Antibody response and intra-host viral evolution after plasma therapy in COVID-19 patients pre-exposed or not to B-cell-depleting agents.

Administration of plasma therapy may contribute to viral control and survival of COVID-19 patients receiving B-cell-depleting agents that impair humoral immunity. However, little is known on the impact of anti-CD20 pre-exposition on the kinetics of SARS-CoV-2-specific antibodies. Here, we evaluated the relationship between anti-spike immunoglobulin G (IgG) kinetics and the clinical status or intra-host viral evolution after plasma therapy in 36 eligible hospitalized COVID-19 patients, pre-exposed or not to B-cell-depleting treatments. The majority of anti-CD20 pre-exposed patients (14/17) showed progressive declines of anti-spike IgG titres following plasma therapy, contrasting with the 4/19 patients who had not received B-cell-depleting agents (p = 0.0006). Patients with antibody decay also depicted prolonged clinical symptoms according to the World Health Organization (WHO) severity classification (p = 0.0267) and SARS-CoV-2 viral loads (p = 0.0032) before complete virus clearance. Moreover, they had higher mutation rates than patients able to mount an endogenous humoral response (p = 0.015), including three patients with one to four spike mutations, potentially associated with immune escape. No relevant differences were observed between patients treated with plasma from convalescent and/or mRNA-vaccinated donors. Our study emphasizes the need for an individualized clinical care and follow-up in the management of COVID-19 patients with B-cell lymphopenia.

Development of health care workers' mental health during the SARS-CoV-2 pandemic in Switzerland: two cross-sectional studies.

BACKGROUND: Virus outbreaks such as the current SARS-CoV-2 pandemic are challenging for health care workers (HCWs), affecting their workload and their mental health. Since both, workload and HCW's well-being are related to the quality of care, continuous monitoring of working hours and indicators of mental health in HCWs is of relevance during the current pandemic. The existing investigations, however, have been limited to a single study period. We examined changes in working hours and mental health in Swiss HCWs at the height of the pandemic (T1) and again after its flattening (T2). METHODS: We conducted two cross-sectional online studies among Swiss HCWs assessing working hours, depression, anxiety, and burnout. From each study, 812 demographics-matched participants were included into the analysis. Working hours and mental health were compared between the two samples. RESULTS: Compared to prior to the pandemic, the share of participants working less hours was the same in both samples, whereas the share of those working more hours was lower in the T2 sample. The level of depression did not differ between the samples. In the T2 sample, participants reported more anxiety, however, this difference was below the minimal clinically important difference. Levels of burnout were slightly higher in the T2 sample. CONCLUSIONS: Two weeks after the health care system started to transition back to normal operations, HCWs' working hours still differed from their regular hours in non-pandemic times. Overall anxiety and depression among HCWs did not change substantially over the course of the current SARS-CoV-2 pandemic.

[Teaching and learning during attending rounds in internal medicine: an anthropological study]. / Enseigner et apprendre lors des grandes visites en médecine interne hospitalière : Une étude anthropologique.

This anthropological research aims to highlight the educational approaches in action during attending rounds. The goal is to understand how specific learning domains, professional socialization and learning environments are influenced by the different ways of conducting attending rounds. Two formats of rounds were noted: the IN format, when the patient case is presented in the patient room, and the OUT format. Six educational approaches were identified. The attending round format has an impact on the approaches used. The latter contribute to the development, to varying degrees, of knowledge, skills and attitudes. Attending rounds remain a space for "top-down" transmission and supervision, even though some approaches involve learner initiatives and peer group logic.

Notre recherche anthropologique vise à mettre en lumière les approches pédagogiques à l'œuvre durant les grandes visites. Comment les domaines d'apprentissages visés, la socialisation professionnelle et l'environnement d'apprentissage sont-ils influencés par les différentes manières de les conduire ? Deux formes de visites sont retrouvées : la forme IN (le cas est présenté au lit du patient) et la forme OUT. Six approches pédagogiques ont été identifiées. La forme de grande visite influence les approches pédagogiques mobilisées. Celles-ci contribuent à développer, à des degrés variables, des savoirs, savoir-faire et savoir-être. Les grandes visites restent un espace de transmission « top-down ¼ et de surveillance, même si certaines approches encouragent les initiatives des apprenants ainsi que les logiques de groupes de pairs.

