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Prevalence of renal impairment is increasing with aging in sickle cell anemia (SCA) patients responsible for a high morbidity and mortality. However, sickle cell nephropathy natural course remains mostly unknown. We conducted a prospective observational cohort study aimed to identify risk factors for CKD stage II in a cohort of SCA patients. Baseline clinical and biological parameters were collected. Renal parameters were updated at each visit. Risk factors were analyzed using Cox model. 535 SCA patients were included with a median follow-up of 5.33 (IQR:2.10-8.13) years. Median age was 22 (IQR:19-30) years old. Glomerular hyperfiltration was detected in 299 (55.9%) patients, microalbuminuria and macroalbuminuria in 180 (34%) and 67 (12.7%) patients respectively. During follow up, CKD stage II onset was detected in 39 patients (7.3%). Risk factors for CKD stage II after adjustment on baseline eGFR and age were macroalbuminuria HR: 3.89 [95% CI: 1.61;9.43], diastolic blood pressure (DBP) above 70 mmHg HR: 2.02 [1.02-3.971], LDH (for 100 UI/L increase) HR: 1.28 [1.12;1.48] and tricuspid regurgitation velocity >2.5 m/sec HR: 2.89 [1.20- 6.99]. Multivariate analysis also found age as a strong independent risk factor with HR: (per year increase) 1.13 [1.09;1.16] and a 13.3 fold increase above 30 years (p

Approximately 20% of patients diagnosed with a phaeochromocytoma or paraganglioma carry a germline mutation in one of the succinate dehydrogenase (SDHx) genes (SDHA, SDHB, SDHC and SDHD), which encode the four subunits of the SDH enzyme. When a pathogenic SDHx mutation is identified in an affected patient, genetic counselling is proposed for first-degree relatives. Optimal initial evaluation and follow-up of people who are asymptomatic but might carry SDHx mutations have not yet been agreed. Thus, we established an international consensus algorithm of clinical, biochemical and imaging screening at diagnosis and during surveillance for both adults and children. An international panel of 29 experts from 12 countries was assembled, and the Delphi method was used to reach a consensus on 41 statements. This Consensus Statement covers a range of topics, including age of first genetic testing, appropriate biochemical and imaging tests for initial tumour screening and follow-up, screening for rare SDHx-related tumours and management of elderly people who have an SDHx mutation. This Consensus Statement focuses on the management of asymptomatic SDHx mutation carriers and provides clinicians with much-needed guidance. The standardization of practice will enable prospective studies in the near future.

This systematic review and meta-analysis aimed to determine whether tramadol intake increases the risk of bleeding in patients receiving oral anticoagulants.This systematic review was registered on PROSPERO, CRD42022327230. We searched PubMed and Embase up to 14 April 2022, and references and citations of included studies were screened. Comparative and non-comparative studies exploring bleeding complications among adult patients on oral anticoagulants and tramadol were included. Risk of bias was assessed using an adaptation of the Drug Interaction Probability Scale for case reports and case series and the Newcastle-Ottawa Scale for comparative studies. A meta-analysis was performed for the risk of serious bleeding (leading to hospitalisation or death) associated with tramadol in patients on vitamin K antagonists.A total of 17 studies were included: 1 case series, 12 case reports, 2 case-control studies and 2 cohort studies. Most of the studies described tramadol-vitamin K antagonists' concomitant use; one case-control study also assessed dabigatran and rivaroxaban; one case report involved dabigatran. Among case reports/series, a total of 33 patients had a bleeding complication while using tramadol and an oral anticoagulant. The 4 comparative studies reported an increased bleeding risk during tramadol and vitamin K antagonist intake which was statistically significant in one study; the pooled risk ratio of serious bleeding was 2.68 [95% CI: 1.45 to 4.96; p 0.001].This systematic review confirms an association between tramadol use and risk of bleeding in patients on vitamin K antagonists. Evidence is too limited to assess whether this risk extends to patients on direct oral anticoagulants, and further studies are needed.

Background The COVID-19 outbreak has dramatically impacted medical education, both bedside and academic teaching had to be adapted to comply with the reorganisation of care and social distancing measures. Objectives To overview the impact of the pandemic on medical education, including the pedagogical responses adopted and their assessment by medical students and residents. Material and methods This restricted systematic review was performed using Rayyan QCRI, to select observational or interventional articles and field experience reports assessing the impact of the COVID-19 pandemic on medical education for medical students and residents. Study design, study population, geographical origin, use of an educational tools (including softwares and social media), their type and assessment, were recorded. For studies evaluating a specific tool the Medical Education Research Study Quality Instrument (MERSQI) was used to assess study quality. Results The literature search identified 1480 references and 60 articles were selected. Most articles focused on residents (41/60; 69%), and half (30/60; 50%) involved surgical specialties. Online courses were the most frequently used pedagogical tool (52/60; 88%). Simulation tools were used more frequently in articles involving surgical specialties (15/29; 52%) compared with medical specialties (2/14; 12%) (p=0.01). Only four studies reported the assessment of pedagogical tools by medical students, their MERSQI scores ranged from 5.5/18 to 9.0/18. Conclusion Medical education was highly impacted by the COVID-19 pandemic particularly in surgical specialties. Online courses were the most frequently attempted solution to cope with social distancing constraints. Medical students' assessment of pedagogical tools was mostly positive, but the methodological quality of those studies was limited.

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.

