[Treatment of pleural space infections]. / Prise en charge des infections de l'espace pleural.

Pleural space infections occur in approximately 10% of patients hospitalized for pneumonia and their incidence is increasing with an aging population. Pulmonary ultrasound is a good bedside diagnostic tool able to reduce complications associated with thoracocentesis and drainage. The RAPID score is being increasingly validated as a predictor for mortality but has not yet been proven useful to guide the treatment strategy and needs incorporation into prospective studies. Awaiting studies on outcome prediction and the comparison of an early surgical strategy versus drainage with intrapleural enzyme therapy, this article presents a summary of current knowledge of this complication.

Les infections de l'espace pleural surviennent chez environ 10 % des patients hospitalisés pour une pneumonie. Leur incidence est en augmentation, en parallèle du vieillissement de la population. L'échographie pleuropulmonaire est un outil diagnostique sensible, directement accessible au lit du malade et permettant de diminuer les complications du drainage grâce au guidage. Le score RAPID a été validé pour prédire la mortalité liée à l'infection de l'espace pleural mais son utilité pour sélectionner la meilleure stratégie thérapeutique reste encore à démontrer. Dans l'attente des résultats d'une étude prospective randomisée comparant une prise en charge chirurgicale précoce au drainage avec fibrinolyse, cet article présente l'état des connaissances concernant le traitement de cette affection.

[Hyperammoniemic encephalopathy: beyond the hepatic cause]. / Encéphalopathie hyperammoniémique : au-delà de la cause hépatique.

Hyperammoniemic encephalopathy is part of the differential -diagnosis in the presence of an acute confusional state. Although associated with liver dysfunction in the majority of cases, it can be observed in many other clinical situations. Often not investigated, the dosage of ammonium in the blood should be integrated in the biological work-up of encephalopathy of unknown origin. Mana-gement focused on etiology is paramount and usually allows for the rapid normalization of ammonium levels and resolution of the clinical syndrome.

L'encéphalopathie hyperammoniémique fait partie des diagnostics différentiels devant un état confusionnel aigu. Le plus souvent liée à une dysfonction hépatique, l'hyperammoniémie peut être observée dans de nombreuses autres situations cliniques. Ainsi, le dosage sanguin de l'ammonium fait partie intégrante du bilan diagnostique de l'état confusionnel sans cause apparente. Une prise en charge centrée sur l'étiologie est primordiale et permet habituellement la normalisation rapide des valeurs d'ammonium et la résolution du syndrome clinique.

[COPD exacerbation: towards a blood eosinophil-guided corticosteroid therapy?] / Exacerbation de BPCO : vers une corticothérapie guidée par les éosinophiles sanguins ?

Measurement of blood eosinophils helps identify COPD patients at increased risk of acute exacerbation who would benefit from the initiation of maintenance therapy with inhaled corticosteroids. This strategy has been included into the GOLD recommendations. Would there be an interest in measuring blood eosinophils to manage COPD exacerbations? Recently, strategies using blood eosinophil count have been developed to better target the group of patients with exacerbations who respond to systemic corticosteroid therapy and also to limit its prescription when the risk/benefit ratio is unfavorable.

Le dosage des éosinophiles sanguins (EOS) permet d'identifier les patients avec une bronchopneumopathie chronique obstructive (BPCO) présentant un risque accru d'exacerbation et bénéficiant de l'instauration d'un traitement de fond par corticostéroïdes inhalés. Cette stratégie a été mise en avant dans les dernières recommandations GOLD. Qu'en est-il de l'intérêt du dosage des EOS dans la prise en charge de l'exacerbation de BPCO ? Récemment, des stratégies d'utilisation des EOS comme biomarqueurs ont émergé, permettant de mieux cibler le groupe de patients avec une exacerbation susceptibles de répondre à une corticothérapie systémique et également de limiter leur prescription en cas de rapport risque/bénéfice défavorable.

[Selected novelties for hospital based internal medicine]. / Nouveautés en médecine interne hospitalière.

