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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.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).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.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.

Introduction Visual pattern recognition is important in many different medical fields, particularly in dermatology. Perceptual learning modules (PLM) are software programs developed to enhance visual pattern recognition through the sequential presentation of images that trainee must quickly diagnose. The aim of this literature review was to determine the scope and effectiveness of PLM in medical education. Methods We carried out a search of MEDLINE, EMBASE, Web of Science and ERIC from its inception through to July 1, 2017. All articles describing an educational intervention based on perceptual learning in a medical field were included. Two investigators worked independently on study selection and data extraction. Results Of 191 references selected, 5 studies were included in the final analysis: 3 before-after studies and 2 randomized studies comparing 12 to 236 trainees taking PLM with 12 to 316 trainees not taking PLM. Four studies reported a statistically significant increase in diagnostic accuracy (lower error rate) and fluency (shorter response time) following PLM interventions (dermatology, pathology, echocardiography), with long-term persistence of the effect in three studies. Conclusion PLM is a promising educational tool to teach pattern recognition that may be used in dermatology and other medical fields to improve diagnostic accuracy and rapidity in daily practice.

Resume Pour homogeneiser les pratiques de l’anamnese a l’occasion de l’accueil d’un nouveau patient a ete developpe l’autoquestionnaire Pneumo-Quest. Il comprend 82 questions principales et 34 subsidiaires destinees a etre completees au domicile par les patients avant leur premiere rencontre avec un pneumologue. Son evaluation a ete menee sur la base de 137 questionnaires retournes. La faisabilite (critere principal) est bonne avec 93 ± 5 % de questions repondues et une duree moyenne de remplissage de 15,1 ± 9,8 minutes (m oyenne± deviation standard). La fiabilite des reponses (critere secondaire) est bonne puisque la concordance entre la reponse du patient et l’avis du medecin s’avere excellente ou bonne pour la majorite des antecedents medicaux et des traitements, comme en temoignent les valeurs elevees du coefficient kappa (> 0,90

Resumen La eleccion de una prueba y de sus modalidades de utilizacion depende estrechamente del contexto de uso. Las propiedades deseables de las pruebas diagnosticas dependen, en especial, del objetivo buscado : deteccion, confirmacion o eliminacion del diagnostico, evaluacion pronostica, control de la evolucion, investigacion medica.

Resumen El procedimiento diagnostico se basa en el analisis clinico que permite estimar la probabilidad de hipotesis diagnosticas que compiten entre si para explicar un problema de salud. Las hipotesis en competencia y su probabilidad inicial determinan entonces la eleccion de las pruebas complementarias y sus valores predictivos.

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.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.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.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.

The Pneumo-Quest self-questionnaire was developed to standardize the practice of recollection when welcoming a new patient. It consists of 82 main questions and 34 subsidiary questions to be completed at home by the patients before their first visit to a pulmonologist. This evaluation was carried out on the basis of 137 returned questionnaires. The feasibility (main criterion) was good with 93±5% of the questions answered and an average completion time of 15.1±9.8minutes (mean±SD). The reliability of the responses (secondary criterion) was good with the agreement between the patient's response and the doctor's opinion being excellent or good for the majority of medical histories and treatments, as evidenced by the high values of the kappa coefficient (0.90;0.90;0.75). Patient and physician perception of the questionnaire was good with 99% and 90% positive ratings, respectively. The use of the questionnaire was unhelpful in the course of the consultation in only 2% of cases. Doctors found the tool useful for obtaining a comprehensive history in 87% of cases and patients declared that it helped them "forgot nothing" in 93% of the cases. The questionnaire helped the doctor to identify the patient's problems rapidly in 71% of cases and saved time in 64%. These positive results encourage a wide dissemination of the questionnaire (www.pneumo-quest.com).

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.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.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 (P0.001) and the length of hospital stay was 30% higher after further adjustment on the Charlson score (P0.001). These differences were consistent for each main diagnosis.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.