Resume Introduction L’aval des urgences represente une part importante des hospitalisations dans les services de medecine interne. L’objectif de cette etude est de caracteriser les patients et l’organisation d’un echantillon de services de medecine interne metropolitains ayant cette activite. Materiel et methodes Entre le 29 juin et le 26 juillet 2015, les services du groupe SiFMI (situations frequentes en medecine interne) volontaires, ont recueilli prospectivement dans des e-questionnaires anonymises les caracteristiques de tous les patients admis via les urgences sur une periode de 7 jours consecutifs. Resultats Dix-huit services de medecine interne, totalisant 1100 lits et 33 530 sejours annuels, dont 56 % (25–95 %) d’aval des urgences ont inclus 365 patients en provenance des urgences. D’âge moyen de 68 ans, 54 % de femmes, 44 % des patients etaient polymediques avec un score de Charlson moyen egal a 2,6. Les principales causes d’hospitalisation a cette periode etaient infectieuses (29 %) et neurologiques (17 %). La duree moyenne de sejour etait egale a 9,2 (±8,2) jours. De taille et d’organisation variable, l’equipe medicale de ces 18 services etait constituee en valeur mediane de 4,5 [2,75–6,25] equivalents temps-plein seniors, dont 86 % internistes. Tous les services sauf un accueillaient des internes pour 60 % de medecine generale. Conclusion Cette etude met en evidence la variabilite des organisations et des pathologies prises en charge en aval des urgences dans les services de medecine interne. Ceci place la medecine interne comme une specialite avec une capacite de prise en charge integrative/globale des patients permettant d’offrir un vaste champ d’apprentissage aux medecins en formation.

Resume Contexte Les referentiels des societes savantes de medecine et des colleges des enseignants des specialites medicales sont utilises comme des references officielles pour les examens facultaires et les epreuves nationales. L’oncologie est une discipline transdisciplinaire, pratiquee et enseignees par les oncologues mais egalement des specialistes d’organe. Ce travail avait pour objectif d’identifier les discordances entre les chapitres traitant du cancer dans les referentiels des colleges d’enseignants en medecine et d’en evaluer l’impact chez les etudiants. Materiel et methodes Les discordances entre les chapitres traitant du cancer dans les referentiels des colleges d’enseignants en medecine ont ete recensees par des etudiants, volontaires, en sixieme annee a la faculte de medecine Sorbonne universite. Il leur etait egalement demande d’evaluer, de maniere individuelle, l’impact de ces discordances sur leur apprentissage. Resultats En mars 2017, les 17 items de cancerologie du programme officiel du deuxieme cycle des etudes medicales etaient traites dans 14 referentiels de colleges d’enseignants en medecine (deux a quatre referentiels par localisation tumorale). Soixante-dix-huit des 390 etudiants de sixieme annee se sont portes volontaires et ont travaille en binomes. Chaque localisation etait analysee par trois binomes (un a deux cancers par binome). Cent cinquante-quatre discordances ont ete relevees (quatre a dix-huit par cancer). L’ensemble des etudiants declarait que l’existence de ces discordances etait source de doute et d’anxiete. Quatre-vingt-cinq pour cent d’entre eux consideraient qu’une harmonisation des referentiels devrait etre recherchee dans l’ensemble des domaines du programme des etudes medicales. Conclusions Les discordances entre referentiels des colleges d’enseignants sont frequentes, generant une anxiete chez les etudiants avec un impact ressenti sur leur apprentissage.

BACKGROUND: There are two approaches to intensify antihypertensive treatment when target blood pressure is not reached: adding a new medication or maximizing dose. It is not known which strategy is better. OBJECTIVE: To assess the frequency of intensification by new medication vs. maximizing dose, and their association with intensification sustainability and follow-up systolic (SBP). DESIGN: Large-scale, population-based, retrospective cohort study. Observational data used to emulate a target trial with two arms: new medication vs. maximizing dose. SETTING: Veterans Health Administration (2011–2013). PATIENTS: Veterans ≥65 years with hypertension, SBP ≥130 mmHg and ≥1 antihypertensive medication at less than maximum dose. MEASUREMENTS: We emulated two intensification approaches: adding a new medication, defined as total dose increase with new medication, and maximizing dose, defined as total dose increase without new medication. We used inverse probability of weighting to assess the observational effectiveness of the intensification approach on sustainability of intensified treatment and follow-up SBP at 3 and 12 months. RESULTS: Among 178,562 patients, 45,575 (25.5%) had intensification by new medication and 132,987 (74.5%) by maximizing dose. Compared to maximizing dose, adding a new medication was associated with less intensification sustainability (average treatment effect [ATE] −15.2%, 95%CI −15.7 to −14.6% at 3 months, and −15.1%, 95%CI −15.6 to −14.5% at 12 months), but with a slightly larger reduction in mean SBP (−0.8 mmHg, 95%CI −1.2 to −0.4 at 3 months, and −1.1 mmHg, 95%CI −1.6 to −0.6 mmHg at 12 months). LIMITATIONS: Observational data, male population. CONCLUSION: Adding a new antihypertensive medication was less frequent and associated with less intensification sustainability but a slightly larger reduction in SBP. Trials would provide the most definitive support to our findings. PRIMARY FUNDING SOURCE: National Institute on Aging and the Veterans Health Administration.

Concomitant nonsteroidal anti-inflammatory drug (NSAIDs) and antithrombotic drug use is associated with an increased risk of bleeding, mainly gastrointestinal. The goal of this study was to quantify the transient increase in the risk of hospitalization for bleeding associated with NSAID use in patients treated with antiplatelet agents or anticoagulants. We performed an unidirectional case-crossover study using the EGB (Echantillon generaliste de beneficiaires), a permanent random sample of the French nationwide health database. Patients receiving antithrombotic therapy and hospitalized for bleeding between 2009 and 2017 were included. We compared their NSAID exposure during a 15-day hazard window immediately prior to hospital admission to three earlier 15-day control windows. The risk of hospitalization for bleeding associated with the recent use of NSAIDs was estimated using conditional logistic regression to estimate odds ratios. During the study period, 33 patients treated with anticoagulants and 253 treated with antiplatelet agents received NSAIDs and were included in the case-crossover analysis. We found an increased risk of hospitalization for gastrointestinal bleeding after exposure to NSAIDs with an adjusted OR of 3.59 (95%CI, 1.58;8.17) in patients receiving anticoagulant therapy and 1.44 (95%CI, 1.07;1.94) in patients receiving antiplatelet therapy. The risk of non-gastrointestinal bleeding was also increased after exposure to NSAIDs with an adjusted OR of 2.72 (95%CI, 1.23;6.04) in patients exposed to anticoagulant therapy. The risk of gastrointestinal and non-gastrointestinal bleeding increases after NSAID use in patients treated with anticoagulants, while the risk of gastrointestinal bleeding increases, but to a lesser extent in those treated with antiplatelets. This article is protected by copyright. All rights reserved.

