The overuse of laboratory tests in hospitals contributes to increased healthcare costs and a larger environmental footprint. This study aimed to evaluate the impact of a rational laboratory test-ordering strategy in an internal medicine department. We conducted a prospective, single-center study in an internal medicine department. The study consisted of a baseline phase without intervention followed by an intervention phase during which internal guidelines promoting rational test ordering were implemented and supervised. The primary outcomes were changes in the volume and cost of the most frequently ordered laboratory tests. Secondary outcomes included hospital activity indicators and morbidity and mortality data. A total of 1,816 patients were admitted for inpatient care between November 2023 and April 2024. Following implementation of the rational prescribing strategy, the volume of orders significantly decreased for the ten targeted laboratory tests (complete blood count, C-reactive protein, vitamins B9 and B12, lipid panel, serum protein electrophoresis, HbA1c, vitamin D, B-type natriuretic peptide [BNP], and thyroid-stimulating hormone [TSH]), with reductions ranging from 33% to 69%. The overall cost of these tests decreased by €11,334 over three months. No significant differences were observed between the two periods in terms of number of admissions, mean length of stay, transfers to intensive care, or in-hospital mortality. Implementing a rational laboratory test-ordering strategy in an internal medicine department significantly reduced the volume and cost of testing without adversely affecting hospital activity indicators or morbidity and mortality outcomes. This simple, reproducible, and well-accepted approach represents a practical opportunity for clinical, economic, and environmental optimization.
CPT-2 deficiency is an autosomal recessive energy metabolism disorder that can present in three forms, the most common being the muscle form, which is characterized by recurrent episodes of rhabdomyolysis throughout life. The diagnosis is usually established during childhood or adolescence, but it may sometimes be delayed and made later in adulthood. Prompt emergency management helps prevent complications related to rhabdomyolysis. We present the case of a 68-year-old patient diagnosed with CPT-2 deficiency 57 years after the initial episode, following an emergency admission for pyelonephritis associated with severe rhabdomyolysis. The medical history revealed a long-standing pattern of recurrent myalgias. Acylcarnitine profile was suggestive of CPT2 deficiency, which was confirmed genetically. This case highlights the importance of considering the diagnosis of such inherited metabolic disease even in older patients. Indeed, subtle clinical presentation and resolution of symptoms between episodes can lead to significant diagnostic delays.
The average length of stay (ALOS) has increased in our Internal Medicine Department since 2020 and we decided to investigate its origin. We analysed retrospective data from hospital stays between 2018 and 2024. In 2024, we also prospectively studied the hospital stays with delayed discharge defined by prolonged stays for no medical reason. Between 2020 and 2024, ALOS increased from 6.5days to 9.3days. Performance index based on ALOS, that allows a stratification of ALOS on patient severity, also increased linearly by 2.6 points per year (R2=0.84). We observed a constant reduction in the access to rehabilitative care departments (-30%). In 2024, 11.0% (96/869) of discharges were considered delayed, cumulating 1261days of stay with no medical reason (15.7% of the activity). Among the causes of hospitalisation, the fall was associated with the highest cumulative delay of discharge (402days for 26stays), the psychiatric disorders were associated with the highest delay per stay (199days for 7stays). Delayed discharges were mainly due to delays to access to rehabilitative departments (55stays; 760days). Improving the ALOS cannot be achieved without a global reflexion including strong social services supported by the hospital management and public policies decisions.