Le cause di grossa gamba rossa sono dominate dall’erisipela. Segni di gravita locali o generali fanno sospettare una dermoipodermite necrotizzante, il cui trattamento e un’urgenza medicochirurgica. Peraltro, alcuni elementi clinici, tra cui l’assenza di evoluzione rapidamente favorevole sotto antibiotici, possono orientare verso altre cause meno comuni dell’erisipela.

Las causas de pierna hinchada y roja estan presididas por la erisipela. Los signos locales o sistemicos de gravedad hacen sospechar una dermohipodermitis necrosante, cuyo tratamiento constituye una urgencia medico-quirurgica. Por otra parte, determinados elementos clinicos, entre ellos la falta de evolucion rapidamente favorable con antibioticos, pueden orientar hacia otras causas menos comunes que la erisipela.

Resume Introduction L’aerosoltherapie par nebulisation est un mode d’administration des medicaments particulierement efficace mais dont la mise en œuvre est complexe. Des recommandations de bonnes pratiques existent mais peu de donnees sont disponibles quant a leur reelle application. L’objectif de l’enquete est de faire un etat des lieux des connaissances et des pratiques des soignants en termes de nebulisation. Methodes Deux auto-questionnaires destines aux infirmiers ou aux medecins ont ete elabores par un groupe de travail et presentes aux soignants des hopitaux universitaires de l’Est Parisien. Un interne en pharmacie a analyse les resultats a l’aide d’un outil de sondage en ligne. Resultats Au total, 481 auto-questionnaires ont ete completes (67 % d’infirmiers et 33 % de medecins). Seulement 241/480 soignants (50 %) savent que les medicaments injectables ne sont pas tous nebulisables, 94/422 soignants (22 %) utilisent systematiquement l’oxygene comme fluide medical et 239/311 infirmiers (77 %) pensent qu’ils peuvent re-utiliser un nebuliseur a usage unique. Conclusions Cette enquete a mis en evidence un manque de connaissances et des mesusages de la part de nombreux soignants. Un guide pratique de la nebulisation a ete elabore pour harmoniser les pratiques dans le groupe hospitalier et aider les soignants a suivre les recommandations.