Glomerular hyperfiltration alone or associated with albuminuria is a well-known feature of sickle cell associated nephropathy. Though, glomerular hyperfiltration is currently considered to be related to a high renal plasma flow and chronic hemolysis, cardiac output influence on measured glomerular filtration rate (mGFR) have not been investigated so far. Thirty seven homozygous sickle cell patients (SCA) from the RAND study investigated before and under angiotensin converting enzyme inhibitor (ACEI) were included. Both mGFR and cardiac index (CI) were high (> 110 ml/min/1.73 m2 and > 3.5 l/m2 in 81% and 97% of cases) with low systemic vascular resistance (SVR) (−5) in 38% of cases. mGFR association with CI and SVR were significant at baseline (respectively ρ: 0.44, p = 0.008 and ρ: − 0.37, p = 0.02) and under ACEI (p = 0.007 and 0.01 respectively), in accordance with previous data showing that hyperfiltration was linked to an increased glomerular perfusion and a glomerulomegaly rather than increased capillary hydrostatic pressure. Of notice, after adjustment on CI, mGFR remained associated with reticulocyte count and albuminuria under ACEI (p = 0.006 and 0.02 respectively). Our results suggest that hyperfiltration is tightly linked to an increased cardiac output which may account for an increased renal blood flow. Chronic hemolysis could be a relevant factor accounting for hyperfiltration potentially acting on glomerular enlargement which appears as a key factor. Our data suggest that cardiac output assessment is a relevant tool in the routine management and monitoring of SCA nephropathy.

STUDY DESIGN Prospective study. OBJECTIVE Determine risk factors and consider impact of low back pain for medical students. SUMMARY OF BACKGROUND DATA Low back pain (LBP) is one of the most prevalent complaints among students. The vulnerability of medical students due to stress and numerous hours of studying and training makes them at risk of LBP. METHODS We submitted an online self-administered modified version of the Standardized Nordic Questionnaire to 1800 medical students from 2nd to 6th year from December 2017 to March 2018. RESULTS A total of 1243/1800 (68.9%) students responded to our survey. Mean age was 23.3 ± 2.9 years ranging from 18 to 44 years. 835 (72.1%) students reported suffering from LBP. In multivariate analysis with logistic regression analysis model, the third year of medical studies (odds ratio [OR]: 0.558, 95% confidence interval [CI] 0.387-0.805; P = 0.002) was identified as an independent prognostic factor of LBP. Moreover, exercising weekly (OR: 1.835, 95% CI 0.933-2.5; P = 0.01) and walking at least 30 minutes a day (OR: 1.458, 95% CI 1.129-1.876; P = 0.01) significantly improve LBP. LBP generate higher monthly consumption of an analgesic (OR: 32.8, 95% CI 4.271-252.2; P

Resume Introduction Des outils d’evaluation des competences professionnelles des internes par observation directe sur le lieu d’exercice sont valides mais leur appropriation reste anecdotique en France. L’objectif de cette etude etait d’evaluer la reproductibilite et la validite d’un carnet d’observation comprenant plusieurs grilles evaluant differentes composantes de la competence professionnelle. Methode Trois grilles ont ete testees, au cours d’une etude multicentrique sur 6 mois impliquant 12 services de medecine interne francais : une grille d’observation de l’examen clinique (mini-EC), une grille d’observation des competences relationnelles (OD_CR) et une grille d’evaluation des competences generiques (E_360), remplie par tous les collaborateurs de l’interne. La reproductibilite a ete evaluee par le coefficient de correlation intraclasse (CCI) et par le coefficient alpha de Cronbach. La validite a ete appreciee par la capacite a detecter une amelioration des competences dans le temps et avec l’anciennete de l’interne. Resultats Vingt-cinq internes ont ete inclus. Le coefficient alpha de Cronbach etait a 0,90 (n = 70) pour la grille mini-EC, 0,89 pour la grille OD_CR (n = 62) et a 0,77 pour la grille E_360 (n = 86). Les CCI etaient tres variables selon les items pour les deux grilles mini-EC et OD_CR, en partie en raison du faible nombre d’observations realisees par interne. Ces grilles ont detecte une progression des internes pour la plupart des items entre M1 et M6. Les scores de la grille E_360 etaient eleves, a 7,3 ± 0,8 a 8,3 ± 2,4 (score maximum 9) et ne variaient que tres peu pas avec l’anciennete de l’interne. Conclusion Garantir la reproductibilite de l’evaluation des competences avec ces grilles ne parait pas faisable en l’etat actuel de nos moyens sur nos lieux d’exercice. En revanche, ces grilles pourraient etre integrees au portfolio des internes comme supports des debriefings, afin de documenter les progres realises au cours de leur formation.

