O. Steichen

Prognostic factors for T1–T2 squamous cell carcinomas of the mobile tongue: A retrospective cohort study

The aim of this study was to identify factors predicting poor prognosis at the time of early oral tongue carcinoma diagnosis.

Physician Cardiovascular Disease Risk Factor Management: Practices in France vs the United States

Cardiovascular risk factor management by French vs US primary care physicians was studied. A survey was conducted that found that French physicians spend >20 minutes while US physicians spend five to 10 minutes (P<.001) addressing cardiovascular risk with patients. Fifty‐three percent of French (vs 33% of US) physicians focus more on lifestyle modification and less on medication management (P<.0001). Sixty‐nine percent of French physicians spend 0% to 20% of their time on administration while 65% of US physicians spend 10% to 30% (P=.0028). Fifty‐one percent of French physicians see patients in one to three months for follow‐up, while 51% of US physicians see patients in three to six months (P<.0001). Eighty‐seven percent of French (vs 39% of US) physicians have guidelines available in the examination room either frequently or very frequently. US physicians report disparities in care more frequently than do French physicians (P<.0001). Forty‐nine percent of French (vs 10% of US) physicians believe that they have relative freedom to practice medicine (P<.001). US physicians report greater administrative efforts, frustration, and disparities in their practice. French physicians focus more of their efforts on lifestyle management and see their patients more frequently and for a longer visit time. J Clin Hypertens (Greenwich). 2011;13:10–18. ©2010 Wiley Periodicals, Inc.

SFE/SFHTA/AFCE consensus on primary aldosteronism, part 6: Adrenal surgery

Treatment of primary aldosteronism (PA) aims at preventing or correcting hypertension, hypokalemia and target organ damage. Patients with lateralized PA and candidates for surgery may be managed by laparoscopic adrenalectomy. Partial adrenalectomy and non-surgical ablation have no proven advantage over total adrenalectomy. Intraoperative morbidity and mortality are low in reference centers, and day-surgery is warranted in selected cases. Spironolactone administered during the weeks preceding surgery controls hypertension and hypokalemia and may prevent postoperative hypoaldosteronism. In most cases, surgery corrects hypokalemia, improves control of hypertension and reduces the burden of pharmacologic treatment; in about 40% of cases, it resolves hypertension. However, success in controlling hypertension and reversing target organ damage is comparable with mineralocorticoid receptor antagonists. Informed patient preference with regard to surgery is thus an important factor in therapeutic decision-making.

User Feedback on the MSF Tele-Expertise Service After a 4-Year Pilot Trial – A Comprehensive Analysis

We surveyed all users of the Médecins Sans Frontières (MSF) tele-expertise service, approximately four years after it began operation. The survey contained 50 questions and was sent to 294 referrers and 254 specialists. There were 163 responses (response rate 30%). There were no significant differences between the responses from French and English users, so the responses were combined for subsequent analysis. Most of the responders were doctors (133 of 157 who answered that question), and most had completed field missions for MSF, i.e., both specialists and referrers. The majority stated that the system was user friendly and that they found it self-explanatory (i.e., they did not need to be shown how to use it). Almost all the referrers found that the telemedicine advice that they received was helpful, changed diagnosis and management, and/or reassured the patient. Similar feedback came from the specialists, who also felt that there was educational value for the field doctor. Although there was general satisfaction with the service, the survey identified various problems. The main concerns of the referrers were the lack of promotion of the system at headquarters’ level, and the main concerns of the specialists were the lack of feedback about patient follow-up. Nonetheless, both referrers and specialists recognized the benefits of telemedicine in improving patient management, providing education, and reducing isolation in the field.

Concordance between CRP and SAA in familial Mediterranean fever during attack-free period: A study of 218 patients.