Mature T-cell lymphoproliferative disorders are rare and aggressive hematologic malignancies characterized by marked clinical and biological heterogeneity. Their incidence is rising worldwide, with significant geographic disparities, particularly between Western countries and Asia. Several environmental, occupational, and infectious risk factors have been suggested, although no causal link has been firmly established. Diagnosis is often delayed due to nonspecific initial presentations and requires close collaboration among hematologists, internists, pathologists, and other specialists. The 2022 WHO classification identifies nine families, based on the cell of origin, clinical context, cytomorphology, and anatomical site of the tumor. In internal medicine, the most frequently encountered subtypes are angioimmunoblastic T-cell lymphoma (AITL), peripheral T-cell lymphoma not otherwise specified (PTCL-NOS), and anaplastic large cell lymphoma. Their clinical presentations commonly include systemic symptoms, generalized lymphadenopathy, cutaneous or visceral involvement, and immune dysregulation that may be inaugural, particularly in AITL. Diagnosis relies on expert cyto-histological analysis, including immunophenotyping, Tcell clonality assessment, and molecular biology. Recent genomic advances have identified recurrent alterations affecting TCR and JAK/STAT pathways, genes regulating epigenetic mechanisms (TET2, DNMT3A, IDH2), and immune escape processes (PD-L1), thereby redefining disease entities and paving the way for targeted therapeutic approaches. Prognosis remains globally poor with conventional polychemotherapy, although outcomes vary by molecular subtype. Early recognition by clinicians is critical to ensure timely referral to expert centers and the initiation of appropriate management strategies.
Subcutaneous (SC) infusion, or hypodermoclysis, is a route of administration involving the injection of fluids or medications into the hypodermis. Historically used and subsequently abandoned due to complications arising from poor technique, it has regained interest since the 1990s, particularly in geriatrics and palliative care. Compared with the intravenous (IV) route, it is less invasive, better tolerated, easier to implement in outpatient settings, and carries a lower risk of serious complications. The pharmacokinetics of the SC route show slightly slower absorption than IV administration, with bioavailability often exceeding 80% for hydrosoluble compounds. Main indications include the preventive or therapeutic management of moderate dehydration, palliative care (analgesics, anxiolytics, antipyretics, antisecretory agents), and some antibiotics (such as ceftriaxone, as well as ertapenem and teicoplanin, with a good level of supporting evidence). In internal medicine departments, the SC route can also be used for furosemide, levetiracetam, and vitamin B12 when no alternative is available. Some vaccines may be administered subcutaneously in patients with contraindications to the intramuscular route. Local adverse events may occur but are generally mild (pain, edema), transient, and infections are rare. Although often used off-label, hypodermoclysis is a safe and practical alternative, particularly suited to elderly or frail patients, and meets current healthcare challenges related to outpatient medicine and hospital overcrowding. Its wider adoption relies on healthcare professional training, standardized protocols, and robust comparative data.
Systemic autoinflammatory diseases (SAIDs) are associated with a dysregulation of innate immunity leading to recurrent or chronic inflammation. There are both well-characterized monogenic forms, such as familial Mediterranean fever, cryopyrinopathies and VEXAS syndrome, and multifactorial forms defined by classification criteria, such as Still's disease, Schnitzler syndrome and SITRAME. However, a significant proportion of patients, estimated at up to 73% in some series, present with an autoinflammatory phenotype without any identified pathogenic variant or established diagnosis based on classification criteria. These situations are grouped under the term undifferentiated systemic autoinflammatory diseases (USAID). In adults, the most common manifestations are recurrent fever, fatigue, myalgia, arthralgia, cutaneomucous and digestive features, ENT or ocular involvement. Clinical heterogeneity contributes to delayed diagnosis, which can take several years. Diagnosis is based on repeated documentation of a biological inflammatory syndrome, the progression of symptoms over at least six months, the exclusion of common differential diagnoses (infections, cancers, haematological disorders or autoimmune diseases) and the absence of criteria allowing to classify the patient to a defined entity. Investigations include repeated biological tests, screening for immune deficiencies or autoantibodies, and sometimes genetic testing to detect monogenic diseases with either germinal or somatic variants. In the absence of specific criteria, response to treatments targeting innate immunity, such as colchicine or cytokine inhibitors (IL-1, IL-6, TNF, JAK), may confirm the diagnosis. USAID in adults is an emerging entity, on the borderline between monogenic and multifactorial diseases, the recognition of which is essential to reduce diagnostic uncertainty and adapt management.
