Revista de práctica general

The primary care physician often has to help diabetic patients suffering from localized neuropathic pain. Most of the current anti-epileptics and anti-depressants however, especially when prescribed to the elderly patients, have troublesome drawbacks: drug-interactions, side effects and tolerability issues. Topical compounded creams might be a good alternative, especially since it is easy to test in the general practice to discover responders to these creams.
At our Institute for Neuropathic Pain we see many patients suffering from peripheral neuropathic pain. We have developed a number of compounded creams based on amongst others amitriptyline 10%, ketamine 10%, clonidine 0.2%, baclofen 5%, and phenytoin 10%. Many patients profit from such topical formulations and we will describe how a primary care physician can fast decide whether as specific compounded cream is useful for a patient. Patients suffering from peripheral neuropathic pain, as in diabetic neuropathy, chronic idiopathic axonal polyneuropathy (CIAP) and chemotherapy induced polyneuropathy (CIPN) as well as from complex regional pain syndrome (CRPS), seem often to be responsive to such topical approach. Meanwhile, more than 800 Dutch medical doctors have been prescribing one or more of our compounded creams, and patients and medical doctors from abroad frequently contact us to explore the therapeutic options for their patients based on these creams. We will give some practical tips how to differentiate between responders and non-responders.

Myoclonus may be defined as sudden muscle contractions that are brief, involuntary, and shock-like. There are many conditions that can lead to myoclonus including spinal cord injury, stroke and as a side effect of certain drugs. Post hypoxic myoclonus is a recognized entity that develops post successful resuscitation of cardiac arrest and this is known in the literature as Lance Adams Syndrome. Often myoclonus is confused with an underlying seizure disorder. Myoclonic status epilepticus at any time after return of spontaneous circulation (ROSC) is even considered to reliably indicate a poor prognosis. Different treatments have been attempted to manage post hypoxic myoclonus including valproic acid and clonazepam and even Bilateral Pallidal Deep Brain Stimulation. The authors would like to present a case report of a 59-years-old male with chronic post hypoxic myoclonus who was successful treated with a combination medication regime of valproic acid and levetiracetam.

Background: Diabetic peripheral neuropathy (DPN) has been prevalent and discussed, and nerve conduction studies (NCS) has been continued. We have checked NCS using recently introduced useful DPN-Check device.
Subjects and Methods: The subjects were 66 patients (pts) classified into 4 groups according to existence of diabetes mellitus (DM) and hemodialysis (HD); Group1: DM (+), HD (+) in 15 pts, group 2: DM (-), HD (+) in 15 pts, group 3: DM (+), HD (-) in 20 pts, group 4: 16 healthy controls. Methods included measurements of sural nerve conduction velocity (SNCV) and sural nerve action potential (SNAP) using HDN-1000.
Results: Average age in each group was 64.4 years to 72.6 years. SNCV value of 4 group in average was 37.1 m/sec, 46.3 m/sec, 49.3 m/sec, 53.2 m/sec, respectively, and value of group 1 was significantly lower than those of group 2,3,4 (p<0.01). Similarly, average SNAP was 4.1 μV, 8.7 μV, 8.0 μV, 21.6 μV, respectively, and group 1,2,3 were significantly lower than group 4 (p<0.01). There was significant correlation between SNCV and SNAP in all subjects (p<0.01). Significant correlations were shown between DM duration and SNCV, and DM duration and SNAP (p<0.01).
Discussion and Conclusion: SNCV and SNAP were measured successfully and easily by HDN-1000, indicating clinical availability. Obtained data suggested that 1) SNCV is not significantly decreased due to only uremic neuropathy, 2) SNCV is significantly decreased in patients with both HD and DM, 3) SNAP is significantly decreased in patents with DM for years and 4) SNAP would be remarkably decreased when HD is in addition to DM. These results would become the basal data of future NCS for DM and HD.

Objective: To identify and characterize, the additional demands (ADs) in the family medicine practice.

Participants and Methods: A qualitative, observational, narrative study, to explore the demand that occur at the end of the visit, with the presentation of a new query motif that is added to the previous one, once this one is finished, from June to August, 2017, in a family medicine office in Toledo, Spain, was carried out, by recording the words used by the patient. From a randomly selected date we included all patients performing additional demand until data saturation. An analysis of the content of the demands collected of each patient included was carried out. The technique to control bias was methodological triangulation between the results obtained with the data that had been reported in the literature.

Results: A total of 116 ADs were included, of which 85 (73%) were from female patients and 31 (27%) were from male patients. The age range was 14 to 91 years. The categories that were assessed as with very high or high importance were: 1) What seems to concern or interest the patient more in that moment or it seems to be the most important or the main reason for the doctor at that time, including the consultation on a chronic topic that presents itself as new; 2) What is related or insists in some way on the previous demand and expresses an action to act, or a fear of the previous demand; 3) to sleep or to “nerves”; 4) more than a demand is a story (usually psycho-social); and 5) demand for another family member present or absent in the consultation. The additional demand phrases that began with the conjunction “And ...” (In addition to) were the most frequent, followed by those that began with “And ... another thing ...”, “Ah!” or “Oh!” (An interjection used to express surprise), and “And since I’m here ... “or” By the way ...”.