Introduction La maladie à coronavirus 2019 (Covid-19) a entraîné un nombre sans précédent d’hospitalisation non programmées, occasionnant une forte pression sur le système de santé. Les scores pronostiques sont scusceptibles d’aider à rationaliser la prise en charge des patients (sortie rapide ou au contraire transfert en soins continus, par exemple), mais la plupart d’entre eux n’ont pas été correctement validés. Notre objectif était la validation externe des scores pronostiques pour Covid-19 publiés et calculables à partir des données recueillies en soins courants. Patients et méthodes Nous avons utilisé “Covid-19 Evidence Alerts” (McMaster University) pour récupérer des scores pronostiques de haute qualité méthodologique prédisant le décès ou le transfert en unité de soins intensifs (USI). Nous avons étudié leur performance dans une cohorte rétrospective multicentrique de patients adultes hospitalisés pour Covid-19 de janvier 2020 à avril 2021 dans notre institution. Les aires sous les courbes ROC (AUC) ont été calculées pour la prédiction du critère de jugement de l’étude princeps, de la mortalité hospitalière à 30 jours et du composite de la mortalité hospitalière ou du transfert en USI à 30 jours. Des analyses en sous-groupe ont été faites en fonction de la vague épidémique et de la catégorie d’âge des patients. Résultats Nous avons inclus 14 343 patients consécutifs hospitalisés pour Covid-19, dont 43 % durant la première vague épidémique. Leur âge moyen était de 68 ans, 43 % étaient des femmes, 2583 (18 %) sont décédés en hospitalisation avant le 30e jour et 5 067 (35 %) sont décédés ou ont été transférés en USI avant le 30e jour. Nous avons examiné 274 scores parmi lesquels 32 répondaient aux critères d’inclusion. Ils utilisaient de façon variable des données démographiques (sexe, âge), cliniques (comorbidités, signes vitaux à l’admission..), biologiques et radiologiques. Les performances observées dans notre cohortes étaient les suivantes : – 19 avaient une AUC significativement plus faible dans notre cohorte que dans les études de validation précédemment publiées pour leur critère de jugement princeps ; – 25 étaient plus performants pour prédire la mortalité hospitalière que le critère composite de la mortalité hospitalière ou du transfert en USI ; – 7 avaient une AUC > 0,75 pour prédire la mortalité hospitalière ; – 2 avaient une AUC > 0,70 pour prédire le critère composite. Parmi les 7 scores avec une AUC > 0,75 pour prédire la mortalité hospitalière, la performance était similaire durant la première vague et les vagues suivantes, mais deux d’entre eux étaient moins performants chez les patients de plus de 65 ans. Malgré leur bonne capacité à identifier les patients les plus graves (AUC), les scores avaient une tendance générale à surestimer la probabilité de décès, surtout après la première vague épidémique.Les variables ayant le plus de poids dans la prédiction étaient l’âge pour 5 scores, l’élévation de la troponine pour un score et un débit de filtration glomérulaire abaissé pour un score. Conclusion Sept scores pronostiques prédisent avec fiabilité le décès des patients hospitalisés pour Covid-19. Le 4 C Mortality Score et l’ABCS se distinguent car ils ont les meilleurs performances, similaires à celles de leur cohorte de validation initiale, et dans notre cohorte d’aussi bon résultats pendant la première vague épidémique et pendant les vagues suivantes, chez les patients e plus ou de moins de 65 ans. Leur intérêt à guider la prise en charge des patients et à rationaliser l’utilisation des ressources médicales demande à être évaluée. En tout état de cause, une révision de leurs coefficients ou des valeurs seuil utilisées pour indiquer un risque élevé sera nécessaire, car le pronostic des patients hospitalisés pour Covid-19 est désormais meilleur qu’à l’époque de leur dérivation.

Introduction Les troubles cognitifs sont frequents et sous-diagnostiques chez les patients drepanocytaires, faisant perdre l’opportunite d’une prise en charge specifique (recherche de complications neurovasculaires, remediation cognitive, adaptations scolaires et professionnelles…). Nos objectifs etaient de decrire le resultat d’un test de depistage cognitif, le Montreal Cognitive Assessment (MoCA), chez des adultes suivis en France et d’etudier l’association entre les scores bas et les caracteristiques des patients ou de leur maladie. Patients et methodes Nous avons mene une etude transversale monocentrique dans un centre de la drepanocytose. Un MoCA a ete realise chez des adultes drepanocytaires consecutifs en consultation ou en hopital de jour sur une periode de 10 semaines. Pour se placer en situation de depistage, les patients souffrant de troubles cognitifs patents de cause psychiatrique ou neurologique etaient exclus. Le score a ete calcule par un neurologue et, corrige pour le niveau d’etude (+ 1 si Resultats 96 adultes drepanocytaires ont ete inclus dont 55 femmes (57 %), 64 de genotype SS ou Sβ0 (67 %) et 32 SC ou Sβ+ (33 %), l’âge moyen etait de 37 ans, 27 (28 %) avaient etudie moins de 12 ans et 50 (52 %) etaient nes hors de France ( Tableau 1 ). Le temps median de passation du test etait de 12 minutes. Le score corrige etait Tableau 1 ) : l’âge plus avance, une duree d’etudes Discussion Sans surprise, un âge plus avance est associe a un risque plus eleve d’avoir un score du MoCA bas. Les patients de genotype SC/Sβ+ en programme de saignees, indique par un phenotype d’hyperviscosite, ont un risque plus eleve d’avoir un score bas que ceux qui ne sont pas en programme de saignees et similaire aux patients SS/Sβ0. Une scolarite courte est predictive de troubles cognitifs chez les patients nes et scolarises en France, alors qu’une scolarite courte chez les patients nes en Afrique est plus souvent la consequence de conditions socio-economiques defavorables et n’a pas la meme valeur predictive. Conclusion Le MoCA est realisable chez les adultes drepanocytaires au cours de leur suivi de routine. Le score est bas chez un grand pourcentage de ces patients representatif des adultes drepanocytaire suivi en France metropolitaine. Nous prevoyons une etude pour valider la valeur predictive positive des scores bas du MoCA avec comme reference une evaluation neurocognitive complete.

Objective To assess psychosocial risk factors for increased emergency hospital utilization by sickle cell patients. Introduction Emergency hospital utilization by sickle cell disease patients is high but heterogeneous between patients and in a given patient over time. Psychosocial factors affect emergency hospital utilization and are a possible target to improve the management of sickle cell disease. Inclusion criteria This review will include all original quantitative studies evaluating the impact of psychosocial risk factors on emergency hospital utilization by sickle cell disease patients. There will be no language restriction. Methods PubMed, Embase, CINAHL, PubPsych, LiSSa, and Web of Science will be searched using a peer-reviewed search strategy. Study selection and extraction of data will be performed independently by two authors. Discrepancies will be solved by consensus or, if needed, by a third author. The authors will assess study quality, as well as perform a narrative synthesis of included studies, and where possible, meta-analyses with evaluation of heterogeneity and publication bias. Systematic review registration number PROSPERO CRD42019140435.

