Breaking bad news: an active learning method for medical students.

BACKGROUND: Breaking bad news is one of the most difficult aspects of communication in medicine. The objective of this study was to assess the relevance of a novel active learning course on breaking bad news for fifth-year students. METHODS: Students were divided into two groups: Group 1, the intervention group, participated in a multidisciplinary formative discussion workshop on breaking bad news with videos, discussions with a pluri-professional team, and concluding with the development of a guide on good practice in breaking bad news through collective intelligence; Group 2, the control group, received no additional training besides conventional university course. The relevance of discussion-group-based active training was assessed in a summative objective structured clinical examination (OSCE) station particularly through the students' communication skills. RESULTS: Thirty-one students were included: 17 in Group 1 and 14 in Group 2. The mean (range) score in the OSCE was significantly higher in Group 1 than in Group 2 (10.49 out of 15 (7; 13) vs. 7.80 (4.75; 12.5), respectively; p = 0.0007). The proportion of students assessed by the evaluator to have received additional training in breaking bad news was 88.2% (15 of the 17) in Group 1 and 21.4% (3 of the 14) in Group 2 (p = 0.001). The intergroup differences in the Rosenberg Self-Esteem Scale and Jefferson Scale of Empathy scores were not significant, and both scores were not correlated with the students' self-assessed score for success in the OSCE. CONCLUSION: Compared to the conventional course, this new active learning method for breaking bad news was associated with a significantly higher score in a summative OSCE. A longer-term validation study is needed to confirm these exploratory data.

Gastric Embolization as Treatment for Overweight Patients; Efficacy and Safety.

OBJECTIVES: The aim of this study was to evaluate the efficacy and safety of left gastric artery (LGA) embolization for the treatment of overweight patients who weren't candidates for bariatric surgery. MATERIALS AND METHODS: We retrospectively collected data of 16 patients who underwent a selective embolization of the LGA. The mean body mass index (BMI) before intervention was 28.9 kg/m2 ± 2.5, and therefore, patients were not candidates for bariatric surgery in Belgium. The embolization was realized with 500-700 µm particles via the right common femoral artery approach. Before and following the intervention, an upper endoscopy was performed. Patient demographics, weight loss, hunger sensation and a satisfactory scale were reviewed. RESULTS: Between February 2015 and May 2017, 16 overweight patients were treated, one embolization was unsuccessful. Four (25%) patients were lost in follow-up. Nine (56%) patients showed early weight loss, one (6%) maintained his bodyweight and one (6%) patient underwent bariatric surgery 2 years after consultation. Only one (6%) patient had a gastric ulceration on control endoscopy. One (6%) patient ended in the intensive care unit for pancreatitis and gastric perforation. The mean weight loss was 8 kg ± 5.12, reducing their mean BMI to 25.5 ± 3.5. The hunger sensation was decreased, and patients were satisfied. CONCLUSION: This is a preliminary study in an overweight population that appears to induce weight loss and appetite suppression. Larger studies are needed to confirm these preliminary findings.

MR imaging, proton MR spectroscopy, ultrasonographic, histologic findings in patients with chronic lymphedema.

Lymphedema is a progressive disease with multiple alterations occurring in the dermis. We undertook this study using high-frequency ultrasonography (US), magnetic resonance imaging, proton MR spectroscopy and histology to examine structural changes occurring in the subcutaneous tissue and precisely describe the nature of intralobular changes in chronic lymphedema. Four cutaneous and subcutaneous tissue biopsies from patients with chronic lymphedema during lymphonodal transplantation were studied. We performed US with a 13.5 MHz transducer, TSE T1 and TSE T2 magnetic resonance images with and without fat-suppression, MR Chemical Shift Imaging Spectroscopy and histological evaluation on these biopsies. We found that normal subcutaneous septa are seen as hyperechogenic lines in US and hyposignal lines in MRI and that hyperechogenic subcutis in US can be due to interlobular and intralobular water accumulation and/or to interlobular and intralobular fibrosis. Our study also confirms the usefulness of MR spectroscopy to assess water or fat content of soft tissue. Thus, multiple imaging modalities may be necessary to precisely delineate the nature of tissue alterations in chronic lymphedema.

[Sonography of peripheral nerves. Part II: lower limbs]. / Echographie des nerfs périphériques -- Deuxième partie: membre inférieur.

