Development of an Objective Structured Clinical Examination (OSCE) to evaluate the diagnosis announcement of chronic neurological disease by residents in neurology

BACKGROUND

There is little consensus on how to make a diagnosis announcement of severe chronic disease in neurology. Other medical specialties, such as oncology, have developed assessment methods similar to the Objective Structured Clinical Examination (OSCE) to address this issue. Here we report the implementation of an OSCE focused on the diagnosis announcement of chronic disease in neurology by residents.

OBJECTIVE

We aimed to evaluate the acceptability, feasibility and validity in routine practice of an OSCE combined with a theoretical course focused on diagnosis announcement in neurology.

METHOD

Eighteen neurology residents were prospectively included between 2019 and 2022. First, they answered a questionnaire on their previous level of training in diagnosis announcement. Second, in a practical session with a simulated patient, they made a 15-min diagnosis announcement and then had 5mins of immediate feedback with an expert observer, present in the room. The OSCE consisted of 4 different stations, with standardized scenarios dedicated to the announcement of multiple sclerosis (MS), Parkinson's disease (PD), Alzheimer's disease (AD) and amyotrophic lateral sclerosis (ALS). Third, in a theory session, expert observers covered the essential theoretical points. All residents and expert observers completed an evaluation of the "practical session" and the "theory session".

RESULTS

Residents estimated their previous level of diagnosis announcement training at 3.1/5. The most feared announcements were AD and ALS. The "practical session" was rated at a mean of 4.1/5 by the residents and 4.8/5 by the expert observers, and the "theory session" at a mean of 4.7/5 by the residents and 5/5 by the expert observers. After the OSCEs, 11 residents felt more confident about making an announcement.

CONCLUSION

This study has shown a benefit of using an OSCE to learn how to make a diagnosis announcement of severe chronic disease in neurology. OSCEs could be used in many departments in routine practice and seem adapted to residents.

[Learnings from the use of CEdRIC strategy in the context of COVID-19 pandemic]

This article relates the experience of mobilisation of the CEdRIC strategy by health promotion staff of the Province of Liège, Belgium between June and September 2020. The perception of the beneficiaries is also approached. Four key messages are discussed in the article: the adjustment of a brief educational intervention strategy to the context of the pandemic and integration into primary care; the need for the citizen to be heard and accompanied in times of crisis; the need to go beyond information to health education embedded in a health promotion approach; the role that a structure such as the Province of Liège can play in the health promotion landscape. This article relates the experience of mobilisation of the CEdRIC strategy by health promotion staff of the Province of Liège, through the eyes of the beneficiaries (citizen) contacted by telephone in the days following the intervention. The results indicate an over-information concerning the rules to be respected and a good knowledge of preventive measures. The participants consider these measures useful, easy to apply and declare that they have a role to play in the fight against the pandemic. Nevertheless, not all of the recommendations made by the government are implemented by all participants. Future research should focus on adherence to preventive measures and the factors that can influence this adherence so that future and sustainable actions can be put in place.

[Quality of life in the medical field : a brief overview of its origin, semantics, measuring instruments and clinical use]

Since the early 1970s, the concept of quality of life has been the subject of increasing interest in the medical field, although no scientific consensus has emerged on how to define and measure it. The aim of this narrative review of the literature is to decrypt the notion of quality of life in the medical field, in order to enable clinicians-researchers and clinicians who use quality of life measurement instruments in clinical practice to form an informed and nuanced opinion on the issue. To do so, the paper is divided into three parts. Firstly, a brief overview of the origin of the concept in the medical field is given by exposing the main factors explaining its emergence and its rise in importance. Next, the plurality of definitions of quality of life and its derivatives (e.g. health-related quality of life), as well as its measurement instruments in the medical field, are explored. Finally, some benchmarks for the use of health-related quality of life instruments in clinical practice are presented.

"Patient participation" and related concepts: A scoping review on their dimensional composition

OBJECTIVES

Several concepts on collaboration between patients and healthcare systems have emerged in the literature but there is little consensus on their meanings and differences. In this study, "patient participation" and related concepts were studied by focusing on the dimensions that compose them. This review follows two objectives: (1) to produce a detailed and comprehensive overview of the "patient participation" dimensions; (2) to identify differences and similarities between the related concepts.

METHODS

A scoping review was performed to synthesize knowledge into a conceptual framework. An electronic protocol driven search was conducted in two bibliographic databases and a thematic analysis was used to analyse the data.

