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La médecine interne prend en charge des patients notamment adressés par les urgences ou par la médecine libérale. Dans le contexte de saturation des urgences et de manque de lits de médecine, la spécialité doit s'inscrire dans un « virage ambulatoire », notamment par un renforcement des liens ville-hôpital. Notre objectif était d'évaluer un nouveau parcours de soin en médecine interne au CHU de Nîmes. Notre service a élaboré un projet institutionnel intitulé RAPIDO pour « Réseau d'Aide à la PrIse en charge Diagnostique et d'Orientation ». Le médecin généraliste adresseur contacte sur une ligne téléphonique spécifique un interniste senior qui peut proposer, après évaluation, une consultation dans un délai de moins de 15 jours. Un avis synthétique est ensuite remis au patient. Entre novembre 2020 et novembre 2021, 254 patients ont été vus via RAPIDO. Le délai moyen de prise en charge était de 6,4 (±4,5) jours pour des symptômes évoluant depuis 2 semaines à 3 mois dans 43 % (n = 109) des cas. Le motif d'appel était, dans 28 % des cas (n = 84), une suspicion de maladie systémique et, dans 16 %, un signe fonctionnel d'un appareil. Un diagnostic était posé dans 89 % des cas. Le dispositif était économiquement équilibré. Un parcours de consultation rapide de médecine interne à destination des médecins généralistes semble être une offre de soin pertinente, faisable et viable, pouvant être transposée dans tout type d'établissement de santé, à condition de prévoir au préalable les moyens humains suffisants. Internal medicine departments manage patients referred by emergency departments or private practitioners. Considering the overcrowding of emergency departments and lack of beds for inpatients, this specialty must be part of an "ambulatory shift", particularly by strengthening the links between community and hospital medicine. Our objective was to evaluate a new care pathway in internal medicine at Nîmes university hospital. Our department has developed the RAPIDO project (Réseau d'Aide à la PrIse en Charge Diagnostique et d'Orientation). The referring general practitioner contacts a senior internist on a dedicated phone line. After careful evaluation, he may offer a consultation within 15 days. A summary report is then given to the patient. Between November 2020 and November 2021, 254 patients were seen via RAPIDO. The average call-consultation time period was 6.4 (±4.5) days, for symptoms lasting for 2 weeks to 3 months in 43% (n = 109) of cases. The reason for the call was a suspicion of systemic disease in 28% of cases (n = 84), or a dysfunction of an organ in 16%. A diagnosis was made in 89% of cases. The budget of the whole procedure was balanced. A quick internal medicine consultation pathway for general practitioners seems to be a relevant, feasible and economically viable healthcare trajectory, which can be transposed to any type of healthcare institution, as soon as sufficient human resources are dedicated. [ABSTRACT FROM AUTHOR]

Importance: Standardized examinations assess both learners and training programs within the medical training system in Japan. However, it is unknown if there is an association between clinical proficiency as assessed by the General Medicine In-Training Examination (GM-ITE) and pursuing specialty. Objective: To determine the relative achievement of fundamental skills as assessed by the standardized GM-ITE based on pursuing career specialty among residents in the Japanese training system. Design: Nationwide cross-sectional study. Setting: Medical residents in Japan who attempted the GM-ITE in their first or second year were surveyed. Participants: A total of 4,363 postgraduate years 1 and 2 residents who completed the GM-ITE were surveyed between January 18 and March 31, 2021. Main measures: GM-ITE total scores and individual scores in each of four domains assessing clinical knowledge: 1) medical interview and professionalism, 2) symptomatology and clinical reasoning, 3) physical examination and treatment, and 4) detailed disease knowledge. Results: When compared to the most pursued specialty, internal medicine, only those residents who chose general medicine achieved higher GM-ITE scores (coefficient 1.38, 95% CI 0.08 to 2.68, p = 0.038). Conversely, the nine specialties and "Other/Not decided" groups scored significantly lower. Higher scores were noted among residents entering general medicine, emergency medicine, and internal medicine and among those who trained in community hospitals with higher numbers of beds, were more advanced in their training, spent more time working and studying, and cared for a moderate but not an extreme number of patients at a time. Conclusions: Levels of basic skill achievement differed depending on respective chosen future specialties among residents in Japan. Scores were higher among those pursuing careers in general medical fields and lower among those pursuing highly specialized careers. Residents in training programs devoid of specialty-specific competition may not possess the same motivations as those in competitive systems. [ABSTRACT FROM AUTHOR]