In this selective overview of articles, we describe new concepts, therapeutic measures and pharmacological agents that may modify current practice in clinical internal medicine. Novelties for the management of cardiovascular disease, such as heart failure, hypoxemic respiratory failure, nosocomial pneumonia and certain allergies are discussed.

À travers quelques articles et études choisis, cet article décrit de nouveaux concepts, mesures thérapeutiques et agents pharmacologiques pouvant modifier les pratiques courantes en médecine interne. Des notions concernant la gestion de maladies cardiovasculaires telles que l'insuffisance cardiaque, les décompensations respiratoires hypoxémiques, les pneumonies nosocomiales et la gestion d'allergies y figurent au premier plan.

Brain functional connectivity alterations associated with neuropsychological performance 6-9 months following SARS-CoV-2 infection.

Neuropsychological deficits and brain damage following SARS-CoV-2 infection are not well understood. Then, 116 patients, with either severe, moderate, or mild disease in the acute phase underwent neuropsychological and olfactory tests, as well as completed psychiatric and respiratory questionnaires at 223 ± 42 days postinfection. Additionally, a subgroup of 50 patients underwent functional magnetic resonance imaging. Patients in the severe group displayed poorer verbal episodic memory performances, and moderate patients had reduced mental flexibility. Neuroimaging revealed patterns of hypofunctional and hyperfunctional connectivities in severe patients, while only hyperconnectivity patterns were observed for moderate. The default mode, somatosensory, dorsal attention, subcortical, and cerebellar networks were implicated. Partial least squares correlations analysis confirmed specific association between memory, executive functions performances and brain functional connectivity. The severity of the infection in the acute phase is a predictor of neuropsychological performance 6-9 months following SARS-CoV-2 infection. SARS-CoV-2 infection causes long-term memory and executive dysfunctions, related to large-scale functional brain connectivity alterations.

[Diagnosis of asthma: new developments in general internal medicine]. / Diagnostic de l'asthme : nouveautés pour la médecine interne générale.

Asthma, a chronic inflammatory lung disease affecting about 10 % of the population, involves both the general internist and the pulmonologist. The risk of over and underdiagnosis generates significant health costs and evitable clinical consequences. Improved screening through dedicated anamneses and questionnaires, as well as use of fractional exhaled nitric oxide (FeNO) may improve the diagnosis of asthma in general internal medicine.

L'asthme, maladie pulmonaire inflammatoire chronique affectant environ 10 % de la population, implique autant la médecine interne générale (MIG) que la pneumologie. Les risques de sous- et surdiagnostic engendrent d'importants coûts et conséquences cliniques évitables. Améliorer le dépistage lors de l'anamnèse avec l'utilisation de questionnaires dédiés et lors des examens fonctionnels par l'utilisation de la mesure de la fraction exhalée de l'oxyde nitrique pourrait être la clé d'un meilleur diagnostic de l'asthme en MIG.

[Advances in hospital based internal medicine]. / Nouveautés en médecine interne hospitalière.

Hospital based internal medicine has been strongly solicited for over two years with the SARS-CoV-2 epidemic. This epidemic continues to evolve and represents a strain for public health. Numerous studies have addressed issues concerning this epidemic, and multiple novelties concerning other frequent pathologies have also been published. Management strategies of cardiovascular, pulmonary, gastro-intestinal and metabolic diseases are discussed.

La médecine interne hospitalière a été fortement sollicitée depuis 2 ans avec l'épidémie de SARS-CoV-2. Celle-ci continue d'évoluer et reste une épreuve pour la santé publique. Une pléthore d'études a tenté de résoudre les multiples défis que représente cette épidémie, mais de multiples nouveautés concernant d'autres pathologies fréquentes sont également apparues. La prise en charge des maladies cardiovasculaires, pulmonaires, gastro-intestinales et métaboliques est évoquée.

[Diabetes and pancreatic cancer - When diabetes indicates a pancreatic cancer]. / Diabète et cancer du pancréas - Quand le diabète est annonciateur de cancer pancréatique.