Metabolic steatotic diseases affect 16.7% of the French population, i.e. approximately 8 million individuals. Approximately 60% of type 2 diabetes patients have hepatic steatosis, 30% of whom also have fibrosis. The progression of fibrosis, linked to systemic inflammation, is associated with a significant increase in cardiovascular and cancer mortality (particularly hepatocellular carcinoma and colorectal adenocarcinoma). In 2023, an international reform of the nomenclature led to the replacement of the old terminology "non-alcoholic fatty liver disease (NAFLD)" and "non-alcoholic steatohepatitis (NASH)" in order to better reflect the metabolic causes. The following terms were defined: "steatotic liver disease (SLD)", which refers to all forms of steatosis, "metabolic dysfunction-associated steatotic liver disease (MASLD)", which explicitly includes metabolic factors, and "metabolic dysfunction-associated steatohepatitis (MASH)", which emphasizes histologically confirmed metabolic steatohepatitis. A new entity, "metabolic alcohol-related liver disease (MetALD)," refers to MASLD with moderate but regular alcohol consumption. The definition of "alcohol-related liver disease (ALD)" remains unchanged (alcohol consumption greater than 50-60g/day). "Cryptogenic steatosis" includes cases with no known cause. This new classification allows for the continued use of previous data and aims to improve patient stratification for personalized treatments.
The immunology of fertilization, implantation and pregnancy is based on a complex balance between maternal immune tolerance and a controlled inflammatory response. Adaptation of the maternal immune system is essential for the survival of the semi-allogenic foetus, and any imbalance can lead to complications such as implantation failure, early pregnancy loss and obstetric pathologies. Several cell types, including uterine Natural Killer (NKu) cells, macrophages and dendritic cells, play a key role in regulating the maternal-fetal interface. Similarly, the balance between pro- and anti-inflammatory cytokines, as well as the expression of specific HLA molecules, determines the success of gestation. Immunological disorders, such as those observed in endometriosis, adenomyosis and chronic endometritis, alter endometrial receptivity and increase the risk of reproductive failure. In addition, abnormalities in NK cell activation and cytokine profile have been implicated in repeated implantation failure and recurrent pregnancy loss. Although immunomodulatory treatments such as corticosteroids, intravenous immunoglobulins and intralipids are being explored to improve pregnancy outcomes, their efficacy has yet to be confirmed by large-scale studies.
The antibiotic susceptibility test (antibiogram) is an essential tool in the treatment of bacterial infections. By guiding the choice of antibiotic based on bacterial susceptibility, it plays a key role in determining therapeutic success. This practical update is intended for clinicians. It covers the principles of how antibiograms are performed, along with the foundations for interpreting their results. Recent changes in EUCAST categorization (S, SFP, R) are explained, with particular emphasis on the concept of "increased exposure" for antibiotics classified as SFP (Susceptible, Increased exposure). The second part focuses on interpreting the antibiogram in a clinical context, taking into account bacteriological, clinical (site of infection, severity, comorbidities), and pharmacological parameters (PK/PD, antibiotic concentration at the infection site). Practical examples of how to use the minimum inhibitory concentration (MIC) are provided to help guide therapeutic decisions. Finally, the specific features of the most frequently encountered bacteria in both outpatient and hospital settings are discussed. This review aims to strengthen prescribers' competencies in adopting a rational and individualized approach to antibiotic therapy, in the face of the growing challenge of bacterial resistance.
Giant cell arteritis (GCA) is the most common vasculitis after the age of 50. Large vessel vasculitis (LVV) is frequently observed in 40 to 70% of cases, primarily affecting the aorta. Extracranial LVV is scarcely described. We present four cases of LVV-GCA without aortitis. LVV was found in 3 cases on PET-CT showing limb involvement, for the last case, CT scan revealed involvement of mesenteric artery. The diagnosis of GCA was confirmed in three of the four cases by temporal artery biopsy. In the last case, the diagnosis was made after PET-CT analysis and ophthalmological examination with a pathognomonic angiography. Three patients developed corticosteroid dependence and the last one was lost to follow-up. LVV without aortitis evolution is rarely described. We report here 4 cases, 3 of whom became corticosteroid dependent. Larger cohort studies are needed to assess the prognosis and therapeutic impact of this particular phenotype of GCA.
