Valsalva Manoeuvre-Induced Pneumothorax and Pneumomediastinum in a Covid-19 Patient with ARDS: An Unusual Mechanism for this Complication.

Background: Until now, only a few cases of Valsalva-induced barotraumas (pneumothorax, pneumomediastinum and subcutaneous emphysema) have been described, and none of them among COVID-19 patients. Case description: A man in his 50s was admitted for SARS-CoV-2-related acute respiratory distress syndrome (ARDS). Initial evolution was favourable with non-invasive ventilatory support, high-flow oxygen nasal cannula and the best supportive drugs available at the time. During the Valsalva manoeuvre while defecating, the patient reported sudden chest pain and showed a new acute hypoxemic respiratory failure due to a pneumothorax. It led to multiple complications (pulmonary embolism, haemoptysis, and cardiac arrest), and despite the best supportive care, led to the patient's death. Discussion: The Valsalva manoeuvre can be an overlooked cause of pneumothorax in patients with COVID-19. Predisposition to barotrauma in COVID-19 patients could be explained by several factors, including the extensive use of non-invasive and invasive ventilation during the pandemic, and the histological changes observed in the lungs of those infected with COVID-19. Conclusion: We report the first description of a Valsalva-induced barotrauma in a COVID-19 infection. We emphasise the importance of treating constipation particularly in severe COVID-19 cases, to prevent complications such as barotrauma. LEARNING POINTS: Pneumothorax is a common complication of severe COVID-19 infection, but Valsalva manoeuvre-induced pneumothorax in COVID-19 patients has never been reported previously.Particular care should be taken to prevent and treat constipation in hospitalised patients as it may cause a wide range of complications, including barotraumatism.The extensive use of non-invasive and invasive ventilation may play a role in barotrauma, but causal association has not been proven.

[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.

[Less is more, Choosing wisely, Smarter medicine : perspectives and issues]. / Less is more, Choosing wisely, Smarter medicine : enjeux et perspectives.

The « Choosing Wisely ¼ initiative aims to reduce overtreatment by issuing specific lists of recommendations. These campaigns have spread around the world over the last ten years, including in Switzerland, under the brand « Smarter Medicine ¼. The methodology used by different medical societies to issue these recommendations remains heterogeneous and heavily consensus-based and could benefit from a better synergy with the recent development of Evidence-Based Medicine and GRADE. Patient partnership, and reflections regarding economic and sustainability issues represent future avenues to enhance the potential impacts of such campaigns.

Le mouvement « Choosing Wisely ¼ a comme objectif de lutter contre la surmédicalisation via le développement de listes de recommandations. La dernière décennie a vu ce mouvement se diffuser à travers le monde, y compris en Suisse sous le nom de « Smarter Medicine ¼. La méthodologie avec laquelle ces recommandations sont élaborées par les sociétés savantes reste hétérogène et fortement basée sur le consensus, et pourrait bénéficier d'une meilleure synergie avec les développements de l'« Evidence-Based Medicine ¼ et de GRADE. Le partenariat avec les patients et les réflexions quant aux enjeux économiques et de durabilité sont autant de perspectives d'évolution de ces mouvements, afin de renforcer leurs impacts.

Trends in management and outcomes of COVID patients admitted to a Swiss tertiary care hospital.

Two successive COVID-19 flares occurred in Switzerland in spring and autumn 2020. During these periods, therapeutic strategies have been constantly adapted based on emerging evidence. We aimed to describe these adaptations and evaluate their association with patient outcomes in a cohort of COVID-19 patients admitted to the hospital. Consecutive patients admitted to the Geneva Hospitals during two successive COVID-19 flares were included. Characteristics of patients admitted during these two periods were compared as well as therapeutic management including medications, respiratory support strategies and admission to the ICU and intermediate care unit (IMCU). A mutivariable model was computed to compare outcomes across the two successive waves adjusted for demographic characteristics, co-morbidities and severity at baseline. The main outcome was in-hospital mortality. Secondary outcomes included ICU admission, Intermediate care (IMCU) admission, and length of hospital stay. A total of 2'983 patients were included. Of these, 165 patients (16.3%, n = 1014) died during the first wave and 314 (16.0%, n = 1969) during the second (p = 0.819). The proportion of patients admitted to the ICU was lower in second wave compared to first (7.4 vs. 13.9%, p < 0.001) but their mortality was increased (33.6% vs. 25.5%, p < 0.001). Conversely, a greater proportion of patients was admitted to the IMCU in second wave compared to first (26.6% vs. 22.3%, p = 0.011). A third of patients received lopinavir (30.7%) or hydroxychloroquine (33.1%) during the first wave and none during second wave, while corticosteroids were mainly prescribed during second wave (58.1% vs. 9.1%, p < 0.001). In the multivariable analysis, a 25% reduction of mortality was observed during the second wave (HR 0.75; 95% confidence interval 0.59 to 0.96). Among deceased patients, 82.3% (78.2% during first wave and 84.4% during second wave) died without beeing admitted to the ICU. The proportion of patients with therapeutic limitations regarding ICU admission increased during the second wave (48.6% vs. 38.7%, p < 0.001). Adaptation of therapeutic strategies including corticosteroids therapy and higher admission to the IMCU to receive non-invasive respiratory support was associated with a reduction of hospital mortality in multivariable analysis, ICU admission and LOS during the second wave of COVID-19 despite an increased number of admitted patients. More patients had medical decisions restraining ICU admission during the second wave which may reflect better patient selection or implicit triaging.