Conclusions: Although some ADs seem to occur in a random manner and to be a superfluous request, most of them, however, can contain issues that most concern the patient or are rated as more important by the physician. ADs with some psychosocial content are the most frequent and important. But, its aspect of commonplace demands, make it difficult to take them into account. Family doctor never should underestimate any demand in closing moments of medical interview of the patient, especially if its content is partly psychosocial, since that may be the real and important motive that led him or her to the consultation. Therefore, a pragmatic, unstructured and strategic interview can be proposed: from where the doctor and the patient can go, in zigzag, “through the field instead of going the path”, taking advantage of the opportunities, as the appearance of ADs.

Background: In recent years, prevention has become increasingly important in General Medicine (GM) and has become the focus of several debates worldwide. The evolution of the Tunisian society urges to seek a preventive approach then a Specific Preventive Consultation (SPC) became a necessity.
Objective: We aimed at determining the output of a SPC within a consultation of GM.
Method: A descriptive study was carried out for 9 months (from November 2016 to July 2017) in a primary care at Monastir governorate. A SPC was incorporated into the daily care consultations. An appropriate questionnaire, highlighting cardiovascular, carcinogenic and depressive risk factors, was sent to 313 consultants who agreed and adapted actions have been proposed to them. We have analyzed follow up results for screened participants according to personalized preventive plan (PPP).
Results: For 313 participants, 48 (15%) have high cardio vascular risk (HCVR). Obesity, physical inactivity, smoking and alcohol consumption were notified respectively among 30.5%, 19%, 19% and 7% of our population. Familial ATCD of breast cancer was present in 2.2%, anxiety in 32% and depression in 23% of our patients. All screened participants provided with a personalized prevention plan (PPP). Therapeutic education was performed for 140 patients; awareness to a tobacco free environment for 155 and 71 mammography was prescribed for women at risk from which one returned with cancer.
Conclusion: SPC has improved the knowledge and practices of patients. It also identified several risk factors and especially breast cancer at an early stage. We concluded that Personalized Preventive Plan can be performed in GM to improve and promote health.

Objective: This study aimed to assess the connection between sexual abuse and self-reported lifetime physical and psychiatric disorders.
Subjects and Method: Samples of 178 French subjects (170 women and 18 men) who have been sexually abused have agreed to answer a computerized questionnaire and give the characteristics of their aggression and the physical and psychiatric pathologies they suffered afterwards. They also reported symptoms of anxiety and depression using the 14-item Hospital Anxiety and Depression (HAD) scale. Reported disorders were grouped by system organ class. χ2 test or exact test of Fisher was used to test association of main characteristics of sexual abuse (type and duration of abuse, multiple/single assault and perpetrator) with each item of medical history.
Results: 83% of respondents had experienced several sexual assaults, with a first assault occurring mainly during childhood and adolescence. The average length of the sexual abuse period was 2.4 times longer in women, compared to men (9.2 vs. 3.8 years). Most frequently alleged types of abuse were touching (85.5%) and rape (76.6%). The mean age of disclosure of sexual violence was approximately 21 years and the average time between the first abuse and disclosure about 12 years. The most frequent reported physical disorders were chronic pain, allergic, dermatological and gynaecological disorders, and surprisingly ENT disorders. There was in the sample a high prevalence of depression, sleep disorders and suicide attempts. At the time of the investigation the mean HAD scores were 7.0+4.7 and 11.7+4.6 for depression and anxiety respectively. Most reported disorders were significantly correlated with the severity of the sexual abuse (rape, duration, number of assaults and/or perpetrators). It was also shown that the delay of disclosure was significantly longer for victims whose first attack occurred when they were younger.
Conclusion: A history of sexual abuse is associated with a high prevalence of multiple physical and psychiatric disorders at rates comparable to those found in previously published studies.

The reduction of incidence and mortality of cancer puts a heavy burden on all actors of the health care system. The primary care personnel who see their exclusive role as treating sick people must not be an exception. As a new task, they have to do their part in the prevention aiming at elimination of lifestyle-related risk factors, and in the efforts to detect and treat cancer as early as possible. This paper indicates how they can take part in these efforts, discusses the natural history of cancer, the methods of prevention and screening, and the benefits and potential harms of interventions. Its message is that the efforts which mostly but not exclusively are the tasks of public health could be successful only by the contribution, change of traditional mentality, active and initiative attitude of primary care personnel.

Objectives: There were few publications which concern psychosocial motivation in pediatric patients with idiopathic nephritic syndrome(INS) to evaluated effects of psychological and social motivation on responsiveness of children with INS to steroid therapy and to detect whether there was relation between psychosocial motivation and the outcome of those children.
Subjects: This work was conducted as a randomized controlled clinical trial, single blinded study in Tanta university pediatric nephrology outpatient clinic on 172 children with Steroid Sensitive Nephrotic Syndrome (SSNS). They were divided randomly into motivational nephrotic group as Group 1 and a control nephrotic group as Group 2. Their aged 2-10 years and mean disease duration 2.6 ± 2.1 and 2.3 ± 2.1 years in Group 1 and 2 respectively.
Methods: Data was collected through a collection of biological, social and psychological data which were formulated, structured for 6 months where their ideas and expectations about disease, the compliance with treatment and follow up visits and frequency of relapses between the two studied patients groups were compared.
Results: There was statistically significant decrease in the number of relapses in Group 1 when compared to Group 2. Regarding compliance with follow up visits, there was a highly significant increase in Group 1 compared to control group. There was statistically significant difference after application of psychosocial motivation regarding patients' ideas and expectations about the disease.
Conclusions: The psychosocial motivation is significantly highly effective in improving the management of SSNS children, so we recommend all physicians to adopt psychosocial motivation to their nephritic children.