Inflammatory enteropathies are frequent in primary immune deficiencies (PID) (up to 21%). Their pathophysiology is complex and combines immune abnormalities (loss of tolerance, deficit in mucosal IgA secretion and altered infectious response) with an abnormal environment (dysbiosis, production of pro-inflammatory endotoxins, epigenetic and epitranscriptomic alterations). This leads to a deregulated inflammatory state of the gastrointestinal tract and thus to enteropathy. These conditions are heterogeneous and manifest not only as an inflammatory bowel disease but also as in lymphocytic, autoimmune, or eosinophilic colitis. Most of the time PID associated enteropathies remain unspecified. Their clinical, biological, and scannographic features are difficult to distinguish from enteropathies in immunocompetent patients. However, some histological specificities are described including graft-versus-host disease phenotype, with apoptotic bodies, and absence of mucosal plasma cells. There is no standardized treatment for this specific condition. Treatments of inflammatory bowel disease in immunocompetent patients are usually used, although refractory cases are more frequent. This entity is associated with an increased risk of autoimmune manifestations notably including autoimmune cytopenia. Finally, IBD in PID are associated with an increased risk of death related to the enteropathy and its treatments.
To estimate the prevalence of burnout among internists practicing in France, identify its determinants, and describe their professional experience based on free-text comments. A national cross-sectional online survey was conducted at the end of 2024 through the French National Society of Internal Medicine (SNFMI). The questionnaire included a modified burnout inventory (mMBI) and contextual items related to work organization, sleep, and mental health. Severe burnout was defined by a high emotional exhaustion (EE) score≥27 or a high depersonalization (DP) score≥10. "Triple impairment" was defined as the combination of high EE, high DP, and low personal accomplishment (PA≤33). Analyses included comparisons across professional profiles and multivariable logistic regressions. A thematic analysis of free-text comments complemented the quantitative findings. Among 434 respondents (123 residents, 244 attending physicians, 67 academic staff), 58% met criteria for severe burnout and 19% for triple impairment. In the adjusted model, severe burnout was associated with≥55 working hours per week (aOR 1.82; P=0.018), insufficient recognition (aOR 3.24; P<0.001), altered sleep (aOR 4.37; P<0.001), and psychotropic medication use (aOR 2.56; P=0.014). Over 70% of participants provided at least one free-text comment, most often describing emotional fatigue, loss of meaning, bureaucratization, and lack of consideration, while also emphasizing a strong sense of vocation, teamwork, and commitment to patients. Burnout among French internists is frequent and multifaceted, primarily driven by organizational factors. Simplifying medical work, enhancing institutional recognition, and strengthening professional autonomy appear to be the key levers.
Internal medicine day hospitals are facing a growing demand for intravenous (IV) iron infusions. This study aimed to describe the clinical characteristics and underlying etiologies of patients receiving IV iron in this setting. A retrospective, single-center study was conducted over a one-year period in an internal medicine day hospital. Data collected included prescriber specialty, patient demographics, etiological work-up, prior treatments, and treatment tolerance. Multivariate analysis was performed to identify risk factors associated with repeated infusions. We included 158 patients (88% women; median age 44 [36-53] years). An etiology was identified in 89%; the main causes were gynecological (51% of women), post-bariatric surgery malabsorption (17%), and gastrointestinal causes (16%). Prior oral iron was documented in 57%. In the gynecological subgroup, 37% had non-mechanical contraception and 43% received an antifibrinolytic. Repeated infusions involved 59/155 (38%). Patients with repeated infusions were older (47 vs 40.5 years; P=0.02); other comparisons were not significant. In age and sex-adjusted models, age remained weakly associated (OR 1.02 [1.00-1.05]; P=0.03), with no significant relationship for other variables. In the multivariate model using forced age and sexe and forward AIC selection of other variables, ferritin (OR 1.02 [0.99-1.05]; P=0.14) and bariatric etiology (OR 2.21 [0.87-5.58]; P=0.09) were retained but however not reaching significancy. Adverse events were recorded in 150 patients: 3% overall (2% allergic, 1% non-allergic). These findings highlight two populations addressed in internal medicine day hospital for iron IV: on the one hand, young women with heavy uterine bleeding, on the other hand, patients suffering from malabsorption following bariatric surgery. Reinforcing the role of primary care- in particular contraception, antifibrinolytic use, etiological investigation, and nutritional follow-up after bariatric surgery - is essential to prevent avoidable iron deficiency and improve long-term management.
