Teaching cardiac auscultation to trainees in internal medicine and family practice: does it work?

BACKGROUND: The general proficiency in physical diagnostic skills seems to be declining in relation to the development of new technologies. The few studies that have examined this question have invariably used recordings of cardiac events obtained from patients. However, this type of evaluation may not correlate particularly well with bedside skills. Our objectives were 1) To compare the cardiac auscultatory skills of physicians in training with those of experienced cardiologists by using real patients to test bedside diagnostic skills. 2) To evaluate the impact of a five-month bedside cardiac auscultation training program. METHODS: 1) In an academic primary care center, 20 physicians (trainees in internal medicine and family practice) and two skilled academic cardiologists listened to 33 cardiac events in 13 patients directly at bedside and identified the cardiac events by completing an open questionnaire. Heart sounds, murmurs and diagnosis were determined beforehand by an independent skilled cardiologist and were validated by echocardiography. Thirteen primary cardiologic diagnoses were possible.2) Ten of the physicians agreed to participate in a course of 45-minute sessions once a week for 5 months. After the course they listened again to the same patients (pre/post-interventional study). RESULTS: 1) The experts were the most skillful, achieving 69% recognition of heart sounds and murmurs and correct diagnoses in 62% of cases. They also heard all of the diastolic murmurs. The residents heard only 40% of the extra heart sounds and made a correct diagnosis in 24% of cases. 2) After the weekly training sessions, their mean percentage for correct diagnosis was 35% [an increase of 66% (p < 0.05)]. CONCLUSIONS: The level of bedside diagnostic skills in this relatively small group of physicians in training is indeed low, but can be improved by a course focusing on realistic bedside teaching.

Médecine génomique et oncologie [Genomics medicine and oncology].

Progress in genomics with, in particular, high throughput next generation sequencing is revolutionizing oncology. The impact of these techniques is seen on the one hand the identification of germline mutations that predispose to a given type of cancer, allowing for a personalized care of patients or healthy carriers and, on the other hand, the characterization of all acquired somatic mutation of the tumor cell, opening the door to personalized treatment targeting the driver oncogenes. In both cases, next generation sequencing techniques allow a global approach whereby the integrality of the genome mutations is analyzed and correlated with the clinical data. The benefits on the quality of care delivered to our patients are extremely impressive.

The development and pilot-testing of a training curriculum in adolescent medicine and health.

PURPOSE: To select and propose a set of knowledge, attitudes, and skills essential for the care of adolescents; to encourage the development of adolescent health multidisciplinary networks; and to set up training programs in as many European countries as possible. METHODS: The curriculum was developed by 16 physicians from 11 European countries with various professional specializations. In line with modern guidelines in medical education, it is a modular, flexible instrument which covers the main teaching areas in the field, such as basic skills (i.e. setting, rights and confidentiality, gender and cultural issues) as well as specific themes (i.e. sexual and reproductive health, eating disorders, chronic conditions). It consists of 17 thematic modules, each containing detailed objectives, learning approaches, examples, and evaluation methods. RESULT: Two international one-week summer schools were used to assess the feasibility and appropriateness of the curriculum. The overall evaluation was good, with most of the items surpassing three on a four-point Likert scale. However, it pointed to several aspects (process and content) which will need to be refined in the future, such as an increase in interactive sessions (role playing), and a better mix of clinical and public health issues.

Diagnostic et prise en charge des douleurs de la région scapulaire [Diagnosis and treatments of scapular pain].

Shoulder pain is one of the most common reasons for bone and joint consultations in general practice. In most situations, it is due to a lesion of the rotator cuff. A detailed history can often exclude a cervical or visceral origin of the pain. A full clinical examination especially active and passive mobility provides a good diagnostic approach. It can be refined by specific clinical tests that must nevertheless be interpreted with caution. The management of pathologies of the rotator cuff does not require imaging immediately. Ultrasound is increasingly recognized as the imaging procedure of choice in most situations. For abarticular shoulder pathologies, therapy is primarily conservative. The exact role of infiltration of steroids remains unclear. Only an acute traumatic rupture of the rotator cuff warrants prompt surgical intervention.