Yoshinori Tokushima,1,2 Masaki Tago,1,2 Midori Tokushima,1,3 Shun Yamashita,1 Yuka Hirakawa,1 Hidetoshi Aihara,1 Naoko E Katsuki,1 Motoshi Fujiwara,1 Shu-ichi Yamashita1 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2Community Medical Support Institute, Faculty of Medicine, Saga University, Saga, Japan; 3Saga Medical Career Support Center, Saga University Hospital, Saga, JapanCorrespondence: Masaki Tago, Department of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, Japan, Tel +81 952 34 3238, Fax +81 952 34 2029, Email tagomas@cc.saga-u.ac.jpIntroduction: The educational effects of a hands-on clinical clerkship on medical students at the Department of General medicine of Japanese university hospitals remain to be clarified. This study aimed to determine how such education affects medical students’ self-evaluation of their clinical skills.Methods: We enrolled 5th-year-grade students at the Department of General Medicine, Saga University Hospital, Japan in 2017. The students were divided into those who were going to have Japanese traditional-style observation-based training mainly in the outpatient clinic (Group O) and those in the 2018, new-style, hands-on clinical clerkship as one of the group practice members in outpatient and inpatient clinics (Group H). A questionnaire survey using the 4-point Likert scale for self-evaluation of the students’ clinical skills at the beginning and the end of their training was conducted in both groups. The pre- and post-training scores of each item in both groups were compared and analyzed using the Mann–Whitney test.Results: All 99 students in Group O and 121 of 123 students in Group H answered the questionnaires. The response rate was 99%. Two items regarding the abilities of “can perform a systemic physical examination quickly and efficiently” and “can clearly explain the current medical condition, therapeutic options, or risks associated with treatment, and discuss the process for obtaining informed consent” showed higher scores in the post-training survey in Group H than in Group O. There were no differences in these scores in the pre-training survey between the two groups.Conclusion: A hands-on clinical clerkship at the Department of General medicine in a university hospital in Japan provided medical students with higher self-confidence in their skills of performing a physical examination and better understanding of patients’ treatment options and the process of informed consent than observation-based training.Keywords: general medicine, hands-on clinical clerkship, medical education, observation-based training

The importance of bioethics as a formal subject has been recognized globally. The purpose of this study was to analyze undergraduate medical and dental students’ knowledge, practice and attitudes regarding bioethical questions through a questionnaire. This cross-sectional study was conducted among students from the Medical Faculty who were in their first or fourth year of education. There were no differences in bioethics awareness between direction (general medicine [GM] or dentistry) or years of study among 301 GM and dental students. In this research, GM and dental students, in general, indicated a positive attitude and knowledge of bioethics.

Background: The objective of this pilot study is to assess feasibility (recruitment and retention rates) of conducting a definitive randomized controlled trial (RCT) to investigate the effectiveness of fluticasone-vilanterol (Long-acting beta agonist+ Inhaled corticosteroids; LABA+ICS) in the management of mild asthma in adults, compared with usual care. Methods: In this 8-month parallel two-arm pilot trial we randomly assigned 18 patients with mild asthma in a 1:1 ratio to the treatment (n=10) or usual care (n=8) arms. The treatment group received daily LABA+ICS therapy while the usual care group continued as required SABA or SABA+ICS combination. The main outcome measures were descriptors of study feasibility. Secondary outcomes were asthma control score, quality of life, and the number of asthma exacerbations. Results: The baseline characteristics of participants did not differ significantly across the two arms at the start of the trial. Because of slow recruitment and limited funding, the study didn’t meet our recruitment target but did successfully meet our retention criteria. At 32 weeks, analysis indicated significant improvement in asthma control scores in the intervention arm (1.31 vs 2.91; 95% CI [0.72, 2.44]; P-value=0.003), but no significant differences were noted in quality-of-life scores (P-value=0.197). There were no significant differences in post-intervention asthma control mean score (P-value=0.361) or QoL mean score (P-value=0.337) between the two arms after adjustment for pre-intervention scores. Conclusions: This pilot RCT indicates that a definitive RCT is feasible in a primary health care setting. We recommend increasing the recruitment rate by relaxing eligibility criteria, extending the timeline, and increasing the number of sites for recruitment. ClincialTrials.gov registration : NCT04265105 (11/02/2020)