Introduction La mastite granulomateuse idiopathique (MGI) est une maladie inflammatoire rare du sein. La MGI se presente cliniquement sous la forme d’une masse inflammatoire mimant un abces ou un cancer agressif. L’histologie trouve une inflammation granulomateuse centree sur les lobules mammaires. Les mastites granulomateuses secondaires sont rares en France (tuberculose essentiellement), l’enquete etiologique est guidee par le contexte et la clinique. Le recours chirurgical est de plus en plus limite et le traitement, essentiellement symptomatique, combine antalgique et evacuation a l’aiguille en cas de collection abcedee. La corticotherapie reduit les manifestations inflammatoires mais avec de frequentes reprises a leur arret, voire un effet rebond. Patients et methodes Etude descriptive des patientes avec une MGI confirmee histologiquement apres prises en charge dans un centre d’oncologie mammaire, en insistant sur les signes extra-mammaires et sur les modalites therapeutiques. L’etude est retrospective de 07/2013 a 07/2015 et prospective ensuite, avec une consultation en medecine interne la plus systematique possible. Resultats Vingt-deux patientes ont ete incluses, dont 16 (73 %) vues par un meme interniste. L’âge median etait de 37 ans [quartiles 31–49] ; 5 patientes (23 %) etaient menopausees, 15 (75 %) avaient deja eu une grossesse, 4 (19 %) fumaient, 7 (32 %) avaient une contraception hormonale. La mastite etait toujours unilaterale (5 seins droits, 16 gauches). Les manifestations cliniques etaient les suivantes : – taille de la lesion (mm) : 46 [25–70] ; – douleur : 15/19 (79 %) ; – retraction du mamelon : 9/20 (45 %) ; – inflammation cutanee : 12/20 (60 %) ; – abcedation : 11/21 (52 %) ; – fistulisation a la peau : 9/21 (43 %) ; – adenomegalie axillaire : 12/21 (57 %) ; – AEG avec perte de poids : 5/18 (28 %) ; – fievre : 5/18 (28 %) ; – arthralgies : 7/19 (37 %) ; – erytheme noueux : 3/19 (16 %). Les presentations radiologiques etaient aspecifiques avec des echographies mammaires montrant des lesions hypoechogenes ou heterogenes et l’IRM des lesions en hypersignal T2 et diffusion, rehaussees par le gadolinium. Les biopsies mammaires montraient une inflammation granulomateuse epithelioides et gigantocellulaire sans necrose caseeuse mais avec des microabces dans 7/22 cas (32 %). Des antibiotiques ont initialement ete prescrits a 11/22 patientes (50 %), adapte a l’eventuelle documentation bacteriologique (staphylocoque × 2, corynebacterie × 1), mais jamais efficace. Une corticotherapie a ete prescrite a 5/22 patientes (23 %) seulement, dont la lesion etait tres inflammatoire, souvent avec des signes generaux. La dose initiale etait de 0,5 mg/kg avec une decroissance progressive pour une duree totale allant de 1 a 7 mois en fonction de la reponse. Du methotrexate etait coprescrit dans deux de ces cas et une fois sans corticoides. Une evacuation d’abces a l’aiguille a ete realisee chez 5/22 patientes (23 %), toujours avec un tres bon effet sur la douleur. Conclusion La MGI touche preferentiellement les femmes en âge de procreer ayant deja eu des enfants mais peut affecter des femmes nulligestes ou menopausees. L’histologie est obligatoire pour retenir le diagnostic, les examens d’imagerie manquant de specificite. Les manifestations extra-mammaires et generales (arthralgie, erytheme noueux, alteration febrile de l’etat general) ne sont pas exceptionnelles et n’indiquent pas une granulomatose generalisees sous-jacente. Elles peuvent faire envisager une courte corticotherapie, eventuellement associee a du methotrexate en cas de manifestations locales tres inflammatoires.

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.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.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.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.

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.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_CR) and the multisource feedback form (E_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.Twenty-five residents have been included. The Cronbach alpha was of 0.90 (n=70) with the mini-CEX, 0.89 with the OD_CR (n=62) and 0.77 with the E_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_360 were high: 7.3±0.8 to 8.3±2.4 (maximum 9) and did not vary according to the level of experience.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.

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.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).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.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.

