Nouveautés en médecine interne hospitalière 2007: perspective des chefs de clinique [Highlights 2007 in hospital-based internal medicine: the point of view from the chief residents]

L'année 2007 a été marquée par la publication de plusieurs études internationales concernant directement le quotidien de l'interniste hospitalier. Un résumé de ces travaux ne saurait être qu'un extrait condensé et forcément subjectif d'une croissante et dynamique diversité. Au gré de leurs lectures, de leurs intérêts et de leurs interrogations, les chefs de clinique du Service de médecine interne vous proposent ainsi un parcours original revisitant les thèmes de l'insuffisance cardiaque, du diabète, de l'endocardite, de la BPCO ou de la qualité des soins. Cette variété de sujets illustre à la fois le vaste champ couvert par la médecine interne actuelle, ainsi que les nombreuses incertitudes liées à la pratique médicale moderne basée sur les preuves. In 2007, several international studies brought useful information for the daily work of internists in hospital settings. This summary is of course subjective but reflects the interests and questions of the chief residents of the Department of internal medicine who wrote this article like an original trip in medical literature. This trip will allow you to review some aspects of important fields such as heart failure, diabetes, endocarditis, COPD, and quality of care. Besides the growing diversity of the fields covered by internal medicine, these various topics underline also the uncertainty internists have to face in a practice directed towards evidence.

Congenital heart disease affects local gyrification in 22q11.2 deletion syndrome.

22q11.2 deletion syndrome (22q11.2DS) is a common genetic condition associated with cognitive and learning impairments. In this study, we applied a three-dimensional method for quantifying gyrification at thousands of points over the cortical surface to imaging data from 44 children, adolescents, and young adults with 22q11.2DS (17 males, 27 females; mean age 17y 2mo [SD 9y 1mo], range 6-37y), and 53 healthy participants (21 males, 32 females; mean age 15y 4mo [SD 8y 6mo]; range 6-40y). Several clusters of reduced gyrification were observed, further substantiating the pattern of cerebral alterations presented by children with the syndrome. Comparisons within 22q11.2DS demonstrated an effect of congenital heart disease (CHD) on cortical gyrification, with reduced gyrification at the parieto-temporo-occipital junction in patients with CHD, as compared with patients without CHD. Reductions in gyrification can resemble mild polymicrogyria, suggesting early abnormal neuronal proliferation or migration and providing support for an effect of hemodynamic factors on brain development in 22q11.2DS. The results also shed light on the pathophysiology of acquired brain injury in other populations with CHD.

Dexamethasone therapy and endogenous cortisol production in severe pediatric head injury.

A prospective randomised study was performed on 25 children aged 1.4 to 15.8 years with severe head injury (Glasgow Coma Scale less than or equal to 7) to determine the clinical effectiveness and the impact on endogenous cortisol production of high-dose steroid therapy. Thirteen patients (group 1) received dexamethasone 1 mg/kg/day during the first 3 days and 12 (group 2) not. All patients were treated with a standardized regimen. Urinary free cortisol was measured by radioimmunoassay, and the clinical data were recorded at hourly intervals. Outcome was assessed 6 months later using the Glasgow Outcome Scale. We found a higher frequency of bacterial pneumonias in the dexamethasone-treated patients (7/13 versus 2/12). Group 1 showed a suppression of endogenous cortisol production from day 1 to day 6. In group 2, mean free cortisol was up to 5-fold higher than under basal conditions. The results in group 2 showed that the endogenous steroid production reacts adequately to the stress of severe head injury. It probably is sufficient to elicit maximum glucocorticoid effects. There was no other statistically significant difference in the clinical and laboratory data between the two groups. We conclude that dexamethasone in high doses suppresses endogenous cortisol production up to 6 days and may increase the risk of bacterial infection without affecting the outcome or the clinical and laboratory data.

Effectiveness of a pediatric palliative home care team as experienced by parents and health care professionals.

OBJECTIVES: Little data are available on palliative home care for children. The objective of this study was to evaluate the effectiveness of a specialized pediatric palliative home care team (PPHCT) as experienced by parents and health care professionals (HCPs). METHODS: Parents and HCPs involved in the care of terminally ill children who died and whom the PPHCT was in charge of were surveyed with questionnaires focusing on satisfaction with the PPHCT, satisfaction with the course of the dying phase, and the development of anxiety, depression, and prolonged grief disorder. RESULTS: Forty-three parent dyads participated (return rate, 88%). Satisfaction with the PPHCT scored a median of 10 (numeric rating scale, 0-10). The child's death was predominantly experienced as very peaceful (median, 9); 71% died at home. According to parents, involvement of the PPHCT led to highly significant (p<0.001) improvements in the children's symptoms and quality of life, as well as in aspects of communication and administrative barrier reduction. Anxiety was detected in 25% of parents, depression in 19%, and prolonged grief disorder in 13%. HCPs (return rate, 83%) evaluated all investigated care domains (particularly cooperation/communication/family support) as being significantly improved (p<0.001). Thirty-five percent of HCPs felt uncertain concerning pediatric palliative care; 79% would welcome specific training opportunities. CONCLUSIONS: Involvement of a PPHCT is experienced as a substantial improvement of care by parents and HCPs. Coordination of palliative care during the last phase of life appears to be an important quality factor for the home care of dying children and their families.

