The culture of doubt: Do medical students really experience clinical uncertainty when they should?

Uncertainty is a fundamental aspect of medical practice, necessitating incorporation into undergraduate medical training. The integrative model of uncertainty tolerance (UT) developed by Hillen and Han serves as a comprehensive framework for exploring clinical uncertainty. While studies have extensively examined UT dimensions, including sources, responses, and moderators, the factors influencing the perception of uncertainty stimuli remain underexplored. However, students' ability to perceive uncertainty and their approach to uncertain stimuli play a crucial role in enabling them to develop adaptive responses to uncertainty, necessary for their comfort in these situations. Defining uncertainty as a metacognitive state suggests significant variability in its perception among individuals and within an individual over time. Moreover, several studies have demonstrated the substantial influence of various individual and contextual factors on how individuals perceive and respond to uncertainty. In this paper, the authors present multiple hypotheses to address the question of whether students genuinely perceive uncertainty stimuli when they should. The authors argue that students' personal relationship with their knowledge is essential in their ability to identify clinical uncertainty, particularly concerning the limits of medical knowledge. Therefore, they propose that an academic culture fostering doubt, through exposing students to a variety of perspectives, would enhance their ability to identify uncertainty zones in a clinical situation at an early stage. Drawing on Dewey's situational theory, the authors emphasize the importance of better understanding, in a work setting, the influence of contextual and situational characteristics on individual perceptions of uncertainty. In line with this idea, ethnographic studies would offer valuable insights into identifying the relationship between the students, their work environment, and their perception of clinical uncertainty.

[Tolerating uncertainty: Towards a competence-based approach]

Uncertainty in inherent to every aspects of medical practice. As the concept of uncertainty in healthcare is still to explore, deciphering the determinants and the roots of this uncertainty would benefit from the insights of various disciplines, such as epistemology, sociology, mathematics, or philosophy. The urgent need to improve physician's ability to cope with uncertainty, has been recently highlighted by the COVID-19 pandemic. Besides, the concept of uncertainty tolerance has been proposed, and could serve as a relevant basis for approaching uncertainty, in medical education. Thus, we propose at first to discuss the uncertainty tolerance framework from Hillen et al. Then, from an educational perspective, we outline some avenues regarding how uncertainty tolerance could be thought, in a competence-based approach, and discuss several educational activities, which have proven efficient in promoting uncertainty tolerance among medical practitioners abroad.

Risk factors for symptomatic vascular events in giant cell arteritis: a study of 254 patients with large-vessel imaging at diagnosis

Aims

To identify factors associated with vascular events in patients with giant cell arteritis (GCA).

Methods

We performed a retrospective study of GCA patients diagnosed over a 20-year-period, who all underwent vascular imaging evaluation at diagnosis. Symptomatic vascular events were defined as the occurrence of any aortic event (aortic dissection or symptomatic aortic aneurysm), stroke, myocardial infarction, limb or mesenteric ischemia and de novo lower limbs arteritis stage 3 or 4. Patients with symptomatic vascular event (VE+) and without were compared, and risk factors were identified in a multivariable analysis.

Results

Thirty-nine (15.4%) of the 254 included patients experienced at least one symptomatic vascular event during follow-up, with a median time of 21.5 months. Arterial hypertension, diabetes, lower limbs arteritis or vascular complication at diagnosis were more frequent in VE+ patients (p < 0.05), as an abnormal computed tomography (CT)-scan at diagnosis (p = 0.04), aortitis (p = 0.01), particularly of the descending thoracic aorta (p = 0.03) and atheroma (p = 0.03). Deaths were more frequent in the VE+ group (37.1 versus 10.3%, p = 0.0003). In multivariable analysis, aortic surgery [hazard ratio (HR): 10.46 (1.41-77.80), p = 0.02], stroke [HR: 22.32 (3.69-135.05), p < 0.001], upper limb ischemia [HR: 20.27 (2.05-200.12), p = 0.01], lower limb ischemia [HR: 76.57 (2.89-2027.69), p = 0.009], aortic atheroma [HR: 3.06 (1.06-8.82), p = 0.04] and aortitis of the descending thoracic aorta on CT-scan at diagnosis [HR: 4.64 (1.56-13.75), p = 0.006] were independent predictive factors of a vascular event.

Conclusion

In this study on GCA cases with large vessels imaging at diagnosis, aortic surgery, stroke, upper or lower limb ischemia, aortic atheroma and aortitis of the descending thoracic aorta on CT-scan, at GCA diagnosis, were independent predictive factors of a vascular event.

Plain language summary

Risk factors for symptomatic vascular events in giant cell arteritisThis study was performed to identify the risk factors for developing symptomatic vascular event during giant cell arteritis (GCA) because these are poorly known.We performed a retrospective study of GCA patients diagnosed over a 20-year-period, who all underwent vascular imaging evaluation at diagnosis.Patients with symptomatic vascular event (VE+) and without (VE-) were compared, and risk factors were identified in a multivariable analysis.Thirty-nine patients experienced at least one symptomatic vascular event during follow-up, with a median time of 21.5 months.Arterial hypertension, diabetes, lower limbs arteritis or vascular complication at diagnosis were significantly more frequent in VE+ patients, as an abnormal CT-scan at diagnosis, aortitis, particularly of the descending thoracic aorta and atheroma. Deaths were more frequent in the VE+ group.Among 254 GCA patients, 39 experienced at least one vascular event during follow-up.Aortic surgery, stroke, upper and lower limb ischemia were vascular event risk factors.Aortic atheroma and descending thoracic aorta aortitis on CT-scan were vascular event risk factors.This study on GCA cases with large vessels imaging at diagnosis, showed that aortic surgery, stroke, upper or lower limb ischemia, aortic atheroma and aortitis of the descending thoracic aorta on CT-scan, at GCA diagnosis, were independent predictive factors of a vascular event.