Diabetes and pancreatic cancer have an intricate relationship where each is a risk factor for developing the other. In case of type 2 diabetes, there is an increased probability of developing pancreatic cancer. Similarly, the onset of diabetes often precedes the diagnosis of pancreatic cancer. Since hyperglycemia is secondary to tumor involvement of the exocrine pancreas, diabetes is considered pancreatogenic. In the current classification, it is part of the entities belonging to type 3c diabetes. The pathophysiology is specific, characterized by a high glycemic variability and a tendency to weight loss. Early identification of inaugural type 3c diabetes would reduce diagnostic delays and could optimize oncologic management. In the absence of specific markers, the challenge for the clinician is indisputable.

Diabète et cancer du pancréas entretiennent une relation intriquée où chacun constitue un risque de développer l'autre. En cas de diabète de type 2, le risque de cancer augmente. La survenue d'un diabète précède aussi souvent le diagnostic de cancer du pancréas. L'hyperglycémie étant secondaire à l'atteinte tumorale du pancréas exocrine, ce diabète est considéré comme pancréatogénique. Dans la dénomination actuelle, il fait partie des entités appartenant au diabète de type 3c. La pathophysiologie est spécifique, caractérisée par une forte variabilité glycémique et une tendance à la perte de poids. Distinguer précocement les diabètes inauguraux de type 3c permettrait de réduire les délais diagnostiques et d'optimiser la prise en charge oncologique. En l'absence de marqueurs spécifiques, le challenge est indiscutable pour le clinicien.

[When to look for cancer in case of unintentional weight loss ?] / Quand rechercher un cancer en cas de perte de poids involontaire ?

The definition of unintentional weight loss (UWL) is heterogeneous and most commonly used as a UWL of >5% over the past 6 months. The differential diagnosis of UWL is very broad and encompasses non-medical causes, somatic illnesses, and psychiatric conditions. One of the feared diagnoses remains the presence of an underlying cancer. It is observed that UWL is more associated with certain types of cancer, in particular digestive. The primary workup for UWL should begin with a history and a detailed physical examination searching for associated symptoms or signs. The age, sex and smoking status are factors to be considered in particular. Management of UWL does not meet established recommendations and should be guided by relevant signs and symptoms. Future studies are necessary, in particular to clarify the place of imaging in the diagnostic process.

La définition de la perte de poids involontaire (PPI) est hétérogène, celle souvent retenue est une PPI > 5 % en 6 mois. Le diagnostic différentiel est très large et prend en compte des causes variées, dont la présence redoutée d'un cancer sous-jacent. Elle est plus souvent associée à certains types de cancer, notamment digestifs. Son bilan primaire commence par une anamnèse et un examen clinique détaillés à la recherche de symptômes associés. L'âge, le sexe et le tabagisme sont des facteurs à prendre en compte. Sa prise en charge ne répond pas à des recommandations clairement établies, mais est guidée par les symptômes associés. De futures études sont nécessaires, notamment pour clarifier la place de l'imagerie dans la démarche diagnostique.

[Healing communication: Therapeutic communication in internal medicine]. / La « communication thérapeutique ¼ en médecine interne.

Caregiver-patient communication is a central element of the therapeutic relationship and a powerful placebo. While poorly adapted communication can have harmful effects, adequate communication offers many benefits for the patient and the caregiver. Therapeutic communication (TC), a set of strategies inspired by clinical hypnosis, is easy to learn and apply. In addition to reinforcing an empathetic attitude, TC appears to be effective in various clinical situations, particularly for its effects on pain and anxiety. In order to better understand the interest of CT in internal medicine, we have conducted a literature review on its efficacy during different medical procedures.

