[Correlation between Objective structured clinical examinations (OSCE) and knowledge examination scores and analysis of factors associated with better OSCE success in fourth and fifth year medicine students at Dijon university hospital]. / Corrélation entre les notes obtenues aux ECOS et aux épreuves de connaissances et analyse des facteurs associés à une meilleure réussite aux ECOS chez les étudiants de DFASM1 et 2 au CHU de Dijon.

RATIONALE: Objective structured clinical examinations (OSCEs) were introduced to evaluate students not only on their knowledge, but also on their clinical skills and attitudes. The objectives were to study the correlation between OSCE scores and scores obtained to traditional knowledge examinations and to analyse factors associated with better OSCE performance in DFASM1 and 2 students at Dijon university hospital. METHODS: This was a prospective observational study conducted among all fourth and fifth year medical students in Dijon. The scores on the OSCE elective tests (2022) and the average score on the knowledge tests (2021-2022) were collected and their correlation measured. A questionnaire asked students about their demographic characteristics, their investment in formative and practicum OSCEs, their level of empathy (Jefferson questionnaire) and their personality traits (NEO-Pi-R). RESULTS: Of 549 students, 513 completed all tests. Scores on OSCE and faculty knowledge tests were correlated (r=0.39, P<0.001). Of these, 111 (20%) students responded to the questionnaire, and 97 were analized. We did not observe any significant difference between students who performed better on OSCEs than on knowledge tests and those who did not, regarding their age, their investment in formative tests, their personality traits or their level of empathy. CONCLUSION: Our results underline the need to optimize the evaluation of empathy and clinical skills in OSCE tests, using new tools, in order to better discriminate between students on these skills.

Antibiotic therapy in the emergency room: Optimal prescription is indeed the best.

INTRODUCTION: Emergency departments (ED) are pivotal for antibiotic prescription, of which the appropriateness and consequences have rarely been assessed. METHODS: A retrospective study included patients referred to the ED and hospitalized with an advocated diagnosis of infection. Day-0 (ED initial prescription) and day-2 (reevaluation) antibiotic therapies were graded as optimal (if fully following the guidelines in terms of molecule, dose, and route of administration), adapted (if the prescribed molecule was microbiologically active but not recommended as first-line treatment, or in case of a wrong dose), or inadequate (other situations). The primary endpoint was onset of an unfavorable event (death, transfer to intensive care unit, or re-hospitalization). Prognosis factors associated with survival without unfavorable event were assessed by multivariate analysis. RESULTS: We included 484 patients. Optimal, adapted, and inadequate initial prescriptions concerned 328 (67.8 %), 110 (22.7 %) and 46 (9.5 %) patients respectively. Compared with an optimal prescription, an initial adapted prescription was associated with a poorer prognosis (HR = 1.95, CI95% [1.18-3.22]; p = 0.01). Reevaluation was performed in 436 (90.1 %) patients. After reevaluation, optimal, adapted, and inadequate prescriptions concerned 326 (74.8 %), 64 (14.7 %), and 46 (10.5 %) patients respectively. After reevaluation, and as compared with optimal prescription, inadequate prescription was significantly associated with unfavorable events (HR = 3.52, CI95% [1.42-8.72]; p = 0.003). CONCLUSION: Antibiotics are frequently prescribed in EDs. Antibiotic prescription has got to be optimal, and not simply adapted, so as to be associated with significant clinical benefit.

[An unusual cause of a decline in general health in a very old person]. / Une cause inhabituelle d'altération de l'état général chez une personne très âgée.

Humans are accidental intermediate hosts and a dead-end for the echinococcosis parasite. No cases of hydatid echinococcosis (hydatid cyst) have ever been described in a French-born very elderly person, who has never been out of France. We report the case of a 90-year-old man hospitalised following a decline in his general health and the discovery of a liver mass on the CT-scan. The abdominal palpation was painless, and no mass was felt. Biological tests revealed hypereosinophilia, a mild inflammatory syndrome, a slight increase in the immunoglobulin E level, and positive serology for Echinococcus granulosus. A diagnosis of hydatid echinococcosis due to Echinococcus granulosus was made given the liver mass on the CT-scan, the positive serology and the hypereosinophilia. Management consisted of watch and wait. This observation is interesting because it was a case of an autochthonous hydatid cyst of an unexpected discovery in a very elderly patient. Indeed, even though the discovery was classical, the clinical presentation was singular because of the context.