Digital ischaemia aetiologies and mid-term follow-up: A cohort study of 323 patients

Upper extremity digital ischaemia (UEDI) is a rare heterogeneous condition whose frequency is 40 times less than that of toe ischaemia. Using a large cohort, the aim of this study was to evaluate aetiologies, prognosis and midterm clinical outcomes of UEDI.All patients with UEDI with or without cutaneous necrosis in a university hospital setting between January 2000 to December 2016 were included. Aetiologies, recurrence of UEDI, digital amputation and survival were analyzed retrospectively.Three hundred twenty three patients were included. UEDI due to cardio-embolic disease (DICE) was the highest occurring aetiology with 59 patients (18.3%), followed by DI due to Systemic Sclerosis (SSc) (16.1%), idiopathic causes (11.7%), Thromboangiitis obliterans (TAO) (9.3%), iatrogenic causes (9.3%), and cancer (6.2%). DICE patients tended to be older and featured more cases with arterial hypertension whereas TAO patients smoked more tobacco and cannabis. During follow-up, recurrences were significantly more frequent in SSc than in all other tested groups (P < .0001 vs idiopathic and DICE, P = .003 vs TAO) and among TAO patients when compared to DICE patients (P = .005). The cumulated rate of digital amputation was higher in the SSc group (n = 18) (P = .02) and the TAO group (n = 7) (P = .03) than in DICE (n = 2).This retrospective study suggests that main aetiologies of UEDI are DICE, SSc and idiopathic. This study highlights higher frequency of iatrogenic UEDI than previous studies. UEDI associated with SSc has a poor local prognosis (amputations and recurrences) and DICE a poor survival. UEDI with SSc and TAO are frequently recurrent.

Large-vessel involvement is predictive of multiple relapses in giant cell arteritis

Background:

Giant cell arteritis (GCA) is the most common systemic vasculitis. Relapses are frequent. The aim of this study was to identify relapse risk factors in patients with GCA with complete large-vessel imaging at diagnosis.

Methods:

Patients with GCA followed in our institution between April 1998 and April 2018 were included retrospectively. We included only patients who had undergone large vascular imaging investigations at diagnosis by computed tomography (CT)-scan and/or positron emission tomography (PET)-scan and/or angio-magnetic resonance imaging (MRI). Clinical, biological, and radiological data were collected. Relapse was defined as the reappearance of GCA symptoms, with concomitant increase in inflammatory markers, requiring treatment adjustment. Relapsing patients (R) and non-relapsing patients (NR) were compared. Relapse and multiple relapses (>2) risk factors were identified in multivariable Cox analyses.

Results:

This study included 254 patients (73.2% women), with a median age of 72 years at diagnosis and a median follow up of 32.5 months. At diagnosis, 160 patients (63%) had an inflammatory large-vessel involvement on imaging, 46.1% (117 patients) relapsed at least once, and 21.3% (54 patients) had multiple relapses. The median delay of first relapse after diagnosis was 9 months. The second relapse delay was 21.5 months. NR patients had more stroke at diagnosis than R (p = 0.03) and the brachiocephalic trunk was involved more frequently on CT-scan (p = 0.046), as carotids (p = 0.02) in R patients. Multivariate Cox model identified male gender [hazard ratio (HR): 0.51, confidence interval (CI) (0.27–0.96), p = 0.04] as a relapse protective factor, and peripheral musculoskeletal manifestations [HR: 1.74 (1.03–2.94), p = 0.004] as a relapse risk factor. Peripheral musculoskeletal manifestations [HR: 2.78 (1.23–6.28), p = 0.014], negative temporal artery biopsy [HR: 2.29 (1.18–4.45), p = 0.015], large-vessel involvement like upper limb ischemia [HR: 8.84 (2.48–31.56), p = 0.001] and inflammation of arm arteries on CT-scan [HR: 2.39 (1.02–5.58), p = 0.04] at diagnosis were risk factors of multiple relapses.

Conclusion:

Male gender was a protective factor for GCA relapse and peripheral musculoskeletal manifestations appeared as a relapsing risk factor. Moreover, this study identified a particular clinical phenotype of multi-relapsing patients with GCA, characterized by peripheral musculoskeletal manifestations, negative temporal artery biopsy, and large-vessel involvement with upper limb ischemia or inflammation of arm arteries.

Plain language Summary

At giant cell arteritis diagnosis, large-vessel inflammatory involvement is predictive of multiple relapses

Gamma heavy chain disease associated with rheumatoid arthritis: a case report

Background

Gamma heavy chain disease (γ-HCD) is a monoclonal gammopathy defined by an abnormal clonal and isolated production of incomplete heavy chain gamma (γ), unable to bind with light chains kappa or lambda. This disease is rare and remains poorly described. Its association to lymphoid neoplasm is well established, but exceptional forms of γ-HCD may also accompany auto-immune diseases. We report here a new case of γ-HCD characterized by an indolent course with a 4-year follow-up, and its association with quiescent rheumatoid arthritis (RA).