On sonographic images, the peripheral nerves have a fibrillary structure, ribboned on longitudinal images and ovoid on cross-section images. The nerves travel between the muscle groups, often with blood vessels, or in canals. Recently improved ultrasound devices are able to investigate the peripheral nerves along their entire length, as far as the sonographer has thorough anatomical knowledge, rigorous technique, and, when searching for pathology, good clinical notions. As in Part I on sonography of the peripheral nerves of the upper limbs, published in this journal, the objective of this general review is to present normal and pathological echoanatomy of the peripheral nerves of the lower limbs in an educational way.

Spontaneous renal artery dissection in an otherwise healthy male.

Dissection of a renal artery is rare and, in most cases, associated with underlying arterial diseases. Spontaneous renal artery dissection (RAD) is exceptional. We report the case of a young and otherwise healthy man with an isolated dissection of the right renal artery without any obvious origin. Diagnosis was made by angiography. He received medical treatment and rapidly recovered. Renal artery dissection can be misdiagnosed because its clinical presentation may be confusing. Selective renal angiography is essential to evaluate the extent of the dissection and the suitability for repair. Control of the hypertension and renal function preservation are the two main goals of the treatment. The place of surgical repair remains unclear because of the poor results on hypertension improvement and high complication rate.

Comparison of iohexol and ioxaglate for intravenous digital subtraction angiography of the neck and head.

Two hundred patients undergoing intravenous digital subtraction angiography of the cerebral circulation were examined on a random basis with either iohexol 350 mg I/mL or ioxaglate 320 mg I/mL. The two low osmotic media provided equally satisfactory image quality and diagnostic possibilities. No significant differences were found in incidence and severity of adverse reactions.

Gadolinium-enhanced MR in the evaluation of preoperative meningioma embolization.

PURPOSE: To evaluate the use of postembolization gadolinium-enhanced MR imaging as a means to judge the efficacy of tumor embolization. METHODS: Fifteen patients with meningiomas were prospectively studied. The following data were evaluated for each tumor: the percentage of vascular supply to the tumor arising from the internal and external carotid arteries; the percentage of the tumor embolized as judged by angiography, by MR imaging, and by CT scanning; the estimated blood loss according to the surgeon; and histologic evidence of necrosis as seen by the neuropathologist. RESULTS: The data reveal an excellent correlation between the amount of tumor embolized as estimated by MR and both the estimated blood loss at time of surgery and the presence of histological necrosis in the specimen. CONCLUSIONS: Postembolization gadolinium-enhanced MR is an excellent means to evaluate the efficacy of an embolization and offers certain advantages over CT and angiography. One important advantage of this technique lies in the fact that it can be performed immediately postembolization.

Subclavian vein thrombosis: a frequent complication of subclavian vein cannulation for hemodialysis.

Subclavian vein cannulation was suggested as a temporary vascular access for hemodialysis since one of its advantages was considered to be no damage to blood vessels. As we observed six patients with symptomatic subclavian vein thrombosis among 148 patients having received subclavian vein cannulation for hemodialysis, we systematically performed subclavian venogram in 42 asymptomatic patients selected on the basis of a history of previous subclavian vein cannulation. Venograms were performed 15.7 +/- 8.9 months after the removal of the last catheter. Eight patients (19%) had complete thrombosis or severe stenosis of the subclavian vein while six patients (14%) had minimal luminal defects. Considering together the 48 patients, the group with thrombosis or severe stenosis (group 1, n = 14) was compared with the group with minimal defects or normal venograms (group 2, n = 34). In group 1, as compared with group 2, there were more female (64% vs 32%, p = 0.02), more cannulations per vein (1.87 +/- 0.35 vs 1.32 +/- 0.08, p less than 0.05) and more cumulative days of cannulation per vein (35.1 +/- 7.9 vs 24.4 +/- 1.1, p less than 0.001). No difference between the two groups was seen for the number of catheter infections, the number of catheters with poor flow or obstruction, the coagulation screening of the patients or the time-length between the removal of the last catheter and the venogram study. Two of the initially asymptomatic patients developed later on clinical problems related to the subclavian vein thrombosis. We conclude that the subclavian vein cannulation leads to significant damages of the vessels, excluding a whole arm, for future vascular access in some patients.

Selective uterine artery embolization in the treatment of cervical pregnancy: two case reports.

Two patients presenting a cervical trophoblastic implantation were treated with selective uterine artery embolization associated with dilatation and curettage. This interventional radiological maneuver helped greatly in the management of the bleeding caused by the ectopic pregnancies.