Low plasma sodium concentration has been recognized as a prognostic factor in several disorders but never evaluated in sickle cell disease. The present study evaluates its value at admission to predict a complication in adult patients with sickle cell disease hospitalized for an initially uncomplicated acute painful episode.The primary outcome of this retrospective study, performed between 2010 and 2015 in a French referral center for sickle cell disease, was a composite criterion including acute chest syndrome, intensive care unit transfer, red blood cell transfusion or inpatient death. Analyses were adjusted for age, sex, hemoglobin genotype and concentration, lactate dehydrogenase (LDH) concentration, and white blood cell count.We included 1218 stays (406 patients). No inpatient death occurred during the study period. Hyponatremia (plasma sodium ≤135 mmol/L) at admission in the center was associated with the primary outcome (adjusted odds ratio [OR] 1.95, 95% confidence interval [CI] 1.3-2.91, P = 0.001), with acute chest syndrome (OR 1.95 [95% CI 1.2-3.17, P = 0.008]), and red blood cell transfusion (OR 2.71 [95% CI 1.58-4.65, P0.001]) but not significantly with intensive care unit transfer (OR 1.83 [95% CI 0.94-3.79, P = 0.074]). Adjusted mean length of stay was longer by 1.1 days (95% CI 0.5-1.6, P0.001) in patients with hyponatremia at admission.Hyponatremia at admission in the medical department for an acute painful episode is a strong and independent prognostic factor of unfavorable outcome and, notably, acute chest syndrome. It could help targeting patients who may benefit from closer monitoring.

International audience

International audience; Purpose: Drug-drug interactions (DDIs) require monitoring in an aging population with increasing polypharmacy exposure. We aimed to estimate the prevalence of exposure to potential DDIs using the French healthcare insurance system database, for six DDIs with various clinical relevance: angiotensin II receptor blockers or angiotensin-converting enzyme inhibitors and nonsteroidal anti-inflammatory drugs (ARBs-ACEIs + NSAIDs), antiplatelet agents and NSAIDs (AAP + NSAIDs), serotonergic drugs and tramadol (SD + T), statins and macrolides (S + M), oral anticoagulant and NSAIDs (OAC + NSAIDs), and colchicine and macrolides (C + M).Methods: We used exhaustive healthcare data from a 1/97th random sample of the population covered by the French health insurance system (EGB) between 2006 and 2016. Exposure to a DDI was defined as overlapping exposure to two interacting drugs. The prevalence of exposure was estimated by year.Results: Prevalence of exposure in 2016 was estimated at 3.7% for ARBs-ACEIs + NSAIDs, 1.5% for AAP + NSAIDs, 0.76% for SD + T, 0.36% for S + M, 0.24% for AOC + NSAIDs, and 0.02% for C + M. In 26% to 58% of episodes of exposure, the two interacting drugs were prescribed by the same physician and dispensed by the same pharmacy the same day. Between 2006 and 2016, the yearly prevalence was increasing for SD + T and for DDIs involving NSAIDs, and it was decreasing for those involving macrolides.Conclusion: Exposures to potential DDIs in France are not uncommon with a high proportion resulting from a co-prescription by the same physician. Monitoring the prevalence of exposure to DDIs is needed to implement prevention measures. Administrative data enable this surveillance in large and representative cohorts.

International audience

Resume Introduction Les patients atteints de troubles psychiatriques souffrent de problemes somatiques nombreux et souvent mal pris en charge. Cette etude vise a etablir le profil des patients avec comorbidites psychiatriques hospitalises en medecine interne depuis les urgences et a comparer leurs durees de sejour avec celles des patients sans comorbidite psychiatrique. Methodes Cette etude observationnelle retrospective sur donnees de soins collectees dans l’Entrepot de Donnees de Sante de l’Assistance publique–Hopitaux de Paris a inclus les patients hospitalises apres passage aux urgences, au cours de l’annee 2017, dans 9 services de medecine interne. L’existence d’une comorbidite psychiatrique et le poids des comorbidites somatiques (score de Charlson) etaient determines par le codage diagnostique. Le score de Charlson et la duree moyenne de sejour etaient compares entre les patients avec et sans comorbidites psychiatriques. Resultats Au total, 8981 sejours etaient inclus (8001 patients), dont 1867 (21 %) avec comorbidite psychiatrique. Apres ajustement sur l’âge, le sexe, le service et le diagnostic principal, le score de Charlson moyen etait superieur de 0,68 chez les patients avec comorbidites psychiatriques (p Conclusion Les patients avec comorbidites psychiatriques sont nombreux en hospitalisation d’aval des urgences. Ils ont des durees de sejour plus longues, incompletement expliquees par des comorbidites somatiques plus lourdes. Une attention particuliere doit etre portee a cette population vulnerable.

International audience; Background: Hy-Result is a validated system designed to help patients complying with the home blood pressure monitoring (HBPM) protocol and understanding their blood pressure (BP) readings. It is available as a standalone web application or within a wireless BP monitor app. Objective: The aim of the study was to explore patients' experience with Hy-Result. Methods: Online survey completed by 512 users of the Hy-Result web application or monitor app, and three focus groups with 24 hypertensive patients who monitor their BP at home and use the Hy-Result web application to record their data. We assessed the experience of patients with the functionalities and medical content of Hy-Result, their feelings and expectations, and the impact of Hy-Result on the physician-patient relationship. Results: (1) Functionalities: Over 90% of survey respondents and all focus group participants found Hy-Result easy to use. The main drawback of the web application is the need to manually enter all BP values at once. (2) Medical content: Hy-Result offers information on arterial hypertension and HBPM that most patients found useful. Users found that Hy-Result triggers appropriate reactions to BP readings, including adequately timed general practitioner visits. (3) Feelings and expectations: Over 90% of survey respondents trust Hy-Result and focus group participants understood that text messages are suggestions, not diagnoses. Hy-Result did not cause anxiety or excessive BP measurements. (4) Physician-patient relationship: Three-quarter of survey respondents agreed that Hy-Result may help when talking with their doctor about their BP values but only one-third of those have shown the report to their physician. For focus group participants, using Hy-Result should ideally be a physician prescription. They were aware that Hy-Result does not replace clinical judgment and that physicians still have a decisive role in BP management. Conclusion: Most of the users described Hy-Result as an easy-to-use and useful tool. Patients are willing to use it on physician request.