[Albumin substitution : A review of the indications in general internal medicine]. / Substitution en albumine : revue des indications en médecine interne générale.

Albumin has multiple physiological functions such as maintenance of oncotic pressure, binding of plasmatic molecule, immunomodulation and endothelial stabilization. Considering potential negative effects of hypoalbuminemia, the question of albumin substitution arises. For cirrhotic patients, indications for substitution are well established with a scientific consensus for spontaneous bacterial peritonitis, paracentesis-induced circulatory dysfunction and hepatorenal syndrome. However, in the case of hepatic encephalopathy or of hypoalbuminemia in non-cirrhotic patients, the scientific consensus is absent, and the results of clinical studies differ. In this article, we present the different indications of albumin substitution by examining the most recent studies.

L'albumine exerce de multiples fonctions physiologiques, notamment : maintien de la pression oncotique, liaison à d'autres molécules plasmatiques, immunomodulation et stabilisation endothéliale. Face aux potentiels effets délétères de l'hypoalbuminémie, la question d'une substitution se pose. Chez le patient cirrhotique, les indications à la substitution sont bien définies avec un consensus scientifique pour la péritonite bactérienne spontanée, la dysfonction circulatoire postparacentèse de grand volume et le syndrome hépatorénal. Néanmoins, en cas d'encéphalopathie hépatique ou d'hypoalbuminémie chez le patient non cirrhotique, le consensus est absent et les résultats des études divergent. Dans cet article, nous présentons les différentes indications à sa substitution, en mettant l'accent sur les études récentes en la matière.

[Psychogenic polydipsia†: a (still) unknown psychosomatic entity]. / Polydipsie psychogène†: une entité somato-psychiatrique (encore) méconnue.

Psychogenic polydipsia, as well referred to as «â€…potomania ¼, is a clinical entity that can be found in psychiatric as well as in physical care settings. Its diagnosis is based on the detection of an excessive fluid intake along with a polyuria, after excluding any potential somatic cause of this clinical presentation. Given the different somatic complications and care complexity, early detection and multidisciplinary interventions are necessary. This article offers a literature review on this topic.

La polydipsie psychogène, également dénommée «â€…potomanie ¼, est une entité clinique que l'on rencontre en milieu psychiatrique, ainsi qu'en milieu somatique. Son diagnostic se base sur la détection d'une consommation excessive d'eau et d'une polyurie, après exclusion de toute cause somatique pouvant être à l'origine du tableau clinique. Vu les diverses complications somatiques et la complexité de la prise en charge, la nécessité de la détection précoce et d'une approche pluridisciplinaire est primordiale. Cet article propose une revue de la littérature scientifique sur ce sujet.

[PROFILES: typical portrait of the future Swiss doctors]. / PROFILES: portrait-type de nos futurs médecins !

In each professional practice, a greater or lesser part of the activity is devoted to teaching. Indeed, the transmission of the medical knowledge is an essential objective for the training of students and residents, but also an opportunity to adapt one's own practices to the current context, since fast changes are not necessarily easy to follow and assimilate. If the relationship with Medical school is rather straightforward in the university hospitals, it is not always the same for those who are more distant, but whose participation in teaching is desired, and clearly growing. In this way, it is therefore crucial that everyone is informed about recent changes to the undergraduated learning objectives (PROFILES) and the resulting needs for educational reforms for all Medical schools in Switzerland.

Dans chaque pratique professionnelle, une part plus ou moins grande de l'activité est dévolue à l'enseignement. En effet, la transmission de l'art médical représente un objectif essentiel pour la formation des étudiant·e·s et des jeunes collègues, mais aussi une opportunité pour adapter ses pratiques au contexte actuel, car les changements, rapides, ne sont pas forcément faciles à assimiler. Si, dans les hôpitaux universitaires, le contact avec les Facultés de médecine est plutôt aisé, il n'en va pas toujours de même pour ceux qui en sont plus distants, mais dont la participation à l'enseignement est souhaitée et croissante. En ce sens, il apparaît crucial que tou·te·s soient informé·e·s sur les modifications récentes des objectifs d'apprentissage prégradué (PROFILES) et sur les réformes qui en découlent pour les Facultés de médecine en Suisse.

