[Systematic analysis of evaluations of Objective Structured Clinical Exam (OSCE) multiple circuits: Explanatory variables and inter-rater correlations]. / Analyse systématique des évaluations de circuits multiples d'examen clinique objectif structuré (ECOS) : variables explicatives et corrélations inter-évaluateurs.

INTRODUCTION: Objective Structured Clinical Examinations (OSCEs) assess professional performance in a simulated environment. Following their integration into the reform of the 2nd cycle of medical studies (R2C), this pedagogical modality was implemented in France. This study investigates the variability of students' OSCE scores, as well as their inter-rater reproducibility. METHODS: This single-center retrospective study covered several sessions of evaluative OSCE circuits conducted between January 2022 and June 2023. Variables collected were: baseline situation family, competency domain, presence of a standardized participant for stations; gender and professional status for evaluators; scores (global, clinical and communication skills), number of previously completed OSCE circuits and faculty scores for students. RESULTS: The variability of the overall score was explained mainly (79.7%, CI95% [77.4; 82.0]) by the station factor. The student factor and the circuit factor explained 7.5% [12.9; 20.2] and<0.01% [2.10-13; 2.10-9] respectively. The inter-rater intra-class correlation coefficient was 87.2% [86.4; 87.9] for the global score. Station characteristics (starting situation, domain) and evaluator characteristics (gender, status) were significantly associated with score variations. CONCLUSION: This first study on the variability of OSCE circuit scores in France shows good reproducibility with influence of station characteristics. In order to standardize circuits, variability linked to the domain competency should be considered as well.

Is it justified to search for cancer in patients with peripheral arterial disease?

BACKGROUND: Cancer is the leading cause of death in European countries, ahead of cardiovascular diseases. Cancer is also the most common co-morbidity among patients hospitalized for the management of cardiovascular diseases. Through an overview, we searched for the frequency and types of cancer associated with peripheral arterial disease (PAD) in order to address the relevance of cancer screening in patients with PAD. METHODS: We searched in PubMed database from 1996 to 2020 for retrospective and prospective cohort or cross-sectional or randomized studies evaluating the frequency of all types of cancer in patients with PAD excluding patients with aneurysmal disease. The keywords used were: peripheral arterial disease, arterial thrombosis, acute leg ischemia, critical leg ischemia, chronic leg ischemia, intermittent claudication, malignant tumor, cancer. RESULTS: Based on published studies, the frequency of cancer in patients with PAD varied widely from 3.8 to 30.4% depending on study design, population, method used to screen for cancer and study period. In medical records database and registers,cancer prevalence varied from 3,8% to 22,4% in 4 retrospective studies of patients with acute limb ischemia and from 10.5 to 30.4% in 3 prospective studies of patients with acute limb ischemia, critical ischemia or intermittent claudication. In 3 retrospective analyses from 2 population-based cohorts and health insurance claims data, incidence of cancer in patients with intermittent claudication, acute limb ischemia or peripheral arterial disease varied from 8% to 11.7%. The frequency of cancer in PAD patients appeared higher than in the general population. Tobacco-dependent cancers seemed to be the most common cancers in PAD. Cancers were also more frequent in case of anemia, amputation and iterative bypass thrombosis in few studies. CONCLUSION: Although there is no recommendation for cancer screening in patients with PAD, the high prevalence of cancer raises the question of screening patients at high risk such as those with acute or critical limb ischemia and especially in case of severe tobacco use, anemia, amputation and iterative bypass thrombosis. These results call for further studies with larger sample size and long term follow-up.

[Lower-limb peripheral arterial disease]. / Artériopathie oblitérante des membres inférieurs.