Introduction La drepanocytose affecte essentiellement les populations originaires d’Afrique sub-saharienne et du sous-continent indien. L’osteomyelite (OM) est l’une des principales complications infectieuses chez les patients drepanocytaires, avec une prevalence estimee entre 12 et 18 % dans les pays a faibles revenus, adultes et enfants confondus. Il existe peu de donnees sur les OM chez les adultes drepanocytaires dans les pays a hauts revenus. Materiels et methodes Cette etude observationnelle monocentrique a inclus tous les patients suivis dans un centre de reference ayant presente au moins une osteomyelite avec documentation microbiologique a l’âge adulte. L’objectif etait de caracteriser le profil clinique et microbiologique de cette complication. Resultats Dix-sept patients ont ete inclus (15/17 (88 %) genotype SS, âge median au diagnostic de l’OM 23 ans, 7/17 (41 %) femmes, 15/17 (88 %) origine subsaharienne), correspondant a une prevalence dans notre centre de 1,2 % (17/1464). Les patients avaient des antecedents d’infections osteo-articulaires pour 41 % (4 OM dans l’enfance, 2 arthrites septiques et 1 infection de prothese). Dans 16/17 (94 %) des cas, l’infection avait debute alors que les patients etaient dans un pays a haut revenu. Les localisations les plus frequentes etaient les membres inferieurs (9/17, 64 %) avec des formes multifocales dans 8/17 (40 %) des cas. La documentation microbiologique etait obtenue par prelevement osseux (5/17, 29 % %) ou hemocultures (7/17, 42 %). Les germes les plus trouves etaient du groupe Salmonella non-typhi (6/17, 35 %) et Staphylococcus spp (5/17, 29 % dont aureus meticilline-sensible (4/5) et epidermidis (1/5)). D’autres agents pathogenes plus rares etaient egalement mis en evidence (Clostridium difficile, Pantoea agglomerans ou Propionebacterium acnes). L’antibiotherapie etait systematique, avec une duree mediane de 90 jours, et 9/17 (75 %) des patients ont requis un debridement chirurgical (sequestrectomie ou drainage d’abces de Brodie). A la derniere consultation de suivi, 3 patients avaient presente une rechute ou une OM persistante malgre un traitement medico-chirurgical adapte. Conclusion L’epidemiologie des OM dans la drepanocytose differe entre pays a faibles et hauts revenus : Salmonella non-typhi en Europe et aux USA et Staphylococcus aureus en Afrique sub-saharienne et au Moyen-Orient. Les facteurs de susceptibilite des patients drepanocytaires sont une immunodepression (asplenisme fonctionnel, alteration du complement) et les infarctus osseux ou perioste qui font le lit de l’infection. Notre etude trouve une prevalence plus faible et une surrepresentation de Salmonella non-typhi par rapport aux pays a faibles revenus. La porte d’entree supposee est la translocation digestive, via les micro-infarcissements parietaux. L’evolution est generalement favorable sans rechute, meme en l’absence de prise en charge chirurgicale.

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.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.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.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.

Introduction Grâce a une prise en charge precoce, l’esperance de vie des patients drepanocytaires homozygotes augmente expliquant l’incidence des complications chroniques liees a cette maladie. La prevalence de la maladie renale chronique (MRC) serait de 85 % chez les patients de plus de 65 ans drepanocytaires. L’objectif de notre etude est de determiner les facteurs de risque d’apparition d’une MRC stade 2. Methodes Etude prospective observationnelle monocentrique d’une cohorte de 688 patients suivis entre 2007 et 2018 dans un centre de drepanocytose. Un total de 660 patients ayant un eDFG > 90 ml/min/1.73 m2 (CKD EPI) ont ete inclus. L’evenement etudie etait l’apparition d’une MRC stade 2 (DFG Resultats obtenus ou attendus Le delai median de suivi etait de 3,7 ans (IQR 0,76–7,36). L’âge median a l’inclusion etait de 22 ans (IQR 19–29), avec 377 (57,12 %) femmes. Une hyperfiltration glomerulaire (DFG > 130 ml/min/1,73m2) etait presente chez 380 patients (57,58 %), une microalbuminurie et une macroalbuminurie chez 218 (33,70 %) et 83 (12,83 %) patients respectivement. Les pressions arterielles systoliques et diastoliques moyennes (± deviation standard) etaient basses ; respectivement 114,8 mmHg (± 13,6) et 66,0 (± 9,7) mmHg. Les facteurs associes a l’apparition d’une MRC stade 2 etaient (analyse multivariee) : la proteinurie (pour 100 mg/mmol creatinine) HR : 1,24 [1,07–1,45] p = 0,005, la pression arterielle diastolique (PAD) (pour 10 mmHg) HR : 1,35 [1,03–1,76] p = 0,029 et les LDH HR : 1,22 [1,04–1,43] p = 0,015, le DFG initial HR : 0,92 [0,90–0,95] p Conclusion Notre etude montre une augmentation significative du risque de degradation de la fonction renale dans les cas de macroalbuminurie, d’augmentation de la PAD et d’hemolyse chronique intense. Ces resultats suggerent l’importance d’un controle tensionnel dans cette population avec des valeurs cibles particulierement basses.