[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.

Comparison of prognostic scores for inpatients with COVID-19: a retrospective monocentric cohort study.

BACKGROUND: The SARS-CoV-2 pandemic led to a steep increase in hospital and intensive care unit (ICU) admissions for acute respiratory failure worldwide. Early identification of patients at risk of clinical deterioration is crucial in terms of appropriate care delivery and resource allocation. We aimed to evaluate and compare the prognostic performance of Sequential Organ Failure Assessment (SOFA), Quick Sequential Organ Failure Assessment (qSOFA), Confusion, Uraemia, Respiratory Rate, Blood Pressure and Age ≥65 (CURB-65), Respiratory Rate and Oxygenation (ROX) index and Coronavirus Clinical Characterisation Consortium (4C) score to predict death and ICU admission among patients admitted to the hospital for acute COVID-19 infection. METHODS AND ANALYSIS: Consecutive adult patients admitted to the Geneva University Hospitals during two successive COVID-19 flares in spring and autumn 2020 were included. Discriminative performance of these prediction rules, obtained during the first 24 hours of hospital admission, were computed to predict death or ICU admission. We further exluded patients with therapeutic limitations and reported areas under the curve (AUCs) for 30-day mortality and ICU admission in sensitivity analyses. RESULTS: A total of 2122 patients were included. 216 patients (10.2%) required ICU admission and 303 (14.3%) died within 30 days post admission. 4C score had the best discriminatory performance to predict 30-day mortality (AUC 0.82, 95% CI 0.80 to 0.85), compared with SOFA (AUC 0.75, 95% CI 0.72 to 0.78), qSOFA (AUC 0.59, 95% CI 0.56 to 0.62), CURB-65 (AUC 0.75, 95% CI 0.72 to 0.78) and ROX index (AUC 0.68, 95% CI 0.65 to 0.72). ROX index had the greatest discriminatory performance (AUC 0.79, 95% CI 0.76 to 0.83) to predict ICU admission compared with 4C score (AUC 0.62, 95% CI 0.59 to 0.66), CURB-65 (AUC 0.60, 95% CI 0.56 to 0.64), SOFA (AUC 0.74, 95% CI 0.71 to 0.77) and qSOFA (AUC 0.59, 95% CI 0.55 to 0.62). CONCLUSION: Scores including age and/or comorbidities (4C and CURB-65) have the best discriminatory performance to predict mortality among inpatients with COVID-19, while scores including quantitative assessment of hypoxaemia (SOFA and ROX index) perform best to predict ICU admission. Exclusion of patients with therapeutic limitations improved the discriminatory performance of prognostic scores relying on age and/or comorbidities to predict ICU admission.

Risk Stratification in Patients with Acute Pulmonary Embolism: Current Evidence and Perspectives.

Risk stratification is one of the cornerstones of the management of acute pulmonary embolism (PE) and determines the choice of both diagnostic and therapeutic strategies. The first step is the identification of patent circulatory failure, as it is associated with a high risk of immediate mortality and requires a rapid diagnosis and prompt reperfusion. The second step is the estimation of 30-day mortality based on clinical parameters (e.g., original and simplified version of the pulmonary embolism severity index): low-risk patients without right ventricular dysfunction are safely managed with ambulatory anticoagulation. The remaining group of hemodynamically stable patients, labeled intermediate-risk PE, requires hospital admission, even if most of them will heal without complications. In recent decades, efforts have been made to identify a subgroup of patients at an increased risk of adverse outcomes (intermediate-high-risk PE), who might benefit from a more aggressive approach, including reperfusion therapies and admission to a monitored unit. The cur-rent approach, combining markers of right ventricular dysfunction and myocardial injury, has an insufficient positive predictive value to guide primary thrombolysis. Sensitive markers of circulatory failure, such as plasma lactate, have shown interesting prognostic accuracy and may play a central role in the future. Furthermore, the improved security of reduced-dose thrombolysis may enlarge the indication of this treatment to selected intermediate-high-risk PE.