L'être humain est un hôte intermédiaire accidentel et une impasse parasitaire pour l'échinococcose. Aucun cas de kyste hydatique (échinococcose hydatique) n'a été décrit chez une personne très âgée née en France et ne l'ayant jamais quittée. Nous rapportons ici le cas d'un patient âgé de 90 ans hospitalisé pour altération de l'état général et découverte d'une masse hépatique à la tomodensitométrie. La palpation abdominale était indolore sans masse perçue. Le bilan biologique révélait une hyperéosinophilie, un discret syndrome inflammatoire, une légère augmentation du taux d'immunoglobuline E et une sérologie de l'Echinococcus granulosus positive. Le diagnostic d'échinococcose hydatique (kyste hydatique) due à Echinococcus granulosus fut alors posé, compte tenu de la masse hépatique découverte à la tomodensitométrie, de la sérologie positive et de l'hyperéosinophilie. La prise en charge a consisté en une attitude «watch and wait¼. Cette observation est intéressante car il s'agissait d'un cas de kyste hydatique autochtone de découverte fortuite chez un patient très âgé. En effet, même si le mode de découverte était classique, le tableau clinique était singulier en raison du contexte.

Is there a need to widely prescribe antibiotics in patients hospitalized with COVID-19?

BACKGROUND: Debate continues regarding the usefulness and benefits of wide prescription of antibiotics in patients hospitalized with coronavirus disease 2019 (COVID-19). METHODS: All patients hospitalized in the Infectious Diseases Department, Dijon University Hospital, Dijon, France between 27 February and 30 April 2020 with confirmed COVID-19 were included in this study. Clinical, biological and radiological data were collected, as well as treatment and outcome data. An unfavourable outcome was defined as death or transfer to the intensive care unit. Patient characteristics and outcomes were compared between patients who did and did not receive antibiotic therapy using propensity score matching. FINDINGS: Among the 222 patients included, 174 (78%) received antibiotic therapy. The univariate analysis showed that patients who received antibiotic therapy were significantly older, frailer and had more severe presentation at admission compared with patients who did not receive antibiotic therapy. Unfavourable outcomes were more common in patients who received antibiotic therapy [hazard ratio (HR) 2.94, 95% confidence interval (CI) 1.07-8.11; P = 0.04]. Multi-variate analysis and propensity score matching indicated that antibiotic therapy was not significantly associated with outcome (HR 1.612, 95% CI 0.562-4.629; P = 0.37). CONCLUSION: Antibiotics were frequently prescribed in this study and this was associated with more severe presentation at admission. However, antibiotic therapy was not associated with outcome, even after adjustment. In line with recent publications, such data support the need to streamline antibiotic therapy in patients with COVID-19.

Comparative review of imipenem/cilastatin versus meropenem.

INTRODUCTION: Carbapenems are broad-spectrum antibacterial molecules. Imipenem-cilastatin and meropenem are the two main molecules used in French healthcare services. OBJECTIVE: We aimed to evaluate the relative strengths and weaknesses of these two molecules by considering their pharmacokinetic, pharmacodynamic, microbiological, and clinical properties. We demonstrated that imipenem-cilastatin and meropenem are not alike. METHOD: Review of the literature by querying the MEDLINE network. RESULTS: Imipenem-cilastatin is the first marketed molecule of the carbapenem class. It is more effective against Gram-positive cocci. Its stability does not allow for long infusions and its main adverse effect on the central nervous system limits its use. Meropenem is more effective against Gram-negative bacilli. Its stability and its milder adverse effects distinguish it from imipenem-cilastatin. CONCLUSION: Meropenem is preferred for daily use in healthcare services when carbapenems are to be used.

[Influenza infection: An update for clinicians]. / La grippe : mise au point pour les cliniciens.

Lower respiratory infections remain the deadliest communicable disease in the world. Influenza infections are particularly involved, whether intrinsically, or more frequently, by promoting bacterial infections and superinfections. The flu is also responsible for the decompensation of many comorbidities and could lead to some myocardial infarction and stroke. The effect of antiviral therapies is limited but preventives measures, such as vaccination, remain a major public health issue. The flu is a major challenge at all levels and all times, from vaccine prevention, to the recognition of atypical forms, and the early management of bacterial complications.

Vitamin D supplementation, bone turnover, and inflammation in HIV-infected patients.

OBJECTIVE: To assess whether vitamin D supplementation could be associated with a modification of inflammatory markers and bone turnover in HIV-1-infected patients. PATIENTS AND METHODS: Patients who participated in an initial survey in 2010 and who were followed in the same department were included in a new study in 2012. Between 2010 and 2012, vitamin D supplementation was offered to patients presenting with hypovitaminosis D as per appropriate guidelines. Clinical examinations were performed, and fasting blood samples were taken for inflammation and bone marker evaluations. RESULTS: Of the 263 patients who participated in the 2010 study, 198 were included in the 2012 study. Hypovitaminosis D was observed in 47% (36/77) of participants supplemented as per appropriate guidelines, in 78% (75/97) of transiently or incompletely supplemented participants, and in 71% (17/24) of non-supplemented participants (mainly because vitamin D levels in 2010 were normal). No significant correlation between vitamin D supplementation and the 2-year inflammation outcome (IL-6 and hsCRP) or C-terminal telopeptide levels was observed. However, a decrease in IL6 levels over the 2 years significantly correlated with reaching a normal vitamin D level (OR=0.89 per+1pg/mL IL6 increase, 95% CI=0.81-0.97, P=0.015). CONCLUSIONS: Vitamin D supplementation decreases the risk of hypovitaminosis D but does not decrease the risk of inflammation nor bone turnover, unless normal 25-OH vitamin D levels are reached.