Resume Malgre leur faible niveau de preuve, les rapports de cas continuent d’etre publies et lus. En raison de leur forme narrative, ils sont plus agreables a lire, faciles a comprendre et a memoriser que les textes theoriques ou les analyses statistiques. Ils sont particulierement aptes a montrer l’impact des specificites d’un cas sur sa prise en charge, et participent ainsi a augmenter l’experience raisonnee du lecteur. Mais les rapports de cas ont egalement un contenu factuel original qui peut avoir une valeur par lui-meme, qu’il s’agisse de suggerer une hypothese ou de la corroborer. A cette fin, les cas doivent etre parfaitement documentes et rigoureusement interpretes. Les deux grandes difficultes sont d’etablir que les observations realisees sur le cas ne sont pas le simple fait du hasard et de savoir a quelle population extrapoler les lecons qu’on en tire.

Le cause di gamba gonfia e arrossata sono dominate dall’erisipela. Segni di gravita locali o generali fanno sospettare una dermoipodermite necrotizzante, la cui gestione e un’urgenza medico-chirurgica. Di fronte a una gamba gonfia e arrossata, alcuni elementi clinici, tra cui l’assenza di un’evoluzione rapidamente favorevole sotto antibiotici, possono orientare verso altre cause meno comuni dell’erisipela.

La causa principal de una tumefaccion eritematosa de la pierna es la erisipela. Los signos de gravedad locales o generales hacen sospechar una dermohipodermitis necrosante, cuyo tratamiento es una urgencia medicoquirurgica. Ante una tumefaccion eritematosa de la pierna, algunos elementos clinicos, como la ausencia de evolucion rapidamente favorable con antibioticos, pueden orientar hacia otras causas menos habituales que la erisipela.

Aerosol therapy is an efficient, but complex procedure. National and international practice guidelines are regularly updated. However, only a few studies have assessed the application of guidelines by users. The aim of this study is to assess the knowledge and practices of physicians and nurses regarding these guidelines.Two self-administered questionnaires were designed by a working team and presented to physicians and nurses of four university hospitals in Paris. A pharmacy resident collected and analyzed the data with the aid of an online survey website.A total of 481 physicians and nurses completed the questionnaires (33 % of physicians and 67 % of nurses). Only 241/480 physicians and nurses (50 %) knew that several intravenous drugs cannot be nebulized. Ninety-four of 422 (22 %) of them always choose oxygen as the driving gas and 239/311 nurses (77 %) think that single use nebulizers can be re-used for the same patient.This survey shows that many physicians and nurses lack knowledge and use inappropriate practices. Based on these results, a booklet has been designed by the working team. This booklet should help health professionals to harmonize practices across hospitals and to follow the guidelines correctly.

Hypernatraemia in hospitalised patients is less common and less studied than hyponatraemia, although it also seems to be associated with a poor prognosis. The present study evaluates its prevalence, risk factors and prognosis in an internal medicine department.Full hospital stays over 28 months in a 36-bed internal medicine department were analysed retrospectively. Patients with at least one plasma sodium ≥ 150 mmol/l were compared first with all other patients and then individually with sex- and age-matched normonatraemic controls.Plasma sodium ≥ 150 mmol÷l was observed during 49÷1945 hospitalisations (2.6%); it was acquired during hospitalisation in 30 cases (61%). Hypernatraemic patients were significantly older with no gender difference. They were comparable with their matched normonatraemic controls regarding the Charlson comorbidity index, although individual comorbidities varied. They were bedridden in 45% vs 15% for controls (p = 0.001). Nearly one-third of hypernatraemic patients had an increased extracellular fluid volume. Hypernatraemia was associated with higher in-hospital mortality (43% vs 2%, p0.001) and longer hospitalisation (median 21 vs 10 days, p = 0.004).Hypernatraemia is more likely to occur in older and dependent patients and is associated with poor prognosis. Unlike classical teaching, it is often associated with increased extracellular fluid volume, even outside intensive care units.

