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Pertussis is a respiratory disease that can be fatal at all ages but especially in infants before their mandatory vaccination. Recent epidemiological data shows a decrease in the number of pertussis cases, but a resurgence cannot be excluded in the coming years due to the cyclic evolution of the disease and the loosening of hygiene measures. Two approaches are used to protect infants before their vaccination: vaccination of the mother during pregnancy and vaccination of all the infant's close relatives (cocooning). The vaccination of the mother during pregnancy is more effective. The uncertain risk of chorioamniotitis associated with vaccination during pregnancy is insufficient to question this strategy., (Copyright © 2023 Société Nationale Française de Médecine Interne (SNFMI). Published by Elsevier Masson SAS. All rights reserved.)

Hypertension is the modifiable risk factor causing the largest loss in healthy life-years. The risk of cardiovascular events increases exponentially with the level of blood pressure (BP), starting from 115mmHg for systolic BP. Out-of-office BP measurements (self-measurements or ambulatory BP measurements) are now preferred for the diagnosis and follow up. In the absence of a preferred indication, antihypertensive treatment is based on thiazide diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. These treatments are associated with a significant reduction in morbidity and mortality in people with office BP ≥ 140/90mmHg (self-measurements ≥ 135/85mmHg). For people at high cardiovascular risk, especially those with a history of cardiovascular disease, starting the treatment for an office BP ≥ 130/80mmHg is also beneficial (self-measurements ≥ 130/80mmHg as well). It is now common to start treatment with half-dose dual therapy, which is more effective and better tolerated than full-dose monotherapy. The clinical effect is assessed at 4 weeks and intensification, if required, is then usually done by switching to the same dual therapy at full-dose for both components., (Copyright © 2023 Société Nationale Française de Médecine Interne (SNFMI). Published by Elsevier Masson SAS. All rights reserved.)

Introduction: Before attending residency, 6th-year French medical students must validate a final examination including a practical clinical test in their faculty. However, the national ranking that determines their future specialty and region solely relies on a computerized knowledge test. Our goal was to investigate the association between the final faculty test and the national ranking test., Methods: In our faculty, the final examination includes a computerized theoretical test (similar to the national one) and a practical test: a standardized evaluation of semiology skills at the bedside and a standardized assessment of relational skills with role plays. The agreements between the national test and faculty computerized and practical tests were analyzed by intraclass correlation coefficients (ICC)., Results: Data from 1806 students who underwent the three examinations from 2017 to 2021 were analyzed. There was a good agreement between the ranks in the faculty and national computerized tests: ICC 0.83 (95% CI 0.81-0.85). By contrast, the agreement between the ranks in the faculty practical test and the national computerized test was poor: ICC 0.13 (95% CI 0.08-0.17). Results were stable over the years., Conclusion: The agreement between the ranking of the current national test and the clinical skills assessed by a specific faculty test is poor. This could relate to a true independence or to different levels of motivation to perform well. Indeed, the result of the national test is the most important one as it determines their career. Incorporating a clinical assessment into the national ranking test will motivate students to acquire clinical skills and value those who perform well this practical dimension., (Copyright © 2022 Société Nationale Française de Médecine Interne (SNFMI). Published by Elsevier Masson SAS. All rights reserved.)

Introduction: Hypo- and hypercalcemia are common and some causes require urgent diagnosis and treatment. Measurement of ionized calcium is the reference test to diagnose calcium disorders but total calcium adjusted for protein or albumin concentration is more often used., Methods: Patients hospitalised in a general internal medicine department from September 2013 to December 2015 who had a total plasma calcium concentration and a serum albumin or protein concentration measured within 24h of a ionized calcium blood measurement were included. Total calcium was adjusted for protein or albumin concentration using widely used formulas and compared to ionized calcium as the gold standard., Results: Among 210 included patients, 46 (22%) had hypocalcemia, 124 (59%) normocalcemia and 40 (19%) hypercalcemia according to ionized calcium concentration. Total calcium had 50% sensitivity and 95% specificity to diagnose hypocalcemia and a 93% sensitivity and 89% specificity to diagnose hypercalcemia. Adjusting total calcium for protein or albumin concentrations did not increase and sometimes decreased diagnostic accuracy., Conclusion: Total calcium, with or without albumin/protein adjustment, is poorly sensitive to screen for hypocalcemia. Unadjusted total calcium is as sensitive as protein- or albumin-adjusted total calcium to screen for hypercalcemia. These data argue against the use of albumin- or protein-adjusted calcium. Ionized calcium measurement should be performed to confirm dyscalcemia in patients with abnormal total calcium concentration and to rule out hypocalcemia in patients with total calcium concentration in the lower range of normal values., (Copyright © 2021 Société Nationale Française de Médecine Interne (SNFMI). Published by Elsevier Masson SAS. All rights reserved.)