International audience; Objective: Several guidelines call for blood pressure (BP) measurement on a bare arm, which is not always easy. This systematic review aims to synthesize existing evidence concerning the effect of a sleeve on BP measurement.Methods: Pubmed and Embase were searched for cross-sectional studies comparing BP values measured on a bare arm, over a sleeve or below a rolled-up sleeve. A meta-analysis was conducted on available data.Results: Thirteen articles were selected from 720 references. All studies reported office BP values, 12 compared measurements on a bare arm and on a sleeve, and four also performed measurements below a rolled-up sleeve, with heterogeneous sleeve types and thicknesses. Most studies had a high risk of bias. Three studies showed a small overestimation of BP measured over a sleeve, but the remaining 10 studies did not find statistically significant differences between measurements. Meta-analysis showed a nonsignificant 0.59 mmHg [95% confidence interval (CI) -0.11 to +1.30; P = 0.10] overestimation of SBP measured over a sleeve when the thinnest sleeve was considered for studies that investigated various thicknesses, a nonsignificant 1.10 mmHg (95% CI -0.21 to +2.40; P = 0.10) overestimation of SBP when the thickest sleeve was considered, and a nonsignificant 2.76 mmHg (95% CI -0.96 to +6.47; P = 0.15) overestimation of SBP measured below a rolled-up sleeve.Conclusion: Measuring BP over a thick sleeve in the office may result in a small overestimation of recorded values but measuring over a thin sleeve does not appear to have a significant impact and, in any case, should be preferred to rolling it up.

Objectives This work aimed to study the prevalence and risk factors associated with well-being and career satisfaction among French internal medicine physicians and residents. Methods A total of 1689 French internal medicine physicians or trainees were surveyed to evaluate their workload, well-being and career satisfaction during February 2018. Results The response rate was 620/1689 (37%). The mean age of the participants was 37 years (±12); 49% of the participants were female, 27% worked in the Paris area, 74% worked in a university hospital and 49% were residents. Sixty-six per cent of the responders were satisfied with their work, and 66% would choose the internal medicine specialty again. However, 71% of the responders worked more than 50 hours a week, 21% worked more than 60 hours a week and 70% believed that they did not have enough time for personal/family activities. Twenty-five per cent of the responders had at least one sign of burnout (19% of the physicians in practice and 32% of the residents). Compared with the graduate physicians in practice, the residents worked more hours a week, had more activities at night, spent more time on administrative tasks, had a worse global appreciation of their work and felt that their work was less meaningful. In multivariate analysis, the factors associated with global satisfaction at work were autonomy and meaningful work. Conclusions French internal medicine physicians have a high rate of career satisfaction. However, residents have a higher workload, less time for personal/family activities and feel that their work is less meaningful.

An increased risk of acute bacterial enteric infections has been reported among patients receiving proton pump inhibitor (PPI) therapy. The risk of acute gastroenteritis (AGE) of viral origin associated with continuous PPI exposure has been less studied.To investigate the association between continuous PPI therapy and AGE occurrence during winter epidemic periods when the circulation of enteric viruses is the highest.A matched cohort study was performed using a prospectively collected drug dispensing database from a large panel of community pharmacies in continental France. All patients recorded in the database during the 2015 to 2016 winter season, with documented age, sex, and use of an identifiable regular panel pharmacy, were eligible for the study. Each patient exposed to continuous PPI therapy was matched to 3 unexposed patients, according to year of birth, sex, and identifiable regular panel pharmacy. Analyses were performed between January 2017 and December 2018.Continuous PPI use during the 2015 to 2016 AGE winter epidemic.The occurrence of at least 1 AGE episode during the 2015 to 2016 AGE winter epidemic was the main outcome. Episodes of AGE were identified using a previously validated algorithm based on drug dispensing data. Relative risks of AGE were estimated using a multivariable log-binomial model adjusted for age, sex, and treatments for chronic conditions.There were 233 596 patients receiving PPI therapy (median [interquartile range] age, 71 [62-81] years; 55.8% female) and 626 887 matched patients not receiving PPI therapy (median [interquartile range] age, 70 [61-80] years; 56.3% female) included in the analyses. At least 1 AGE epidemic episode was identified in 3131 patients (1.3%) receiving PPI therapy and in 4327 patients (0.7%) not receiving PPI therapy. The adjusted relative risk of AGE for those receiving PPI therapy was 1.81 (95% CI, 1.72-1.90) for all ages considered, 1.66 (95% CI, 1.54-1.80) among those aged 45 to 64 years, 2.19 (95% CI, 1.98-2.42) among those aged 65 to 74 years, and 1.98 (95% CI, 1.82-2.15) among those aged 75 years and older.Continuous PPI therapy was associated with an increased risk of developing AGE during periods of highest circulation of enteric viruses. These findings support the hypothesis that PPI use is associated with an increased risk of enteric viral infections.

Resume Contexte La reforme du troisieme cycle des etudes medicales se veut centree sur l’acquisition de competences. En medecine interne, une evaluation des connaissances theoriques par e-learning et des connaissances pratiques par un e-carnet de stage sont en cours de creation. Parallelement, une reflexion se met en place sur des grilles d’evaluation des competences cliniques. Dans ce cadre, nous avons voulu evaluer la reproductibilite et la validite de deux grilles d’evaluation par observation directe. Methode Une etude multicentrique et prospective a ete menee de novembre 2015 a octobre 2016 pour evaluer les traductions francaises du MINI-Clinical Examination Exercice (MINI-CEX) et du Standardized Patient Satisfaction Questionnaire (SPSQ). La passation etait realisee 2 fois au cours du semestre, par le meme binome d’observateur pour chaque interne. Resultats Dix-neuf internes ont ete inclus. La reproductibilite inter-juge etait satisfaisante pour le MINI-CEX : coefficients de correlation intraclasse (CCI) entre 0,4 et 0,8 et moyenne pour le SPSQ : CCI entre 0,2 et 0,7 avec une bonne coherence interne pour les deux grilles (Cronbach entre 0,92 et 0,94). Des differences significatives entre les distributions des scores donnes par les deux observateurs ont ete constatees ainsi qu’une variabilite importante des scores selon le centre. Conclusion La valeur absolue des scores, trop variable, ne doit pas etre prise en compte dans l’evaluation mais peut avoir un interet pour le suivi de la progression des competences. Ces grilles pourraient servir de support pour le debriefing en s’appuyant sur les tendances generales donnees par les scores.