[Medical students at the bedside of COVID-19 patients†: motivations and challenges]. / Étudiant·e·s en médecine engagé·e·s au chevet des patient·e·s hospitalisé·e·s pour COVID-19 - Motivations et enjeux.

The SARS-CoV-2 pandemic is putting our healthcare system under exceptional pressure, given the number of affected patients. In a context of limited human healthcare resources, senior medical students represent a valuable workforce that can quickly be mobilized for patient care. This is the approach followed in Switzerland and other countries, in several outpatient structures or inpatient services, including the Department of Internal Medicine, of the Lausanne University Hospital (CHUV). In this article, we first give the floor to students who responded to our call. We conclude with important considerations in terms of students' clinical supervision. It is reminded that the involvement of students in the care of COVID-19 patients should only occur on a vo luntary basis.

La pandémie de COVID-19 met notre système de santé sous une pression exceptionnelle, au vu du nombre de patient·e·s atteint·e·s. Dans un contexte de ressources humaines médico-soignantes limitées, les étudiant·e·s en médecine avancé·e·s dans leur cursus représentent un renfort très précieux, rapidement mobilisable auprès des patient·e·s. C'est la démarche suivie en Suisse et ailleurs dans le monde par diverses structures ambulatoires ou services hospitaliers, dont le Service de médecine interne du Centre hospitalier universitaire vaudois (CHUV). Dans cet article, nous donnons tout d'abord la parole aux étudiant·e·s qui ont répondu à notre appel. Nous terminons par des considérations importantes quant à l'accueil et l'accompagnement de ces étudiant·e·s. Il est rappelé que l'engagement d'étudiant·e·s auprès de patient·e·s souffrant de COVID-19 devrait se faire sur une base volontaire uniquement.

[Organizational Impacts and Clinical Challenges of the COVID-19 Pandemic on a Swiss Tertiary Internal Medicine Department]. / Impacts organisationnels et défis cliniques de la pandémie COVID-19 pour un service hospitalier de médecine interne universitaire.

The rapid progression of COVID-19 is an organizational challenge for all hospitals. To secure the patient overflow, the Department internal medicine of the University Hospital of Lausanne increased nurse and medical workforces as well as bed capacity by 65 %, with extraordinary help from other departments. The implemented crisis management stood upon three pillars : a crisis management team, steering documents and internal communication. In this new form, the Department had already taken care of 442 COVID-19 admissions by April 16, 2020. Alongside organizational challenges, clinical issues such as rapid respiratory distress, clinical suspicions with negative PCR and treatment uncertainties in the absence of sufficient evidence were overcome. Despite the peak of the pandemic appearing to have passed, the next phase could be just as complicated.

La progression rapide du COVID-19 constitue un défi organisationnel pour tous les hôpitaux. Pour anticiper un afflux important de patients, le service de médecine interne du CHUV a ainsi augmenté ses forces de travail médico-soignantes et son nombre de lits de 65 % avec un soutien extraordinaire de toute l'institution. Pour opérer ces changements majeurs, l'organisation de crise mise en place s'est appuyée sur trois piliers : une cellule de conduite, des documents de pilotage et une communication interne. Sous cette nouvelle forme, le service a pris en charge 442 hospitalisations COVID-19 jusqu'au 16 avril 2020. Si les enjeux organisationnels ont été majeurs, la gestion des situations complexes, comme les manifestations respiratoires et les multiples incertitudes cliniques diagnostiques et thérapeutiques, ont été également une gageure. Le pic de la pandémie semble passé, mais la prochaine phase pourrait constituer un nouveau défi organisationnel.

[Visual diagnosis†: between medical education and advances in artificial intelligence]. / Le diagnostic visuel†: au carrefour de la pédagogie médicale et des progrès en intelligence artificielle.