Introduction: Script concordance tests (SCTs) have been developed to assess clinical reasoning in uncertain situations. Their reliability for the evaluation of undergraduate medical students has not been evaluated., Methods: Twenty internal medicine SCT cases were implemented in undergraduate students of two programs. The results obtained on the SCTs were compared to those obtained by the same students on clinical-based classical multiple-choice questions (MCQs)., Results: A total of 551/883 students (62%) answered the SCTs. The mean aggregate score (based on a total 20 points) was 11.54 (3.29). The success rate and mean score for each question did not differ depending on the modal response but the discrimination rate did. The results obtained by the students on the SCT test correlated with their scores on the MCQ tests. Among students, 446/517 (86%) considered the SCTs to be more difficult than classical MCQs, although the mean score did not differ between the SCT and MCQ tests., Conclusion: The use of SCTs is a feasible option for the evaluation of undergraduate students. The SCT scores correlated with those obtained on classical MCQ tests., (Copyright © 2020 Société Nationale Française de Médecine Interne (SNFMI). Published by Elsevier Masson SAS. All rights reserved.)

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., (Copyright © 2020 Société Nationale Française de Médecine Interne (SNFMI). Published by Elsevier Masson SAS. All rights reserved.)

Introduction: Patients with psychiatric disorders suffer from a higher rate of somatic disorders than those without psychiatric disorder, often inappropriately managed. Our study aimed to describe patients with psychiatric comorbidity in post-emergency internal medicine units and to compare their length of hospital stay to patients without psychiatric disease., Methods: This French cross sectional study used the data warehouse of the greater Paris hospitals. It included, all patients hospitalized through the emergency department in 9 internal medicine departments during the year 2017. Psychiatric disorders and the burden of somatic disorders (Charlson score) were determined through diagnostic coding. Charlson score and hospital length of stay were compared between patients with and without psychiatric comorbidity., Results: In total, 8981 hospital stays (8001 patients) were included, 1867 (21%) with psychiatric comorbidity. After adjusting for age, gender, hospital and main diagnosis, the Charlson score was on average 0.68 higher in the psychiatric comorbidity group (P<0.001) and the length of hospital stay was 30% higher after further adjustment on the Charlson score (P<0.001). These differences were consistent for each main diagnosis., Conclusion: Patients with psychiatric comorbidity are frequent in post-emergency internal medicine wards. They experience longer hospital stays, only partly related with a higher burden of somatic disorders. Special attention should be paid to this vulnerable population., (Copyright © 2020 Société Nationale Française de Médecine Interne (SNFMI). Published by Elsevier Masson SAS. All rights reserved.)

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&#95;CR) and the multisource feedback form (E&#95;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&#95;CR (n=62) and 0.77 with the E&#95;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&#95;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., (Copyright © 2019 Société Nationale Française de Médecine Interne (SNFMI). Published by Elsevier Masson SAS. All rights reserved.)

Objective: To determine whether career development in academic medicine is more difficult for women than for men, and, if any, the nature and level of barriers to this progression., Methods: Extraction of full-time medical staff in a Parisian hospital group, through the SIGAPS platform; an online questionnaire survey of career choices and barriers experienced by full-time male and female physicians. The study population comprises 181 hospital practitioners and 141 academic physicians (49 associate professors and 92 full professors)., Results: Women represent 49% of the medical staff but 15% of full professors. This underrepresentation of women is more important among intensivists/anesthesiologists than technique-based specialists (such as radiologists, biologists…). There is no difference in scientific output, marital status and parenthood between women and men. On the other hand, there is a difference in attitudes highlighted by the EVAR risk-taking scale as well as in the burden of familial involvement and the prejudices felt by women during the academic selection process., Conclusion: The glass ceiling exists in one of the largest French hospital group. Career development principles promote merit, but should decrease the benefit of "masculine" attitudes in the competition for academic positions. Academic selection criteria should evolve to limit the disadvantage of women related to deeper familial involvement and less competitive strategies and risk-taking attitudes., (Copyright © 2018 Société Nationale Française de Médecine Interne (SNFMI). Published by Elsevier Masson SAS. All rights reserved.)