Peripheral arterial disease is a result of atheroma. This disease is frequent in subjects with vascular risk factors. This disease is also frequent in low income countries. The detection and the diagnosis of peripheral arterial disease is obtained by calculating the ankle brachial index. Patients with peripheral arterial disease are not always symptomatic thus explaining how this disease is under diagnosed. The symptoms can be absent, and especially in case of diabetes or in women. In case of peripheral arterial disease, atheroma often involves other arterial vascular networks especially the coronaries. An adapted treatment reduces the morbi-mortality linked to this disease. This treatment is based on the correction of the vascular risk factors and especially tobacco cessation, walking rehabilitation and drugs (antiplatelet agent, statin, renin angiotensin system blocker). In case of rest or critic ischemia, the first-line treatment is a revascularisation. In peripheral arterial disease, management of patients is often non optimal and therapeutic targets fairly often obtained.

Management of cancer-related thrombosis in the era of direct oral anticoagulants: A comprehensive review of the 2019 ITAC-CME clinical practice guidelines. On behalf of the Groupe Francophone Thrombose et Cancer (GFTC).

Venous thromboembolism (VTE) is a common disease complication in cancer patients and the second cause of death after cancer progression. VTE management and prophylaxis are critical in cancer patients, but effective therapy can be challenging because these patients are at higher risk of VTE recurrence and bleeding under anticoagulant treatment. Numerous published studies report inconsistent implementation of existing evidence-based clinical practice guidelines (CPG), including underutilization of thromboprophylaxis, and wide variability in clinical practice patterns across different countries and various practitioners. This review aims to summarize the 2019 ITAC-CME evidence-based CPGs for treatment and prophylaxis of cancer-related VTE, which include recommendations on the use of direct oral anticoagulants specifically in cancer patients. The guidelines underscore the gravity of developing VTE in cancer and recommend the best approaches for treating and preventing cancer-associated VTE, while minimizing unnecessary or over-treatment. Greater adherence to the 2019 ITAC guidelines could substantially decrease the burden of VTE and improve survival of cancer patients.

Performance analysis of walking of 10,000 regular users of a connected activity tracker.

BACKGROUND: According to the World Health Organization, individuals should walk 10,000 per day. Our aim was to determine the factors influencing this objective by using connected activity trackers. METHODS: Anonymized data of 10,000 regular users of the Withings pulse Ox over a 3-month period. RESULTS: Ratio men/women was 2.2, mean age 44.9±10.6 years, mean BMI 27.0±5.3kg/m2, proportion of individuals living in big towns 21.4%, proportion of physical activity<2 METs 66%. The frequency of achieving 10,000 daily steps was similar for work days, weekends and whole weeks. Mean number of daily steps, mean daily covered distances and slopes were higher during work days (P<0.0001); mean speed was higher during the weekends (P<0.0001). According to a quartile-repartition (percentages of use-days with 10,000 steps), the goal was more often achieved during work days (P<0.0001), if BMI<25kg/m2 (P<0.001), in individuals living in big towns (P<0.001) or having≥2 acquaintances to take up challenges (P<0.001). CONCLUSION: Connected activity trackers represent a valuable tool for evaluating the number of daily steps and for providing feedback to promote walking.

[College of the French Vascular Medicine Teachers (CEMV) statement: Arterial Doppler waveforms analysis (simplified Saint-Bonnet classification)]. / Recommandations du Collège des enseignants de médecine vasculaire (CEMV) : analyse des flux artériels Doppler (classification de Saint-Bonnet simplifiée).

Lower extremity peripheral artery disease is a frequent disease. Arterial Doppler waveforms analysis is a key element in vascular medicine, especially to diagnose lower peripheral artery disease. Although Doppler waveforms are often used, descriptions are highly heterogeneous. This review presents the simplified Saint-Bonnet classification that is tought to vascular medicine residents in order to homogenize arterial flow description.

Symptomatic lower-limb giant-cell arteritis: Characteristics, management and long-term outcome.