RESULTS

The search process returned 39 articles after exclusion for full data extraction and analysis. Through the thematic analysis, the dimensions, influencing factors and expected outcomes of "patient participation" were determined. Finally, differences between the included concepts were identified.

CONCLUSION

This global vision of "patient participation" allows us to go beyond the distinctions between the existing concepts and reveals their common goal to include the patient in the healthcare system.

PRACTICE IMPLICATIONS

This scoping review provides useful information to propose a conceptual model of "patient participation", which could impact clinical practice and medical training programs.

Regulation of hepatokine gene expression in response to fasting and feeding: Influence of PPAR-α and insulin-dependent signalling in hepatocytes

AIM

In hepatocytes, the peroxisome proliferator-activated receptor (PPAR)-α and insulin receptor (IR) are critical for transcriptional responses to fasting and feeding, respectively. The present report analyzes the effects of nutritional status (fasting vs feeding) on the expression of a large panel of hepatokines in hepatocyte-specific PPAR-α (Pparα^hep-/-) and IR (IR^hep-/-) null mice.

METHODS

Pparα^hep-/- and IR^hep-/- mice, and their wild-type littermates, were subjected to fasting or feeding metabolic challenges, then analyzed for hepatokine gene expression. Experiments were conducted in mice of both genders.

RESULTS

Our data confirmed that PPAR-α is essential for regulating fasting-induced Fgf21 and Angptl4 expression. In mice lacking PPAR-α, fasting led to increased Igfbp1 and Gdf15 gene expression. In the absence of hepatic IR, feeding induced overexpression of Igfbp1, follistatin (Fst) and adropin (Enho), and reduced activin E (Inhbe) expression. Gender had only a modest influence on hepatokine gene expression in the liver.

CONCLUSION

The present results highlight the potential roles of hepatokines as a class of hormones that substantially influence nutritional regulation in both female and male mice.

[Alcohol consumption : from epidemiology to prevention]

The epidemiological data about alcohol consumption show that the current preventive measures have their limits. Worryingly, the morbidity and mortality associated remain significant in the world. Two main types of preventive approaches, based on individual affect exist: the negative approach based on fear and threat and the so-called Social Norm Approach (SNA). The last original and more positive approach has been used across the Atlantic for thirty years and shows to be efficient. It aims to reduce an individual's consumption of addictive substance by confronting his own social norm (what he thinks people drink, quantities generally overestimated) to the real norm of consumption by a reference social group. A cross-border project is currently evaluating the feasibility of this approach in the Euregio Meuse-Rhin.

[Patient partner approach into question]

Patient engagement in health care system can be regarded as a lever for the general improvement of people's health, the quality and safety of care. Among the many approaches that co-exist, the model of Patient Partner is relatively recent and declares itself as the most successful to promote this engagement. The authors of this article propose to present briefly the above model and to raise the remaining questions on its operational application. We will then present the research program «Patient Partner Approach to Care» (INTERREG Va) that questions the Patient Partner model in an interregional context (Wallonia - Grand Duchy of Luxembourg - Lorraine - Rhineland-Palatinate and Saarland).

[Exploratory population study of overweight and obese subjects' perceptions: Searching for improved management practices]

BACKGROUND

Overweight and obesity are major public health problems of growing concern. Few studies have investigated the representations and perceptions of subjects with overweight and obesity, especially in the general population, as compared to people in a medical weight loss process. The objective of this study was to fill this gap by enabling participants to express their feelings and experience about their overweight, and to assess the extent of the body mass index (BMI) as a determinant of these perceptions.

METHODS

A total of 4155 persons participated in an exploratory study conducted in Wallonia (Belgium). Data were collected by means of a web-based questionnaire. This study investigated the following parameters: sociodemographic and anthropometric factors, perceived health, quality of life, diet perception, enrolment in a weight loss process and weight loss target. The influence of BMI was considered, on one hand, looking at how the above variables evolve according to BMI category, secondly, as a mediation factor in the relationship between socioeconomic level and these same variables.