Introduction: The revision of the French medical studies' third cycle ought to be competency-based. In internal medicine, theoretical and practical knowledge will be assessed online with e-learning and e-portfolio. In parallel, a reflection about clinical skills assessment forms is currently ongoing. In this context, our aim was to assess the reproducibility and validity of two assessment forms based on direct clinical observation., Method: A prospective and multicentric study has been conducted from November 2015 to October 2016 aiming at evaluating the French translations of the MINI-Clinical Examination Exercice (MINI-CEX) and the Standardized Patient Satisfaction Questionnaire (SPSQ). Included residents have been assessed 2 times over a period of 6 months by the same binoma of judges., Results: Nineteen residents have been included. The inter-judge reproducibility was satisfactory for the MINI-CEX: intraclass coefficients (ICC) between 0.4 and 0.8 and moderate for the SPSQ: ICC between 0.2 and 0.7 with a good internal coherence for both questionnaires (Cronbach between 0.92 and 0.94). Significant differences between the distributions of the scores given by the judges and a significant inter-center variability have been found., Conclusion: If the absolute value of the scores should not be taken into account in the evaluation process given its high variability, it could be of interest for the follow-up of the progression in the competencies. These forms could support the residents' debriefing based on the general trends given by the scores., (Copyright © 2017 Société Nationale Française de Médecine Interne (SNFMI). Published by Elsevier SAS. All rights reserved.)

Purpose: Clinical examination skills are poorly evaluated by theoretical tests. We observed the clinical examination of real patients by 6th year medical students., Methods: Four internists involved in teaching activities defined 11 clinical examination items, with two objective performance criteria each. The students were evaluated in two internal medicine departments during the rotation preceding or following their national graduation test. Scores by item and by criterion and an overall score were calculated and correlated with their rank at the national graduation test., Results: Thirty-two students were evaluated in one department and 18 in the other; each evaluation lasted approximately 30 minutes. The results were similar in both departments. Only 2 items got a score over 75% in this students' sample (acute respiratory failure, peripheral pulses); 4 items were satisfied at less than 50% (lymph nodes, right heart failure, liver failure, and attention). The mean overall score was 6.5/11 (standard deviation 1.5). National rankings were good (median 1605/8001, interquartile 453-3036) but uncorrelated with the global score (Spearman coefficient -0.13; P=0.39)., Conclusion: Bedside evaluation of the students reveals substantial deficiencies, a few months or weeks before taking their position as residents. Several elementary skills are mastered by a minority of them (search for an asterixis, distended jugular veins, deep tendon reflexes), even among those successful at the national graduation test. Bedside evaluation of clinical examination skills should be more systematically performed., (Copyright © 2014 Société nationale française de médecine interne (SNFMI). Published by Elsevier SAS. All rights reserved.)

Purpose: Idiopathic retroperitoneal fibrosis (IRF) is an inflammatory disorder, affecting the aorta and the surrounding vessels and tissues. The prognosis is mainly driven by the risks of chronic kidney disease and relapse. Our aim was to assess the prevalence of chronic kidney disease at follow-up., Methods: We retrospectively reviewed the medical records of patients diagnosed for IRF in Seine-Saint-Denis (France) between 1987 and 2011. We collected informations about presentation, radiologic findings and follow-up. Diagnosis of IRF was confirmed when all the following criteria were met: infiltration of the infrarenal aorta or iliac vessels, absence of aneurysmal dilation, lack of clinical suspicion of malignancy., Results: Thirty patients were identified, with a male/female ratio of 4.9. Mean age was 55±13 years old. The mean creatinine clearance was 66 mL/min/1.73 m(2) and the mean CRP was 45±36 mg/L. In 24 (80%) patients, the location of IRF was periaortic and periiliac. Eleven patients (37%) underwent a diagnostic biopsy, and 14 (47%) required an ureteral procedure. A mean follow-up of 63 months was available for 29 patients: 69% relapsed, 7 developed chronic renal disease (24%), and one died of urinary sepsis. Older age (P=0.023), diabetes (P=0.007), and initial renal insufficiency (P=0.05) were associated with a risk of chronic renal insufficiency., Conclusion: The high frequency of relapses and chronic renal disease emphasizes the need of close follow-up in patients diagnosed with IRF., (Copyright © 2013 Société nationale française de médecine interne (SNFMI). Published by Elsevier SAS. All rights reserved.)

