[Short antibiotic therapy in hospitalized pneumonia: A cohort study]. / Antibiothérapie courte au cours de la pneumonie : PNEUMOSHORT.

INTRODUCTION: Pneumonia is one of the most common indications for antibiotic. Shortening the duration of antibiotic therapy should help reduce bacterial resistance. To date, three randomized control trials have shown non-inferiority of short courses of antibiotic therapy (3 days) compared with 7 days in non-severe pneumonia. The aim of this study was to assess this strategy in real life. METHOD: This retrospective observational cohort study included all patients with pneumonia hospitalized in an internal medical ward from 11/01/2022 to 05/31/2023. We implemented the strategy based on early discontinuation of antibiotic therapy in patients with pneumonia who were clinically stable after 3 days of ß-lactam treatment. RESULTS: Among 49 patients included, median age was 72, median antibiotic duration was 4 days (IQR 3-6), and cure rate at D30 was 88 %. At day 30, we observed one death (2 %), four new antibiotic therapy (9 %), and two new hospitalisation (5 %), among five immunosuppressed patients. Among immunosuppressed patients (n=17; 35 %), failure rate was three times higher in case of short antibiotic courses (3/8; 38 %) than long antibiotic courses (1/7; 14 %). CONCLUSION: Strategy based on early discontinuation of antibiotic therapy in immunocompetent patients with pneumonia who were clinically stable after 3 days of ß-lactam treatment is safe, and easy to implement in a medical ward.

[Messages from the estates general on French internal medicine]. / Que retenir des états généraux de la médecine interne française ?

Internal medicine is a medical specialty that is often poorly understood by the general public and sometimes misidentified. In an era of increasing subspecialization and high technicality, it is characterized by a comprehensive approach centered on clinical evaluation. Unlike what is observed in most developed countries, where systemic autoimmune diseases are managed by organ specialists based on their mode of presentation, French internists are at the forefront for diagnosing and managing these diseases. Their multidisciplinary training gives them legitimacy to justify this role. Internists also play a crucial role in the management of patients requiring unplanned hospitalizations downstream from emergency departments and in connection with primary care. Internists primarily practice in a hospital setting, with a specific position in the French healthcare system aligned with the training frameworks of all medical specialties. To better define internal medicine, its role in care activities, as well as in education and research, internists organized a General Assembly of internal medicine that took place on September 28, 2023, in Paris. Structured around think tanks focusing on care, education, and research activities, the general assembly aimed to improve visibility on internal medicine and internists. This article recounts the discussions that animated this meeting and highlights the main ideas that emerged. These general assemblies constitute a foundational step and will be followed by a Consultation Conference in order to better identify and promote internal medicine and internists, regardless of their types and places of practice.

Patients with persistent symptoms after COVID-19 attending a multidisciplinary evaluation: Characteristics, medical conclusions, and satisfaction.

OBJECTIVE: Among patients attending a multidisciplinary day-hospital program for persistent symptoms after COVID-19, we aimed i) to describe their characteristics ii) to present the medical conclusions (diagnoses and recommendations) and iii) to assess the patients' satisfaction and its correlates. METHODS: For this retrospective chart review study, frequent symptoms were systematically assessed. Standardized questionnaires explored fatigue (Pichot scale), physical activity (Ricci & Gagnon scale), health-related quality of life (Short-Form Health Survey), anxiety and depressive symptoms (Hospital Anxiety and Depression scale) and associated psychological burden (Somatic-Symptom-Disorder B criteria Scale). Medical record conclusions were collected and a satisfaction survey was performed at 3-months follow-up. RESULTS: Among 286 consecutive patients (median age: 44 years; 70% women), the most frequent symptoms were fatigue (86%), breathlessness (65%), joint/muscular pain (61%) and cognitive dysfunction (58%), with a median duration of 429 days (Inter-quartile range (IqR): 216-624). Questionnaires revealed low levels of physical activity and quality of life, and high levels of fatigue, anxiety, depression, and psychological burden, with 32% and 23% meeting the diagnostic criteria for a depressive or anxiety disorder, respectively. Positive arguments for a functional somatic disorder were found in 76% of patients, including 96% with no abnormal clinical or test findings that may explain the symptoms. Physical activity rehabilitation was recommended for 91% of patients. Patients' median satisfaction was 8/10 (IqR: 6-9). CONCLUSION: Most patients attending this program presented with long-lasting symptoms and severe quality of life impairment, received a diagnosis of functional somatic disorder, and reported high levels of satisfaction regarding the program.

