulate a mild procedural pain in the ED.

[Self-care for anxiety in primary care]. / Anxiété en médecine générale : quels types d'autosoins proposer ?

Anxiety is a very common problem in primary care consultations. In addition to standard treatments (psychotropic medications and psychotherapy), many self-care techniques can improve patients' anxiety. A few explanations (psychoeducation) about the role of the autonomic nervous system in stress and anxiety can be helpful to motivate patients to experiment techniques that allow their body to relax and unwind, and to thus take care of themselves. Family doctors who have practiced some of these techniques for themselves can easily teach them to their patients, but they can also recommend face-to-face or Internet courses on the subject.

L'anxiété est un problème très courant dans les consultations de médecine générale. En complément aux traitements classiques (psychotropes et psychothérapie), de très nombreux autosoins (selfcare) peuvent amener un grand bénéfice aux patients anxieux. Quelques explications (psychoéducation) sur le rôle du système nerveux autonome dans le stress et l'anxiété aideront le médecin traitant à motiver son patient à expérimenter des techniques permettant le ressourcement de l'organisme et à s'autoriser à prendre soin de lui-même. Dans l'idéal, le médecin traitant sera capable d'enseigner certaines de ces techniques à ses patients, après les avoir expérimentées lui-même. De nombreux cours et démonstrations existent aussi sur internet ou en présentiel.

Prevalence of ECG abnormalities and risk factors for QTc interval prolongation in hospitalized psychiatric patients.

BACKGROUND: Psychiatric patients are at risk of cardiovascular diseases, and many psychotropic drugs can prolong QTc interval. Requirements for electrocardiogram (ECG) monitoring have been set up in our psychiatric university hospital. The objective of this study was to determine the proportion of adult patients who had an ECG during their hospitalization, the prevalence of ECG abnormalities, the evolution of the QTc after admission, and the risk factors for QTc prolongation. METHODS: Retrospective analysis of ECGs and clinical data of all patients with a complete hospitalization in 2015. Assessment of the influence of covariates on QTc using linear mixed-effects models. RESULTS: At least one ECG (n = 600) was performed during 37.6% of the stays (n = 1198) and in 45.5% of the patients (n = 871). Among the patients with an ECG, 17.9% had significant ECG abnormalities, including 7.6% with a prolonged QTc. QTc measured at admission and during hospitalization did not change significantly (n = 46, 419.4 ± 29.7 ms, 417.2 ± 27.6 ms, p = 0.71). In the multivariate model (292 patients, 357 ECGs), the covariates significantly associated with the QTc were gender (+15.9 ms if female, p < 0.0001), age (+0.4 ms/year, p = 0.0001), triglyceride levels (+5.7 ms/mmol/l, p = 0.005), and drugs with known risk of torsades de pointes (+6.2 ms if ⩾1 drug, p = 0.028). CONCLUSIONS: The prevalence of hospitalized psychiatric patients with an abnormal ECG indicates that ECGs should be performed systematically in this population. Prescription of psychotropic drugs should be done cautiously, particularly in patients with QTc prolongation risk factors.

[Doctor : « I hurt everywhere ¼]. / « Docteur, j'ai mal partout ¼.

Faced with diffuse pain, the doctor must evoke a wide range of pathologies. It is necessary to think about rare illnesses such as myopathy or vasculitis, but also more common illnesses such as fibromyalgia. Contrary to popular belief, it is difficult to give a diagnosis of fibromyalgia, on average 2 years after the onset of symptoms. This can be explained by heterogeneous complaints and the doctor delaying the diagnosis with unnecessary complimentary examinations.Patient education and physical activity are the most important steps of treatment. Few drugs have proven effective and their use is limited due to significant side effects. The evolution of fibromyalgia is chronic, with a mixed prognosis.

Face aux algies diffuses, le médecin doit évoquer un large éventail de pathologies. Il faut penser à la fois aux maladies rares comme les myopathies ou les vasculites, mais aussi aux maladies plus fréquentes comme la fibromyalgie. Contrairement aux idées reçues, le diagnostic de fibromyalgie est difficile à poser, en moyenne 2 ans après le début des symptômes. Ceci s'explique par des plaintes hétérogènes, mais aussi par le médecin lui-même qui retarde le diagnostic par des examens complémentaires inutiles. L'éducation du patient et l'activité physique sont les étapes les plus importantes de la prise en charge. Peu de médicaments ont prouvé leur efficacité et leur utilisation est limitée par d'importants effets secondaires. L'évolution de la fibromyalgie est chronique avec un pronostic plutôt mitigé.

[Prolonged or chronic fatigue of unknown origin]. / Fatigue prolongée ou chronique d'origine indéterminée.

Although prolonged or chronic fatigue is a very common complaint in primary care medicine, a biomedical obvious cause is often not found. In such a case, for women between 18 and 50 years with a ferritin level of less than 50 µg/l in the absence of anaemia, an iron supplementation may be associated with an improvement in fatigue. Appropriate treatment is also important for depression, anxiety or insomnia. In other cases, the approach is essentially non-pharmacological in the form of lifestyle advice, empathy and cognitive behavioural therapy as well as progressive and adapted physical exercises.

[Chronic fatigue syndrome]. / Syndrome de fatigue chronique.

Chronic fatigue syndrome (CFS) is a debilitating disorder, characterized by a severe, persistant and unexplained fatigue, which can be associated with diffuse pain, sleep difficulties, neurocognitive and neurovegetative troubles. Its prevalence has been estimated between 0.3 and 0.9%. Though its physiopathology remains controversial, evidence is growing that dysimmunity, oxidative stress and mitochondrial dysfunction are involved in its pathogeny. No medication has demonstrated specifc efficacy in the CFS. The management of CFS involves limiting unnecessary investigations, promoting graded exercice therapy, and providing empathic counselling in order to prevent negative thoughts.

[2013 literature findings in internal general medicine]. / Acquisitions thérapeutiques en médecine ambulatoire en 2013.

The prescribing of antibiotics for uncomplicated skin abscesses and diverticulitis has no benefit. Some antibiotics are more at risk of causing a Clostridium difficile infection. The tests used to exclude a history of a penicillin allergy are safe. A threshold of D-dimer adjusted for the age significantly improves the specificity of the test without affecting the sensitivity. The prescription of paraclinics tests is not an effective "treatment" for the patient's anxiety. In the sleep apnea syndrome, treatment with CPAP (Continuous positive airway pressure) appears to have more benefits compared to the mandibular advancement prosthesis. The work of primary care physicians can be supported by the work of advanced practice nurses. The limitation placed on the working hours of doctors in hospitals seems to affect their ability to spend time with their patients.

[Urinary incontinence in women: management in primary care]. / Incontinence urinaire chez la femme: prise en charge en médecine de premier recours.

Urinary incontinence in women is a largely under-evaluated problem that affects nearly one out of two adult women. Even thouh its physiopathology is complex and its etiologies are multiple (and often intricate), urodynamic investigations are not considered necessary before starting a conservative therapy, which can be initiated by the primary care physician. Conservative management is based upon lifestyle modifications, specialized physiotherapy, and in certain cases medication. In the case of insufficient response after three months, the patient should be recommended to a specialist who can evaluate the need for a surgical procedure.