Hintergrund: Unterschiedlichste Publikationen der jüngeren Vergangenheit beschäftigten sich mit der Versorgungsrealität von Patient:innen mit spastischen Bewegungsstörungen in Deutschland und offenbarten eine Versorgung, die nicht mit den aktualisierten Empfehlungen der DGN Leitlinien übereinstimmt. Studiendaten zur Versorgungslage von Patient:innen mit spastischer Bewegungsstörung in Deutschland sind bisher leider kaum vorhanden. Die Vermutung liegt daher nahe, dass die Lebensqualität der Patient:innen sowie deren medizinische Versorgung aufgrund einer permanenten Fehl- und Unterversorgung in Deutschland leidet und ein deutlich erhöhter Pflegeaufwand daraus resultiert. Methodik: Drei Publikationen der letzten Jahre, die sich mit verschiedenen Bereichen der Versorgung von Patient:innen mit spastischem Syndrom in Deutschland beschäftigt haben, sollen verglichen und kanalisiert werden, um die Versorgungsrealität übersichtlicher darstellen zu können. Die zu vergleichenden Publikationen wurden kurz und fokussiert rekapituliert. Darauf aufbauend wurden die Resultate im Kontext der Versorgungssituation und der verwendeten Therapiemaßnahmen dargelegt. Ergebnisse: Im Kontext des Pflegegrades zeigt sich, dass die stationär untergebrachten Patient:innen eine stärkere Gewichtung bei den höheren Pflegegraden 3-5 (66%) haben, wogegen die Patient:innen des Surveys von Potempa et al. hauptsächlich den Pflegegraden 2-4 (66%) zugeordnet waren. 2018 (Potempa et al.) gaben die Allgemeinmediziner an, dass ihren Patient:innen hauptsächlich Physiotherapie verschrieben wurde, die zu 90% mit 12-24 Sitzungen im Quartal stattfand. Auf das Quartal gerechnet erhielten 2019 (Völkel et al.) lediglich 25% der Patient:innen 12-24 Sitzungen. In der aSPEkt-Studie (Katzenmeyer et al.) ergab sich, dass von den betreuten Patient:innen 10% eine First-Line-Therapie erhielten, bei der BoNT A inkludiert ist. Gemäß der Patientenbefragungen erhielten lediglich sehr geringe Anteile der Patient:innen (2018: 9%, 2019: 4%) BoNT A. Eine „nicht vorhandene Verfügbarkeit“ war die dominierende Ursache für diese Unterversorgung (2018: 43%, 2019: 47%). Schmerzmittel wurden den Patient:innen aufgrund der spastischen Bewegungsstörung in 50% der Fälle (2018) verschrieben und dagegen in 63% bei Patient:innen in stationären Pflegeeinrichtungen. Dies entspricht den Resultaten der aSPEkt-Studie, bei der die Pflegekräfte angaben, dass bei 85% der betreuten Patient:innen Schmerzen mit zu den größten Folgeproblemen des nicht suffizient behandelten spastischen Syndroms zählt. Konklusion: Zur Beurteilung der Versorgungsrealität von Patient:innen mit SMD in Deutschland wurden drei verschiedene Publikationen vergleichend betrachtet. Dabei ist festzustellen, dass die Publikationen, deren Daten jeweils aus verschiedenen Jahren stammen (2016, 2018, 2019), übereinstimmend eine große Diskrepanz zwischen der empfohlenen leitliniengerechten Versorgung und der tatsächlichen Versorgungsrealität in Deutschland aufzeigen. Allumfassend kann dargelegt werden, dass die Versorgung von Patient:innen mit SMD in Deutschland einer zügigen und effizienten Adaptation bedarf. Die empfohlene First-Line-Therapie, bei der es sich um eine Kombination aus Physiotherapie und der Behandlung mit BoNT A handelt, bedarf einer flächendeckenden Anwendung, um die Versorgung von Patient:innen mit SMD bundesweit zu verbessern sowie Folgeprobleme und Komorbiditäten und somit höhere Kosten für das Sozialsystem zu verhindern.