The nurse-to-patients ratio in internal medicine and general medicine departments is not regulated by the French Public Health Code, unlike in certain acute care units. Yet this ratio has an impact not only on the quality of working life, but also on mortality and the length of stay for patients. We carried out a national survey to identify the ratios existing in internal and general medicine units. A national descriptive online survey was carried out under the impetus of the scientific council of the Conseil National Professionnel de Médecine Interne. One hundred and thirty responses were received. Of these, 63% were hospital practitioner and 14.6% were professors. Their specialty was internal medicine in 80% of cases, and 46% of them practiced in a university hospital, while 42% worked in a local hospital. The mean age of respondents was 44.8 years, 62% of whom were men. The mean number of beds per unit was 25.6, and 69.6% of patients hospitalized in internal medicine units came from emergency departments. The mean age of patients was 70.7 years. Seventy-two percent of practitioners felt that the nurse staffing should not be less than 1/8 (98%, 1/10) and 80% of practitioners felt that the auxiliary nurse staffing ratio should not be less than 1/8 (98%, 1/10). One hundred and eleven departments (85%) reported more than 8 patients per nurse, including 46 university hospital (77%) and 65 local hospital (93%), and 91 units (72%) more than 8 patients per caregiver. The average number of patients per nurse was greater in local hospitals (11,4±2 versus 10±1, p=5.10-5). This survey shows wide disparities in current caregiver/patient ratios. However, there is a clear consensus to identify target ratios for nurses, auxiliary nurses and auxiliary nurses.
Recurrent pericarditis is characterised by repeated episodes of pericardial inflammation separated by an asymptomatic interval of at least 4 to 6 weeks. Diagnosis relies on typical clinical features (chest pain, pericardial friction rub), imaging-primarily echocardiography, with MRI when needed-and inflammatory markers, particularly C-reactive protein (CRP). The initial assessment aims to identify an underlying cause, which is most often idiopathic (frequently presumed post-viral) but may be autoimmune, autoinflammatory, or infectious. Management requires close coordination between specialists and reference centres, with the primary goal of preventing recurrence. Colchicine is the cornerstone of therapy and should be prescribed for 3 to 6 months, and often longer. During acute flares, NSAIDs or aspirin are recommended in combination with colchicine. Corticosteroids are no longer indicated, except in highly specific situations. In severe or refractory forms, early use of interleukin-1 inhibitors-particularly anakinra or rilonacept-should be considered. Long-term follow-up includes clinical and laboratory monitoring to ensure symptom resolution and normalisation of CRP levels, as well as regular assessment of quality of life. Treatment withdrawal must be very gradual, over several months or even years, and supported by therapeutic patient education to help patients recognise early warning signs. Coordinated follow-up within structured care networks is essential to ensure optimal access to treatment and advanced therapies. This French Protocol for Diagnosis and Management aims to provide clinicians with clear, harmonised, and up-to-date guidance to improve the diagnosis, treatment, and long-term care of patients with recurrent pericarditis.
Peripherally inserted central catheters (PICCs) are increasingly used in France for prolonged intravenous therapies such as chemotherapy, parenteral nutrition, or antibiotics. They are easier to place than traditional central venous catheters and carry fewer immediate risks, but remain associated with delayed complications, mainly infections, thromboembolic events, and mechanical issues. This literature review aimed to identify risk factors for PICC-related infections and thrombosis. The study used BIBOT, an artificial intelligence program for natural language processing, already validated in prior reviews and the IA language model LLaMA3. PubMed was searched for studies published between 2013 and 2023. Using the AI-based tool BIBOT, 1896 PubMed abstracts on PICCs were automatically screened. After filtering and AI-assisted content analysis, 343 original articles focusing on PICC complications were identified, enabling a targeted selection of 113 articles on infectious and 281 on thrombotic complications. In total, 20 infectious and 59 thrombotic risk factors were manually identified. Among these, the most frequently reported in the reviewed articles for infections were number of lumens, chemotherapy and catheter dwell time. For thrombosis, the most commonly cited factors included cancer or hematologic disease, chemotherapy, PICC diameter and number of lumens (>2). The study highlights the value of AI-based tools to accelerate article selection and data extraction in medical literature. However, human validation remains essential to avoid errors and misinterpretations, particularly with acronyms or heterogeneous definitions. Hybrid approaches combining AI with expert review save considerable time and are expected to improve further with multimodal models and multi-agent strategies.