The electrocardiogram, chest x-ray, and skin lesion interpretation are a diagnostic process that applies image analysis. Knowledge and sufficient clinical experience are necessary to achieve expertise in these fields. However, recent advances in medical informatics, particularly in deep learning, are challenging this diagnostic process and physicians' performance. Only a fraction of clinical diagnostic support based on artificial intelligence (AI) has been validated in a clinical environment, limiting its use at the patient's bedside. Gradual AI integration into medical practice will require that the physicians remain able to assess the strengths and limitations of these new algorithms.

La lecture d'un ECG, l'analyse d'une radiographie du thorax ou l'approche d'une lésion dermatologique mettent l'interprétation d'une image au centre de la démarche diagnostique. Elles imposent un apprentissage des bases théoriques nécessaires et une exposition suffisante en milieu clinique. Or, les avancées récentes en informatique médicale, en particulier du deep learning, remettent en question l'approche diagnostique classique, disputant leurs performances aux médecins. Cependant, seul un petit nombre d'études relatives à l'intelligence artificielle sont validées à ce jour dans un contexte clinique, limitant son usage au lit du patient. A l'avenir, l'intelligence artificielle pourra progressivement être introduite dans la pratique médicale, pour autant que les médecins eux-mêmes restent capables d'évaluer la qualité de l'aide au diagnostic proposée par le deep learning.

[Importance of handoffs for patient safety]. / Sécurité des patients : importance des transmissions médicales.

Handoffs are defined as the transfer of mission specific information and care authority from one healthcare professional to another. Handoffs may create gaps that are especially vulnerable to errors and may have an impact on patient safety. Conceptualising handoffs that are safe gains in importance in medicine with the growing clinical complexity, the reduction of working hours, and a great amount of care fragmentation. Different strategies on the handoff procedure have been identified to improve patient safety. An institutional approach with adaptations to the specific characteristics of each medical discipline is necessary.

Les transmissions médicales sont à risque de générer des discontinuités qui peuvent entraver la sécurité des patients. Avec la complexité croissante des situations cliniques, la réduction des heures de travail ainsi que la fragmentation des prises en charge, la conceptualisation de transmissions médicales sûres a gagné en importance dans le quotidien clinique. De nombreux modèles qui visent l'amélioration des transmissions médicales ont étés étudiés et se sont avérés efficaces pour augmenter la sécurité des patients. L'intégration d'un modèle de transmissions sûres nécessite un changement dans la culture institutionnelle ainsi qu'une approche adaptée aux spécificités de chaque discipline.

[E-learning : an effective and necessary complement to the postgraduate training]. / E-learning : un complément efficace et nécessaire à la formation postgraduée.

The evolution of modern medicine largely influenced the development of new postgraduate training programs, which requirements are more engaging and constraining. Time dedicated to education more and more often comes into competition with the resident's clinical and administrative activities. In this context, E-learning could be an interesting solution, if used complementary to the classical training which does not further overload the clinical activity. By focusing on the recognition of clinical images, and interpretation of functional tests, we target some well known knowledge gaps of our trainees. Our program allows every participant to be exposed to some important, prototypical or rare situations, independent of the clinical exposure. The quality of our program is ensured by the collaboration with several specialty departments of our hospital.

L'évolution de la médecine est à l'origine du développement de programmes de formation postgraduée de plus en plus complexes et contraignants. Le contenu de cette formation est donc en pleine évolution et le temps dédié entre en compétition directe avec les activités cliniques et administratives du médecin assistant. Dans ce contexte, la formation en ligne (e-learning) peut être une solution complémentaire à la formation classique. Elle présente plusieurs avantages comme celui de pouvoir être effectuée au moment le plus propice, sans surcharger l'activité clinique et en réduisant les interruptions. Nous avons développé un programme de formation en ligne ciblant des thématiques qui nous semblent lacunaires chez nos médecins en formation. La qualité du programme est assurée par une fructueuse collaboration avec plusieurs services de spécialités de notre hôpital.

[2015 highlights in hospital-based internal medicine by chief residents]. / L'année 2015 mise en perspective par les internistes hospitaliers.

The year 2015 gave us many scientific publications, among whom some will have an impact on our daily practice and some will influence our way of considering some well known diseases. Chief residents in the Service of internal medicine of the Lausanne University hospital, gathered like every year, to share their readings together in order to presentyou a small part of the many publications of 2015, which have been considered to have an impact on our future daily practice.