Abstract Background Randomized controlled trials (RCTs) and cohort studies are the most common study design types used to assess treatment effects of medical interventions. We aimed to hypothetically pool bodies of evidence (BoE) from RCTs with matched BoE from cohort studies included in the same systematic review. Methods BoE derived from systematic reviews of RCTs and cohort studies published in the 13 medical journals with the highest impact factor were considered. We re-analyzed effect estimates of the included systematic reviews by pooling BoE from RCTs with BoE from cohort studies using random and common effects models. We evaluated statistical heterogeneity, 95% prediction intervals, weight of BoE from RCTs to the pooled estimate, and whether integration of BoE from cohort studies modified the conclusion from BoE of RCTs. Results Overall, 118 BoE-pairs based on 653 RCTs and 804 cohort studies were pooled. By pooling BoE from RCTs and cohort studies with a random effects model, for 61 (51.7%) out of 118 BoE-pairs, the 95% confidence interval (CI) excludes no effect. By pooling BoE from RCTs and cohort studies, the median I 2 was 48%, and the median contributed percentage weight of RCTs to the pooled estimates was 40%. The direction of effect between BoE from RCTs and pooled effect estimates was mainly concordant (79.7%). The integration of BoE from cohort studies modified the conclusion (by examining the 95% CI) from BoE of RCTs in 32 (27%) of the 118 BoE-pairs, but the direction of effect was mainly concordant (88%). Conclusions Our findings provide insights for the potential impact of pooling both BoE in systematic reviews. In medical research, it is often important to rely on both evidence of RCTs and cohort studies to get a whole picture of an investigated intervention-disease association. A decision for or against pooling different study designs should also always take into account, for example, PI/ECO similarity, risk of bias, coherence of effect estimates, and also the trustworthiness of the evidence. Overall, there is a need for more research on the influence of those issues on potential pooling.