OBJECTIVE: To describe characteristics and long-term outcomes of the rare symptomatic lower-limb giant-cell arteritis (LL-GCA). METHODS: Retrospective analysis of 8 patients (6 women; mean±SD age, 63.6±10.9 years; follow-up, 137.3±57.3 months). RESULTS: Four patients satisfied≥3 American College of Rheumatology (ACR) GCA-classification criteria; 4 had<3 criteria and histological LL-GCA proof or associated typical upper-limb involvement. Patients had 2.1±1.1 vascular risk factors. Bilateral and rapidly progressive arterial claudication was the first LL sign; 2 had rest ischemia. Imaging-visualized most-to-least frequent inflammatory lesion localizations were: superficial femoral, popliteal, tibiofibular trunk, posterior tibial arteries. All received corticosteroids for 132±76.2 months; 2 required immunosuppressive agent adjunction. Only 3 required 1-6 revascularizations: twice during the first month post-diagnosis and twice later. Thromboendarterectomy and endovascular procedures did not work while bypasses were successful. LL-claudication regressed for 7 (10.5±12.1 months) and disappeared for 5 (16.8±9.8 months). Three patients stopped corticosteroids (26-90 months), 1 restarted 45 months later. Every patient relapsed once (23.9±26.7 months, mean corticosteroid dose: 0.28±0.30mg/kg/day). LL-GCA caused only 1 of the 4 deaths. CONCLUSION: Symptomatic LL-GCA attributable long-term mortality seems to be low despite frequent relapses and corticosteroid-dependence.

[Prevalence of macrovascular arterial involvement of the 4 limbs in systemic sclerosis: About a case series of 14 patients]. / Prévalence de l'atteinte artérielle macrovasculaire des 4 membres dans la sclérodermie systémique : à propos de 14 patients.

INTRODUCTION: Trophic disorders of the extremities are a common complication of systemic sclerosis (SSc), mainly related to microvascular damage. However, SSc seems to be a risk factor for premature athero-thrombotic disease that can affect the peripheral arteries, participate in the occurrence of trophic disorders and promote the occurrence of infectious complications. The objective of this study was to assess the prevalence of arterial disease of the limbs in SSc patients. METHODS: Consecutive inclusions in the context of a multidisciplinary consultation centered on disability of the hand with collection of clinical data [cardiovascular risk factors (CVRF), history of trophic disorders of ischemic origin, peripheral pulse palpation, Allen maneuver the upper (UL) and lower limbs (LL)], and hemodynamic data (flow recorded by Doppler in radial, ulnar, anterior and posterior tibial arteries, and measurement of systolic indices ankles). RESULTS: Fourteen patients were included (11 right-handers, 2 left-handers, 1 ambidextrous). The sex-ratio male/female was 0.27 and the average age of 58.1±10.4 years. The main CVRF were age and smoking. In the UL, 42.8% of patients had a history of trophic disorders, Allen maneuver was abnormal for 35.7% of the superficial palmar arch, 42.9% of ulnar pulse were not perceived and there was no recordable flow in 25% of ulnar artery. In the LL, 14.3% of patients had already presented trophic disorders toes, Allen maneuver was abnormal for 15.4% of the posterior tibial artery, 25.6% of posterior tibial pulse were not perceived and flow of 15.4% of posterior tibial arteries was pathological. CONCLUSION: The distal macrovascular disease preferentially affecting the ulnar and posterior tibial arteries with a high frequency to the UL and two times less at LL. The pathophysiology is unclear but it could be a proper manifestation of SSc. It seems necessary that SSc patients have a strict balance of their CVRF and a screening of macrovascular arterial lesions. There is also the question of the place of an anti-atherosclerotic therapy in these patients.

[Analysis of the anatomical sites of 172 lower-limb venous thromboses occurring in a hormonal context in 996 young women; impact of the duplex-Doppler exploration]. / Analyse de la distribution anatomique de 172 thromboses veineuses des membres inférieurs chez 996 jeunes femmes en contexte hormonal. Impact sur l'exploration écho-Doppler.