Hepatic encephalopathy is a neuropsychologic disorder due to hyperammonaemia, related to liver failure and/or portosystemic shunts for instance. We herein describe the case of a 74-year-old woman who developed hepatic encephalopathy in the context of portal hypertension secondary to chronic stenosis of the left common femoral vein. A 74-year-old woman presented with confusion and major hyperammonemia (>100μmol/L). She had a past medical history of angioma of the left leg treated with radiotherapy. Post radiotherapy stenosis of the left common femoral vein occurred, then bypass paths leading to large pelvic varicose veins draining into the inferior mesenteric vein. There was no evidence for liver failure and common causes of confusion were excluded. The liver biopsy was refused by the patient. In the absence of another etiology, the retained diagnosis was an hepatic encephalopathy secondary to portal hypertension, related to inferior mesenteric vein hyper flow draining into the splenic vein, then into the portal vein. Treatment by lactulose and rifaximine allowed clinical improvement and hyperammonemia reduction. An hepatic encephalopathy may occur without any evidence of hepatopathy, in the context of venous malformations responsible for portal venous hyper flow, as illustrated by this unusual case report.
Double-negative T lymphocytes with αβ TCR (CD3+CD4-CD8-TCRαβ+) are a population of T cells present in low proportions in the blood under normal conditions. They can be abnormally elevated in various pathological situations. A 64-year-old female patient was hospitalized due to a general deterioration of health. Laboratory tests revealed a monoclonal proliferation of double-negative αβ T lymphocytes, representing 28% of T cells (219/mm3). A thoraco-abdomino-pelvic CT scan revealed two suspicious intrahepatic masses, multiple enlarged lymph nodes, and peritoneal nodules. These lesions were hypermetabolic on 18FDG PET scan. A biopsy of the hepatic masses showed histological features consistent with cholangiocarcinoma. We report a case illustrating how the investigation of a proliferation of double-negative αβ T lymphocytes led to the diagnosis of cholangiocarcinoma. Although a direct link between the two cannot be proven, we hypothesize that tumor antigenic stimulation selected a T lymphocyte clone.
Aspiration pneumonia is a specific respiratory infection. It is frequent and severe, and represents a pressing issue given the growing ageing population. For the first time, French guidelines clarify how to manage this infection. We therefore wanted to present a revised review on this topic. The main aim is to highlight strategic elements based on pathophysiology. Diagnosis is based on clinical and radiological criteria; however, the aspiration event remains difficult to define. Biological tests are still important for follow-up and evaluating the impact of the disease on different organ systems. Microbiological examinations should not be performed systematically, but only under specific conditions. Antibiotherapy is based on simple principles: amoxicillin-clavulanic acid is the first-line treatment, administered orally wherever possible, and metronidazole should not be used. A careful analysis of the context and risk factors is essential for effective prevention. This is a multimodal and multidisciplinary approach involving rehabilitation, nutritional care and oral hygiene.
Bispecific T-cell engagers (BiTEs) represent a new generation of immunotherapies capable of redirecting T lymphocytes toward specific targets, particularly B cells and their plasmacytic derivatives. Initially developed in hematology for the treatment of malignant hematologic disorders, BiTEs are now attracting increasing interest in the field of severe or refractory autoimmune diseases. Their mechanism of action relies on the formation of an immunological synapse between cytotoxic T cells and B cells and/or plasma cells expressing antigens such as CD19, CD20, or BCMA, thereby reducing autoantibody production through depletion of B cells and their plasmacytic derivatives. Unlike cellular therapies, this strategy does not require genetic modification or patient-specific manufacturing, offering potential advantages in terms of depth and durability of response, while also raising questions regarding safety, feasibility, and cost. This article provides an overview of preclinical and clinical data on the use of BiTEs in autoimmune diseases and discusses the perspectives and challenges associated with their development in this therapeutic area.