Introduction Sickle cell disease is the most frequent genetic hemoglobinopathy worldwide and early childhood mortality has dramatically decreased in high-income countries. However, in the aging sickle cell disease population, the morbidity related to chronic organ damage, especially kidney and heart, has become a major concern. The disease is well characterized in homozygous SS patients, but the complications associated with Haemoglobin SC disease (HbSC) are mostly unknown. Dyspnea is frequent in SS patients and associated with poor quality of life, this symptom was not investigated in HbSC patients. Our objective is to investigate the prevalence and the factors associated with dyspnea in HbSC patients. Method A total of 221 HbSC patients (mean age 35 years, 47% men) were prospectively investigated. Clinical and biological data were collected, and 109 (49%) patients underwent an echocardiography. Results A dyspnea was observed in 28 (13%) patients. Compared to the rest of the cohort, these patients were older and had a lower hemoglobin level (P Fig. 1 ). Conclusion Dyspnea is relatively uncommon in adult HbSC patients and related to age and hemoglobin level. Cardiac involvement seems not to be a major factor associated to dyspnea in HbSC patients.

Introduction La drepanocytose entraine la synthese d’une hemoglobine defectueuse (HbS) responsable d’une anemie hemolytique chronique. L’experience clinique suggere que les patients drepanocytaires ont a l’etat stable une concentration d’hemoglobine qui leur est propre, dite hemoglobine de base. Toutefois, peu de donnees existent sur la variabilite inter-individuelle et intra-individuelle de l’hemoglobine pour en quantifier les limites de variation attendues a l’etat stable. Patients et methodes Il s’agit d’une etude retrospective monocentrique menee dans un centre expert. Les patients drepanocytaires ayant au moins deux consultations avec biologie a l’etat stable entre septembre 2013 et juin 2019 ont ete inclus. Les consultations dans les 15 jours suivant une hospitalisation ou une visite aux urgences ont ete exclues (episodes douloureux aigus), ainsi que dans les 120 jours suivant une hospitalisation de jour (transfusion ou echange transfusionnel). Apres elimination des patients avec des valeurs aberrantes d’hemoglobine par rapport a leur propre distribution ou de la distribution de leur groupe, nous avons utilise de modeles a effets mixtes pour calculer les valeurs moyennes de l’hemoglobine, les coefficients de variation (CV = ecart-type/moyenne) intra-individuels (CVt) et les CV inter-individuel (CVg), en stratifiant les analyses selon le genotype de l’hemoglobine et le sexe. A titre d’illustration, nous donnons l’amplitude de variation attendue de la concentration d’hemoglobine a l’etat stable (intervalle de pari a 95 %, IP 95 %) pour un ou une patiente typique dont la concentration d’hemoglobine individuelle moyenne serait celle de son sous-groupe. Resultats Nous avons inclus 711 patients avec des donnees analysables repartis en deux groupes selon leur genotype : groupe SS (SS = 533, Sbeta0 = 14) et groupe SC (SC = 140, Sbeta + =24). Leurs caracteristiques sont reportees dans le Tableau 1 sous forme de nombres et pourcentages, medianes et quartiles. Les donnees de 49 patients ont ete exclues des analyses de variabilite en raison de valeurs d’hemoglobine aberrantes. Les moyennes de concentration d’hemoglobine etaient differentes dans chacun des sous-groupes definis par le genotype et le sexe (p Tableau 2 . Discussion Le CV intra-individuel moyen de l’hemoglobine est de l’ordre de 8 a 9 % chez les patients drepanocytaires a l’etat stable, quel que soit leur sexe et leur genotype. En general, le CV intra-individuel d’une variable biologique est d’autant plus grand que sa demi-vie est plus courte. Cela explique que le CV intra-individuel de l’hemoglobine soit nettement plus important chez les patients drepanocytaires que dans la population generale : l’equilibre intra-individuel de la concentration de l’hemoglobine est instable meme a l’etat stable, soumis aux fluctuations d’intensite de l’hemolyse et d’efficacite de la regeneration. Conclusion Il ne faudrait plus parler d’hemoglobine de base chez les patients drepanocytaires a l’etat stable, mais d’intervalle de base de l’hemoglobine, ayant typiquement une largeur de 3 g/dL autour de la moyenne individuelle. La difference critique correspondante (reference change value) est de l’ordre de 2 g/dL. Autrement dit, une variation de l’hemoglobine jusqu’a 2 g/dL entre deux mesures consecutives chez un meme individu est compatible avec l’etat stable et doit etre controlee avant de declencher une discussion etiologique.