INTRODUCTION Monitoring SAA level in attack-free FMF patients is recommended in order to adjust colchicine dose, and minimize the risk of AA amyloidosis. In countries where this test is not available, C-reactive protein (CRP), another acute phase reactant, is used instead. However, CRP is low and SAA is increased in some patients and vice versa. OBJECTIVES To determine the threshold of CRP corresponding to SAA<10mg/L in patients with FMF and to assess their concordance at the patient level. PATIENTS AND METHODS Consecutive FMF patients in attack-free period and no other cause of intermittent inflammation including infections were recruited during their regular visits in the French reference center for FMF. Demographic and genetic data were recorded; CRP and SAA were tested simultaneously. The threshold value of CRP corresponding to 10mg/L for SAA was determined and the concordance between the two markers was assessed with Cohens kappa index. RESULTS 399 samples were obtained from 218 patients, mean age of 27years (33% under 18years old), 55% of female, from Sephardic Jewish origin in 71%. MEFV mutation was M694V homozygous or compound heterozygous in 52%, and simple heterozygous in 18%. Six patients had AA amyloidosis. The appropriate CRP threshold was found to be 5mg/L in children and 8.75mg/L in adults. Global agreement with SAA<10mg/L was 84% [95% confidence interval: 82 to 86%], leading to a kappa index at 0.62 [95% confidence interval: 0.57 to 0.68]. CONCLUSION CRP<5mg/L in FMF children or 8.75mg/L in FMF adults during attack-free periods might be a convenient substitute to guide therapeutic decisions when SAA is unavailable.

A Cross-Cultural Analysis of Physician Management of Obesity. Comparing the US, France, Israel and Japan: Little Interest and Little Success

Background: Obesity is a global health problem. Physicians are frequently engaged with overweight and obese patients. Obesity guidelines have been successfully implemented on a small scale, but generally physicians struggle to manage obesity effectively. Methods: In a web-based survey, primary care physicians in the United States (US), France, Israel and Japan, were asked how they manage cardiovascular risk factors. They were specifically asked how frequently they saw patients in follow-up for hypertension, hyperlipidemia and obesity. Results: Respondents (956) included 656 French, 198 Israeli, 45 Japanese, and 53 US physicians. Follow-up for obesity no sooner than 3 months was recommended, by 73% (US) and 79% (Israeli) physicians, whereas 67% of French and 66% of Japanese physicians recommended more frequent follow-up (3 months or less). Hypertension and hyperlipidemia was managed more aggressively, especially the US, Israel and Japan. Discussion: Obesity is an international concern, with rates increasing everywhere. The prevalence of obesity is high in the US and Israel and much lower in France and Japan. Chronic disease management is most effective with frequent follow-up. US obesity guidelines recommend frequent (often monthly) follow-up visits. US and Israeli physicians do not appear to be aggressive in managing obesity, whereas French and Japanese physicians report more effort to manage obesity. In the US, obesity management is not considered effective and physicians are uncomfortable attempting to manage obesity with their patients. In France especially, physicians have a more social relationship with their patients and seem oriented toward chronic disease management, including greater attention to lifestyle change. Conclusion: Obesity has been medicalized and is a profound problem internationally. The medical care system must address obesity management more effectively. Further studies are needed to understand how physicians manage obesity and new approaches should be promoted to improve the outcomes of obesity management.

Miming neurological syndromes improves medical student's long-term retention and delayed recall of neurology

Basic examination and diagnostic skills in neurology are important for every graduating medical student. However, a majority of medical students consider neurology as complex and difficult to master. We evaluate the impact a learner-friendly, innovative simulation-based training programme has on long-term retention and delayed recall of neurological semiology amongst third-year medical students from the University Pierre et Marie Curie in Paris, France. The 2013 class received standard teaching in neurological semiology. The 2015 class who received the same standard teaching in neurological semiology were also invited to voluntarily participate in The Move, a mime-based role-play training programme of neurological semiology. During the Move, students were trained to simulate a patient with a neurological syndrome or the physician examining the patient. Students were evaluated with an assessment thirty months after their neurological rotation, including 15 questions to evaluate long-term retention of neurological semiology, and 10 to test background knowledge in general semiology. The semiology test was performed by 366/377 students from the 2013 class (standard education group) and by 272/391 students from the 2015 class, among which 186 participated in The Move (The Move group) and 86 did not (standard education group). The mean neurological semiology score was higher in the 2015 class compared to the 2013 class (p = 0.007) and remained so after adjustment for the general semiology performance (p = 0.003). The adjusted mean neurological semiology score was 1.21/15 points higher [95% CI 0.66, 1.75] in The Move group compared to the standard education group, corresponding to a 14% better ranking. The Move programme improves medical students long-term retention and delayed recall of neurological semiology. This learner-friendly interactive teaching may in turn enhance clinical proficiency of future physicians in neurological semiology.