Case presentation

We report the case of a 85-year old French white man followed for quiescent anti-CCP+ rheumatoid arthritis treated by prednisolone 4 mg/day and hydroxychloroquine 200 mg/day since 10 years, and a monoclonal gammopathy of undetermined significance for 6 years, who was hospitalized for costal fractures after a fall. Serum protein electrophoresis showed a stable small monoclonal peak, and capillary electrophoresis/immunosubtraction technique identified an isolated clonal γ-heavy chain (HC). Bone marrow aspiration was normal and he had no other lymphoproliferation. The monoclonal peak remained stable after 4 years of follow-up.

Conclusions

In case of monoclonal peak without complete monoclonal Ig on serum protein electrophoresis, the diagnosis of γ-HCD should be discussed and capillary electrophoresis/immune-subtraction is a mean to detect isolated monoclonal heavy chain (HC). Gamma-HC disease is rare, may be associated to RA, and may have an indolent course.

Progressive clinical case-based multiple-choice questions: An innovative way to evaluate and rank undergraduate medical students

INTRODUCTION

In France, at the end of the sixth year of medical studies, students take a national ranking examination including progressive clinical case-based multiple-choice questions (MCQs). We aimed to evaluate the ability of these MCQs for testing higher-order thinking more than knowledge recall, and to identify their characteristics associated with success and discrimination.

METHODS

We analysed the 72 progressive clinical cases taken by the students in the years 2016-2019, through an online platform.

RESULTS

A total of 72 progressive clinical cases (18 for each of the 4 studied years), corresponding to 1059 questions, were analysed. Most of the clinical cases (n=43, 60%) had 15 questions. Clinical questions represented 89% of all questions, whereas basic sciences questions accounted for 9%. The most frequent medical subspecialties were internal medicine (n=90, 8%) and infectious diseases (n=88, 8%). The most frequent question types concerned therapeutics (26%), exams (19%), diagnosis (14%), and semiology (13%). Level 2 questions ("understand and apply") accounted for 59% of all questions according to the Bloom's taxonomy. The level of Bloom's taxonomy significantly changed over time with a decreasing number of level 1 questions ("remember") (P=0.04). We also analysed the results of the students among 853 questions of training ECNi. Success and discrimination significantly decreased when the number of correct answers increased (P<0.0001 both). The success, discrimination, mean score, and mean number of discrepancies did not differ according to the diagnosis, exam, imaging, semiology, or therapeutic type of questions.

CONCLUSION

Progressive clinical case-based MCQs represent an innovative way to evaluate undergraduate students.

Burnout level and associated factors in a sub-Saharan African medical setting: prospective cross-sectional survey

BACKGROUND

Burnout in the hospital environment is a problem that affects care and training. Often explored in the high-income medical context, burnout is poorly studied in low and middle-income countries characterized by a precarious hospital situation and a high stake linked to the Millennium Development Goals. The aim of our study was to determine in medical practitioners, in a sub-Saharan African country's medical context, the burnout level and associated factors.

METHODS

A prospective cross-sectional study by using a self-administered Likert-scale questionnaire addressed to doctors and doctoral medical students in Gabon. Maslach Burnout Inventory scale has been used. Burnout symptoms were defined by high level in at least one of the 3 dimensions. Severe burnout defined by high level in all dimensions. Explored factors: socio-demographic and psychometric. Multiple logistic regression has been performed.

RESULTS

Among 104 participants, severe burnout prevailed at 1.9% (95% CI: 0.2-6.8%) and burnout symptoms at 34.6% (95% CI: 25, 6-44.6%). The associated factors with burnout symptoms: age (OR = 0.86, p = 0.004), clinical activity in a university hospital center (OR = 5.19, p = 0.006), the easy access to the hospital (OR = 0.59, p = 0.012), number of elderly dependents living with the practitioner (OR = 0.54, p = 0.012), place of residence (same borough where the hospital is located: OR = 4.09, p = 0.039) and to be favorable to traditional medicine (OR = 1.82, p = 0.087). Nagelkerke's R-squared:53.1%.

CONCLUSION

In Gabon, middle-income country, almost one practitioner in two has burnout symptoms. The young age, the university hospital center, the difficulty to access to hospital and to live in the borough where the hospital is located increase the probability of burnout symptoms. These results must put question to relevant authorities regarding health and medical education, to set up: a public transport for practitioners, an optimal primary health care system, a regulation of medical tasks in hospitals, a training in clinical supervision.

[Reliability and validity of a workbook for assessment of professional competencies of internal medicine residents]

INTRODUCTION

Though several assessment tools for resident professional skills based on workplace direct observation have been validated, they remain scarcely used in France. The objective of this study was to evaluate the reliability and the validity of a workbook including several assessment forms for different components of the professional competency.

METHODS

Three assessment forms have been tested over a period of 6 months in a multicentric study including 12 French internal medicine departments: the French version of the mini-CEX, an interpersonal skills assessment form (OD_CR) and the multisource feedback form (E_360). Reliability has been assess using the intra-class correlation coefficient (ICC) and the Cronbach alpha coefficient. Arguments for validity have been provided looking at the ability of the forms to detect an increase in the scores over time and according to the level of experience of the resident.

RESULTS

Twenty-five residents have been included. The Cronbach alpha was of 0.90 (n=70) with the mini-CEX, 0.89 with the OD_CR (n=62) and 0.77 with the E_360 (n=86). ICC showed a wide variation according to the items of the mini-CEX and the OD-CR probably due to the poor number of observations performed by residents. The scores of most of the items of these two forms increased between M1 and M6. The scores of the E_360 were high: 7.3±0.8 to 8.3±2.4 (maximum 9) and did not vary according to the level of experience.