Female residents experiencing medical errors in general internal medicine: a qualitative study.

BACKGROUND: Doctors, especially doctors-in-training such as residents, make errors. They have to face the consequences even though today's approach to errors emphasizes systemic factors. Doctors' individual characteristics play a role in how medical errors are experienced and dealt with. The role of gender has previously been examined in a few quantitative studies that have yielded conflicting results. In the present study, we sought to qualitatively explore the experience of female residents with respect to medical errors. In particular, we explored the coping mechanisms displayed after an error. This study took place in the internal medicine department of a Swiss university hospital. METHODS: Within a phenomenological framework, semi-structured interviews were conducted with eight female residents in general internal medicine. All interviews were audiotaped, fully transcribed, and thereafter analyzed. RESULTS: Seven main themes emerged from the interviews: (1) A perception that there is an insufficient culture of safety and error; (2) The perceived main causes of errors, which included fatigue, work overload, inadequate level of competences in relation to assigned tasks, and dysfunctional communication; (3) Negative feelings in response to errors, which included different forms of psychological distress; (4) Variable attitudes of the hierarchy toward residents involved in an error; (5) Talking about the error, as the core coping mechanism; (6) Defensive and constructive attitudes toward one's own errors; and (7) Gender-specific experiences in relation to errors. Such experiences consisted in (a) perceptions that male residents were more confident and therefore less affected by errors than their female counterparts and (b) perceptions that sexist attitudes among male supervisors can occur and worsen an already painful experience. CONCLUSIONS: This study offers an in-depth account of how female residents specifically experience and cope with medical errors. Our interviews with female residents convey the sense that gender possibly influences the experience with errors, including the kind of coping mechanisms displayed. However, we acknowledge that the lack of a direct comparison between female and male participants represents a limitation while aiming to explore the role of gender.

[General internal medicine in hospital practice: the year 2013 put into perspective by residents]. / Médecine interne générale en pratique hospitalière: l'année 2013 mise en perspective par les chefs de clinique.

2013 was full of significant advances in all areas of medicine, which may have an impact on daily practice in general internal medicine. From salt and water restriction in heart failure to transfusion threshold in upper gastrointestinal bleeding and fecal infusion in Clostridium difficile colitis; from new data in resuscitation and persistent questions in palliative care and intensive care medicine, through pneumology, nephrology and endocrinology, the literature has been rich in new considerations. Each year, the residents of the Department of internal medicine of the University hospital of Vaud (CHUV) meet to share their most interesting readings. Thirteen of them are reviewed and commented here.

A multi-method approach to drafting candidate entrustable professional activities for a general internal medicine residency programme.

INTRODUCTION: Entrustable professional activities (EPAs) are units of concrete daily clinical tasks that trainee physicians should be able to handle with increasing autonomy during their postgraduate training. EPAs are gaining international recognition as an essential component of competency-based medical training programmes. The process of developing EPAs for a nationwide training programme is complex and requires an in-depth understanding of EPAs as a concept and good knowledge of appropriate development processes. This article provides a detailed description of the methodology and results of a multi-step approach for developing a list of candidate EPAs for Switzerland's postgraduate training programme in general internal medicine (GIM). METHODS: We took a multi-step approach including a systematic review of international literature, four national focus groups, a national consensus process using a RAND appropriateness method, and a quality check of the selected candidate EPAs using EQual criteria. RESULTS: These steps generated a final list of 247 candidate EPAs in general internal medicine that were submitted for the national consensus process. After two rounds of rating, experts agreed on the appropriateness for general internal medicine postgraduate training of 225 candidate EPAs. Twenty-two were deemed inappropriate, and disagreement persisted only for two EPAs. DISCUSSION: This multi-step programme is one of the few describing in detail the process of developing a list of EPAs and providing evidence of validity at each step. The clinical breadth of our candidate EPAs, together with the detailed description of our methodology, could serve as a useful starting point from which medical education specialists or clinicians could develop or revise applicable lists of EPAs, particularly for postgraduate training programmes in either general internal medicine or family medicine.