[Splenic dysfunction in sickle cell disease: An update]. / Dysfonction splénique au cours de la drépanocytose : mise au point.

The spleen filters blood cells and contributes to the immune defense. The red pulp clears the blood from altered red blood cells via its unique microcirculatory network ; while the white pulp is a secondary lymphoid organ, directly connected to the bloodstream, whose specificity is the defense against encapsulated bacteria through the production of "natural" IgM in the marginal zone. Various health conditions can cause acquired impairment of the splenic function (or hyposplenism) directly and/or through therapeutic splenectomy. Hypo/asplenia is complicated by an increased susceptibility to encapsulated germ infections, but an increased risk of thrombosis and pulmonary hypertension has also been reported after surgical splenectomy. Homozygous sickle cell disease is the most common disease associated with functional asplenia. The latter appears early in childhood likely through repeated ischemic alterations caused by the sickling of red blood cells. In addition, specific complications such as hypersplenism and acute splenic sequestration can occur and may be life-threatening. We provide here an update on the role and physiology of the spleen, which will allow a better understanding of the pathophysiology of spleen damage and its consequences in sickle cell disease.

[Gallstone complications in sickle cell patients]. / Complications lithiasiques chez les patients drépanocytaires.

Chronic haemolysis exposes patients with sickle cell disease (SCD) to the development of black pigment gallstones, which can trigger biliary complications. In order to avoid these complications, elective cholecystectomy is recommended in France for all SCD patients with detected gallstones. However, all surgeries, and especially abdominal surgeries, entail an increased risk of vaso-occlusive complications in the peri- and post-operative periods, the most dreadful one being the acute chest syndrome. Preoperative transfusion has been shown in several studies to reduce acute postoperative complications, but exposes the patient to definitive alloimmunization, or even delayed post- transfusion haemolysis, justifying a recent trend towards transfusion sparing. The conditions for avoiding transfusion for a simple and frequent surgery such as cholecystectomy are based on a benefit- risk balance, and must be discussed on a case-by-case basis by the SCD specialist. In particular, it seems fully justified to perform prophylactic preoperative transfusion in patients with a history of recent vaso-occlusive crisis or acute chest syndrome (within 6 months preoperatively), and those operated on in an emergency setting, who are particularly at risk of postoperative events.

[Characteristics of patients admitted from emergency units in 18 internal medicine departments and organisation of these departments: A cross sectional study from SNFMI (SiFMI study group) in 2015]. / Caractéristiques des patients admis en médecine interne dans 18 hôpitaux français en aval des urgences et organisation de ces services : enquête transversale de la SNFMI (groupe d'étude SiFMI) en 2015.

INTRODUCTION: Patients admitted from emergency units represent a large portion of the population in internal medicine departments. The aim of this study is to identify characteristics of patients and organization of these departments. METHODS: Between June 29th and July 26th 2015, voluntary internal medicine departments from the SiFMI group prospectively filled anonymized internet forms to collect data of each patients admitted in their ward from emergency units, during seven consecutive days. RESULTS: Three hundred and sixty-five patients from emergency departments were admitted in 18 internal medicine inpatients departments, totalling 1100 beds and 33,530 annual stays, 56% of them for emergency units inpatients. Mean age was 68 years, 54% were women, mean Charlson score was 2.6 and 44% of the patients took at least three drugs. Main causes of hospitalization were infectious (29%) and neurological (17%) diseases. Mean length of stay was 9.2 days. The medical team was composed by a median value of 4,5 [2,75-6,25] senior full-time equivalents, 86% were internists. Each department except one received residents, two third of them were from general medicine. CONCLUSION: This study highlights a high organizational variability among internal medicine departments and patients, and sets internal medicine as a specialty with a great capacity to achieve an integrative/comprehensive management of patients and to offer a comprehensive basis for physicians in training.