Introduction Malgre des solutions alternatives avec un rapport benefice risque au moins equivalent et une plus grande simplicite d’administration, l’heparine standard continue a etre largement utilisee a la mise en route d’une anticoagulation efficace dans certaines indications liees a l’urgence et/ou au benefice/risque de ce traitement. Les recommandations internationales et les RCP francaises de l’heparine standard preconisent la realisation d’un bolus IVD en fonction du poids a l’initiation d’une anticoagulation efficace par heparine IVSE ou SC. Nous avons evalue la connaissance et l’application pratique de ces recommandations par les premiers prescripteurs de ces molecules : les internes des services de medecine aigue, qu’ils soient de formation medecine generale ou medecine interne. Materiels et methodes Un questionnaire on-line evaluant les connaissances et les pratiques de prescription de l’heparine standard a ete diffuse par mail par l’association des jeunes internistes (AJI) et 5 des 28 syndicats regionaux d’internes en medecine generale (SIMG). Le questionnaire a ete renvoye chaque premier jour du mois de fevrier a avril 2014, soit 3 relances. Outre les caracteristiques demographiques des repondants et des services, ce questionnaire declaratif evaluait : les connaissances declarees des internes ainsi que leurs pratiques justifiees dans leur stage actuel, et la connaissance d’existence de protocoles conformes aux recommandations sur leur lieu de travail. Resultats Au total, 372 internes de medecine generale et de medecine interne ont repondu au questionnaire (taux de reponse 19 % et 12 % respectivement pour l’AJI et SIMG). Quarante-deux pour cent des internes declaraient realiser un bolus d’heparine intraveineux direct (IVD) a l’initiation du traitement intraveineux a la seringue electrique (IVSE) et 13 % a l’initiation de traitement sous-cutane (SC). Ce bolus etait adapte au poids dans 83 % des cas en IV, 88 % pour le SC. Trente-deux pour cent des internes declaraient savoir que le bolus etait preconise avant le traitement IVSE et 63 % avant le traitement SC. Dans 29 % des cas, les internes disposaient dans leur service d’un protocole de prescription pour l’IVSE et dans 13 % des cas un protocole de prescription pour le SC. Le bolus initial etait inclus dans respectivement 57 % et 12 % des cas. Discussion La prescription d’un bolus lors de l’initiation d’un traitement par HNF est etayee par une etude montrant une anticoagulation plus rapidement efficace sans surrisque hemorragique [1] . La balance benefice/risque est donc en faveur de cette attitude, sauf peut-etre dans les situations a haut risque hemorragique. Le Groupe d’etude hemostase et thrombose (GEHT) conseille d’utiliser un bolus de 80 UI/kg, reduit a 50 UI/kg pour les personnes âgees [2] . Il n’y a donc pas lieu de surseoir au bolus initial si l’heparine standard est choisie pour une anticoagulation efficace, meme chez une personne âgee. L’GEHT, la SNFMI, le site Thromboclic et la FFMP pourraient s’associer pour creer un livret de protocole pour les anticoagulations et le diffuser nationalement (papier et electronique) comme il a ete fait pour la fiche d’equianalgesie. Dans ce cas, une nouvelle etude pourrait etre realisee afin de savoir si le taux de suivi des recommandations a augmente. Conclusion Moins de 50 % des praticiens sortant juste de leur formation medicale initiale et en premiere ligne de prescription d’une anticoagulation efficace urgente, ici par HNF, suivent les recommandations de bonne pratique nationales et internationales. Plus que l’inadaptation de l’Evidence Based Medicine au patient reel, la non-connaissance, mais aussi les « habitudes » locales semblent expliquer ce faible taux d’application des recommandations… Des propositions structurantes de formation et de suivi sont a envisager.