La communication soignant-e/soigné-e est un élément central de la relation thérapeutique et un puissant placebo dont il serait dommage de se priver. Mal adaptée, elle peut avoir des effets néfastes, efficace, elle offre de nombreux bénéfices pour les patient-e-s et soignant-e-s. La communication thérapeutique (CT), un ensemble de stratégies inspirées de l'hypnose clinique, est facile à apprendre et à appliquer. En plus de renforcer une attitude empathique, la CT semble efficace dans diverses situations cliniques, notamment pour ses effets sur la douleur et l'anxiété. Dans le but de mieux comprendre l'intérêt de la CT en médecine interne, nous avons effectué une revue de littérature démontrant son utilisation lors de gestes techniques auxquels les patient-e-s sont fréquemment confronté-e-s.

[VEXAS syndrome : when do we have to consider it ?] / Syndrome VEXAS : quand y penser ?

VEXAS syndrome was recently discovered in patients who developed late in adulthood an inflammatory syndrome with fever, cytopenias, dysplastic bone marrow, cutaneous and pulmonary neutrophilic inflammation, arthritis, chondritis, or vasculitis. It is the result of an inactivating somatic mutation affecting methionine codon 41 of the UBA1 gene which encodes an ubiquitin activating enzyme (E1). Systemic corticosteroids generally reduce symptoms, while other immunosuppressive drugs only have limited long-term effects. Azacitidine is a promising treatment, but further studies are warranted. Here, we describe 2 new cases including one associated with pyoderma gangrenosum and cryoglobulinemia.

Le syndrome VEXAS (Vacuoles, E1 Enzyme, X-Linked, Auto- Inflammatory, Somatic Syndrome) a été récemment découvert chez des patients développant tardivement à l'âge adulte un syndrome inflammatoire associé à de la fièvre, des cytopénies, une moelle osseuse dysplasique, une inflammation neutrophilique cutanée et pulmonaire, des arthrites, des chondrites ou des vasculites. Il est le résultat d'une mutation somatique inactivatrice affectant le codon méthionine 41 du gène UBA1 qui encode une enzyme E1 activant l'ubiquitine. Les corticostéroïdes systémiques permettent généralement de diminuer les symptômes alors que les autres immunosuppresseurs ont un effet limité à long terme. L'azacitidine est l'un des traitements ayant démontré une efficacité, cependant de nouvelles études sont souhaitables. Nous décrivons ici 2 cas dont l'un est associé à un pyoderma gangrenosum et une cryoglobulinémie.

[Latest progress in internal medicine]. / Avancées récentes en médecine interne.

Internal medicine continues de evolve as a result of further insight and evidence for the efficacy of given interventions. Although numerous studies have addressed issues concerning the SARS-COV-2 epidemic, multiple novelties concerning other frequent pathologies have also been presented. Management strategies of cardiovascular disease, infectious diseases and venous thromboembolism are particularly concerned.

La médecine interne continue d'évoluer au fur et à mesure de nouvelles évidences d'efficacité par rapport aux diverses interventions. Une pléthore d'études a tenté de résoudre les multiples défis que représente l'épidémie au SARS-CoV-2, mais de multiples nouveautés concernant d'autres pathologies fréquentes sont également apparues. La prise en charge des maladies cardiovasculaires, de maladies infectieuses et la maladie thromboembolique sont particulièrement concernées.

COVID-19 encephalopathy: Clinical and neurobiological features.