RESULTS

A large majority (87.5%) of subjects were overweight (32.2%) or obese (obese class I 29.9%, class II 14.8%, class III 10.6%). Perceived health was found to deteriorate with the BMI (P<0.0001); obese class III had a 5.9-fold risk to present bad perceived health compared to subjects with normal weight. The physical and psychological quality of life reported by the subjects decreased significantly with the BMI (P<0.0001) particularly for the physical quality of life. The percentage of poor diet perception (frustration, weight gain, aggressiveness, inefficacy and impossibility) as well as the weight loss targeted by the subjects increased with the BMI. Between overweight subjects and obese class III subjects, weight loss target increased from 13% to 34% of the initial weight. The majority of subjects judged that diet represents "aggressiveness", "weight gain" and "impossibility". A partial mediation role of BMI was identified in the relationship between social status and the variables of interest.

CONCLUSIONS

This study focused on a sample of people from the general population. It confirmed previous results of others studies. All results gave a feeling of resignation and powerlessness which can seize obese individuals (especially when BMI increases). As a consequence, there is a need for more adapted weight management to achieve a genuine therapeutic alliance.

[Health literacy, a way to reduce social health inequalities]

Health Literacy (HL) is defined as «the knowledge, motivation, and competences to access, understand, appraise and apply health information in order to make judgments and take decisions in everyday life concerning health care, disease prevention and health promotion to maintain or improve quality of life». This concept begins to be recognized as a priority area for action at political level in Belgium. Indeed, a limited HL may affect health by leading, for example, with poorer management of chronic diseases, more hospital admissions and premature deaths. This paper addresses the question of HL evaluation, improvement interventions as well as the many challenges that remain in this area. HL seems fundamental to the development of better health management. It would allow patients to play a more active role in health care, to involve all health stakeholders, and to contribute to a more sustainable health system. Improving HL could allow better equal access to health care.e.

[Birth weight discordance in dichorionic twins: diagnosis, obstetrical and neonatal prognosis]

OBJECTIVE

To describe neonatal and obstetrical prognosis in dichorionic (DC) twins with a birth weight discordance under 20% and evaluate the influence of intrauterine growth restriction on the management.

PATIENTS AND METHODS

We studied retrospectively 67 DC twins birth between July 2002 and July 2012 at our university labour ward. Birth weight discordance was considered slight between 20-25%, moderate between 25-30%, and severe over 30%.

RESULTS

Prevalence of birth weight discordance in DC twins is estimated at 11.4% in our study. Eighty percent of severe discordance was diagnosed before delivery, 41% for moderate discordance and 20% for slight discordance. We note 30% of pre eclampsia in our population with 44% in the severe discordance group. Mean gestational age was 35.1 weeks for slight and moderate discordances, and 33 weeks for severe discordance. Caesarean section rate was 48% for severe discordance and only 36% for slight discordance. Vaginal delivery rate is 56.7%. More than half of patient with a severe discordance gave birth vaginally. Intrauterine growth restriction rate under the 10th percentile was 18.7%. Prevalence of IUGR was 24% in sever discordance group, 23.5% in the moderate discordance group and 10% in the slight group. Neonatal morbidity rate was 20.8% mainly in children with IUGR.

DISCUSSION AND CONCLUSION

Neonatal mortality and morbidity rate are mainly increased in severe discordant twins. These pregnancies are at high risk of maternal morbidity. Vaginal delivery must be preferred for slight and moderate discordances. In case of severe discordance, vaginal delivery should be considered depending on the degree of intrauterine growth retardation.

Lumiracoxib Does Not Affect the Ex Vivo Antiplatelet Aggregation Activity of Low-Dose Aspirin in Healthy Subjects

This randomized, double-blind, placebo-controlled study evaluated the pharmacodynamic effects of concomitant low-dose aspirin and lumiracoxib in healthy subjects. Participants received lumiracoxib 400 mg once daily (n = 14) or placebo (n = 14) for 11 days, with concomitant low-dose aspirin (75 mg once daily) from days 5 to 11. Ex vivo pharmacodynamic assessments included assays of platelet aggregation and urinary thromboxane and prostacyclin metabolite profile. Arachidonic acid-stimulated platelet aggregation was reduced from 76.3% on day 4 to 4.8% on day 11 in the placebo group and from 75.8% on day 4 to 5.1% on day 11 in the lumiracoxib group. Collagen-induced platelet aggregation was reduced from 77.5% on day 4 to 52.8% on day 11 in the placebo group and from 79.5% on day 4 to 55.9% on day 11 in the lumiracoxib group. Urinary thromboxane and prostacyclin were unaffected by lumiracoxib. In conclusion, concomitant lumiracoxib did not interfere with the cyclooxygenase-1-mediated antiplatelet effects of low-dose aspirin.