Infected false aneurysm following carotid endarterectomy with vein patch angioplasty.

The authors report a case of infected false aneurysm that developed after carotid endarterectomy with vein patch angioplasty. This complication is extremely rare and occurs most commonly when a Dacron patch graft has been employed. Various clinical presentations are described and the etiology of infection is discussed. Surgical management consisted of the resection of the pseudoaneurysm and segmental replacement with vein. Parenteral antibiotic therapy was given for three weeks and topical irrigation with an antiseptic solution performed for two weeks.

Giant fusiform aneurysm of the basilar artery. Clinico-pathological report of 3 cases.

From 9000 autopsies, three giant fusiform aneurysms of the basilar artery were found in middle-aged men with arterial hypertension, atherosclerosis, symptoms of encephalic circulatory disturbances, transient then permanent cranial nerves palsy. Neuroradiological investigations suggested a basilar dolichomegartery in one case. Anatomically, these unruptured giant aneurysms (respectively: 2, 2.5 and 4.5 cm largest transversal diameter) compressed the brainstem; a recent softening destroyed the midpons in one case, and both cerebral peduncles in another. A review of the literature underlined the paucity of similar cases, and the difficulty of differential diagnosis of giant basilar aneurysms detected only by neuroradiological investigations without anatomical verifications.

Bronchiolar morphology after systemic arterial interruption.

To assess ischemic lesions as a factor in obliterative bronchiolitis after lung transplantation, the authors severed the left bronchial arteries of 15 dogs, together with the left stem bronchus, the latter being immediately reanostomosed. They examined the bronchioles at weekly interfals up to three and a half months. On the week chosen each dog was anesthetized, totally heparinized, and exsanguino-perfused with saline. Just after heart arrest, the thoracic aorta was injected with a barium solution until this white medium appeared in the bronchial arteries. The heart-lung blocs were excised en bloc, submitted to soft-tissue x ray, fixed, and then sliced to 1 cm. Corresponding right and left 5-mm-thick samples of these slices were prepared for contact microradiography followed by histologic 5-to-20-micron-thick, stained, correlated specimens. For two weeks the left bronchial arteries remained empty, but there was no necrosis or edema. Between two and four weeks barium solution appeared in the bronchial arteries, and the bronchiolar epithelium had become multistratified. Later the left bronchiangiogram became similar to the right, but there were more folds of the mucosa and a little submucosal fibrosis. These studies provide proof that no significant ischemic lesions occurred during repermeation of the bronchiolar vascular bed. Ischemia, if existent, is not a significant factor in obliterative bronchiolitis.

Vertebral arteriovenous fistula following central venous cannulation: a case report.

The authors report a case of vertebral arteriovenous fistula that has been disclosed three years after central venous cannulation (CVC). The real incidence of this complication is discussed and various clinical presentations are enumerated. From a review of the literature, some recommendations are made to prevent the diagnosis from being missed and chiefly to reduce the risk of arterial puncture that results in fistula formation.

Role of the captopril test in renovascular hypertension: a case report.

This article reports the case of a rapidly severe stenosis of the right renal artery, causing uncontrolled hypertension. After failure of a percutaneous transluminal renal angioplasty, which provoked the thrombosis of the vessel, a surgical revascularization was performed after +/- eighteen hours of renal ischemia. Blood pressure, blood urea nitrogen and serum creatinine returned to normal values. A dramatic improvement of the right renal function was attested at the hippuran scintigraphy after a dose test of captopril. The results of renographic studies obtained in this clinical case underline the role of the captopril radionuclide test in detection and follow-up after treatment of renovascular hypertension.

Cerebral venous thrombosis and procoagulant factors--a case study.

Cerebral venous thrombosis is a polymorphic clinical entity for which diagnosis has become more frequent with the advent of neuroradiology. The superior sagittal and transverse sinuses are frequently involved, whereas cavernous sinus thrombosis is much less frequent. Inherited resistance to the anticoagulant action of activated protein C (APC resistance), antithrombin deficiency, protein C and S deficiencies, and hyperhomocysteinemia seem to represent major causes of thrombophilia when unusual thromboembolic events (ie, before the age of 45 years) are observed. The authors present the combined occurrence of protein C and protein S deficiencies in a 32-year-old woman, manifested by extensive cerebral venous thrombosis.

[Right ventricular migration of a stent after endovascular treatment of a superior vena cava syndrome]. / Migration ventriculaire droite d'un stent après traitement endovasculaire d'un syndrome cave supérieur.