Hypertension is a common health problem with serious consequences for individuals and a heavy attributable burden for populations. Reducing this burden requires preventive actions at the population level and early diagnosis at the individual level, followed by proactive interventions with proven benefits. Given the variability of blood pressure measurement, diagnosis is established only after repeated measurements under standardized conditions, if possible outside the clinic. Lifestyle changes can modestly reduce blood pressure; their impact is significant if they can be achieved on a large scale. Hypertension treatment requires a rational pharmacological approach, which can reach the target blood pressure within less than 6 months and three pharmacological classes at most in more than 80% of cases. Specialized consultation is required in the remaining 20% to detect secondary hypertensions, to optimize drug therapy and to discuss, in a minority of cases, non-pharmacological treatments. Recommendations are written by experts who select, interpret, and extrapolate the results of clinical research. As a consequence, they are sometimes unsuitable for primary care practice and frequently inconsistent across guidelines. Efforts are currently made to produce less disputable and more usable guidelines., (Copyright © 2013 Société nationale française de médecine interne (SNFMI). Published by Elsevier SAS. All rights reserved.)

Tuberculous peritonitis was suspected in a 33-year-old man, without significant past medical history or risk factor for tuberculosis, who presented with constitutional manifestations including fatigue and weight loss, fever for several weeks and inflammatory ascites. Echo-guided percutaneous biopsy of the thickened omentum showed numerous epithelioid granulomas, avoiding laparoscopic peritoneal biopsies. Recovery was uneventful under antituberculous treatment., (Copyright © 2010 Société nationale française de médecine interne (SNFMI). Published by Elsevier SAS. All rights reserved.)

Purpose: To determine if trends in antihypertensive drug prescriptions by non-specialist physicians reflect evidence from clinical research., Methods: Comparison of antihypertensive drugs prescribed to patients before they attended a hypertension clinic in 2001 and 2006, with a special consideration for thiazide diuretics in drug combinations and angiotensin converting enzyme inhibitors (ACEI) in hypertensive patients at high cardiovascular risk (diabetes or secondary prevention)., Results: Overall, 1072 hypertensive patients attended the hypertension clinic in 2001 (mean age 53.9 years) and 1040 in 2006 (mean age 55.6 years); both genders were equally represented. Patients already treated when they came at the consultation received a mean number of 2.24 antihypertensive drug classes in 2001 and 2.44 in 2006 (p = 0.002). The prescription of three antihypertensive drug classes increased between 2001 and 2006: Calcium channel blockers from 49 % of treated patients in 2001 to 56 % in 2006 (p = 0.007), angiotensin receptor antagonists from 28 to 42 % (p <0.001) and thiazide diuretics from 31 to 39 % (p = 0.001). Thiazide diuretics were included in 48 % of the antihypertensive combinations in 2001 and 55 % in 2006 (p = 0.02). The prescription of ACEI in patients at high cardiovascular risk remained stable around 31 %., Conclusion: Antihypertensive treatments were more intensive in 2006 than 2001, but thiazide diuretics remained underused in drug combinations. The prescription of ACEI did not increase in patients at high cardiovascular risk despite convincing evidence of their benefit.

Introduction: Aortic aneurysms are a well known but rare complication of tuberculosis. Their major complication is aneurysmal rupture, unforeseeable and lethal., Exegesis: Chest pain and hemoptoic expectoration revealed a false aneurysm of the aortic isthmus in a 48-year-old man. Endovascular repair with a stent graft was urgently undertaken. Tuberculosis was diagnosed 6 weeks thereafter by the growth of gastric juice cultures and medically treated. Most tuberculous aortic aneurysms are false aneurysms, caused by an adjacent tuberculous focus eroding the aortic wall. They present with pain, bleeding or as para-aortic masses., Conclusion: Tuberculous false aneurysms of the aorta necessitate an early intervention before they rupture. Surgical treatment remains the preferred option but endovascular repair with a stent graft is a therapeutic alternative, to be considered in high-risk surgical patients.

Introduction: Visual complications of temporal arteritis are frequent and serious. Their risk prompts glucocorticoid therapy, but this treatment may also cause ophthalmologic troubles., Exegesis: A sudden and isolated monocular visual blur, occurring in a 66 years old woman after 4 month of glucocorticoid treatment for temporal arteritis, revealed a case of iatrogenic central serous chorioretinopathy. The diagnosis of this disease is established by fluorescein angiography and its functional prognosis is excellent. Tapering the doses of glucocorticoids, as fast as the underlying disease allows, hastens visual recovery., Conclusion: When the treatment of temporal arteritis is commenced for more than a month, new visual complications are rare. Central serous chorioretinopathy induced by glucocorticoids belongs to the diagnoses that should be evoked in this case, especially if there is no clinical manifestation of arteritis and no inflammatory markers.