AIM: To analyze localizations of duplex ultrasonography-diagnosed lower-limb venous thrombosis in young women in hormonal periods in order to optimize the ultrasound exploration. PATIENTS AND METHODS: From 42,018 standardized ultrasonography report forms, incremented in a database (January 2001 - July 2013), those performed for a first diagnosis of venous thrombosis in women ≤ 45 years were selected (n = 996). Among those, diagnosed venous thrombosis (n = 172) were classified into three groups: oral contraception (n = 74), pregnancy (n = 39) and post-partum period (n = 59). Clinical symptoms and thrombosis distribution were analyzed. RESULTS: In the contraception group, pulmonary symptoms at presentation were much more frequent than in the obstetrical group: 69% vs 20% (P < 0.001). The thrombosis was limited to the iliac veins in 31% (23/74) and to the left internal iliac vein in six patients. During pregnancy, the thrombosis was limited to the iliac veins in 28% (11/39), and to the left internal iliac vein in two patients. In the post-partum period, superficial venous thromboses were found more frequently (37/59). Among the 22 deep venous thromboses, nine were limited to the proximal segment, including four in the vena cava coming from a right ovarian vein thrombosis. CONCLUSION: Duplex ultrasonography in young women taking oral contraception, as during pregnancy, must target iliac venous segments, especially on the left side, otherwise one thrombosis out of three may be missed; in the post-partum period, the inferior vena cava and superficial veins are to be explored too.

[Antiphospholipid syndrome and pregnancy: Obstetrical prognosis according to the type of APS]. / Syndrome des anticorps antiphospholipides et grossesse : pronostic obstétrical selon le type de SAPL.

OBJECTIVE: The objective of our study was to compare treatment-based obstetrical outcomes in women with either thrombotic or obstetrical antiphospholipid syndrome (APS). MATERIALS AND METHODS: This was a historical cohort study conducted between 1998 and 2009 in 23 patients who had a total of 83 pregnancies. The syndrome was diagnosed using the 2006 Sapporo criteria. RESULTS: Thirty-one of these 83 pregnancies were valid before the diagnosis was made. A live infant was born in 22% of them, the infant being small for gestational age in 26% of cases. The fetus died in utero in a further 26% of cases. Pregnancies were subdivided into 2 groups depending on whether the initial event leading to APS diagnosis was obstetrical or thrombotic. Treatment (aspirin and low molecular weight heparin) was based on this classification: the latter was given in a curative dose for thrombotic events, in a preventive dose for obstetrical events. No fetal loss was observed when treatment was administered according to the protocol. Nevertheless, 20% of the pregnancies with obstetrical APS were complicated by smallness for gestational age and only 38% of the infants were live births. More than 87% of the thrombotic forms treated were free of complications and led to birth of a living child. CONCLUSION: Appropriate treatment appears to improve the prognosis for pregnancies in patients with APS. These patients are nevertheless at increased risk of an obstetrical event and require close monitoring, especially in obstetrical manifestations, which appear to have a poorer prognosis. Multidisciplinary follow-up by an experienced team is essential.

[Incidence and distribution of 1026 lower limb venous thrombi diagnosed by ultrasonography in 3263 patients with cancer]. / Incidence et distribution de 1026 thromboses veineuses des membres inférieurs diagnostiquées par écho-Doppler chez 3263 patients atteints de cancer.