The influence of patient gender on medical students' care: Evaluation during an objective structured clinical examination.

OBJECTIVES: To assess whether men and women are evaluated and treated differently by medical students. METHODS: We evaluated patient care provided by 110 fifth-year medical students during an objective structured clinical examination (OSCE), using two clinical cases with standardized patients (SPs): generalized anxiety disorder (GAD) and ascending aortic dissection (AAD). Half of the students encountered male and half female SPs. Except for gender, the cases were identical. We compared diagnosis and treatment of male vs female SPs. RESULTS: Students diagnosed GAD more often in female SPs than in male SPs (diagnosis completed, partially completed, and not completed in 47%, 16% and 36% respectively vs. 22%, 20%, and 58% for male SPs, p = 0.02). The nature of symptoms was better described for male SPs. For AAD, the emergency was more frequently identified and the examination of femoral pulses better performed in female SPs. CONCLUSION: Medical students have a gender bias when evaluating patients with GAD and AAD. PRACTICE IMPLICATION: The observed gender bias in the evaluation of patients, likely leads to differences in treatment between male and female patients (i.e. under-recognition of anxiety in men). Medical schools should implement gender-sensitive medical education initiatives to improve inclusive patient care.

Meanings and perceptions of patient-centeredness in social work, nursing and medicine: a comparative study.

Answering patients' evolving, more complex needs has been recognized as a main incentive for the development of interprofessional care. Thus, it is not surprising that patient-centered practice (PCP) has been adopted as a major outcome for interprofessional education. Nevertheless, little research has focused on how PCP is perceived across the professions. This study aimed to address this issue by adopting a phenomenological approach and interviewing three groups of professionals: social workers (n = 10), nurses (n = 10) and physicians (n = 8). All the participants worked in the same department (the General Internal Medicine department of a university affiliated hospital). Although the participants agreed on a core meaning of PCP as identifying, understanding and answering patients' needs, they used many dimensions to define PCP. Overall, the participants expressed value for PCP as a philosophy of care, but there was the sense of a hierarchy of patient-centeredness across the professions, in which both social work and nursing regarded themselves as more patient-centered than others. On their side, physicians seemed inclined to accept their lower position in this hierarchy. Gieryn's concept of boundary work is employed to help illuminate the nature of PCP within an interprofessional context.

Entrustable professional activities for residency in general internal medicine: a systematic review.

CONTEXT: Entrustable Professional Activities (EPAs) are observable tasks that are regular parts of a physician's daily clinical work. Before being permitted to accomplish these tasks independently, trainees must gain their supervisors' trust. Defining the list of EPAs that should be mastered by the end of a residency is critical to setting clear expectations about autonomous practice. OBJECTIVE: To collect all the lists of EPAs defined for residencies in general internal medicine and synthesise them into a reference work useful for developing new lists of EPAs or improving existing ones. METHOD: This systematic review searched five databases and relevant grey literature using keywords related to EPAs and postgraduate education, from 2005, when the first article on EPAs was published, to April 2022. Inclusion criteria were the availability of an EPAs list and a focus on general internal medicine. Two reviewers independently selected the studies, extracted data and performed a quality assessment using QATSDD and AACODS tools. Mean values and inter-rater reliability were calculated. RESULTS: The review yielded 3292 records, with 16 articles meeting the inclusion criteria, mostly from North America. Synthesising their 16 lists generated 395 EPAs. The reviewers then inductively categoried those EPAs, 308 of which fell into 6 domains, 14 themes and 24 subthemes. The domains were: (1) care and management of the general adult population (n = 103 EPAs); (2) care and management of patients with specific needs (n = 67); (3) care coordination and communication (n = 52); (4) management and leadership (N = 21); (5) healthcare quality, education, and research (n = 41); and (6) miscellaneous (n = 24). The remaining 87 EPAs were disease-specific and did not fit into this categorisation. CONCLUSIONS: Categorising EPAs created a unique synthesis of the existing lists of EPAs for educating residents in general internal medicine. This synthesis could be used as a reference for anyone tasked with developing new lists of EPAs or improving existing ones.