Severe acute respiratory coronavirus 2 (SARS-CoV-2) has been associated with neurological complications, including acute encephalopathy. To better understand the neuropathogenesis of this acute encephalopathy, we describe a series of patients with coronavirus disease 2019 (COVID-19) encephalopathy, highlighting its phenomenology and its neurobiological features. On May 10, 2020, 707 patients infected by SARS-CoV-2 were hospitalized at the Geneva University Hospitals; 31 (4.4%) consecutive patients with an acute encephalopathy (64.6 ± 12.1 years; 6.5% female) were included in this series, after exclusion of comorbid neurological conditions, such as stroke or meningitis. The severity of the COVID-19 encephalopathy was divided into severe and mild based on the Richmond Agitation Sedation Scale (RASS): severe cases (n = 14, 45.2%) were defined on a RASS < -3 at worst presentation. The severe form of this so-called COVID-19 encephalopathy presented more often a headache. The severity of the pneumonia was not associated with the severity of the COVID-19 encephalopathy: 28 of 31 (90%) patients did develop an acute respiratory distress syndrome, without any difference between groups (p = .665). Magnetic resonance imaging abnormalities were found in 92.0% (23 of 25 patients) with an intracranial vessel gadolinium enhancement in 85.0% (17 of 20 patients), while an increased cerebrospinal fluid/serum quotient of albumin suggestive of blood-brain barrier disruption was reported in 85.7% (6 of 7 patients). Reverse transcription-polymerase chain reaction for SARS-CoV-2 was negative for all patients in the cerebrospinal fluid. Although different pathophysiological mechanisms may contribute to this acute encephalopathy, our findings suggest the hypothesis of disturbed brain homeostasis and vascular dysfunction consistent with a SARS-CoV-2-induced endotheliitis.

Role of Intermediate Care Unit Admission and Noninvasive Respiratory Support during the COVID-19 Pandemic: A Retrospective Cohort Study.

BACKGROUND: The COVID-19 pandemic has led to shortage of intensive care unit (ICU) capacity. We developed a triage strategy including noninvasive respiratory support and admission to the intermediate care unit (IMCU). ICU admission was restricted to patients requiring invasive ventilation. OBJECTIVES: The aim of this study is to describe the characteristics and outcomes of patients admitted to the IMCU. METHOD: Retrospective cohort including consecutive patients admitted between March 28 and April 27, 2020. The primary outcome was the proportion of patients with severe hypoxemic respiratory failure avoiding ICU admission. Secondary outcomes included the rate of emergency intubation, 28-day mortality, and predictors of ICU admission. RESULTS: One hundred fifty-seven patients with COVID-19-associated pneumonia were admitted to the IMCU. Among the 85 patients admitted for worsening respiratory failure, 52/85 (61%) avoided ICU admission. In multivariate analysis, PaO2/FiO2 (OR 0.98; 95% CI: 0.96-0.99) and BMI (OR 0.88; 95% CI: 0.78-0.98) were significantly associated with ICU admission. No death or emergency intubation occurred in the IMCU. CONCLUSIONS: IMCU admission including standardized triage criteria, self-proning, and noninvasive respiratory support prevents ICU admission for a large proportion of patients with COVID-19 hypoxemic respiratory failure. In the context of the COVID-19 pandemic, IMCUs may play an important role in preserving ICU capacity by avoiding ICU admission for patients with worsening respiratory failure and allowing early discharge of ICU patients.

Medical students' perceptions and coping strategies during the first wave of the COVID-19 pandemic: studies, clinical implication, and professional identity.

BACKGROUND: The unfolding of the COVID-19 pandemic during spring 2020 has disrupted medical education worldwide. The University of Geneva decided to shift on-site classwork to online learning; many exams were transformed from summative to formative evaluations and most clinical activities were suspended. We aimed to investigate the perceived impact of those adaptations by the students at the Faculty of Medicine. METHODS: We sent an online self-administered survey to medical students from years 2 to 6 of the University of Geneva, three months after the beginning of the pandemic. The survey explored students' main activities during the first three months of the pandemic, the impact of the crisis on their personal life, on their training and on their professional identity, the level of stress they experienced and which coping strategies they developed. The survey consisted of open-ended and closed questions and was administered in French. RESULTS: A total of 58.8% of students responded (n = 467) and were homogeneously distributed across gender. At the time of the survey, two thirds of the participants were involved in COVID-19-related activities; 72.5% voluntarily participated, mainly fueled by a desire to help and feel useful. Many participants (58.8%) reported a feeling of isolation encountered since the start of the pandemic. Main coping strategies reported were physical activity and increased telecommunications with their loved ones. Most students described a negative impact of the imposed restrictions on their training, reporting decreased motivation and concentration in an unusual or distraction-prone study environment at home and missing interactions with peers and teachers. Students recruited to help at the hospital in the context of increasing staff needs reported a positive impact due to the enriched clinical exposure. Perceived stress levels were manageable across the surveyed population. If changed, the crisis had a largely positive impact on students' professional identity; most highlighted the importance of the health care profession for society and confirmed their career choice. CONCLUSION: Through this comprehensive picture, our study describes the perceived impact of the pandemic on University of Geneva medical students, their training and their professional identity three months after the start of the pandemic. These results allowed us to gain valuable insight that reinforced the relevance of assessing the evolution of the situation in the long run and the importance of developing institutional support tools for medical students throughout their studies.