Introduction La reaction paradoxale (RP) tuberculeuse est un phenomene immunologique qui consiste en l’aggravation de lesions tuberculeuses ou l’apparition de nouvelles lesions d’allure tuberculeuse, survenant au cours ou au decours d’un traitement antituberculeux bien conduit. Chez le patient infecte par le VIH, elle est secondaire a la restauration immunitaire survenant lors de l’introduction du traitement antiretroviral. Une RP peut egalement survenir chez un patient immunocompetent, notamment au cours d’une tuberculose extrapulmonaire, bien que ses mecanismes ne soient pas completement elucides dans cette population. Les objectifs de cette etude sont d’estimer l’incidence des RP au cours du traitement de la tuberculose extrapulmonaire chez les patients immunocompetents et d’en identifier les facteurs de risque. Patients et methodes Il s’agit d’une etude prospective conduite entre mars 2011 et fevrier 2017, dans 17 centres hospitaliers de region parisienne. Les criteres d’inclusion etaient : une tuberculose confirmee (anatomopathologie et/ou microbiologie) avec au moins une localisation extrapulmonaire chez un sujet majeur. Les criteres d’exclusion etaient : presence d’une immunodepression, indication a une corticotherapie d’emblee (notamment tuberculose du systeme nerveux central), tuberculose multiresistante, suivi prevu inferieur a 6 mois. Les patients inclus ont beneficie d’une evaluation clinique, biologique et d’un scanner thoraco-abdominal a l’inclusion, a deux mois et a la fin du traitement, ainsi qu’en cas de RP. Un bilan biologique etait egalement realise a dix jours, associe a un examen clinique a un mois et trois mois de traitement. Le diagnostic de RP etait confirme par un comite d’adjudication et classe comme certain ou probable (si un diagnostic alternatif etait moins probable mais non elimine). Des facteurs de risque de RP (certaine ou probable) ont ete cherches par regression logistique parmi les caracteristiques cliniques et biologiques des patients a l’inclusion ou a 10 jours de traitement. Resultats Parmi les 135 patients inclus, 17 patients ont ete exclus pour suivi inferieur a 3 mois, et 2 ont ete exclus pour diagnostic de tuberculose non confirme. Parmi les 116 patients analyses, 65 (56 %) avaient au moins deux localisations tuberculeuses, 83 (72 %) avaient au moins une localisation ganglionnaire, 18 (16 %) avaient une atteinte sereuse, 8 (7 %) avaient une atteinte osteoarticulaire. Vingt-quatre patients (20,7 %) ont developpe une RP certaine et 4 (3,5 %) une RP probable. Le delai median de survenue de RP etait de 57 jours (extremes : 12–356 jours). Huit patients ont eu une RP radiologique sans manifestation clinique. Chez 22 patients (78,6 %), des lesions preexistantes se sont aggravees et chez 13 patients (46,4 %), de nouvelles lesions sont apparues : nouvelles localisations ganglionnaires chez 7 patients (55 %), apparition d’abces visceraux ou musculaires chez 4 patients (31 %) et apparition d’epanchement sereux chez 3 patients (23 %). L’evolution a ete favorable pour la totalite des patients. L’extension de la maladie tuberculeuse initiale (nombre de localisations superieur ou egal a 2) et l’origine asiatique etaient independamment associees a la survenue d’une RP (respectivement OR 4,1 [IC95 1,5 ; 10,9], et OR 3,94 [IC95 1,28 ; 12,2]). Sur le plan biologique, une numeration lymphocytaire initiale inferieure a 1000/mm3 et une augmentation de plus de 20 % des lymphocytes entre le debut et j10 de traitement etaient associees a la survenue d’une RP (respectivement OR 4,1 [IC95 1,5 ; 10,9] et OR 3,0 [IC95 1,1 ; 8,3]), ainsi qu’une numeration monocytaire initiale inferieure a 450/mm3 (OR 3,4 [IC95 1,31 ; 8,9]). Conclusion Une RP clinique et/ou radiologique survient chez environ un quart des patients immunocompetents traites pour une tuberculose extrapulmonaire (hors systeme nerveux central). Il s’agit, dans cette population, d’un phenomene generalement sans gravite ne necessitant aucun traitement. Les facteurs de risques de RP que nous avons mis en evidence sont une maladie tuberculeuse plus etendue, l’origine asiatique, une lymphopenie initiale et l’ascension rapide des lymphocytes durant les 10 premiers jours de traitement. Ces resultats sont coherents avec ceux decrits chez les patients infectes par le VIH, chez qui la profondeur de l’immunodepression initiale et la restauration rapide et precoce du taux de lymphocytes CD4 sont predictifs de la survenue de RP.

International audience; Objectif : Déterminer si la progression au sein des carrières hospitalo-universitaires est plus difficile pour les femmes que pour les hommes et, le cas échéant, la nature et le niveau des freins à cette progression. Méthodes : Extraction des effectifs médicaux temps plein dans un groupe hospitalier parisien, par la plateforme SIGAPS ; enquête par un questionnaire en ligne sur les choix de carrière et les freins ressentis chez des hommes et des femmes médecins occupant un poste de titulaire. La population étudiée comporte 181 praticiens hospitaliers et 141 médecins hospitalo-universitaires, dont 49 maitres de conférence-praticiens hospitaliers et 92 professeurs des universités-praticiens hospitaliers (PU-PH). Résultats : Les femmes représentent 49 % des effectifs médicaux et seulement 15 % des PU-PH. Cette sous-représentation des femmes PU-PH est plus importante en anesthésie-réanimation et moins dans les disciplines médicotechniques. Il n'y a pas de différence en matière de production scientifique, de statut marital et de parentalité entre les femmes et les hommes hospitalo-universitaires. En revanche, il existe une différence d'attitudes, mise en évidence par l'échelle de prise de risque EVAR, ainsi que dans le poids des obligations familiales et les préjugés ressentis par les femmes lors de la sélection universitaire. Conclusion : Le plafond de verre existe au sein d'un des plus grands groupe hospitaliers français. Les critères de sélection universitaire devraient évoluer pour limiter le désavantage des femmes lié à un engagement familial plus important et à des attitudes moins centrées sur la compétition et la prise de risque. Mots clés MeSH (français) : Corps enseignant et administratif en médecine ; Femmes médecins ; Femmes qui travaillent ; Mobilité de carrière ; Facteurs sexuels.

Background Medecins Sans Frontieres (MSF), a medical humanitarian organization, began using store-and-forward telemedicine in 2010. The aim of the present study was to describe the experience of developing a telemedicine service in low-resource settings. Methods We studied the MSF telemedicine service during the period from 1st July 2010 until 30th June 2017. There were three consecutive phases in the development of the service, which we compared. We also examined the results of a quality assurance program which began in 2013. Results During the study period, a total of 5646 telemedicine cases were submitted. The workload increased steadily, and the median referral rate rose from 2 to 18 cases per week. The number of hospitals submitting cases and the number of cases per hospital also increased, as did the case complexity. Despite the increased workload, the allocation time reduced from 0.9 to 0.2 hours, and the median time to answer a case decreased from 20 to 5 hours. The quality assurance scores were stable. User feedback was generally positive and more than 90% of referrers who provided a progress report about their case stated that it had been sent to an appropriate specialist, that the response was sufficiently quick and that the teleconsultation provided an educational benefit. Referrers noted a positive impact of the system on patient outcome in 39% of cases. Conclusions The quality of the telemedicine service was maintained despite rising caseloads. The study showed that offering direct specialist expertise in low-resource settings improved the management of patients and provided additional educational value to the field physicians, thus bringing further benefits to other patients.