[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.

Occupational risk of SARS-CoV-2 infection and reinfection during the second pandemic surge: a cohort study.

OBJECTIVES: This cohort study including essential workers, assessed the risk and incidence of SARS-CoV-2 infection during the second surge of COVID-19 according to baseline serostatus and occupational sector. METHODS: Essential workers were selected from a seroprevalence survey cohort in Geneva, Switzerland and were linked to a state centralised registry compiling SARS-CoV-2 infections. Primary outcome was the incidence of virologically confirmed infections from serological assessment (between May and September 2020) to 25 January 2021, according to baseline antibody status and stratified by three predefined occupational groups (occupations requiring sustained physical proximity, involving brief regular contact or others). RESULTS: 10 457 essential workers were included (occupations requiring sustained physical proximity accounted for 3057 individuals, those involving regular brief contact, 3645 and 3755 workers were classified under 'Other essential occupations'). After a follow-up period of over 27 weeks, 5 (0.6%) seropositive and 830 (8.5%) seronegative individuals had a positive SARS-CoV-2 test, with an incidence rate of 0.2 (95% CI 0.1 to 0.6) and 3.2 (95% CI 2.9 to 3.4) cases per person-week, respectively. Incidences were similar across occupational groups. Seropositive essential workers had a 93% reduction in the hazard (HR of 0.07, 95% CI 0.03 to 0.17) of having a positive test during the follow-up with no significant between-occupational group difference. CONCLUSIONS: A 10-fold reduction in the hazard of being virologically tested positive was observed among anti-SARS-CoV-2 seropositive essential workers regardless of their sector of occupation, confirming the seroprotective effect of a previous SARS-CoV2 exposure at least 6 months after infection.

Risk of Reinfection After Seroconversion to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2): A Population-based Propensity-score Matched Cohort Study.

BACKGROUND: Serological assays detecting anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies are being widely deployed in studies and clinical practice. However, the duration and effectiveness of the protection conferred by the immune response remains to be assessed in population-based samples. To estimate the incidence of newly acquired SARS-CoV-2 infections in seropositive individuals as compared to seronegative controls, we conducted a retrospective longitudinal matched study. METHODS: A seroprevalence survey including a representative sample of the population was conducted in Geneva, Switzerland, between April and June 2020, immediately after the first pandemic wave. Seropositive participants were matched one-to-two to seronegative controls, using a propensity-score including age, gender, immunodeficiency, body mass index (BMI), smoking status, and education level. Each individual was linked to a state-registry of SARS-CoV-2 infections. Our primary outcome was confirmed infections occurring from serological status assessment to the end of the second pandemic wave (January 2021). RESULTS: Among 8344 serosurvey participants, 498 seropositive individuals were selected and matched with 996 seronegative controls. After a mean follow-up of 35.6 (standard deviation [SD] 3.2) weeks, 7 out of 498 (1.4%) seropositive subjects had a positive SARS-CoV-2 test, of whom 5 (1.0%) were classified as reinfections. In contrast, the infection rate was higher in seronegative individuals (15.5%, 154/996) during a similar follow-up period (mean 34.7 [SD 3.2] weeks), corresponding to a 94% (95% confidence interval [CI]: 86%- 98%, P < .001) reduction in the hazard of having a positive SARS-CoV-2 test for seropositives. CONCLUSIONS: Seroconversion after SARS-CoV-2 infection confers protection against reinfection lasting at least 8 months. These findings could help global health authorities establishing priority for vaccine allocation.

[Internal medicine in 2020]. / 2020 en revue par les internistes hospitaliers.

2020: annus horribilis for hospital medicine? The past year, notable because of the current pandemic, has had a profound impact on multiple aspects of medical practice. Just as all medical staff and the general population, hospital internists were put under immense strain in 2020. This year has more than ever reinforced our belief in the importance of keeping a critical and scientific eye on the mass of new studies and data produced every year. The internists of the HUG propose a critical review of selected recent publications that may influence our daily management of patients.

2020 : annus horribilis pour la médecine hospitalière ? L'année écoulée, marquée par la pandémie en cours, a eu un impact majeur sur de multiples aspects de notre pratique. Comme l'ensemble du monde médico-soignant et de la population, les internistes hospitaliers ont été mis à rude épreuve en 2020. Cette année a plus que jamais renforcé notre conviction de l'importance de porter un regard scientifique sur la masse de nouveautés qui surviennent chaque année. Les internistes hospitaliers des HUG vous proposent de partager leur vision critique de publications scientifiques récentes utiles pour notre pratique quotidienne.