[BNP and NT-proBNP: reference values and cutoff limits]

Natriuretic peptides, particularly BNP and NT-proBNP, are increasingly used as screening test in patients with symptoms suggestive of heart failure (HF). Due to their high negative predictive values, natriuretic peptide determinations allow to exclude chronic HF with great certainty and to identify patients for whom echography is not necessary. These biomarkers are also useful for diagnostic purposes, high plasma levels being related to an increased risk of cardiovascular hospitalisation and death. Risk stratification in patients with HF symptoms is based on "low" and "high" cut-off limits, for which different values have been proposed. The aim of this paper is to discuss the delineation of the decision limits and the intermediate grey zone in comparison to NT-proBNP reference values obtained in a representative group of subjects living in the Liège area (Belgium). Data were analysed in relation to age and gender, two of the main parameters influencing the natriuretic peptide plasma levels.

[Therapeutic education: a solution to reduce therapeutic inertia and noncompliance]

Therapeutic education (TPE) aims to enable the patient suffering from a chronic diseases to manage his/ her illness and treatment, and prevent avoidable complications, while keeping or improving his/her quality of life. It comprises a set de practical tools aiming the patient to acquire skills to manage himself/herself the disease, its care and supervision, in partnership with healthcare providers. TPE may contribute to improve therapeutic compliance and to reduce clinical inertia, two drawbacks frequently encountered in the management of patients with chronic diseases. As an illustration, we briefly present EDUDORA ("Education thérapeutique et préventive face au diabète et a l'obésité a risque chez l'adulte et l'adolescent" = "Preventive and therapeutic education for diabetes and at risk obesity in adults and adolescents"), an ongoing original project in three frontier regions (Wallonia - Grand-Duchy of Luxembourg - Lorraine).

Physiopathologie de la maladie de Behçet

SUBJECT

Pathophysiology of Behçet's disease (BD) is complex. Recent experimental data shed new light on the mechanisms leading to organ lesions.

MAIN ISSUES

Neutrophils and cytotoxic lymphocytes are now recognized as key effector cells in BD. Genetic susceptibility, environmental factors (virus and/or bacterial infections), inflammatory response abnormalities (heat shock proteins, dysregulated NO production) and abnormal immune response play also a major role in BD pathogeny.

PERSPECTIVES

Better understanding of the BD pathophysiology will allow the development of new therapies more specific of BD.

Abcès sous-cutanés à Mycobacterium avium liés à la reconstitution immunitaire chez les patients sida

Clinical presentations of opportunistic infections in AIDS patients have dramatically changed since the introduction of HAART. The immune reconstitution syndrome (IRS) is typical of this change. The authors discuss the case of an AIDS female patient presenting with subcutaneous abcesses and abdominal lymph node enlargement due to Mycobacterium avium and occurring 10 weeks after initiation of HAART. This was related to the exacerbation of immune response against the bacteria that had previously infected the patient. Many cases of IRS involving M. avium have now been described, but cutaneous localisations remain infrequent. The treatment consists in HAART continuation associated with anti mycobacterial antibiotics and possibly anti inflammatory drugs.

Operating characteristics of the Finapress system to predict elevated left ventricular filling pressure

BACKGROUND

Dyspnea is a common symptom and can be caused by many different conditions. The detection of congestive heart failure (CHF) is sometimes difficult.

HYPOTHESIS

The pulse amplitude ratio (PAR) measured by the Finapress procedure during a Valsalva maneuver can detect elevated left ventricular end-diastolic pressure (LVEDP) accurately over a wide range of values.

METHODS

Comparison of the estimated LVEDP by PAR with the invasively measured LVEDP before and after ventriculography during coronography was made in 101 consecutive stable patients referred for chest pain and/or chronic dyspnea.

RESULTS

A significant correlation was found between the catheter-measured LVEDP (range 3-40 mmHg) and the PAR (R2 = 0.70, p < 0.001). The receiver operator characteristics (ROC) of the PAR to detect an LVEDP > 15 mmHg can be considered to be excellent, with an area under the ROC curve achieving 0.92 (95% confidence interval [CI] 0.87-0.96; p < 0.001). A PAR of > 0.675 predicted the presence of an LVEDP > 15 mmHg with a sensitivity of 0.865 (95% CI 0.780-0.926) and a specificity of 0.847 (95% CI 0.730-0.928). The positive and negative LRs were 5.70 and 0.16, respectively.