[Evaluation of the use of a simulation software in the learning of cardiopulmonary auscultation in undergraduate medical students]. / Evaluation de l'utilisation d'un logiciel de simulation dans l'apprentissage de l'auscultation cardio-pulmonaire chez les étudiants en premier cycle d'études médicales.

INTRODUCTION: Medsounds™ software allows to create an auscultation learning platform, by providing real pre-recorded cardiopulmonary sounds on virtual chests. The study aimed at comparing the skills in cardiopulmonary auscultation between students who benefited from this platform and students who did not have access to it. METHODS: A controlled trial was conducted with 2nd year medical students randomised into three groups. Groups A, B and C received 10 h of cardiopulmonary clinical training. In addition, group B benefited from an online access to the educative platform, and group C had a demonstration of the platform during their clinical training, then an online access. The main outcome was a 3-point multiple-choice questionnaire based on 2 original case vignettes about the description of cardiopulmonary sounds. The secondary outcome was the faculty exam on high-fidelity cardiopulmonary simulator. RESULTS: Groups A and B included 127 students, and group C 117. Students in group C had a significantly higher score than those in group A (1.72/3 versus 1.48/3; p = 0.02), without difference between the groups B and C. Students who actually had a demonstration of the platform and used it at home had a higher score than those who did not use it (1.87 versus 1.51; p = 0.01). Students who had a demonstration of the platform before using it performed a better pulmonary examination on high-fidelity simulators. CONCLUSION: The supervised use of an online auscultation simulation software in addition to the traditional clinical training seems to improve the auscultation performances of undergraduated medical students.

[Opioid-induced adrenal insufficiency: Case report and synthesis of the literature]. / Insuffisance surrénale secondaire aux opioïdes : rapport de cas et synthèse de la littérature.

INTRODUCTION: Opioid therapy for pain relief is associated with several adverse effects. Herein, we report the potential consequences of opioid use on the adrenal function. OBSERVATION: A 49-year-old woman with sickle cell anemia (Hemoglobin SS) was admitted for the treatment of a vaso-occlusive crisis. Morphine was used for pain management, provided by intravenous intermittent dosing (patient-controlled analgesia). She developed during the hospitalization low blood pressure, due to secondary adrenal insufficiency (cortisol 74 nmol/L; ACTH 2.9pmol/L). Pituitary gland was normal on brain magnetic resonance imaging and adrenal function recovered after morphine discontinuation. CONCLUSION: Opioids suppress cortisol secretion, primarily mediated by direct negative effect on hypothalamus and pituitary gland. Further studies are needed to define the incidence and the clinical significance of opioid-induced adrenal insufficiency, as well as the need for hormone replacement.

[Functional somatic syndromes: A comprehensive cognitive model]. / Troubles somatiques fonctionnels : un modèle cognitif pour mieux les comprendre.

Functional somatic syndromes are frequent in general and specialized medicine practices. Several treatments can be useful. However, the treatment program is often hampered by patients' reluctance to acknowledge the diagnosis because of erroneous lay representations. Recent advances in cognitive science offer a new understanding of the pathophysiology of functional somatic disorders, making this diagnosis more acceptable for patients and caregivers. Simply explained with practical examples, the Bayesian model in particular provides some insights into the underlying cognitive mechanisms of functional somatic syndromes and their treatments. Advantages of this approach are twofold: it is consistent with current scientific knowledge and it can facilitate the physician-patient relationship.

[Reliability and validity of a workbook for assessment of professional competencies of internal medicine residents]. / Évaluation multicentrique de la reproductibilité et de la validité d'un carnet d'évaluation des compétences professionnelles des internes de médecine interne.