Update on childhood and adult infectious tracheitis.

The trachea is a pivotal organ of the respiratory tract. Rather than a genuine anatomic border, it acts as a crossroad in all respiratory infectious processes. Even though not strictly limited to the trachea, infections such as laryngotracheitis and tracheobronchitis are frequently diagnosed in children, in particular during the winter season. Infectious tracheitis etiologies are diverse and the distinction between viral and bacterial origins, albeit difficult, remains relevant considering the substantial differences in terms of gravity and therapeutic management. This literature review summarizes the microbiological and clinical aspects of community-acquired and nosocomial tracheitis in adults and children, as well as the adequate diagnostic and therapeutic approaches. It also highlights the emergence of fungal tracheitis in immunocompromised patients, of ventilator-associated tracheitis in intensive care medicine, and beyond all that the potential short and long-term consequences of tracheitis.

[Isolated tracheobronchial involvement by atrophic polychondritis: role of PET scanning]. / Atteinte trachéobronchique isolée de la polychondrite atrophiante: intérêt du TEP-scanner.

INTRODUCTION: Atrophic polychondritis is a rare and serious disease characterised by multifocal inflammatory lesions of cartilage. The diagnosis, though urgent, is difficult when there is isolated tracheal involvement. CASE REPORT: We report the case of a woman of 55 with recent, non-infectious febrile episodes accompanied by a steroid sensitive inflammatory syndrome. Auscultation, lung function tests and a thoracic CT scan suggested tracheobronchomalacia. Atrophic polychondritis was suspected without being confirmed on the basis of histological or biological tests; particularly as no other cartilaginous involvement was discovered. Laryngeal and tracheal hypermetabolism on a PET scan, performed in the absence of corticosteroid treatment, was also in favour of this diagnosis. One month after resumption of steroid treatment at increased dosage, this examination was normal. Secondarily, after careful reduction of steroids, the patient developed nasal chondritis, confirming the diagnosis of atrophic polychondritis. CONCLUSION: The PET scanner could be useful in the diagnosis of atrophic polychondritis in its isolated tracheobronchial form. Its place in the follow-up of this disease remains to be evaluated and should take account of the irradiation dose of this examination.

[HIV infection in France in 2012: reality, risks and challenges for a chronic multisystem disease]. / L'infection par le VIH en France en 2012 : réalité, risques et enjeux d'une polypathologie chronique.

Thirty years after the discovery of HIV and 15 years since the advent of Highly Active Antiretroviral Therapy (HAART), the features of HIV infection have evolved and need a new approach, which is both more comprehensive and specialized. Indeed, the burden of a chronic disease with multiple determining features has replaced the rapidly fatal infection of the past, which was almost exclusively related to the effects of immunosuppression. Physicians have to be concerned with "new risks" associated with treatment side effects; the consequences of ongoing inflammation and ageing of the HIV-infected population. These include metabolic, cardiovascular, neurocognitive and renal disease as well as lipodystrophy and malignancy. Antiretroviral treatment has been a major step forward, subject to accessibility, tolerance and adherence, but it has not solved all the problems associated with this infection, as it becomes a chronic illness.

[Recurrent atypical mycobacterial infections in the adult: think of autoantibodies against interferon-gamma !]. / Infections récurrentes à mycobactéries atypiques chez l'adulte : attention aux autoanticorps anti-interféron-gamma!

INTRODUCTION: Disseminated non-tuberculosis mycobacterial infections are associated with a defect of the cellular immune response. They have been mainly reported in AIDS patients. Cases related to the presence of anti-interferon-γ autoantibodies are rare. CASE REPORT: We report a non HIV-infected 45-year-old Thai woman, with a past medical history of Graves' disease. She presented with recurrent disseminated and severe non-tuberculous mycobacterial infections that were related to the production of anti-interferon-γ autoantibody. The diagnosis was suspected in the presence of a negative interferon-γ release assay (IGRA) including with the positive control, and evidenced by the identification of specific antibodies. CONCLUSION: Anti-interferon-γ autoantibody production is a rare cause of non tuberculous mycobacterial infection. Such a mechanism should be suspected in non HIV-infected patients and especially in those having an Asiatic ethnicity or an associated immune disorder. A negative IGRA (including with the positive control) is a reliable diagnostic tool and should be completed with the identification of specific autoantibodies.