CONCLUSION

This study suggest that it would be difficult to ensure a sufficient reliability for professional skills assessment using these tools given our available current human and material resources. However, these assessment forms could be added to the resident portfolio as supports for the debriefing in order to document their progression during their formation.

[Hemolytic disorders and venous thrombosis: An update]

Many factors can contribute to the risk of venous thrombosis observed in hemolytic diseases. Some mechanisms are related to hemolysis by itself, while others seem more specific to each disease. Despite recent advances in the quantification of this risk and in understanding its physiopathology, the association of hemolysis with venous thrombosis is often unknown. The purpose of this general review is to clarify the main pro-thrombotic mechanisms during hemolysis and to synthesize the clinical data currently available. We will focus on the main types of hemolytic pathologies encountered in current practice, namely paroxysmal nocturnal hemoglobinuria, hemoglobinopathies, auto-immune hemolytic anemia and thrombotic microangiopathies.

[Validity and reproducibility of two direct observation assessment forms for evaluation of internal medicine residents' clinical skills]

INTRODUCTION

The revision of the French medical studies' third cycle ought to be competency-based. In internal medicine, theoretical and practical knowledge will be assessed online with e-learning and e-portfolio. In parallel, a reflection about clinical skills assessment forms is currently ongoing. In this context, our aim was to assess the reproducibility and validity of two assessment forms based on direct clinical observation.

METHOD

A prospective and multicentric study has been conducted from November 2015 to October 2016 aiming at evaluating the French translations of the MINI-Clinical Examination Exercice (MINI-CEX) and the Standardized Patient Satisfaction Questionnaire (SPSQ). Included residents have been assessed 2 times over a period of 6 months by the same binoma of judges.

RESULTS

Nineteen residents have been included. The inter-judge reproducibility was satisfactory for the MINI-CEX: intraclass coefficients (ICC) between 0.4 and 0.8 and moderate for the SPSQ: ICC between 0.2 and 0.7 with a good internal coherence for both questionnaires (Cronbach between 0.92 and 0.94). Significant differences between the distributions of the scores given by the judges and a significant inter-center variability have been found.

CONCLUSION

If the absolute value of the scores should not be taken into account in the evaluation process given its high variability, it could be of interest for the follow-up of the progression in the competencies. These forms could support the residents' debriefing based on the general trends given by the scores.

Efficiency of Systematic Thrombophilia Screening in Idiopathic Venous Thrombosis: A Prospective Study in Internal Medicine

In case of unprovoked venous thromboembolism (VTE), the screening of thrombophilia is recommended whatever the age of the patient and the type of risk factors (RF). This prospective study was conducted in patients with unprovoked VTE to detect some predictive factors to have a higher risk of thrombophilia, focusing on age, history of venous thromboembolism, and the existence of a triggering event. From July 2000 to July 2002, in an Internal Medicine Department, unrelated patients with unprovoked VTE were included. Those unprovoked thromboembolic events were defined by the absence of association between permanent and transient RF. The primary outcome measure was the positivity of the thrombophilia screening for any type of abnormality detected (deficit of protein C, S, antithrombin, presence of a lupus anticoagulant, research of V and II mutations). Seventy-four patients were included. Eight died during the follow-up. A higher risk of thrombophilia was found in patients younger than 40 (p=0.03), or with a family but not personal history of VTE (p=0.01) or with transient RF (p=0.02). The most frequent abnormality of coagulation found in patients younger than 40 was the presence of a lupus anticoagulant. As a new strategy for the screening of thrombophilia, one could propose the following attitude: only patients with transient RF or family history of VTE could undergo a complete screening; for all the remaining patients who are younger than 40, a research of a lupus anticoagulant would be only performed. This strategy should now be balanced against the currently recommended systematic attitude in further studies.

Comparison of idiopathic (isolated) aortitis and giant cell arteritis-related aortitis. A French retrospective multicenter study of 117 patients

OBJECTIVES

The aim of the study was to compare clinical/imaging findings and outcome in patients with idiopathic (isolated aortitis, IA) and with giant cell arteritis (GCA)-related aortitis.

METHODS

Patients from 11 French internal medicine departments were retrospectively included. Aortitis was defined by aortic wall thickening >2mm and/or an aortic aneurysm on CT-scan, associated to inflammatory syndrome. Patients with GCA had at least 3 ACR criteria. Aortic events (aneurysm, dissection, aortic surgeries) were reported, and free of aortic events-survival were compared.

RESULTS

Among 191 patients with non-infectious aortitis, 73 with GCA and 44 with IA were included. Patients with IA were younger (65 vs 70 years, p=0.003) and comprised more past/current smokers (43 vs 15%, p=0.0007). Aortic aneurisms were more frequent (38% vs 20%, p=0.03), and aortic wall thickening was more pronounced in IA. During follow-up (median=34 months), subsequent development of aortic aneurysm was significantly lower in GCA when compared to IA (p=0.009). GCA patients required significantly less aortic surgery during follow-up than IA patients (p=0.02). Mean age, sex ratio, inflammatory parameters, and free of aortic aneurism survival were equivalent in patients with IA ≥ 60 years when compared to patients with GCA-related aortitis.

CONCLUSIONS

IA is more severe than aortitis related to GCA, with higher proportions of aortic aneurism at diagnosis and during follow-up. IA is a heterogeneous disease and its prognosis is worse in younger patients <60 years. Most patients with IA ≥ 60 years share many features with GCA-related aortitis.