International perspectives on general internal medicine and the case for "globalization" of a discipline.

General internal medicine (GIM) has flourished in the United States (U.S.). Unlike other subspecialties of internal medicine, however, GIM's evolution has not been global in scope, but rather appears to have occurred in isolation within countries. Here, we describe international models of GIM from Canada, Switzerland, Australia/New Zealand, Argentina, and Japan, and compare these with the U.S. model. There are notable differences in the typical clinical roles assumed by General Internists across these 7 countries, but also important overlap in clinical and academic domains. Despite this overlap, there has been a relative lack of contact among General Internists from these and other countries at a truly international GIM meeting; the time is now for increased international exchange and the "globalization" of GIM.

Report on a review of certain expenditures made by the Iowa Department of Public Health, including the Iowa Board of Pharmacy, the Iowa Dental Board, the Iowa Board of Medicine, and the Iowa Board of Nursing, from July 1, 2011 through August 31, 2014

Report on a review of certain expenditures made by the Iowa Department of Public Health, including the Iowa Board of Pharmacy, the Iowa Dental Board, the Iowa Board of Medicine, and the Iowa Board of Nursing, from July 1, 2011 through August 31, 2014

The Lausanne Institutional Biobank: a new resource to catalyse research in personalised medicine and pharmaceutical sciences.

Breakthrough technologies which now enable the sequencing of individual genomes will irreversibly modify the way diseases are diagnosed, predicted, prevented and treated. For these technologies to reach their full potential requires, upstream, access to high-quality biomedical data and samples from large number of properly informed and consenting individuals and, downstream, the possibility to transform the emerging knowledge into a clinical utility. The Lausanne Institutional Biobank was designed as an integrated, highly versatile infrastructure to harness the power of these emerging technologies and catalyse the discovery and development of innovative therapeutics and biomarkers, and advance the field of personalised medicine. Described here are its rationale, design and governance, as well as parallel initiatives which have been launched locally to address the societal, ethical and technological issues associated with this new bio-resource. Since January 2013, inpatients admitted at Lausanne CHUV University Hospital have been systematically invited to provide a general consent for the use of their biomedical data and samples for research, to complete a standardised questionnaire, to donate a 10-ml sample of blood for future DNA extraction and to be re-contacted for future clinical trials. Over the first 18 months of operation, 14,459 patients were contacted, and 11,051 accepted to participate in the study. This initial 18-month experience illustrates that a systematic hospital-based biobank is feasible; it shows a strong engagement in research from the patient population in this University Hospital setting, and the need for a broad, integrated approach for the future of medicine to reach its full potential.

Médecine interne et gériatrie en soins aigus: mariage de raison [General internal medicine and geriatrics in the acute care setting: opportunities for collaboration]

The health care system faces a difficult challenge as a result of the demographic evolution. The acute hospital is especially challenged by the steady increase of the elderly population. The collaboration between internal medicine and geriatrics in this setting could prove useful to facilitate the adaptation of the acute care setting and greatly enhance education of the health care professionals. Internists and geriatricians can benefit from each other skills and competencies to develop together new models of acute care that would better match the elderly population needs.

Systems medicine and integrated care to combat chronic noncommunicable diseases

We propose an innovative, integrated, cost-effective health system to combat major non-communicable diseases (NCDs), including cardiovascular, chronic respiratory, metabolic, rheumatologic and neurologic disorders and cancers, which together are the predominant health problem of the 21st century. This proposed holistic strategy involves comprehensive patient-centered integrated care and multi-scale, multi-modal and multi-level systems approaches to tackle NCDs as a common group of diseases. Rather than studying each disease individually, it will take into account their intertwined gene-environment, socio-economic interactions and co-morbidities that lead to individual-specific complex phenotypes. It will implement a road map for predictive, preventive, personalized and participatory (P4) medicine based on a robust and extensive knowledge management infrastructure that contains individual patient information. It will be supported by strategic partnerships involving all stakeholders, including general practitioners associated with patient-centered care. This systems medicine strategy, which will take a holistic approach to disease, is designed to allow the results to be used globally, taking into account the needs and specificities of local economies and health systems.