INTRODUCTION: Though several assessment tools for resident professional skills based on workplace direct observation have been validated, they remain scarcely used in France. The objective of this study was to evaluate the reliability and the validity of a workbook including several assessment forms for different components of the professional competency. METHODS: Three assessment forms have been tested over a period of 6 months in a multicentric study including 12 French internal medicine departments: the French version of the mini-CEX, an interpersonal skills assessment form (OD_CR) and the multisource feedback form (E_360). Reliability has been assess using the intra-class correlation coefficient (ICC) and the Cronbach alpha coefficient. Arguments for validity have been provided looking at the ability of the forms to detect an increase in the scores over time and according to the level of experience of the resident. RESULTS: Twenty-five residents have been included. The Cronbach alpha was of 0.90 (n=70) with the mini-CEX, 0.89 with the OD_CR (n=62) and 0.77 with the E_360 (n=86). ICC showed a wide variation according to the items of the mini-CEX and the OD-CR probably due to the poor number of observations performed by residents. The scores of most of the items of these two forms increased between M1 and M6. The scores of the E_360 were high: 7.3±0.8 to 8.3±2.4 (maximum 9) and did not vary according to the level of experience. CONCLUSION: This study suggest that it would be difficult to ensure a sufficient reliability for professional skills assessment using these tools given our available current human and material resources. However, these assessment forms could be added to the resident portfolio as supports for the debriefing in order to document their progression during their formation.

[Use of pocket-sized ultrasound in internal medicine (hospitalist) practice: Feedback and perspectives]. / Échographie ultraportable en médecine interne : retour d'expérience et point de vue.

INTRODUCTION: Point of care ultrasound (POCUS) is routinely used by intensivists and emergency physicians for many years. Its interest is not arguable any more for these specialists, despite the large variety of diseases they care. Hospitalists and internists also should find some interest in POCUS, which convenience and wide range of indications responds well to the variety of their practice. However, it is still not widely used in internal medicine departments. METHODS: We here report our experience of using a pocket-sized ultrasound device in a French internal medicine department. The device used was a Vscan Dual Probe, GE, whose two probes and presets allow for cardiac, abdominal, pulmonary, obstetric, vascular, pulmonary, and superficial soft tissue exploration. One physician of the ward received a course for POCUS that was initially dedicated for emergency physicians. This study reports on the results of the examinations made between January and September 2015. For each examination performed, clinical usefulness was assessed at the time of patient discharge, by two independent physicians who reviewed the clinical course and the results of conventional imaging and rated their evaluation on a Likert scale. RESULTS: One hundred and four examinations were evaluated. The mean duration of the ultrasound examination was 9±5minutes. The POCUS conclusions were corrected by disease course or the results of conventional imaging in 10 (9.6%) cases. The presets of the device: heart, soft tissue, lung, abdomen and vascular were used respectively in 32, 30, 21, 12 and 5% of the examinations. The main indications of POCUS examination were for identification of pleural, pericardial or peritoneal effusion, and to assess the central venous pressure by inferior vena cava examination. Eighteen examinations were performed for puncture of effusion. The retrospectively evaluated clinical benefit was clearly demonstrated in 78% of cases. The agreement between the two blinded assessors was good (kappa coefficient at 0.82). CONCLUSION: Pocket-sized ultrasound device could be used in internal medicine wards. However, its limited performance compared to more sophisticated echography limits the possible explorations and their reliability, which encourages caution and makes critical the question of the initial training of doctors and medical students.

[Hyperlactatemia induced by inhaled ß2 agonists: An underrecognized side effect. Report of two cases]. / Hyperlactatémie induite par les ß2 mimétiques inhalés : un effet secondaire mal connu. À propos de deux cas.

BACKGROUND: Repeated use of inhaled ß2 agonists is common in asthma or COPD exacerbations. It can lead to hyperlactatemia. CASE REPORTS: We report two asthmatic patients who presented in the emergency department for an asthma exacerbation. The first patient developed hyperlactatemia at 3.9 mmol/L and the second patient developed hyperlactatemia at 5.6 mmol/L after terbutaline treatment. Both patients had a favorable outcome after adjusting the aerosol dose to clinical parameters. DISCUSSION: Lactic acidosis induced by the use of inhaled ß2 agonists is not synonymous of clinical deterioration. However, this side effect may be complicated by a tachypnea compensating for metabolic acidosis and should be known to avoid unnecessary therapeutic escalation.

[Acquisition of clinical observation skills by medical students improves with discipline-based teaching. The example of neurological examination]. / L'enseignement par discipline de la sémiologie en deuxième année de médecine améliore l'acquisition des compétences. Exemple de la sémiologie neurologique.

