Unité d’attente d’hospitalisation : une organisation simple et une place pour les internistes pour améliorer la filière d’hospitalisation non programmée à partir des urgences

IntroductionThe adult emergency department at Rouen University hospital (CHU) welcomes over 100.000 patients per year. In order to streamline unscheduled hospital admissions from the emergency room (ER), a 20-bed pre-hospitalization unit and a centralized bed management system (bed manager, bed manager software, dedicated beds) have been put into place.Patients and methodsEmergency admissions have increased by (+ 3.5% between 2017 and 2018) with 20% direct hospitalization from the ER to other conventional units (2/3 in medicine, 1/3 in surgery). In 2018, 3450 patients, of which 54% aged over 75 years have been admitted in the pre-hospitalization unit with an average length of stay of 1.3 ± 1.4 days: 35.4% stayed less than 24 hours and 34.8% more than 48 hours of which 5.2% stated more than 4 days, 132 patients (3.8%) died, 805 patients (23.3%) were discharged at home, 220 (6.4%) transferred to another facility, and 2287 (66.3%) were secondarily hospitalized in another hospital unit: more than 9 times out of 10 in a medicine unit (internal medicine 30%, geriatrics 27.9%, respiratory medicine 12.2%). This unscheduled emergency hospitalization allowed a daily hospitalization of 50 short stay inpatients beds. It has to be noted that the number of available inpatient beds clearly decreases during the week-ends. The main pathologies were respiratory infections (14.2%), heart diseases (9.7%), metabolic disorders (3.9%), and urinary tract infections (13.6%).ConclusionThis pre-hospitalization unit associated with a centralized bed management system has clearly improved the unscheduled hospital admissions, in particular concerning the emergency medical sector. The lack of inpatient beds at the week-end and the management of epidemic periods still remain a challenge that has to be taken up.     

Functioning gonadotroph adenoma with severe ovarian hyperstimulation syndrome: A new emergency in pituitary adenoma surgery? Surgical considerations and literature review

The authors reported 2 cases of functioning gonadotroph pituitary adenoma (FGPA) revealed by an ovarian hyperstimulation syndrome (OHSS) in young women. In the first case, OHSS was observed after GnRH analog injection. Pelvic echography revealed multiple voluminous ovarian cysts. Dopamine agonist posology failed in estradiol hypersecretion control, which necessitated endoscopic endonasal transsphenoidal surgery. The patient experienced improvement in pelvic pain as estradiol hypersecretion decreased during the first few postoperative days. Outcome was favorable, and her menstrual cycle was normal after two months. The second case was a young girl with spontaneous pelvic pain and elevated plasma FSH and estradiol levels. FGPA was confirmed on cerebral MRI. Dopamine agonists were introduced, and surgical removal of the pituitary tumor was scheduled for 7 days later. In the meantime, the patient was admitted and underwent surgery for bilateral adnexal torsion related to OHSS. The pituitary tumor was removed one week later. Outcome was favorable, and estradiol and FSH plasma levels were normal after 3 months. The ovarian cysts were no longer visible on echography after 3 months. Given the lack of efficacy of the current standard medical therapy, surgical removal of pituitary adenomas is the reference treatment for FGPA. The authors suggest that severe OHSS related to FGPA should be considered as a relative surgical emergency and that surgery should not be unduly delayed, given the unpredictable risk of adnexal torsion, particularly in case of voluminous ovarian cysts. The authors performed a literature review on this topic.     

Vascularite de l’artère hépatique : à propos d’un cas d’atteinte d’organe isolée

Introduction

Vasculitis usually have a systemic involvement. Rare cases of localized vasculitis have been described, but the exclusive involvement of the hepatic artery is exceptional. We report the case of a patient who developed a vasculitis of the right and left hepatic arteries.

Pseudohypoparathyroidism type Ib in 2015

The term pseudohypoparathryoidism (PHP) refers to a group of rare genetic and epigenetic disorders characterized by resistance to the action of parathyroid hormone (PTH) that activates cAMP signaling in target cells. Together with pseudohypoparathyroidism, Albright hereditary osteodystrophy (AHO) and progressive osseous heteroplasia (POH) represent rare, related and deeply impairing disorders encompassing heterogeneous features, such as brachydactyly, ectopic ossifications, short stature, mental retardation and endocrine deficiencies due to resistance to the action of different hormones. The two main subtypes, PHP-Ia and PHP-Ib, are caused by mutations in GNAS exons 1-13 and methylation defects in the imprinted GNAS cluster respectively, while mutations in the PRKAR1A and PDE4D genes (also involved in mediating cAMP signalling) have been demonstrated in patients with acrodysostosis, a disease of bone formation with characteristics similar to AHO. The molecular overlap among these disorders indicates the need for different classification models and seriously alters our understanding of the mechanisms through which GNAS defects, together with the new recently described defects involving other components of the cAMP signalling cascade, cause AHO-related disorders.     