Cold climate could be an etiologic factor involved in Raynaud's phenomenon physiopathology. Epidemiological investigation from 954 consultations in general practic

AIM

The physiopathology of Raynaud's phenomenon (RP) is not currently fully resolved. The cold seems to be not only an important factor triggering attacks, but also inducing RP. The aims of this study were to assess the prevalence of RP in Nantes urban district, and study the relationship between RP prevalence and cold climate.

METHODS

Patients aged between 10 and 80 years old, consulting in five Nantes General Practices, from June 2011 and March 2012, were included. Patients presenting RP underwent a full clinical examination. Subjects not meeting Allen and Brown criteria benefited from at least a dosage of Anti-Nuclear Antibodies and a naifold Capillaroscopy. Climate data provided by French national weather agency allowed establishing an average of observed temperatures during the past five years and correlating them to the observed prevalence.

RESULTS

Of 954 patients included, 78 had a RP, for an overall prevalence estimated at 8.2%. The prevalence among women (8.9%) was slightly higher than men (7.3%). Secondary form represented 5.1% of RP. In the RP group, 13 patients were active smokers, mean BMI was 22.3±3.2 kg/m², and only 4 patients were treated by vasoconstrictor therapy. According to French national weather agency, between 2007 and 2011, mean temperature of January in Nantes area was 5.8 °C.

CONCLUSION

We confirmed that the lower winter temperatures a region experiences, the higher the prevalence of RP, thus raising the question of the physiopathological role of the cold in the induction or in the revelation of RP.

Long-term effectiveness and safety of interleukin-1 receptor antagonist (anakinra) in Schnitzler's syndrome: a French multicenter study

The aim of this study is to assess the long-term effectiveness and safety of IL1Ra in Schnitzler syndrome (SchS). Between 2010 and 2012, we performed a nationwide survey among French internal medicine departments to identify SchS patients. We retrospectively analyzed the long-term efficacy and safety of IL1Ra and the outcome of patients that did not receive this treatment. Forty-two patients were included in the study, 29 of whom received IL1Ra. The mean age at disease onset was 59.9years. Disease manifestations included urticaria (100%), fever (76%), bone/joint pain (86%), bone lesions (76%), anemia (67%), and weight loss (60%). The monoclonal gammopathy was overwhelmingly IgM kappa (83%). The mean follow-up was 9.5years (range: 1.6-35). Two patients developed Waldenström's macroglobulinemia and one developed AA amyloidosis. All of the 29 patients who received IL1Ra responded dramatically. After a median follow-up of 36months (range: 2-79), the effectiveness remained unchanged. All patients remained on anti-IL-1 therapy. Twenty-four patients (83%) went into complete remission and five (17%) into partial remission. Three patients experienced grade 3-4 neutropenia. Six patients developed severe infections. No lymphoproliferative diseases occurred while on IL1Ra. When last seen, all patients without anakinra had an active disease with variable impact on their quality of life. Their median corticosteroids dosage was 6mg/d (range: 5-25). IL1Ra is effective in SchS, with a sharp corticosteroid-sparing effect. Treatment failures should lead to reconsider the diagnosis. Long-term follow-up revealed no loss of effectiveness and a favorable tolerance profile. The long-term effects on the risk of hemopathy remain unknown.

Effect of stress on clinical reasoning during simulated ambulatory consultations

BACKGROUND

The goal of this study was to examine the impact of subjective and physiological stress responses on medical students' diagnostic reasoning and communication skills.

METHOD

A prospective randomized quantitative study was undertaken, looking at ambulatory consultations in internal medicine. On the first day (baseline day), volunteer year 6 students (n = 41) participated in a simulated ambulatory consultation with standardized patients (SPs). On the second day (study day), one week later, they were randomly assigned to two groups: a low stress (n = 20) and a high stress (n = 21) simulated ambulatory consultation. Stress was measured using validated questionnaires and salivary cortisol. The SPs assessed the students' reasoning and communication. The students completed assessments of their clinical reasoning after the consultations.

RESULTS

Although stress measures were all significantly higher in the high-stress condition (all p < 0.05), no differences were found in diagnostic accuracy and justification scores. However, correlational analyses revealed a negative correlation between multiple-stress measures and the students' ability to generate arguments for differential diagnoses.

CONCLUSION

Stress was associated with impairments in clinical reasoning, of a nature typically suggestive of premature closure.

[Superior vena cava syndrome induced by pacemaker probes, 12 years after introduction]

Superior vena cava syndrome is a rare disease, most often found to result from a malignant process, which causes extrinsic compression of the superior vena cava. In recent years, there has been an increase of superior vena cava syndrome related to medical devices (implantable site, pacemaker [PM], central venous line for parenteral nutrition...). We report the case of a 37-year-old patient who developed a superior vena cava syndrome 12 years after implantation of a PM. The diagnosis was established on venography after two negative venous-CT focused on the superior vena cava. The superior vena cava syndrome improved immediately after angioplasty and stenting covering the PM probes at the superior vena cava/brachiocephalic venous trunk junction.

High-efficiency metallic multistratum concave diffraction grating

A concave diffraction grating for integrated optics is constructed by replacing the reflective metallic part by multiple thin elements of metal, each partially reflecting the light, arranged in elliptical fashion in order to distribute the diffraction/reflection of light and provide aberration-free focusing by combining the diffraction condition and Bragg condition of these curved reflectors. It results in increasing the reflection from 39% to 73%, as simulations show.