INTRODUCTION: Since 2014-2015, practical teaching of clinical observation skills for 2nd year medical students at our faculty has been discipline-based; previously, each clinical lecturer had to cover all medical fields. We assessed the impact of this teaching reform on the neurological examination skills of medical students in a before-and-after study. METHODS: Pre-reform 3rd and post-reform 2nd and 3rd year medical students (n=62, n=71 and 52, respectively) had to perform 7 neurological examination items, for which performance criteria had been pre-defined. Subsequently, we assessed whether the mean grade in neurological examination skills during the test at the end of the 2nd year was different between students who had received neurological teaching from a neurologist (n=29) or another specialist (n=102). RESULTS: The median [interquartile range] number of items acquired by post-reform 3rd year students (4 [2-5]) was higher than that of pre-reform 3rd year students (2 [1-3]; P<0.001), but lower than that of post-reform 2nd year students (5 [4-6]; P=0.01). The mean grade obtained during the practical test was not different in students trained by a neurologist or another specialist. CONCLUSION: Acquisition of neurological examination skills improved after the teaching reform which consisted of: (1) a discipline-based practical teaching of clinical observation skills; (2) a training of clinical lecturers to teach a limited list of educational objectives; and (3) the introduction of a practical test at the end of the 2nd year of medical studies. However, there was a decline in clinical observation skills between 2nd and 3rd year medical students.

[Benign metastasizing leiomyoma: An unusual cause of aggressive femoral bone tumor]. / Léiomyome métastatique bénin : une cause inhabituelle de tumeur osseuse fémorale agressive.

BACKGROUND: Benign metastasizing leiomyoma (BML) is a rare condition characterized by histologically benign "metastatic" smooth muscle tumors, which can affect women with history of uterine surgery. We report the case of a patient with bone metastases of BML. CASE REPORT: A 78-year-old woman who had undergone uterine surgery six years before hospital admission, was diagnosed with large pulmonary and pleural metastases that necessitated surgical removal. Pathological examination allowed the diagnosis of BML with positive staining for estrogen and progesterone receptors. Three years later, a BML metastasis in the right femoral diaphysis was unexpectedly discovered and treated by osteosynthesis because of a high risk of fracture. Despite an aromatase-inhibitor treatment, new lungs lesions appeared in the next few months. CONCLUSION: BML is a potential cause of aggressive, although histologically benign, bone tumor in women with a history of uterine surgery.

Sickle cell retinopathy and other chronic complications of sickle cell anemia: A clinical study of 84 Sub-Saharan African cases (Cameroon).

OBJECTIVE: Sickle retinopathy is a severe complication of sickle cell disease than can lead to blindness. We aim to describe the epidemiology of sickle retinopathy in homozygous sickle cell (SS) African patients and to analyze its association with non-ophthalmologic disease complications of sickle cell anemia. METHODS: We conducted a nested study within the CADRE cohort in Cameroon. Eighty-four consecutive SS outpatients, aged 10 years and older, with no visual symptoms, underwent an ophthalmologic examination. Mean age was 23±10 years. Clinical and biological features were compared between patients with and without sickle retinopathy. We compared the prevalence of the clinical complications and main biological characteristics in patients with and without sickle retinopathy using a univariate logistic regression. The same analysis was used to compare the patients with non-proliferative sickle retinopathy to those with proliferative sickle retinopathy. Statistical analyses were done using the R software (version 3.1.2). RESULTS: Fifty-two patients (62%) displayed sickle retinopathy, among them 23 (27%) had a non-proliferative sickle retinopathy, and 29 (35%) had proliferative sickle retinopathy. Patients with proliferative sickle cell retinopathy had a mean age of 28±11 years. Sickle retinopathy was associated with higher hemoglobin level (P=0.047) and fewer leg ulcers (P=0.018). Proliferative SR was associated with increasing age (P=0.008) and male sex (P=0.025) independently of the hemoglobin level. CONCLUSIONS: Sickle retinopathy is particularly frequent in sub-Saharan sickle cell SS patients, which advocates for early systematic screening.