CONCLUSIONS

The observed likelihood ratios confirm that the PAR determined by the Finapress procedure may be a useful bedside diagnostic tool in patients with cardiac conditions.

Effect of pregnancy, in the year prior and after treatment for breast carcinoma, on survival and recurrence in women with breast cancer younger than 35 years. GETNA GROUP

553

Background: The goal of this study was to assess the effect of pregnancy on the subsequent risk of recurrences after treatment for breast carcinoma, adjusted on established prognostic factors Methods: Between 1990 and 1999, 908 patients aged under 35 years old were treated for a non metastatic and unilateral invasive breast carcinoma in eight french hospitals, members of the GETNA association. The median follow-up period was 87 months. Mean age was 31.4 years old. Estrogen receptor (ER) status, lymph node involvement, tumor size, histological grade and pregnancy were evaluated as potential risk factors for recurrence and death in a multivariate analysis. A modified model was constructed using the four independent variables derived from the previous multivariate Cox model and the annual risk of death and recurrences were studied. Results: Women who gave birth within one year prior to diagnosis (n=105, 11, 8%) were more likely to have axillary node positive (> N1:48%, vs 35%, p=0.009) important tumor size (>T2:75% vs 55%, p=0.0002), and ER negative (54%, vs 42%, p=0.031). In univariate analysis, pregnancy the year before carcinoma diagnosis increased the risk of death, HR=1.5 [1.05–2.20] (p=0.028) and local recurrence, HR=1.71 [1.06–2.76] (p=0.027). In multivariate analysis, only influence on local recurrence is confirmed, HR=1.75 [1.08–2.84] (p=0.006). Patients who experienced a pregnancy after diagnosis and treatment (n=118, 13.4%) did not tend to have better prognosis regarding axillary node positive (> N1:71%, vs 61%, p=0.051), tumour size (> T2:53.4% vs 59.2%, p=0.49), ER negative (ER:44.2% vs 43.6%, p=0.92) and were significantly younger (<30 years old 52.5% vs 28%, p<10−4). The overall survival after five years was 97% for women who experienced a pregnancy and only 80% for those who did not (p< 0.0001). Conclusions: In this large study population, pregnancy was not associated with poorer survival and the healthy mother effect was studied. For the purpose of advising women on the decision to go forward with pregnancy, was studied after the diagnosis and treatment of breast carcinoma, the annual risk of recurrences. Study granted by Sanofi-Aventis. Acknoledgements to OSMO for its operational support.

No significant financial relationships to disclose.

Oxidation of low density lipoproteins by myeloperoxidase at the surface of endothelial cells: an additional mechanism to subendothelium oxidation

The present paradigm of atherogenesis proposes that low density lipoproteins (LDL) are trapped in subendothelial space of the vascular wall where they are oxidized. Myeloperoxidase (MPO) plays a key role in oxidative damage. We propose that LDL oxidation by myeloperoxidase (Mox-LDL) could occur at the surface of the endothelial cells and not restricted to the subendothelial space. The triad constituted by endothelial cells, circulating LDL and MPO in close interaction, constitutes a synergic mechanism for the genesis of Mox-LDL.

Surgical repair for aortic valve fibro-elastoma: a case report

Valvular cardiac tumours are rare but account for a high prevalence of stroke or sudden death. We report a case of an incidental finding on echocardiographic screening of a 65-year-old man. He was admitted to the emergency department for an episode of sinus bradycardia due to B-blocker overdose. Diagnosis of fibro-elastoma was rapidly suspected and the patient underwent surgery in order to prevent embolization. Epidemiology, diagnosis and treatment are discussed.

Tissue penetration by ertapenem, a parenteral carbapenem administered once daily, in suction-induced skin blister fluid in healthy young volunteers

The penetration of 1 g of intravenous ertapenem once daily for 3 days in suction-induced skin blisters was evaluated. Ten forearm blisters were formed (n = 12) 12 h prior to the last dose. Concentrations of ertapenem in blister fluid exceeded 4 micro g/ml (the MIC at which 90% of the isolates tested are eliminated) for the entire dosing interval. The area under the concentration-time curve for 0 to 24 h ratio of blister fluid to plasma was 61% (90% confidence interval, 56, 65%) suggesting good blister penetration.