Validity of four short physical activity questionnaires in middle-aged persons.

PURPOSE: Self-administered questionnaires continue to be the most widely used type of physical activity assessment in epidemiological studies. However, test-retest reliability and validity of physical activity questionnaires have to be determined. In this study, three short physical activity questionnaires already used in Switzerland and the International Physical Activity Questionnaire (IPAQ) were validated. METHODS: Test-retest reliability was assessed by repeated administration of all questionnaires within 3 wk in 178 volunteers (77 women, 46.1+/-14.8 yr; 101 men 46.8+/-13.2 yr). Validity of categorical and continuous data was studied in a subsample of 35 persons in relation to 7-d accelerometer readings, percent body fat, and cardiorespiratory fitness. RESULTS: Reliability was fair to good with a Spearman correlation coefficient range of 0.43-0.68 for measures of continuous data and moderate to fair with Kappa values between 0.32 and 0.46 for dichotomous measures active/inactive. Total physical activity reported in the IPAQ and the Office in Motion Questionnaire (OIMQ) correlated with accelerometry readings (r=0.39 and 0.44, respectively). In contrast, correlations of self-reported physical data with percent body fat and cardiorespiratory fitness were low (r=-0.26-0.29). Participants categorized as active by the Swiss HEPA Survey 1999 instrument (HEPA99) accumulated significantly more days of the recommended physical activities than their inactive counterparts (4.4 and 2.7 d.wk, respectively, P<0.05). However, compared with accelerometer data, vigorous physical activities were overreported in investigated questionnaires. CONCLUSION: Collecting valid data on physical activity remains a challenging issue for questionnaire surveys. The IPAQ and the three other questionnaires are characterized to inform decisions about their appropriate use.

RED BLOOD CELL MICROPARTICLES: ROLE IN TRANSFUSION MEDICINE?

RésuméLes microparticules sont des vésicules phospholipidiques de moins d‟un micromètre relâchées dans le sang par différents types cellulaires, comme les cellules endothéliales, les plaquettes ou encore les globules blancs et rouges. Elles sont bioactives et impliquées dans de nombreux processus physiologiques incluant l‟hémostase. De plus, un nombre élevé de microparticules circulantes dans le sang a été observé dans différentes pathologies.Dans le domaine de la transfusion, les microparticules de globules rouges ont été détectées dans les concentrés érythrocytaires. Le but de cette recherche était de caractériser les microparticules de globules rouges et d‟évaluer si ces dernières avaient un rôle en transfusion. Pour ce faire, une approche globale utilisant différentes techniques comme la cytométrie de flux, la protéomique, la microscopie ainsi que des tests d‟hémostase de routines, a été adoptée.Le présent travail de thèse a démontré que les microparticules de globules rouges s‟accumulent dans les concentrés érythrocytaires pendant le stockage. Leur bioactivité a été démontrée de part leur rôle actif dans le processus de la coagulation. En effet, lors de test de génération de thrombine, elles peuvent non seulement supporter ce processus de coagulation, mais aussi le déclencher par un mécanisme inconnu sous certaines circonstances. Les microparticules de globules rouges présentent aussi des antigènes de groupes sanguins à leur surface, toutefois, leur implication potentielle dans l‟induction d‟une réponse immunitaire n‟est pas connue. Bien que le mécanisme de formation et d‟émissions des microparticules par les globules rouges ne soit pas complètement élucidé, il a été démontré qu‟elles n‟ont pas toutes le même contenu protéique et donc qu‟elles pourraient avoir des fonctions différentes.Au vu des résultats, notamment par leur implication dans la coagulation, il est fort probable que la présence de microparticules puisse affecter la qualité des produits sanguins, et causer des réactions transfusionnelles.

Unstable shoes increase energy expenditure of obese patients.