The authors report a case of migration of a Palmaz stent used for treatment of a patient with a malignant superior vena caval syndrome. Transoesophageal echocardiography showed the metallic device in the tricuspid subvalvular apparatus. Several attempts to recover the stent percutaneously failed. This case illustrates a rare but serious complication of endovascular stenting: migration of the material. Although it is often possible to reposition the stent by radiological interventional techniques, when the stent is located in the right ventricle, the procedure is more difficult and usually fails. Transoesophageal echocardiography enables accurate localisation of the material with respect to the surrounding cardiac structures, especially the tricuspid valve.

[Doppler study of gluteal arteries. A useful tool for excluding gluteal arterial pathology snd an important adjunct to lower limb Doppler studies]. / Le Doppler des artères fessières. Un outil efficace pour exclure une pathologie artérielle fessière et un complément important du Doppler des membres inférieurs.

PURPOSE: 1) To determine the negative predictive value (VPN) of duplex scan in patients complaining of buttock or hip pain and thereby to distinguish vascular claudication from other musculoskeletal or neurological diseases. 2) To show its complementarity in doppler investigation of lower limb arteries. MATERIALS AND METHODS: Prospective study by duplex scan and arteriography of 60 gluteal arteries in 30 consecutive patients referred to check up for lower limb arteriopathy or sexual impotence. Duplex scan was performed by posterior approach. Correlation between doppler ultrasound and arteriography was studied. RESULTS: The study of normal arteries was possible in all cases and only one normal gluteal artery could not be detected in a diabetic overweight patient. On 60 arteries, sensitivity of duplex was 100 percent, specificity 96 percent and VPN 100 percent. Significant obstructive lesions were always associated with pathological velocimetric waveform or were not detected. CONCLUSIONS: Buttock claudication can appear like a typical vascular claudication or mimic neurological or musculoskeletal diseases. It is very useful to rule out a vascular causality responsible for buttock or hip pain by simple, non-invasive and cheap exploration. A normal doppler ultrasound of gluteal arteries can rule out vascular disease responsible for buttock or hip pain thereby avoiding arteriography. The strategy of diagnostic or therapy can be modified by such additional information as shown in two case reports.

[Venous exploration of impotence of vascular origin]. / Exploration veineuse de l'impuissance d'origine vasculaire.

Vascular origin accounts for more than 25% of cases of disturbances of erection. Venous pathology may explain the majority of erectile dysfunctions in patients with normal arterial anatomy. We have performed cavernography in 115 patients with monitoring of intracavernous pressure. Nocturnal plethysmography was recorded in all cases to prove the organic etiology of the erectile dysfunction. Cavernography was realized after puncture of both corpora cavernosa by two microcatheters (19-21 G). The intracavernous pressure was recorded through 1 of them and the contrast medium infused through the other. The contrast medium is infused at a rate of 80-120 ml/min. until the penis appears erect. The simultaneous recording of the intracavernous pressure then showed a rapid increase of the pressure curve followed by a stabilization at greater than or equal to 90 mHg. The flow to maintain the erection reach 1/3 of the flow needed to induce the erection. The venous leak is characterized by the absence of erection, no increase in intracavernous pressure and a rapid opacification of the vein. Artificial erection induced in impotent men allows to classify patients with vascular organic impotence into three categories: those with pure arterial insufficiency, those with pure venous leak, and patients with both.

[Carotid dissection during childbirth]. / Dissection carotidienne au cours d'un accouchement.

A 33-year-old woman presented transient ischemic attach (hemiparesis of the left arm and right amaurosis), 14 days after childbirth, due to dissection of the right carotid that occurred probably during delivery as suggested by right earache at that time. Carotid dissection during pregnancy or after childbirth is rare an exceptional during delivery. Neurological symptoms and arterial lesions were followed by duplex ultrasound.

[A predictive thermographic test of the effect of lumbar sympathectomy]. / Test thermographique prédictif de l'action de la sympathectomie lombaire.

The benefit of lumbar sympathectomy in the treatment of arteriopathy of the lower limb has been widely proved. To predict objectively its efficiency we developed a simple pharmacologic test under thermographic control. 1 mg of Reserpine is injected in a femoral artery, a digitalized thermography enables to follow the chronological evolution of temperatures of the lower limbs. Thirty patients were investigated, 27 responded positively. The mean increase in temperature of the injected limb reached 1.62 degrees C beginning 2 h 46 after the injection of Reserpine.