[Intermediate-risk pulmonary embolism - Update on risk stratification and clinical management]. / Embolie pulmonaire à risque intermédiaire - Point sur la stratification du risque et implications thérapeutiques.

Intermediate-risk pulmonary embolism (PE) is usually defined as PE associated with right ventricular dysfunction (echocardiographic, radiological and/or biological) without hemodynamic instability. It is associated with significant mortality, and its management is challenging for the clinician due to its variable clinical presentation. In its recent recommendations, the European Society of Cardiology proposes to differentiate high intermediate risk from low intermediate risk, based on clinical, biological and radiological criteria. The management strategy differs for these two categories, particularly about the need for monitored surveillance. Beyond therapeutic anticoagulation, which remains the first-line treatment in intermediate-risk PE, other therapeutic modalities can be considered, and will be discussed.

L'embolie pulmonaire (EP) à risque intermédiaire est habituellement définie comme une EP associée à une dysfonction ventriculaire droite (échocardiographique, radiologique et/ou biologique) sans instabilité hémodynamique. Elle est liée à une mortalité significative, et sa prise en charge est un défi pour le clinicien du fait de sa présentation clinique variable. Dans ses recommandations récentes, l'European Society of Cardiology propose de différencier le risque intermédiaire haut du risque intermédiaire bas, sur la base de critères cliniques, biologiques et radiologiques. La stratégie de prise en charge diffère pour ces deux catégories, notamment quant au besoin de surveillance monitorée. Au-delà de l'anticoagulation thérapeutique, qui reste le traitement de première intention dans l'EP à risque intermédiaire, d'autres modalités thérapeutiques peuvent être considérées et seront discutées.

Tobacco Stained Fingers and Its Association with Death and Hospital Admission: A Retrospective Cohort Study.

BACKGROUND: Among smokers, the presence of tobacco stains on fingers has recently been associated with a high prevalence of tobacco related conditions and alcohol abuse. OBJECTIVE: we aimed to explore tobacco stains as a marker of death and hospital readmission. METHOD: Seventy-three smokers presenting tobacco-tar staining on their fingers and 70 control smokers were followed during a median of 5.5 years in a retrospective cohort study. We used the Kaplan-Meier survival analysis and the log-rank test to compare mortality and hospital readmission rates among smokers with and smokers without tobacco stains. Multivariable Cox models were used to adjust for confounding factors: age, gender, pack-year unit smoked, cancer, harmful alcohol use and diabetes. The number of hospital admissions was compared through a negative binomial regression and adjusted for the follow-up time, diabetes, and alcohol use. RESULTS: Forty-three patients with tobacco-stained fingers died compared to 26 control smokers (HR 1.6; 95%CI: 1.0 to 2.7; p 0.048). The association was not statistically significant after adjustment. Patients with tobacco-stained fingers needed a readmission earlier than smokers without stains (HR 2.1; 95%CI: 1.4 to 3.1; p<0.001), and more often (incidence rate ratio (IRR) 1.6; 95%CI: 1.1 to 2.1). Associations between stains and the first hospital readmission (HR 1.6; 95%CI: 1.0 to 2.5), and number of readmissions (IRR 1.5; 95%CI: 1.1 to 2.1) persisted after adjustment for confounding factors. CONCLUSIONS: Compared to other smokers, those presenting tobacco-stained fingers have a high unadjusted mortality rate and need early and frequent hospital readmission even when controlling for confounders.

Human papillomavirus self-sampling in Cameroon: women's uncertainties over the reliability of the method are barriers to acceptance.

OBJECTIVE: The study aimed to assess acceptability and preference for self-collected human papillomavirus tests (self-HPV) compared with traditional physician-sampled Pap tests (physician sampling) in a low-resource country. MATERIALS AND METHODS: Women were recruited through a cervical cancer screening campaign conducted in Cameroon. Written and oral instructions were given to carry out an unsupervised self-HPV, followed by a physician-collected cervical sample for HPV testing and cytology. Subsequently the women were asked to answer a questionnaire. RESULTS: A total of 243 women were prospectively enrolled in this study. Median age of participants was 39 years (range = 25-65 years). Acceptability score was higher for self-HPV (p < .001) compared with physician sampling. Preference was lower for self-HPV than physician sampling (29% vs 62%; p < .001). Most participants thought that physician sampling was more reliable than self-HPV (59% vs 1%; p < .001). Women who preferred physician sampling were significantly more likely to have low knowledge about cervical cancer and a low educational level. CONCLUSIONS: Although most of the women were more comfortable and less embarrassed with the self-HPV, they did not trust the method and did prefer physician sampling. The study underlines the need not only to educate women about HPV, cervical cancer, and its prevention but also to reassure them about the accuracy of self-HPV.