Simulation en santé et médecine interne : quel avenir ?

Simulation-based learning (SBL) is developing rapidly in France and the question of its use in the teaching of internal medicine (IM) is essential. While HAS encourages its integration into medical education, French Young Internists (AJI) set up a working group to reflect on the added-value of this tool in our specialty. Different sorts of SBL exist: human, synthetic and electronic. It enables student to acquire and evaluate technical skills (strengths, invasive procedures, etc.) and non-technical skills (relational, reasoning…). The debriefing that follows the simulation session is an essential time in pedagogical terms. It enables the acquisition of knowledge by encouraging the students’ reflection to reshape their reasoning patterns by self-correcting. IM interns are supportive of its use. The simulation would allow young internists to acquire skills specific to our specialty such as certain gestures, complex consulting management, the synthesis of difficult clinical cases. SBL remains confronted with human and financial cost issues. The budgets allocated to the development and maintenance of simulation centres are uneven, making the supply of training unequal on the territory. Simulation sessions are time-consuming and require teacher training. Are faculties ready to train and invest their time in simulation, even though the studies do not allow us to conclude on its pedagogical validity?     

Réaction anaphylactoïde post-BCG : le rôle du dextran ?

The authors describe the case of a 16-year-old male without any medical history who developed anaphylactic shock a few minutes after the injection of the intradermal vaccine BCG Pasteur. Chronology of events, lack of any other drug intake and the dramatic increase of serum tryptase level account for the anaphylactic reaction consecutive to vaccine injection. A few weeks after the accident, the allergic data donˈt reveal much. At this time, serum anti dextran IgG are significantly high (8 mg/L), suggesting the involvement of dextran in this severe adverse reaction.     

La saturation de la structure des urgences et le rôle de l'organisation hospitalière : réflexions sur les causes et les solutions

Emergency Department (ED) overcrowding is a silent killer. Thus, several studies in different countries have described an increase in mortality, a decrease in the quality of care and prolonged hospital stays associated with ED overcrowding. Causes are multiple: input and in particular lack of access to lab test and imaging for general practitioners, throughput and unnecessary or time-consuming tasks, and output, in particular the availability of hospital beds for unscheduled patients. The main cause of overcrowding is waiting time for available beds in hospital wards, also known as boarding. Solutions to resolve the boarding problem are mostly organisational and require the cooperation of all department and administrative levels through efficient bed management. Elderly and polypathological patients wait longer time in ED. Internal Medicine, is the ideal specialty for these complex patients who require time for observation and evaluation. A strong partnership between the ED and the internal medicine department could help to reduce ED overcrowding by improving care pathways.     

Nouveaux outils d’évaluation du contrôle de l’asthme : le NO expiré et le NO nasal

Nitric oxide (NO) is present in the upper and lower human airways. Nasal and exhaled levels of NO can be determined by non-invasive techniques using chemiluminescence analysers. NO levels in the upper airways are 10–100-fold higher than in the lower airways. International recommendations for standardized measurement of nasal and exhaled NO have been published recently. Exhaled NO is increased in patients with untreated asthma, and this elevation reflects, at least partially, bronchial inflammation. Measurement of exhaled NO may be useful when the diagnosis is doubtfull and for differentiation from other causes of chronic cough. Nasal NO is usually also increased in asthma but this is related to the frequency of allergic rhinitis in asthmatic patients. However, in patients with nasal polyps and asthma, nasal NO is decreased in proportion to the extent of sinusoidal involvement. Levels of exhaled NO decrease rapidly in asthmatic patients treated with anti-inflammatory drugs. Further studies are needed to establish more precisely the place of exhaled NO measurement in monitoring the control of asthma, especially in comparison with other non-invasive markers of bronchial inflammation.     

Nouveaux outils d'évaluation pour le contrôle de l'asthme : apport de l'expectoration induite

Asthma is an inflammatory disease of the airways, as demonstrated by bronchoalveolar lavage and bronchial biopsy. The diagnosis and monitoring of asthma are usually based on the results of pulmonary function tests. It has been demonstrated that examination of induced sputum is a non-invasive, reliable technique for monitoring bronchial inflammation in patients with asthma. Induced sputum reveals aspects of inflammation that are distinct from those measured by functional assessment. In particular, enumeration of eosinophils in induced sputum provides useful information on the status of an asthmatic patient, independent of functional tests, and can be repeated in the long-term follow-up of patients. Recent studies suggest that induced sputum can be used as a guide to therapy, with the aim of preventing exacerbations of asthma. Nevertheless, additional studies are needed to determine in which asthmatic populations induced sputum monitoring could be useful.     

L’insuline par voie inhalée : un modèle pour l’absorption systémique pulmonaire ?

European Union has recently approved a form of insulin intended to be inhaled. This innovative presentation has the potential to partially or completely replace the injections and thus facilitate starting insulin therapy which is considered with apprehension and too often differed. On this occasion, we reviewed the issues raised by this pulmonary route for systemic absorption (anatomical and cytological limits, cellular mechanisms, relevant physical parameters, facilitating chemical cofactors, role of tobacco smoking and of common respiratory diseases). The pharmacokinetics of inhaled and injectable insulins are comparable, apart from an appreciably faster absorption of the former and both show the same intra-individual variability. The total biodisponibility is definitely lower with the inhaled way but it is notably increased in smokers. These characteristics can vary according to the inhalation system used. A frequent induced cough, the increase in circulating anti-insulin antibodies and a potentially higher cost are not really determining obstacles. The indications will have to be clearly specified and the long-term inocuity of long term inhalation of such a mitogene especially in children and former smokers remains to be formally proven.     

Les échinococcoses : un modèle parasitaire pour la compréhension des maladies allergiques ?

Relationship between parasitic and allergic diseases has often been stressed. Parasitic diseases do offer a model to study the role of those events that may determine the final outcome of immune responses and the type of their effector stage. At first glance, the pathophysiological mechanisms involved in Echinococcus sp infections, hydatid cyst (cystic echinococcosis) and alveolar echinococcosis, appear quite different: IgE-dependent responses seem to be involved in the former and cell-mediated immunity in the latter. However, an analysis of the cytokine profile in these two cestodoses shows that, in both cases, Th1 responses are protective, and are present in “abortive” forms of infection; conversely, Th2 responses characterised by IL-5 and especially IL-10 synthesis are the hallmarks of the “progressive” forms of infection, leading to the disease and its clinical complications. In patients, it seems that all known actors of the effector cell-mediated responses actually surround the parasitic cells but are somehow “paralysed”, at least partially, by anti-inflammatory cytokines and other mediators such as nitric oxide; hence the chronic evolution of the disease and all complications related to fibrosis and necrosis. Both are the results of an inefficient immune response deviated by the parasite and favoured by immunogenetic characteristics of the host. The IgE synthesis that results from the Th2 immune response also participate in the occurrence of clinical complications. The comparison between parasitic and allergic diseases, through the “echinococcosis model” may be used to better understand the immune mechanisms involved both in the increase in allergic disorders in developed countries and in “mixed-type allergic lesions” which associate cellular immunity and IgE-dependent responses, such as atopic dermatitis.