[Advance directives in hospital practice: A matter of concern for every healthcare professional and consumer]. / Les directives anticipées à l'hôpital : l'affaire de tous ?

INTRODUCTION: In France, Leonetti and Claeys-Leonetti laws relating to patients' rights and end-of-life practice have introduced the advance healthcare directives (ADs). Although family doctor's role is important in initiating discussions regarding AD, hospital healthcare professionals should also be concerned by the health care planning laws. METHODS: A descriptive, quantitative and qualitative study was conducted in Paris Saint-Joseph hospital to evaluate the knowledge of nursing personnel regarding ADs. Among healthcare professionals present on 02/06/2016 and agreeing to participate, 50 non-medical caregivers and 50 doctors were randomly selected and took part in this survey. Three trainee lawyers conducted interviews, recorded and anonymized them. The Nvivo software analyzed the qualitative part of the results. RESULTS: Only 10% of healthcare professionals knew these legal and ethical issues in health care. Most caregivers were not in favor of informing all patients admitted to a hospital (hospitalized patients or patients received consultations). For 44%, only hospitalized end-of-life patients should be informed about ADs. For 76% of the people questioned, family doctor has a unique position to guide the patient on the preparation and registration of living wills. In hospital stay, the nurse was proposed by 52% of the staff as the preferred caregiver for AD communication, as part of an interdisciplinary healthcare team approach. Finally, the clear majority of caregivers (85%), called for discussions and documentation about ADs, and end-of-life training. CONCLUSION: Advance directives remain poorly known in the hospital, 12 years after the first Leonetti law. The attitude of professionals about ADs is not homogenous but interest for the subject is obvious in the vast majority of caregivers. The results of this survey highlighted that discussions and documentation about ADs as well as training on end-of-life patient care are essential.

[Deep venous thrombosis of the upper limb in a violin player: The "bow syndrome"]. / Thrombose veineuse profonde du membre supérieur chez une violoniste : « le syndrome de l'archet ¼.

BACKGROUND: Exercise-induced thrombosis is a rare cause of deep venous thrombosis (DVT) of the upper limb and usually affects young subjects without comorbid conditions. The diagnosis may be challenging. CASE REPORT: A 23-year-old female right-handed French teacher and amateur violin player presented with edema of the root of the right arm associated with erythrocyanosis of the extremity and collateral circulation of the shoulder. History taking revealed oral contraception and recent change in violin playing habits. D-dimers were negative. A second duplex-Doppler was required before visualization of a DVT in the right subclavian vein. The patient was given low-molecular-weight heparin alone, followed by rivaroxaban. The outcome was very favorable at 48h. The patient was seen at 4 months and had not had a recurrent episode. DISCUSSION: The diagnosis of DVT of the upper limb is basically clinical. There is a clinical probability score for the introduction of anticoagulation even if the duplex-Doppler fails to visualize DVT, a situation that can occur due to the clavicular superposition in this region. Exercise-induced DVT should be suspected in patients with minimally intense but repeated exercise (hyper-abduction), e.g. as here playing the violin. Anticoagulation is the treatment of choice. The role for surgery and pharmacomechanical strategies remains to be defined. CONCLUSION: Exercise-induced thrombosis (Paget-Schroetter syndrome) should be suspected in young patients free of any comorbidity who develop a thrombosis of the upper limb. Studies comparing different therapeutic options would be useful to achieve more homogeneous management practices despite the heterogeneous clinical presentations.

[Can the vascular specialist improve patient awareness about advanced directives?]. / Le médecin vasculaire peut-il sensibiliser ses patients aux directives anticipées sur la fin de vie ?

INTRODUCTION: In France, the Leonetti law, adopted on April 22, 2005, stipulates the regulations concerning advanced directives. This is a patient's right that is not well known and rarely applied. In 2015, a new law project was thus presented in which the French National Authority for Health recommended that doctors, including all specialists, bring up the subject, especially during consultation. OBJECTIVES: To evaluate the vascular specialist's possibility to mention the topic of advanced directives during consultations. METHOD: A single and non-interventional prospective study conducted with the help of patients who consulted a private practitioner vascular specialist: recurrent patients regularly consulting a private practitioner vascular specialist were included. First-time consultants, minors and patients to whom it was not adapted to speak about the subject were not included. RESULTS: Between July 27 and September 23, 2015, 159 consecutive patients were examined. Fifty-five first-time consultants and four patients for whom the interview was unsuitable were excluded. In all, 100 patients were questioned. None of them refused to talk about the subject. Women made up a majority of the population (63 %) with an average age of 67 years (23-97). The principal diagnostics were common to vascular medicine consultations: deep vein thrombosis (20 %), peripheral arterial disease (15 %), varicose veins (11 %), lymphedema (11 %) and leg ulcers (9 %). Thirteen percent of the people had a history of cancer. Half of the patients had had follow-ups for over 10 years. The average time devoted to discussing the topic was 12minutes (5-40). Only 22 % of the patients declared having been familiar with advance directives. Once informed however, 78 % chose to write up an adapted form: 36 % with the help of their doctor and 42 % with a doctor and a relative. Seventy-three percent of the consultants thought that talking about the advance directives would reinforce the confidence link between the doctor and the patient. CONCLUSION: In private practice vascular medicine, it seems possible to mention the subject of advance directives, as recommended by the French authorities. The procedure is well perceived by the patients. It nevertheless implies allotting a non-negligible amount of additional consultation time. The reinforcement of the doctor-patient relationship suggested by these results should be confirmed by a qualitative study made up of meetings.

Lymph Nodes Number in Surgical Specimen Modifies Prognosisin Advanced Stage Gastric Cancer Patients– Study of the Will-Rogers Phenomenon

Background: The AJCC 2002 staging system recommends the study of at least 15 lymph nodes in the surgical specimen. Thisnumber varies and sometimes it is not achieved since it is influenced by surgeons, pathologists and patients and may modifythe patient’s staging and survival. Methods: This is an observational study of 201 patients with gastric cancer submitted tosurgery in the period of January 1997 to December 2001, and followed-up until July 2003 in the Brazilian National CancerInstitute. Data related to surgeon and pathologist productivity as well as survival were analyzed. Results: All patients that haveundergone D2 lymphadenectomy had more than 15 lymph nodes. The factors related to varied number of lymph nodes were:surgeon (31.5±9.3 to 43.8 ±16.8); surgical procedure (total gastrectomy, 41.4 ±15.5); extended resection (40.8 ±15.9);pN3 and stage IV (55.1 ±15.8). Multivariate analysis showed the surgeon as an independent variable (p=0,02). The morelymph nodes studied, the more nodal metastasis found (p=0.01), but this fact has been significant only in pT3 patients(p=0.007). The variables related to survival have been surgical procedure, resection of another organ, site of the tumor; pT andpN. The independent variables have been pT (p=0,01) and pN (p=0,004). Conclusion: The surgeon’s technique is the mainfactor related to number of lymph nodes in the surgical specimen and for accurate staging of pT3 patients over 30 lymph nodesarenecessary.

Carcinoma epidermóide do estômago: apresentaçäo de um caso e revisäo da literatura / Primary squamous cell carcinoma of the stomach: report of a case and review of literature

O carcinoma epidermóide primário do estômago é uma lesao rara e sua histogênese é controversa. Os autores descrevem um caso desta neoplasia numa mulher de 46 anos e que se manifestou através de hemorragia digestiva. A patogênese deste tumor, com comportamento biológico agressivo é discutida.