Données actualisées sur la physiopathologie, les phénotypes et les traitements de la maladie de Still de l'adulte [Pathophysiology, subtypes, and treatments of adult-onset Still's disease: An update].

Adult-onset Still's disease is a rare and difficult to diagnose multisystemic disorder considered as a multigenic autoinflammatory syndrome. Its immunopathogenesis seems to be at the crossroads between inflammasomopathies and hemophagocytic lymphohistiocytosis, the most severe manifestation of the disease. According to recent insights in the pathophysiology and thanks to cohort studies and therapeutic trials, two phenotypes of adult-onset Still's disease may be distinguished: a systemic pattern, initially highly symptomatic and with a higher risk to exhibit life-threatening complications such as reactive hemophagocytic lymphohistiocytosis, where interleukin-1 blockade seems to be very effective, a chronic articular pattern, more indolent with arthritis in the foreground and less severe systemic manifestations, which would threat functional outcome and where interleukin-6 blockade seems to be more effective. This review focuses on these data.

Systems Medicine and Integrated Care to Combat Chronic Noncommunicable Diseases.

We propose an innovative, integrated, cost-effective health system to combat major non-communicable diseases (NCDs), including cardiovascular, chronic respiratory, metabolic, rheumatologic and neurologic disorders and cancers, which together are the predominant health problem of the 21st century. This proposed holistic strategy involves comprehensive patient-centered integrated care and multi-scale, multi-modal and multi-level systems approaches to tackle NCDs as a common group of diseases. Rather than studying each disease individually, it will take into account their intertwined gene-environment, socio-economic interactions and co-morbidities that lead to individual-specific complex phenotypes. It will implement a road map for predictive, preventive, personalized and participatory (P4) medicine based on a robust and extensive knowledge management infrastructure that contains individual patient information. It will be supported by strategic partnerships involving all stakeholders, including general practitioners associated with patient-centered care. This systems medicine strategy, which will take a holistic approach to disease, is designed to allow the results to be used globally, taking into account the needs and specificities of local economies and health systems.

Back to the island of calm: mallorcan human traditional medicine and ethnobotany

This study reveals that a successful ethnobotanical survey can take place still nowadays, even close to one of the hotspots of tourism in the Mediterranean coast. This is the first approach in this field entirely based on interviews with local people in Mallorca. An amount of 235 informants has been inquired from all the 53 municipalities of the island. The data collected have been analyzed from the botanical and ethnographical points of view, and managed using the online platform of our research team (details at www.etnobiofic.cat). The Mallorcan ethnopharmacopoeia includes 255 plant taxa referring more than 150 medicinal use categories. Ethnomedical queries as the one here presented contribute to the knowledge of the traditional use of plants of the island and appreciate the benefits of this knowledge, applied to the present and future of its society.

Back to the island of calm: Mallorcan human traditional medicine and ethnobotany

This study reveals that a successful ethnobotanical survey can take place still nowadays, even close to one of the hotspots of tourism in the Mediterranean coast. This is the first approach in this field entirely based on interviews with local people in Mallorca. An amount of 235 informants has been inquired from all the 53 municipalities of the island. The data collected have been analyzed from the botanical and ethnographical points of view, and managed using the online platform of our research team (details at www.etnobiofic.cat). The Mallorcan ethnopharmacopoeia includes 255 plant taxa referring more than 150 medicinal use categories. Ethnomedical queries as the one here presented contribute to the knowledge of the traditional use of plants of the island and appreciate the benefits of this knowledge, applied to the present and future of its society.