Rating the blood pressure outcome after adrenalectomy for unilateral primary aldosteronism

Primary aldosteronism is defined by autonomous aldosterone hypersecretion, which almost invariably leads to high blood pressure and sometimes to hypokalaemia. Primary aldosteronism also induces cardiovascular and kidney damage, partly independent from the effects of increased blood pressure. If the aldosterone hypersecretion originates from a single adrenal gland, it can be cured by unilateral adrenalectomy. Plasma aldosterone and potassium concentrations are expected to normalise and blood pressure to decrease postoperatively. The normalisation of aldosterone secretion should also prevent further blood pressureindependent target organ damage and can even reverse such damage. From the patient’s perspective, the immediate benefits of adrenalectomy are improved blood pressure control, a decrease in antihypertensive drug burden, or both. However, high blood pressure is cured in only about 40% of cases, with a wide variability across published series. Estimates of blood pressure improvement are even more heterogeneous because of the absence of a consensual definition that integrates both postoperative blood pressure and drug treatment changes. In The Lancet Diabetes & Endocrinology, the Primary Aldosteronism Surgery Outcome (PASO) study investigators report the results of an impressive international collaborative effort to standardise postoperative assessment and to show the value of applying uniform criteria across case series. The PASO investigators set up an international and multidisciplinary panel of 31 experts (including endocrinologists, surgeons, internists, cardiologists, and nephrologists) who used the Delphi method to reach consensual definitions of postoperative biochemical and blood pressure outcomes, distinguishing cure and improvement. They then used these criteria to assess postoperative outcomes in retrospective case series from 12 centres, including data for 705 patients. Overall, they reported that 259 (37%) of 705 patients were cured of hypertension (ie, achieved complete clinical success) and a further 334 (47%) improved (ie, achieved partial success), both with wide variability across series. Finally, the investigators showed that sex and age were strongly associated with the blood pressure outcome at the patient level. Female patients were more likely than male patients to have complete clinical success (odds ratio [OR] 2·25, 95% CI 1·40–3·62) and complete or partial clinical success (OR 2·89, 1·49–5·59), and younger patients were more likely than older patients to have complete clinical success (OR 0·95 per extra year, 0·93–0·98) and complete or partial clinical success (OR 0·95 per extra year, 0·92–0·98). Multilevel modelling then showed that the age and sex case-mix accounted for a substantial part of blood pressure outcome variability across centres. Nonetheless, several caveats need to be addressed. First, for the investigators to label the absence of a postoperative decrease in blood pressure or drug use as absent clinical success is a misnomer because the benefit on target organs is partly independent of blood pressure. To focus on blood pressure and drug changes might only be scratching the surface of clinical benefit following adrenalectomy. Second, the investigators refer only to office blood pressure measurements to define blood pressure improvement, probably because the case series used to validate the criteria were collected at times when out-of-office blood pressure measurements were not

Hidradenitis suppurativa and familial Mediterranean fever: a report of 6 cases and literature review

Familial Mediterranean fever (FMF) is the most frequent monogenic autoinflammatory disease (AID). Hidradenitis suppurativa (HS) is an inflammatory skin disease characterized by recurrent abscesses and scarring in apocrine gland-bearing areas. HS shares common features with AID including a positive correlation between the increase of acute phase reactants (APR) and the severity of the disease. HS can be associated with other AID.