Impact du bruit professionnel sur le développement de l’hypertension artérielle : enquête réalisée au sein d’une centrale de production d’électricité et de gaz en Tunisie

BackgroundNoise pollution is one of the major environmental pollutants that can adversely affect public health. Cardiovascular diseases are the primary out-auditory adverse outcome caused by occupational noise exposure.AimsTo investigate the association between occupational exposure to high level of noise and blood pressure among a group of workers in a company of electricity production in the Centre of Tunisia.Material and methodsA total of 120 occupational noise-exposed workers and 120 non-exposed employees were recruited to conduct a cross-sectional survey exploring the association between occupational noise-exposed and arterial hypertension. Data collection was based on a questionnaire, a clinical exam and biomarkers. Blood pressure was measured using a mercury sphygmomanometer following a standard protocol. The occupational noise level was measured with a portable calibrated sound meter. Multiple logistic regression was used to calculate the odds ratio (OR) and 95 % confidence interval (CI) of noise exposure adjusted by potential confounders.ResultsThe noise level to which our population was exposed ranged from 75 dB to 103 dB with an average noise level of 89 dB. Mean systolic blood pressure (SBP), mean diastolic blood pressure (DBP) and the prevalence of hypertension were significantly higher in exposed individuals than in non-exposed. In multivariate analysis, elevated SBP in exposed workers was associated with high-salt diet (OR adjusted = 1.71, 95% CI adjusted [1.14–1.98]) and occupational seniority more than 8 years (adjusted OR = 5.31, 95% CI [2.22–12.72]). The factors associated with high BP in the exposed group were diabetes (OR adjusted to 15.31; 95% adjusted CI [2.61–89.58]), history of hypertension in the family (OR adjusted to 11.46; 95% adjusted CI [5.18–83][1.58–83.05]), mean of age (OR adjusted to 6.65; 95% adjusted CI [1.87–23.59]) and high-salt diet (OR adjusted to 0.29; 95% adjusted CI [0.09–0.95]).ConclusionOccupational chronic noise exposure was associated with higher levels of SBP, DBP, and the risk of hypertension. These findings indicate that effective and feasible measures should be implemented to reduce the risk of hypertension caused by occupational noise exposure in companies of electricity production.     

Surdité sous-hydroxychloroquine : premier cas de réintroduction positive et analyse de la base française de pharmacovigilance

Introduction

Several cases of hearing loss induced by hydroxychloroquine have been reported in the literature but the role of hydroxychloroquine still remains debated.

État des lieux de l’enseignement théorique et pratique de 3e cycle de médecine interne en France : résultats d’une enquête nationale

Objective

To make an inventory of training of Internal Medicine in France.

Fertility of tomorrow: Are there any restrictions left?

As the concepts of society, parenthood and family evolve, the French law on bioethics has recently been updated by authorizing oocyte and sperm cryopreservation for all individuals who wish to do so, in the absence of medical indications. For women, aging irremediably impairs reproductive competence, both quantitatively and qualitatively. For men, aging has a negative impact on sperm parameters. Hence, this possibility of social oocyte/sperm freezing is a real breakthrough, offering to all the opportunity to better anticipate age-related fertility decline and be better actors of one's reproductive life. In its current form, the new French bioethics law allows unrestricted access to fertility preservation techniques to all women and men that fulfill the age criteria. In light of the lack of official recommendations, many questions remain. In clinical practice, it is therefore up to centers to determine on a case-by-case basis the limits of these procedures, notably to define when to stop fertility preservation. This also questions the place of the patient as a decision maker in the procedure and to which extent these procedures should be performed according to patient preference. Altogether, despite the wide range of possibilities enabled by these major legal and technical advances, it is essential to make clear to all that undergoing fertility preservation procedures is not a guarantee of future pregnancy and does not replace timely care of fertility issues.