Takashi Watari,1– 3 Yasuhisa Nakano,4 Ashwin Gupta,2,3 Minami Kakehi,4 Ayuko Tokonami,4 Yasuharu Tokuda5 1General Medicine Center, Shimane University Hospital, Izumo, Shimane, Japan; 2Department of Medicine, University of Michigan Medical School, Ann Arbor, MI, USA; 3Medicine Service, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; 4Faculty of Medicine, Shimane University, Izumo, Shimane, Japan; 5Muribushi Okinawa Clinical Training Center, Urasoe, Okinawa, JapanCorrespondence: Takashi Watari, Shimane University Hospital, General Medicine Center, 89-1, Enya-cho, Izumo, Shimane, 693-8501, Japan, Tel +81-853-20-2005, Fax +81-853-20-2375, Email wataritari@gmail.comBackground: Japan created a specialty system for general medicine in 2018. However, Japanese academic generalists’ contribution to research remains unclear. This study examines the popularity of Japanese general medicine research, the characteristics of journal publications, annual trends, and the characteristics/differences among publications in journals with an impact factor (IF).Methods: This bibliometric analysis extracted international, English-language, journal articles published on PubMed between January 1, 2015, and December 31, 2020. Analysis included articles with either the first, second, or last author in general medicine. We classified articles according to publication or article type and field of research. We obtained standard descriptive statistics for each publication type. Chi-squared test or Fisher’s exact test was used to compare nominal variables. For continuous variables, t-tests or Wilcoxon rank-sum tests were used, as appropriate.Results: Of the 2372 articles analyzed, original articles were most common (56.3%), followed by case reports (30.1%), reviews (7.63%), and letters/others (5.9%). Publication volume increased 2.64-fold annually over 5 years. Clinical research (60.5%) was most common among original articles, followed by basic experimental research (17.5%) and public health/epidemiology (12.7%). Medical quality and safety (4.1%), medical and clinical education (3.1%), and health services (1.42%) received comparatively little attention. Eighty percent of articles were published in journals with IF; however, these journals rarely published case reports. Among original articles, the likelihood of publishing in journals with IF was high for basic laboratory medicine articles with higher IF (median IF 3.83, OR 1.71, 95% CI 2.20– 5.95, p=0.044) and lower for clinical education research with the lowest IF (median IF 1.83, OR 0.56, 95% CI 01.8– 0.75, p< 0.001).Discussion: General medicine physicians’ international research output is increasing in Japan; however, research achievements have not been generalized, but rather much influenced by clinical subspecialty backgrounds. This will likely continue unless an academic generalist discipline is established.Keywords: general medicine, academic generalist, research productivity, research trend, impact factor

Background and purpose: Responsive medical education considers the priority of society's health issues in all its operational areas, and its goal is to train doctors who want and can serve their society. Based on this, the aim of this research was to design and validate an ideal model for social responsiveness in general medical education. Materials and methods: In this study, grounded theory as a qualitative approach was used. The participants included 21 key informants of medical education (managers, supervisors, doctors of academic staff, and educational-therapeutic centers leadership) in Mazandaran province who were selected by snowball purposive sampling. Data were collected using semi-structured interviews. Data analysis was done at three stages of open, axial, and selective coding, and based on that, the qualitative research model was designed. Also, acceptability index was used for accreditation. Results: The research showed 104 concepts shaped by 29 main categories which define a paradigmatic model of social accountability in general medical education at six inclusive layers (causal conditions, contextual conditions, intervening conditions, central phenomenon, strategies, and consequences) to be deep and rich. Conclusion: The present study, by applying grounded theory, proposes a holistic-systematic perspective and model on social accountability in education that can be used by the Ministry of Health, Treatment and Medical Education and policy makers and planners. [ABSTRACT FROM AUTHOR]

Purpose: To assess how previous experiences and new information contributed to COVID-19 vaccine intentions. Design: Online survey (N = 1264) with quality checks. Setting: Cross-sectional U.S. survey fielded June 22-July 18, 2020. Sample: U.S. residents 18+; quotas reflecting U.S. Census, limited to English speakers participating in internet panels. Measures: Media literacy for news content and sources, COVID-19 knowledge; perceived usefulness of health experts; if received flu vaccine in past 12 months; vaccine willingness scale; demographics. Analysis: Structural equation modelling. Results: Perceived usefulness of health experts (b =.422, P <.001) and media literacy (b =.162, P <.003) predicted most variance in vaccine intentions (R-squared=31.5%). A significant interaction (b =.163, P <.001) between knowledge (b = −.132, P =.052) and getting flu shot (b =.185, P <.001) predicted additional 3.5% of the variance in future vaccine intentions. An increase in knowledge of COVID-19 associated with a decrease in vaccine intention among those declining the flu shot. Conclusion: The interaction result suggests COVID-19 knowledge had a positive association with vaccine intention for flu shot recipients but a counter-productive association for those declining it. Media literacy and trust in health experts provided strong counterbalancing influences. Survey-based findings are correlational; thus, predictions are based on theory. Future research should study these relationships with panel data or experimental designs. [ABSTRACT FROM AUTHOR]