Stress responses in medical students in ambulatory and in-hospital patient consultations

CONTEXT

 Little is known about health professionals' responses to acute stressors encountered in the clinical environment. The goal of this study was to measure the subjective and physiological stress responses of medical students to consultations in familiar (in-hospital) and unfamiliar (ambulatory) settings. We hypothesised that: (i) providing a consultation in an unfamiliar setting would result in increased stress responses in medical students, and (ii) some differences in stress responses according to gender might become apparent.

METHODS

A quantitative cross-over study was conducted over a 6-month period. Participating students were invited to provide consultations to patients in an ambulatory setting. In order to provide a control condition, each student was required to conduct a similar consultation (without reporting back to the patient) with an in-hospital patient during his or her rotation in internal medicine. Pre- and post-consultation subjective and physiological responses were measured using a visual analogue scale (VAS), the State-Trait Anxiety Inventory (STAI), a cognitive appraisal scale and salivary cortisol levels.

RESULTS

All of the subjective and physiological stress responses were greater in the ambulatory setting than the in-hospital setting. There was an effect of gender on the responses. Women showed greater pre-consultation subjective stress levels in the ambulatory setting, whereas men exhibited greater physiological stress levels in the ambulatory setting. No correlations were observed between subjective and cortisol responses.

CONCLUSIONS

Ambulatory consultations are more stressful for medical students than consultations carried out in the more familiar in-hospital setting. Further studies should be conducted to investigate the nature of the stressors in this particular environment, to explore the possible explanations for a gender effect, and to explore the effects of these stress responses on students' diagnostic skills.

Exploring how students think: a new method combining think-aloud and concept mapping protocols

OBJECTIVES

A key element of medical competence is problem solving. Previous work has shown that doctors use inductive reasoning to progress from facts to hypotheses and deductive reasoning to move from hypotheses to the gathering of confirmatory information. No individual assessment method has been designed to quantify the use of inductive and deductive procedures within clinical reasoning. The aim of this study was to explore the feasibility and reliability of a new method which allows for the rapid identification of the style (inductive or deductive) of clinical reasoning in medical students and experts.

METHODS

The study included four groups of four participants. These comprised groups of medical students in Years 3, 4 and 5 and a group of specialists in internal medicine, all at a medical school with a 6-year curriculum in France. Participants were asked to solve four clinical problems by thinking aloud. The thinking expressed aloud was immediately transcribed into concept maps by one or two 'writers' trained to distinguish inductive and deductive links. Reliability was assessed by estimating the inter-writer correlation. The calculated rate of inductive reasoning, the richness score and the rate of exhaustiveness of reasoning were compared according to the level of expertise of the individual and the type of clinical problem.

RESULTS

The total number of maps drawn amounted to 32 for students in Year 4, 32 for students in Year 5, 16 for students in Year 3 and 16 for experts. A positive correlation was found between writers (R = 0.66-0.93). Richness scores and rates of exhaustiveness of reasoning did not differ according to expertise level. The rate of inductive reasoning varied as expected according to the nature of the clinical problem and was lower in experts (41% versus 67%).

CONCLUSIONS

This new method showed good reliability and may be a promising tool for the assessment of medical problem-solving skills, giving teachers a means of diagnosing how their students think when they are confronted with clinical problems.

Tunable structures comprising two photonic crystal slabs--optical study in view of multi-analyte enhanced detection

Using finite-difference time-domain method, we characterize the normal-incidence transmission properties of a two slab photonic crystal device in a view of its applications in fluorescence enhancement and multi-analyte detection. Individual slabs consist of a square or a triangular lattice of air holes embedded into a silicon nitride slab. The geometrical parameters are chosen so that the individual slabs operate in a guided resonance regime where strong reflectivity under the normal incidence angle is observed in a broad spectral range. When placed in the close proximity of each other, the two photonic crystal slab system exhibits a narrow Fabry-Perot type transmission peak corresponding to the excitation of a resonant mode in the cavity formed by the two slabs. We then study the effects of the size of the air gap between the two photonic crystal slabs on the spectral position and bandwidth of a resonance transmission peak. Finally, we investigate the electromagnetic energy distributions at the wavelength of a transmission resonance in the double slab photonic crystals. As a final result we demonstrate that this structure can provide electric field enhancement at the slab surface, which can be used for fluorescence enhancement.

[Prolongation of anti vitamin K treatment for 18 months versus placebo after 6 months treatment of a first episode of ideopathic pulmonary embolism: a mutlicentre, randomised double blind trail. The PADIS-EP Trial]

BACKGROUND

After stopping a 3 to 6 months course of oral anticoagulation for a first episode of idiopathic venous thromboembolism (VTE), the risk of recurrent VTE is high (10% per year). In this setting, international guidelines recommend at least 6 months treatment. However, this recommendation is not satisfactory for the following reasons: (1) no randomized trial has compared 6 months to extended duration (2 years) anticoagulation; and (2), even though the frequency of recurrent VTE is similar after pulmonary embolism (PE) and deep vein thrombosis (DVT), the fatality rate of recurrent VTE after PE is higher than that after DVT.

METHODS

A French multicentre double blind randomized trial. The main objective is to demonstrate, after a first episode of symptomatic idiopathic PE treated for 6 months using a vitamin K antagonist, that extended anticoagulation for 18 months (INR between 2 and 3) is associated with an increased benefit / risk ratio (recurrent VTE and severe anticoagulant-related bleeding) compared to placebo. The double blind evaluation is ensured using by active warfarin and placebo, and blinded INR. The protocol was approved by the ethics board of the Brest Hospital on the 7th of March 2006. For an alpha risk of 5% and a beta risk of 20%, the estimated sample size is 374 patients.

