Shift in emergency department utilization by frequent attendees with sickle cell disease during the COVID-19 pandemic: A multicentre cohort study.

While the coronavirus disease-2019 (COVID-19) might have increased acute episodes in people living with sickle cell disease (SCD), it may also have changed their reliance on emergency department (ED) services. We assessed the impact of the COVID-19 pandemic and lockdowns on ED visits in adult SCD people followed in five French reference centres, with a special focus on 'high users' (≥10 visits in 2019). We analysed the rate of ED visits from 1 January 2015 to 31 December 2021, using a self-controlled case series. Among 1530 people (17 829 ED visits), we observed a significant reduction in ED visits during and after lockdowns, but the effect vanished over time. Compared to pre-pandemic, incidence rate ratios for ED visits were 0.59 [95% CI 0.52-0.67] for the first lockdown, 0.66 [95% CI 0.58-0.75] for the second and 0.85 [95% CI 0.73-0.99] for the third. High users (4% of people but 33.7% of visits) mainly drove the reductions after the first lockdown. COVID-19 lockdowns were associated with reduced ED visits. While most people returned to their baseline utilization by April 2021, high users had a lasting decrease in ED visits. Understanding the factors driving the drop in ED utilization among high users might inform clinical practice and health policy.

"SCULP" study: The benefits of skin graft pellets on the pain of sickle cell leg ulcers (SCLU).

BACKGROUND: Leg ulcers associated with major sickle cell disease (SCLU) are a chronic, painful complication, often treated by autologous skin graft. The analgesic effect of skin grafting in SCLU is poorly studied. The aim of this study was to evaluate the effect of skin grafting on the pain and healing of SCLU. METHODS: Patients hospitalized for SCLU skin grafting were included in a retrospective and prospective observational cohort, between 2019 and 2023: 53 autologous pinch grafts were performed on a total of 35 SCLUs in 25 sickle cell patients. The primary endpoint was the evaluation of the analgesic effect of the skin graft, measured by visual analog scale (VAS) and weekly cumulative analgesic consumption between day (D)0, D7 and D30. Wound healing was assessed by variation in wound areas between D0 and D30. RESULTS: Twenty-five patients with a median age range of 45.5years old were included, 68% were men, SS genotype was present in 96% of the cases. At D7, a significant decrease in VAS and consumption of analgesics of all classes was observed. At D30, only a significant decrease in VAS and consumption of mild opioids was present, as well as a significant reduction in wound surface area compared with D0. CONCLUSION: Pinch grafts have a significant early analgesic effect in the management of patients with SCLU, and significantly notice reduction of wound surface area within one month.

[Prevention of pertussis in newborns: Should pregnant women be vaccinated at each pregnancy?] / Prévention de la coqueluche chez le nouveau-né : faut-il vacciner les femmes enceintes à chaque grossesse ?

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

[Hypertension: Who to treat, to what extent and how?] / Hypertension artérielle : qui traiter, jusqu'où et comment ?

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

[Association between students' clinical performance and their success in the computerized national ranking tests: A single-center retrospective cohort study]. / Association entre les performances cliniques des étudiants et leur réussite aux Épreuves classantes nationales informatisées : une étude de cohorte rétrospective monocentrique.

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

Poor performance of albumin or protein-adjusted plasma calcium to diagnose dyscalcemia in hospitalized patients: A confirmatory study in a general internal medicine department.

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

Literature review of perceptual learning modules in medical education: What can we conclude regarding dermatology?

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.

Are script concordance tests suitable for the assessment of undergraduate students? A multicenter comparative study.

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.

[Characteristics of patients admitted from emergency units in 18 internal medicine departments and organisation of these departments: A cross sectional study from SNFMI (SiFMI study group) in 2015]. / Caractéristiques des patients admis en médecine interne dans 18 hôpitaux français en aval des urgences et organisation de ces services : enquête transversale de la SNFMI (groupe d'étude SiFMI) en 2015.

INTRODUCTION: Patients admitted from emergency units represent a large portion of the population in internal medicine departments. The aim of this study is to identify characteristics of patients and organization of these departments. METHODS: Between June 29th and July 26th 2015, voluntary internal medicine departments from the SiFMI group prospectively filled anonymized internet forms to collect data of each patients admitted in their ward from emergency units, during seven consecutive days. RESULTS: Three hundred and sixty-five patients from emergency departments were admitted in 18 internal medicine inpatients departments, totalling 1100 beds and 33,530 annual stays, 56% of them for emergency units inpatients. Mean age was 68 years, 54% were women, mean Charlson score was 2.6 and 44% of the patients took at least three drugs. Main causes of hospitalization were infectious (29%) and neurological (17%) diseases. Mean length of stay was 9.2 days. The medical team was composed by a median value of 4,5 [2,75-6,25] senior full-time equivalents, 86% were internists. Each department except one received residents, two third of them were from general medicine. CONCLUSION: This study highlights a high organizational variability among internal medicine departments and patients, and sets internal medicine as a specialty with a great capacity to achieve an integrative/comprehensive management of patients and to offer a comprehensive basis for physicians in training.