Background: New-onset insomnia and other sleep disturbances occur more frequently in the inpatient setting due to a variety of physical and psychological factors. Studies have found that non-pharmacologic interventions can be effective in treating insomnia in the inpatient setting, particularly in the ICU, to prevent adverse outcomes, but further research is needed to identify optimal pharmacologic interventions. Objective: To compare treatment outcomes of patients initiated on melatonin and trazodone to treat new-onset insomnia in non-ICU hospitalized patients based on the need for an additional sleep aid therapy during hospitalization and to compare the rate of adverse events of each agent. Methods: A retrospective chart review was conducted for adult patients admitted to a non-ICU general medicine or surgical floor at a community teaching hospital between July 1, 2020 and June 30, 2021. Patients were included if they were initiated on scheduled melatonin or trazodone for the treatment of new onset insomnia during their hospitalization. Patients were excluded if they had a previous diagnosis of insomnia, were prescribed 2 sleep aids simultaneously, or if their admission medication reconciliation included pharmacologic treatment for insomnia. Clinical data collected included non-pharmacologic interventions, sleep aid dose, number of doses of sleep aid administered, and total number of nights an additional sleep aid was needed. The primary outcome was the percentage of patients needing additional therapy defined as, administering an additional sleep aid between 2100-0600 or utilizing more than 1 sleep aid agent during hospitalization compared between melatonin and trazodone. Secondary outcomes of this study included the rate of adverse events such as difficulty awakening, daytime sleepiness, serotonin syndrome, falls, and development of in hospital delirium. Results: Of 158 included patients, 132 received melatonin and 26 received trazodone. Male sex (53.8% [melatonin] vs. 53.8% [trazodone]; P = 1), hospital length of stay (7.7 vs 7.7 days; P =.68), and administration of drugs that could cause insomnia (34.1% vs 23.1%vs; P =.27) were similar between sleep aids. Percentage of patients needing an additional sleep aid during hospitalization (19.7% vs 34.6%; P =.09), and patients prescribed a sleep aid at discharge (39.4% vs 46.2%; P =.52) were similar between sleep aids, respectively. Rates of adverse events were similar between sleep aids. Conclusions: There was no significant difference between the 2 agents in terms of the primary outcome, even though a higher rate of patients treated with trazodone for new-onset insomnia during hospitalization required an additional sleep aid compared to those treated with melatonin. No difference in adverse events was observed. [ABSTRACT FROM AUTHOR]

Herpes simplex encephalitis (HSE) is the most common cause of infectious encephalitis. Our case is of a 75‐year‐old woman who presented with dysuria and altered mental status. Our case addresses the difficulties in diagnosis and highlights the importance of early recognition of HSE and its associated neurological sequelae. [ABSTRACT FROM AUTHOR]

Background: Communication skills required for doctors do not consist of simple uses of particular linguistic forms but include uses that are sensitive to the interactional context. In consultations where the doctors have pre‐existing information about their patients, this can complicate the context of problem solicitation. We investigated how doctors tailor opening questions to a context in which they get pre‐existing information from a medical questionnaire (MQ) filled out by the patients. Methods: The data for this study were 87 video recordings of first visits to the department of general medicine at a university hospital in Japan. We qualitatively analyzed doctors' practices in problem solicitation in an opening phase using conversation analysis and triangulated it with quantitative analysis. Results: Open‐ended questions accounted for 26.4% of opening questions. Among the closed‐ended questions, 75.0% were confirming questions about symptoms. In cases with open‐ended questions, doctors minimized the relevance of the MQ to problem solicitation by giving license to repeat the description from the MQ. In cases with closed‐ended questions, doctors highlighted the relevance of the MQ by sharing the MQ. Through these practices, they avoided patients' possible confusion about problem presentation while simultaneously maximizing the possibility of soliciting the patients' narratives. Conclusions: Doctors adjusted the level of relevance of pre‐existing information to problem solicitation through both verbal and nonverbal management of the MQ. It will be useful to instruct such context‐dependent practices to improve communication skills in medical school curriculum. [ABSTRACT FROM AUTHOR]