[COVID-19-related acute encephalopathy: physiopathological hypothesis]. / Encéphalopathie aiguë et Covid-19: hypothèses physiopathologiques.

Acute encephalopathy is one of the most frequent neurological complication in patients hospitalized for COVID-19. Electrolyte imbalance, drugs, and hypoxemia can all affect brain homeostasis, leading to acute cognitive dysfunction and direct implications of the SARS-CoV-2 are not completely understood. Neurological complications of SARS-CoV-2 infection are poorly understood: an inflammatory insult to the endothelium affecting the blood-brain barrier may explain the clinical presentation, but other hypotheses including direct viral damage or an immune-mediated reaction are also suggested. Among these various potential mechanisms, often combined, the controversy remains.

L'encéphalopathie aiguë est l'une des principales complications neurologiques des patients hospitalisés pour un Covid-19. Si les complications électrolytiques, les différents traitements et l'hypoxémie ont un effet sur l'homéostasie cérébrale entraînant une perturbation de la cognition, les conséquences cérébrales directes ou indirectes du SARS-CoV-2 ne sont pas complètement élucidées. L'implication du virus entraînant une atteinte endothéliale des vaisseaux cérébraux pourrait participer à cette encéphalopathie, via une fragilisation de la barrière hémato-encéphalique et un passage facilité des cytokines pro-inflammatoires. L'atteinte virale directe ou la réaction autoimmune secondaire ont également été invoquées. Face aux multiples mécanismes physiopathologiques possibles pouvant expliquer cette encéphalopathie, le débat est ouvert.

Prognosis of patients eligible for dapagliflozin in acute heart failure.

BACKGROUND: Dapagliflozin, a sodium-glucose cotransporter 2 inhibitor, was shown in the DAPA-HF study to reduce the risk of worsening heart failure or death in symptomatic patients with left ejection fraction <40%, irrespective of diabetes. The aim of this study was to evaluate eligibility status for dapagliflozin in non-selected patients hospitalized for acute decompensated heart failure (ADHF), as well as prognostic implications of this status. MATERIALS AND METHODS: Analysis of 815 patients recruited in a prospective cohort of acute heart failure at the University Hospitals of Geneva, consisting of consecutive patients admitted with ADHF. Eligibility for dapagliflozin was determined using criteria described DAPA-HF. RESULTS: Of 815 patients, 220 (27%) were eligible for dapagliflozin treatment. In survival analysis, patients who were eligible for dapagliflozin had better clinical outcomes with respect to all-cause mortality and rehospitalization as compared to those who were not eligible. In multivariate analysis, the hazard ratio for all-cause mortality or readmission in patients eligible for dapagliflozin was 0.82 (95% CI 0.68-0.999, P = .049) as compared to the non-eligible. CONCLUSIONS: Using DAPA-HF criteria, only 27% of non-selected patients admitted for ADHF are theoretically eligible for dapagliflozin. This eligibility for dapagliflozin is associated with better outcomes. Further evaluation of the benefits of dapagliflozin in selected HF patients may be of interest. This may have implications for selection criteria in future randomized effectiveness studies.

[A pragmatic approach to the syndromes of thrombotic microangiopathy]. / Approche pragmatique des syndromes de microangiopathie thrombotique.