Summary Objective: To select papers published in 2014, illustrating how information technology can contribute to and improve patient-centered care coordination.Method: The two section editors performed a literature review from Medline and Web of Science to select a list of candidate best papers on the use of information technology for patient-centered care coordination. These papers were peer-reviewed by external reviewers and three of them were selected as “best papers”. Results: The first selected paper reports a qualitative study exploring the gap between current practices of care coordination in various settings and idealized longitudinal care plans. The second selected paper illustrates several unintended consequences of HIT designed to improve care coordination. The third selected paper shows that advanced analytic techniques in medical informatics can be instrumental in studying patient-centered care coordination. Conclusions: The realization of true patient-centered care coordination is dependent upon a number of factors. Standardization of clinical documentation and HIT interoperability across organization and settings is a critical prerequisite for HIT to support patient-centered care coordination. Enabling patient involvement is an efficient means for goal setting and health information sharing. Additionally, unintended consequences of HIT tools (both positive and negative) must be measured and taken into account for quality improvement.

Resume Introduction Les complications visuelles de la maladie de Horton sont frequentes et graves. Leur risque justifie l'instauration rapide d'une corticotherapie, mais ce traitement peut lui aussi induire des problemes ophtalmologiques. Exegese Un flou visuel monoculaire brutal et isole, survenant chez une patiente de 66 ans sous corticoides depuis quatre mois pour une maladie de Horton, revelait un cas de chorioretinopathie sereuse centrale iatrogene. Le diagnostic de cette maladie est porte par l'angiographie retinienne a la fluoresceine et le pronostic visuel est excellent. La decroissance des corticoides, aussi rapide que la maladie de fond le permet, accelere la recuperation fonctionnelle. Conclusion Lorsque le traitement de la maladie de Horton est debute depuis plus d'un mois, la survenue d'une nouvelle complication visuelle est rare. La chorioretinopathie sereuse centrale secondaire aux corticoides figure parmi les diagnostics a evoquer dans ce cadre, surtout en l'absence de manifestation clinique d'arterite et de syndrome inflammatoire.

Clinical examination skills are poorly evaluated by theoretical tests. We observed the clinical examination of real patients by 6th year medical students.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.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).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.

Introduction L’ECBU constitue l’examen bacteriologique le plus realise a l’hopital [1] . Les examens non pertinents ont un cout personnel et materiel important et peuvent deboucher sur des prescriptions d’antibiotiques injustifiees (augmentation des resistances et autres effets indesirables). Nous evaluons la part d’ECBU injustifies et l’effet d’une action d’amelioration des pratiques. Patients et methodes Les patients hospitalises dans un service de medecine interne de 49 lits ayant eu un ECBU durant une des periodes d’enquete ont ete inclus, avant (novembre 2012) ou apres (octobre 2013) la realisation d’une information aux medecins et infirmieres et la mise en place d’une fiche d’indication clinique pour accompagner chaque demande. Les ECBU conformes aux recommandations de l’AFSSAPS 2008 etaient tenus pour justifies [2] . Resultats Phase 1 : 130 patients ont ete hospitalises, 37 (29 %) ont eu un ECBU, dont 67 % etaient prescrits et 33 % etaient pertinents, qui ont permis le diagnostic de 3 infections de l’appareil urinaire (aucun ECBU non pertinent n’a diagnostique d’infection, un des ECBU injustifies etait positif dans le cadre d’une pyelonephrite compliquee mais non comptabilise comme diagnostic, car un EBCU pratique 24 h avant dans un autre service avait deja mis en evidence la pyelonephrite). Phase 2 : 185 patients ont ete hospitalises, 23 (12 %, p p = 0,004, 52 % accompagnes de la fiche) et 71 % etaient justifies ( p = 0,005), qui ont permis le diagnostic de 3 infections de l’appareil urinaire (aucun ECBU injustifie n’a diagnostique d’infection). Conclusion Beaucoup d’ECBU etaient envoyes par notre service en bacteriologie sans prescription ou sans que la prescription soit pertinente. Une intervention simple et facilement reproductible a ete suivie d’une diminution du nombre d’ECBU total, du nombre d’ECBU non prescrits et du nombre d’ECBU injustifies. Nous envisageons de rendre la fiche d’indication clinique obligatoire pour la realisation des ECBU.