[Pneumo-Quest: A standardised self-questionnaire to be completed at home before a first appointment at a respiratory clinic]. / Pneumo-Quest, auto-questionnaire standardisé à compléter au domicile avant une première consultation en pneumologie : étude de validation.

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).

[Association between psychiatric comorbidities and hospital length of stay in post-emergency internal medicine patients]. / Association des comorbidités psychiatriques avec la durée de séjour des patients en médecine interne d'aval des urgences.

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

[Reliability and validity of a workbook for assessment of professional competencies of internal medicine residents]. / Évaluation multicentrique de la reproductibilité et de la validité d'un carnet d'évaluation des compétences professionnelles des internes de médecine interne.

INTRODUCTION: Though several assessment tools for resident professional skills based on workplace direct observation have been validated, they remain scarcely used in France. The objective of this study was to evaluate the reliability and the validity of a workbook including several assessment forms for different components of the professional competency. METHODS: Three assessment forms have been tested over a period of 6 months in a multicentric study including 12 French internal medicine departments: the French version of the mini-CEX, an interpersonal skills assessment form (OD_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. RESULTS: Twenty-five residents have been included. The Cronbach alpha was of 0.90 (n=70) with the mini-CEX, 0.89 with the OD_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. CONCLUSION: This study suggest that it would be difficult to ensure a sufficient reliability for professional skills assessment using these tools given our available current human and material resources. However, these assessment forms could be added to the resident portfolio as supports for the debriefing in order to document their progression during their formation.

[Glass ceiling for women in academic medicine in France]. / Plafond de verre pour les femmes dans les carrières hospitalo-universitaires en France.

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

[Validity and reproducibility of two direct observation assessment forms for evaluation of internal medicine residents' clinical skills]. / Validité et reproductibilité de deux grilles d'observation des compétences cliniques des internes en DES de médecine interne.

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

[Assessment of physicians' and nurses' knowledge and practices of aerosol therapy]. / Évaluation des connaissances et des pratiques de la nébulisation par les soignants.

INTRODUCTION: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

European Society of Endocrinology Clinical Practice Guideline for long-term follow-up of patients operated on for a phaeochromocytoma or a paraganglioma.

Phaeochromocytomas and paragangliomas (PPGLs) are rare neuroendocrine tumours. Standard treatment is surgical resection. Following complete resection of the primary tumour, patients with PPGL are at risk of developing new tumoural events. The present guideline aims to propose standardised clinical care of long-term follow-up in patients operated on for a PPGL. The guideline has been developed by The European Society of Endocrinology and based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) principles. We performed a systematic review of the literature and analysed the European Network for the Study of Adrenal Tumours (ENS@T) database. The risk of new events persisted in the long term and was higher for patients with genetic or syndromic diseases. Follow-up in the published cohorts and in the ENS@T database was neither standardised nor exhaustive, resulting in a risk of follow-up bias and in low statistical power beyond 10 years after complete surgery. To inform patients and care providers in this context of low-quality evidence, the Guideline Working Group therefore prepared recommendations on the basis of expert consensus. Key recommendations are the following: we recommend that all patients with PPGL be considered for genetic testing; we recommend assaying plasma or urinary metanephrines every year to screen for local or metastatic recurrences or new tumours; and we suggest follow-up for at least 10 years in all patients operated on for a PPGL. High-risk patients (young patients and those with a genetic disease, a large tumour and/or a paraganglioma) should be offered lifelong annual follow-up.

'The Move', an innovative simulation-based medical education program using roleplay to teach neurological semiology: Students' and teachers' perceptions.

INTRODUCTION: Neurological disorders are frequently being managed by general practitioners. It is therefore critical that future physicians become comfortable with neurological examination and physical diagnosis. Graduating medical students often consider neurological examination as one of the clinical skills they are least comfortable with, and they even tend to be neurophobic. One way to improve the learning of neurological semiology is to design innovative learner-friendly educational methods, including simulation training. METHODS: The feasibility of mime-based roleplaying was tested by a simulation training program in neurological semiology called 'The Move'. The program was proposed to third-year medical students at Pierre and Marie Curie University in Paris during their neurology rotation. Students were trained to roleplay patients by miming various neurological syndromes (pyramidal, vestibular, cerebellar, parkinsonian) as well as distal axonopathy, chorea and tonic-clonic seizures. Using an anonymous self-administered questionnaire, the students' and teachers' emotional experience and views on the impact of the program were then investigated. RESULTS: A total of 223/365 students (61%) chose to participate in the study. Both students and teachers felt their participation was pleasant. Students stated that The Move increased their motivation to learn neurological semiology (78%), and improved both their understanding of the subject (77%) and their long-term memorization of the teaching content (86%). Although only a minority thought The Move was likely to improve their performance on their final medical examination (32%), a clear majority (77%) thought it would be useful for their future clinical practice. Both students (87%) and teachers (95%) thought The Move should be included in the medical curriculum. CONCLUSION: Mime-based roleplaying simulation may be a valuable tool for training medical students in neurological semiology, and may also help them to overcome neurophobia.