EXPECTED RESULTS

This study has the potential to: (1) demonstrate that the benefit / risk ratio of extended anticoagulation for 18 months is higher than that observed with placebo in patients with a first episode of idiopathic PE initially treated for 6 months, during and after the treatment period; and (2) to validate or invalidate the contribution of isotope lung scans, lower limb Doppler ultrasound and D-Dimer at 6 months of treatment as predictors of recurrent VTE (medico-economic analysis included).

[Drugs and venous thromboembolism]

Among the many factors likely to favour the occurrence of venous thromboembolism (VTE), exposure to certain drugs has to be taken into account. Although hormone treatments, oral contraception and hormone replacement therapy (HRT) for menopause have been studied, these are not the only drugs associated with an increased risk of VTE. The antipsychotics have also been incriminated in the occurrence of venous thromboembolism. The association of thalidomide and dexamethasone, used in the treatment of multiple myeloma, is responsible for a major increase in the risk of VTE. The physiopathological mechanisms accounting for the possible prothrombotic effect of most of these drugs is still not fully understood. Further observational and interventional clinical studies should provide a better understanding of VTE, potentially associated with drugs. However, certain drugs may be associated with a reduced risk of VTE. Although several studies indicate that aspirin and statins may favourably influence the risk of VTE, it is still not possible to draw up any practical recommendations.

Guided-mode resonance photonic crystal slab sensors based on bead monolayer geometry

Using finite-difference time-domain method, we investigate photonic crystal slabs consisting of spherical voids or silica beads embedded into a dielectric slab as bio-chemical sensors. We study the dependence of the spectral position of guided-mode resonances on the refractive index of a slab material. The most sensitive design is based on voids filled with analyte. We also study the effects of the slab and analyte thicknesses on guided-mode resonance properties. We eventually demonstrate an aqueous analyte sensor with high sensitivity at visible wavelength as electro-magnetic energy distribution in some guided-mode resonances can be strongly localized in the analyte region.

D-dimers, thrombin-antithrombin complexes, and risk factors for thromboembolism in hospitalized patient

INTRODUCTION

There is lack of data about the correlation between hemostatic markers and the clinical and biological risk factors (RFs) for venous thromboembolism (VTE) in medical inpatients without suspicion of acute VTE.

MATERIAL AND METHODS

To evaluate the coagulation activation status in patients with current known RFs for VTE, the authors measured 2 markers of hypercoagulability, thrombin antithrombin (TAT) complexes and D-dimers, at day 1 in 165 patients hospitalized in internal medicine wards without suspected acute VTE. All known RFs for VTE were systematically assessed at admission and classified in a chronological way as permanent or transient.

RESULTS

Surprisingly, TAT values followed a multimodal distribution. D-dimers showed a normal distribution after a logarithmic transformation (P = .34, Shapiro-Wilk test). Interestingly, a significant progression in D-dimer levels was found according to the chronological classification of RFs. D-dimer variations on multivariate analysis (not applicable for TAT because of the multimodal distribution) correlated independently with a recent inability to walk and an increase in C reactive protein level more than 10 mg/L.

CONCLUSIONS

(a) this study is the first to describe the variations of hypercoagulability markers according to a systematic screening of RFs for VTE in inpatients without suspicion of acute VTE, (b) TAT appeared as a less relevant marker of hypercoagulability than D-dimers in internal medicine inpatients, (d) the chronological classification of RFs identified clearly groups at risk for the prethrombotic state, and (d) an increased hypercoagulability state was demonstrated in patients with an association between a recent immobility and increased inflammatory markers.

Aortic involvement in recent-onset giant cell (temporal) arteritis: a case-control prospective study using helical aortic computed tomodensitometric scan

OBJECTIVE

The prevalence of the involvement of large vessels in giant cell arteritis (GCA) is 3-13%. Aortitis is the most serious complication of GCA. Computed tomodensitometric (CT) scan allows analysis of both the aortic wall and endoluminal part of the aorta. Therefore, we conducted a study using CT scan to analyze aortic abnormalities in patients with recent-onset GCA.

METHODS

This prospective controlled study compared patients with biopsy-proven GCA with a matched control group based on sex, age, and cardiovascular risk factors. During the 4-week period following diagnosis of GCA, patients underwent an aortic CT scan. The aortic imaging results were blindly compared between both groups.

RESULTS

From January 5, 1998 to January 11, 1999, 22 patients and 22 controls were screened by CT scan for aortic involvement. Thickening of the aortic wall was more frequent among patients than controls (45.4% versus 13.6%; P = 0.02). Aortic thickening (mean 3.3 mm) was located on the ascending part of the thoracic aorta in 22.7% of the patients, with no evidence of thickening in the controls (P = 0.05). Thickening of the abdominal aortic wall was noted in 27.3% of the patients and none of the controls (P = 0.02).

CONCLUSION

This study suggests that inflammatory aortic thickening, detected by CT scan, occurs frequently at the time of diagnosis of GCA, and that this condition predominantly occurs on the ascending part of the aorta.

[Risk of venous thromboembolism in the course of acute medical illness. Part 1: Basic research, clinical models, descriptive and analytic epidemiology]

PURPOSE

Some acute medical illnesses are associated with an increased risk of venous thromboembolism. This risk is difficult to assess in medical patients on account of the multiplicity of their pathologies, leading to potential interactions between numerous risk factors.