BACKGROUND: Ergonomic unstable shoes, which are widely available to the general population, could increase daily non-exercise activity thermogenesis as the result of increased muscular involvement. We compared the energy expenditure of obese patients during standing and walking with conventional flat-bottomed shoes versus unstable shoes. METHODS: Twenty-nine obese patients were asked to stand quietly and to walk at their preferred walking speed while wearing unstable or conventional shoes. The main outcome measures were metabolic rate of standing and gross and net energy cost of walking, as assessed with indirect calorimetry. RESULTS: Metabolic rate of standing was higher while wearing unstable shoes compared with conventional shoes (1.11 ± 0.20 W/kg(-1) vs 1.06 ± 0.23 W/kg(-1), P=.0098). Gross and net energy cost of walking were higher while wearing unstable shoes compared with conventional shoes (gross: 4.20 ± 0.42 J/kg(-1)/m(-1)vs 4.01 ± 0.39 J/kg(-1)/m(-1), P=.0035; net: 3.37 ± 0.41 J/kg(-1)/m(-1) vs 3.21 ± 0.37 J/kg(-1)/m(-1); P=.032). CONCLUSION: In obese patients, it is possible to increase energy expenditure of standing and walking by means of ergonomic unstable footwear. Long-term use of unstable shoes may eventually prevent a positive energy balance.

Palliative care and prehospital emergency medicine: analysis of a case series.

Palliative care, which is intended to keep patients at home as long as possible, is increasingly proposed for patients who live at home, with their family, or in retirement homes. Although their condition is expected to have a lethal evolution, the patients-or more often their families or entourages-are sometimes confronted with sudden situations of respiratory distress, convulsions, hemorrhage, coma, anxiety, or pain. Prehospital emergency services are therefore often confronted with palliative care situations, situations in which medical teams are not skilled and therefore frequently feel awkward.We conducted a retrospective study about cases of palliative care situations that were managed by prehospital emergency physicians (EPs) over a period of 8 months in 2012, in the urban region of Lausanne in the State of Vaud, Switzerland.The prehospital EPs managed 1586 prehospital emergencies during the study period. We report 4 situations of respiratory distress or neurological disorders in advanced cancer patients, highlighting end-of-life and palliative care situations that may be encountered by prehospital emergency services.The similarity of the cases, the reasons leading to the involvement of prehospital EPs, and the ethical dilemma illustrated by these situations are discussed. These situations highlight the need for more formal education in palliative care for EPs and prehospital emergency teams, and the need to fully communicate the planning and implementation of palliative care with patients and patients' family members.

Urban health: l'irrémédiable urbanisation de la vie et de la médecine [Urban health: the irremediable urbanization of life and medicine].

Since 2007, the number of people living in cities exceeds that of rural areas. Thus, cities and their organizations have a major influence on all spheres of human life, especially health. This influence may generate inequality, suffering and disease, but also represent an opportunity for health and well-being. This paper introduces the concept of urban health, particularly in terms of primary care medicine and presents solutions that encompass a wide field (politics, urban planning, social inequality, education). Improving urban health requires collaboration of medical with non-medical actors, in order to become of development (re-) urban structure and promotes the health of all.

Impaired antibody memory to varicella zoster virus in HIV-infected children: low antibody levels and avidity*.

OBJECTIVE: HIV-infected children have impaired antibody responses after exposure to certain antigens. Our aim was to determine whether HIV-infected children had lower varicella zoster virus (VZV) antibody levels compared with HIV-infected adults or healthy children and, if so, whether this was attributable to an impaired primary response, accelerated antibody loss, or failure to reactivate the memory VZV response. METHODS: In a prospective, cross-sectional and retrospective longitudinal study, we compared antibody responses, measured by enzyme-linked immunosorbent assay (ELISA), elicited by VZV infection in 97 HIV-infected children and 78 HIV-infected adults treated with antiretroviral therapy, followed over 10 years, and 97 age-matched healthy children. We also tested antibody avidity in HIV-infected and healthy children. RESULTS: Median anti-VZV immunoglobulin G (IgG) levels were lower in HIV-infected children than in adults (264 vs. 1535 IU/L; P<0.001) and levels became more frequently unprotective over time in the children [odds ratio (OR) 17.74; 95% confidence interval (CI) 4.36-72.25; P<0.001]. High HIV viral load was predictive of VZV antibody waning in HIV-infected children. Anti-VZV antibodies did not decline more rapidly in HIV-infected children than in adults. Antibody levels increased with age in healthy (P=0.004) but not in HIV-infected children. Thus, antibody levels were lower in HIV-infected than in healthy children (median 1151 IU/L; P<0.001). Antibody avidity was lower in HIV-infected than healthy children (P<0.001). A direct correlation between anti-VZV IgG level and avidity was present in HIV-infected children (P=0.001), but not in healthy children. CONCLUSION: Failure to maintain anti-VZV IgG levels in HIV-infected children results from failure to reactivate memory responses. Further studies are required to investigate long-term protection and the potential benefits of immunization.