Whilst the pathophysiology underlying the diverse thrombotic microangiopathy syndromes is better understood, management of these entities and of the various therapeutic options currently available remains challenging. Early identification of these syndromes is essential to improving prognosis. In the absence of treatment, mortality is high, including in the first days following diagnosis. We present a summary of the diagnostic strategy and therapeutic management of thrombotic microangiopathy in adults.

Alors que la physiopathologie de la microangiopathie thrombotique est de mieux en mieux comprise, la gestion de cette entité en aigu et les différentes options thérapeutiques à disposition restent moins claires. Son identification précoce est indispensable pour permettre une amélioration du pronostic. En l'absence de traitement, le taux de mortalité est très élevé, et ce dans les premiers jours qui suivent le diagnostic. Cet article a pour objectif de permettre une synthèse des stratégies diagnostique et thérapeutique à adopter devant une suspicion de microangiopathie thrombotique chez l'adulte.

[New onset atrial fibrillation in patients hospitalized with sepsis : is there an indication for anticoagulation ?] / Fibrillation auriculaire inaugurale lors d'un sepsis : y a-t-il une indication à une anticoagulation ?

Atrial fibrillation (AF) is the most common cardiac arrhythmia in the general population and in patients with sepsis hospitalized in intensive care. The indication for long-term anticoagulation is based on expert recommendations that take into account data from the general population and thus recommend therapeutic anticoagulation for AF longer than 48 hours. However, a majority of new onset AF in intensive care seem to last less than 48 hours and additional risk factors such as the type of sepsis, the drugs administered as well as the presence of a central venous catheters, are involved. Moreover, the increased of minor and major hemorrhage renders it difficult to apply the usual recommendations. In this literature review, we will focus on the various risk factors, prognosis, and indication of long-term anticoagulation in the new onset AF in this population.

La fibrillation auriculaire (FA) est l'arythmie cardiaque la plus fréquente chez les patients en sepsis admis aux soins intensifs. L'indication à une anticoagulation au long cours se fonde sur des recommandations d'experts qui proposent une anticoagulation thérapeutique pour les FA de plus de 48 heures, compte tenu de données populationnelles. Or, la majorité de ces FA inaugurales semblent durer moins longtemps. La sévérité du sepsis, les médicaments administrés, la présence d'une voie veineuse centrale sont autant de facteurs de risque de survenue. S'y ajoute un risque hémorragique accru, rendant difficile l'application des recommandations usuelles. Nous allons, dans cette revue de littérature, nous intéresser aux facteurs de risque, au pronostic et à l'indication d'une anticoagulation au long cours de la FA inaugurale dans cette population.

[A first-line guide to the evaluation of « Penicillin Allergy ¼ in general medical practice]. / Proposition de prise en charge de l'« allergie à la pénicilline ¼ en médecine interne et de premier recours.

« Penicillin allergy ¼ is a common finding in patient's medical files (up to 10 %). Although it is important not to neglect such records (due to the serious and life-threatening reactions an allergic patient may suffer from), most of the time these reported notions of allergy are wrong and lead to the unfortunate avoidance of all betalactamins. This in turn leads to increased risks of antibiotic resistance and increased health costs. This review aims to summarize the current knowledge on penicillin allergy epidemiologic data and proposes a first-line guide for general practitioners to the evaluation of the patient with a history of « penicillin allergy ¼.

La « notion d'allergie à la pénicilline ¼ dans les dossiers des patients est une trouvaille assez fréquente (jusqu'à 10 %) et généralement erronée. Cette dernière peut mener à une sous-utilisation des bêtalactamines avec des conséquences négatives sur l'émergence de germes résistants, la prise en charge et les coûts médicaux. D'un autre côté, il s'agit néanmoins d'un diagnostic à ne pas ignorer ni à banaliser (notamment devant une anamnèse incomplète) étant donné la sévérité des réactions qu'une exposition pourrait occasionner. Cet article propose un résumé des connaissances actuelles des données épidémiologiques sur le sujet, et un algorithme de prise en charge en première intention des « notions d'allergie à la pénicilline ¼.