UNLABELLED: The study objective was to evaluate the incidence, characteristics and distribution of lower limb deep venous thrombi diagnosed by ultrasound among known cancer patients, in order to determine additional criteria that could be used to help select patients with unprovoked deep venous thrombosis caused by occult cancer. PATIENTS AND METHODS: From January 2001 to May 2012, standardized report forms (n=38,424) were entered into a database. A total of 3263 report forms corresponding to cancer patients with suspected venous thrombo-embolic disease were selected from which 1026 cases of deep venous thrombosis were diagnosed by ultrasonography. Baseline characteristics, incidence, and anatomic distribution of venous thrombi were analyzed. RESULTS: For 3263 patients with cancer, the venous thrombosis incidence was: total 31.4% (n=1026), proximal 14.5% (n=472), bilateral 8.5% (n=278) and multiple venous sites 4.6% (n=149). The rate of clinical suspicion of pulmonary embolism was 49.9% (n=1628). For 1026 patients with thrombosis, proximal thrombi were nearly as frequent as distal thrombi, with 17.6% (n=181) iliocaval thrombi. Gastrocnemial, popliteal and femoral veins were almost equally concerned by thrombosis with respective rates of 28.7% (n=278), 27.1% (n=294) and 25.6% (n=263). Superficial veins were concerned in 23.5% (n=241). Partial or floating clots occurred frequently in 4 localizations: common femoral, external iliac, femoral and popliteal veins. CONCLUSION: Proximal, multiple, partial, mobile thrombi, and such unusual locations as gastrocnemial or superficial thromboses, are potentially indicators for selecting patients that may benefit from a cancer check-up because their venous thrombosis could be due to cancer.

Beware of suboptimal medical management of patients with atherosclerosis requiring revascularization.

AIM: The aim of this paper was to assess a daily-life evaluation of vascular risk factor control, pharmacological treatment and prognosis in patients with atherosclerosis referred for revascularization. METHODS: Prospective observational study conducted in a French University Hospital with collection of atherosclerosis referral site information, reported patient history, documented atherosclerosis sites seen on examination, biological data, and clinical outcomes. RESULTS: 956 patients (82.6% men, 64.5±10.1 years) were enrolled for supra-aortic vessel disease (SVD, 24.6%), coronary heart disease (CHD, 40.4%), peripheral artery occlusive disease (PAOD, 34.2%), and visceral artery disease (1.7%). Involvement of >2 vascular territories was documented in 85%. Vascular risk factor frequency results were: previous (65.7%) or current (10.6%) tobacco use, hypertension (64.3%), hyperlipidaemia (75.4%), diabetes (25.8%), overweight (43.8%), and obesity (25.2%). LDL-cholesterol was >100 mg/dL for 38.1%, most frequently seen in patients with PAOD referral (P<0.001) or history (P=0.002), and for 29.2% of the patients taking a statin. HbA1c levels were >6.5% for 53.8% of patients with diabetes. The triple combination of an antiplatelet agent, a statin, and a renin-angiotensin-system inhibitor was not prescribed often enough, especially for PAOD referrals (PAOD referrals, 45.1%; SVD referrals, 48.1%; CHD referrals, 65.9%). Independent risk factors for all-cause mortality were: a previous CHD or PAOD clinical event, body mass index <25 kg/m2, HbA1c >6.5%, and no aspirin treatment. CONCLUSION: Even at the time of revascularization, medical management of atherosclerosis was not optimal. The need for continuing education of physicians and patients remains essential.

[Vascular Ehlers-Danlos syndrome and pregnancy: an obstetrical specific support]. / Syndrome d'Ehlers-Danlos de type vasculaire et grossesse : une prise en charge obstétricale spécifique.

The Ehlers-Danlos syndrome (EDS) is a rare inheritable disease, characterised by a defect in collagen synthesis. Various types have been described and the type IV or vascular type is the most severe characterised by vascular, gastrointestinal and gynaecologic complications. We describe in a case report the specific obstetrical support we applied to avoid the most frequent complications such as early spontaneous abortions, pre-term delivery, tearing of perineum, uterine and vascular rupture and hard healing. Pregnancy is very risky in women with vascular EDS. Combination of multidisciplinary support and advice of the rare vascular disease national reference centre may reduce the morbi-mortality rate, including celiprolol long-term treatment.

[Peripheral arterial involvement in giant cell arteritis: how to differentiate between atheroma and inflammation?]. / Atteinte artérielle périphérique dans la maladie de Horton : comment différencier athérome et inflammation ?

Giant cell arteritis (Horton's disease) is an inflammatory arteritis involving medium and large diameter arteries. The disease typically occurs in patients aged 50 years or more who may otherwise have atherothrombotic lesions. It is sometimes difficult to determine whether an arterial stenosis arises from an inflammatory or an atherothrombotic mechanism in a patient with giant cell arteritis. Therefore we describe, through a case report, the clinical features and complementary investigation data helpful for distinguishing between these two entities.

[Incidence and distribution of venous thrombosis of the lower limbs diagnosed by duplex ultrasonography after total hip or total knee arthroplasty, and hip fracture surgery. Results from 5981 exams and 2123 cases of venous thrombosis over 10 years]. / Incidence et distribution des thromboses veineuses des membres inférieurs diagnostiquées par écho-doppler au décours de prothèses de hanche, de genou et de fractures de hanche. Résultats portant sur 5981 explorations et 2123 thromboses en dix ans.

AIM: To determine the incidence and distribution of lower limb venous thrombosis diagnosed by duplex ultrasonography, including calf exploration, after total hip or knee replacement or hip fracture, and to compare them with the venographic results reported by recent randomized control trials testing new antithrombotic drugs. PATIENTS AND METHODS: From January 2001 to December 2009, 30,510 standardized report forms incremented a database from which files corresponding to major orthopaedic surgery were selected: 1652 after total hip replacement (THR), 1440 after total knee replacement (TKR) and 2889 after hip fracture (HF). Base-line characteristics, incidence and anatomic distribution of venous thrombosis were analysed in the three populations. RESULTS: Systematic screening was applied for 95.1% of the exams (n=5689). Incidence of total and proximal venous thrombosis was, respectively, 27.8% (n=460) and 2.8% (n=46) for THR, 32.5% (n=939) and 4.4% (n=126) for HF, and 50.3% (n=724) and 3.8% (n=55) for TKR. Venous thrombosis was distal in 89.3% (n=1896). More than half (n=1014) of distal venous thromboses were strictly muscular soleal locations. Ilio-caval thrombosis incidence was 0.18% (n=11), and superficial venous thrombosis incidence was 1.5% (n=89). CONCLUSION: This study shows that incidence and distribution of venous thromboses diagnosed with a complete and standardized duplex ultrasonographic screening are very close to the rates published with venographic screening in recent trials.

[A negative first-line work-up of Raynaud's phenomenon: And what if it were cancer?]. / Phénomène de Raynaud avec négativité du bilan de première intention : et si c'était un cancer ?

Raynaud's phenomenon is a transient paroxysmal vasomotor phenomenon affecting the extremities including manifestations of ischemia. It is a common phenomenon in the general population. In a routine clinical situation, the first step is to differentiate Raynaud's disease from a secondary Raynaud's phenomenon, the latter requiring complementary investigations. We report here the case of an 80-year-old woman who presented a secondary Raynaud's phenomenon. First-line investigations remained negative. A mammography was performed and revealed breast cancer. Raynaud's phenomenon disappeared after treatment of the breast carcinoma and did not recur during the 2-year follow-up.

[Thrombophilias and peripheral arterial occlusive disease]. / Thrombophilies et artériopathie oblitérante des membres inférieurs.

Peripheral arterial occlusive disease is a frequent disease due to the classical vascular risk factors such as smoking, diabetes mellitus, dyslipidemia, and hypertension. Despite these risk factors, many thrombophilias (physiological inhibitors defects, Factor V Leiden and 20210A prothrombin gene variant, antiphospholipid antibodies, mild hyperhomocysteinemia 15-30micromol/l) can be evoked in some clinical forms of peripheral arterial occlusive disease. This paper provides a synthesis of the published data about this topic. Screening for these thrombophilias is justified in patients with venous thromboembolic disease, or signs of antiphospholipid syndrome and possibly in different situations such as premature atheroma of lower limbs, chronic ischaemia, evolutive disease despite adapted treatment and revascularisation failures without evident technical explanation. Except for the antiphospholipid syndrome, there is currently no consensus for systematic screening of thrombophilia and treatment in patients with peripheral arterial occlusive disease.