CURRENT KNOWLEDGE AND KEY POINTS

A rational analysis of the risk of venous thrombosis in acute medical setting may be derived from pathogenic models and be based on elementary risk factors for venous thromboembolism classified as transient, permanent, major and intermediate factors. The systematic study of pathophysiological mechanisms in process, in each medical patient could guide the physician attitude toward still non-evaluated situations.

FUTURE PROSPECTS AND PROJECTS

A synthesis of the last epidemiological and pathophysiological data is developed in the first part of this literature review, whereas the risk linked to specific situations in ambulatory, hospital or internal medicine settings will be described in the second part.

[Risk of venous thromboembolism in acute medical illnesses. Part 2: Situations at risk in ambulatory, hospital and internal medicine settings]

PURPOSE

The increased risk of thromboembolism in acute medical illnesses (AMI) is difficult to assess because of the diversity of medical conditions. The first part of this review of the literature was dedicated to methods of risk analysis based on our current pathophysiological knowledge. This second part describes more specifically the risk of venous thrombosis linked to AMI in hospital, ambulatory and internal medicine settings.

CURRENT KNOWLEDGE AND KEY POINTS

The incidence of venous thromboembolism is higher in hospital than in ambulatory setting, albeit the latter remains significant. Stroke and affections leading to intensive care management represent conditions at great risk. Several mechanisms leading to a prothrombotic state have been identified, explaining the increased risk observed during relapses of pathologies specifically treated in internal medicine such as lupus erythematosus, Wegener granulomatosis, inflammatory bowel diseases and Behcet's disease.

FUTURE PROSPECTS AND PROJECTS

Next to the pathophysiological understanding of venous thrombosis, the assessment of the specific thrombogenic burden of an AMI is an additive tool to screen medical patients at high risk. This systematic review of the literature shows uncertainties towards some risk factors as bedrest or acute inflammatory response. Taking into account the methodological difficulties inherent to prospective and epidemiological studies, a meta-analysis focusing on these factors would be useful to refine prevention guidelines for venous thromboembolism in medical setting.

Efficient coupling into slow-light photonic crystal channel guides using photonic crystal tapers

Photonic crystal tapers have been designed for coupling of light from ridge waveguides into low group velocity photonic crystal channel guides. The coupling efficiency is increased from 3 % (case of butt-coupling) to 97 % for frequencies in the band-edge region, corresponding to a group index close to 100, as predicted using 2D finite-difference time-domain simulations.

Prévalence et description des hyponatrémies dans les services de médecine interne de l'ouest de la France. Une enquête descriptive multicentrique type « jour donné »

PURPOSE

Few data are available on the prevalence and causes of hyponatremia in medical setting and to our knowledge, no recent descriptive study has been performed about hyponatremias in the French Departments of internal medicine.

METHOD

A "one day" descriptive multicentric study was performed in the medicine departments of the France West area. A questionnaire was mailed to physicians who had to take part in a annual regional meeting about "hyponatremias", one month later. Hyponatremia was defined by a blood sodium level under the normal value of the local laboratory. Each internist had to precise for all hyponatremias in course at the study day, the exact value, the discovery circumstances, the mechanisms and etiologies, the associated diseases, the course and treatments.

RESULTS

Seventy-four hyponatremias were identified. The overall prevalence was 12,1%. The prevalence of severe hyponatremias (under 120 mmol/l) was 1,1%. These latter represented 9,4% of the whole hyponatremias (7/74). Associated symptoms and diseases, the mechanisms, the suspected etiologies, the course and treatments are described in detail.

CONCLUSION

This multicentric study reports for the first time the prevalence, the clinical and etiological characteristics of hyponatremias coming from Internal Medecine Departments of the West area from France. The overall prevalence is lower in comparison with values usually reported in hospitalized patients, but the frequency of severe and moderate hyponatremias, the mechanisms and the suspected etiologies are identical to those reported in others countries.

Power and polarization beam-splitters, mirrors, and integrated interferometers based on air-hole photonic crystals and lateral large index-contrast waveguides

Air hole 2D photonic crystals (PhC) and air slots have been used in association with semiconductor ridge waveguides to produce highly compact beam-splitters (less than 10 microm x10 microm) for power or polarization separators and mirrors. An efficiency of 99 % (in both 2D and 3D formulations) has been obtained for the power beam-splitter using finite-difference time-domain (FDTD) simulations - and around 95 % has been measured experimentally for structures realized in silicon-on-insulator (SOI) waveguides. In the polarization splitter, an extinction ratio as large as 11 dB was also reached experimentally. Examples of combinations of these elements in the form of interferometers are also presented.

Sténoses endobronchiques au cours de la granulomatose de Wegener

INTRODUCTION

Endobronchial stenoses are rare in the course of Wegener's granulomatosis, and they occur even more rarely than subglottic stenoses.

EXEGESIS

We report seven cases of endobronchial stenoses in the setting of Wegener granulomatosis. Neither the pulmonary symptoms nor the systemic manifestations of vasculitis were specific. However 6/7 patients presented a wheezing or an hemoptysis. Bronchial endoscopy has permitted the diagnosis in all cases. Local evolution was cicatricial and symptomatic stenosis in 3 cases (42,8%).

CONCLUSION

Thus these lesions must be research in any case of pulmonary abnormality in the course of Wegener's granulomatosis, because they may lead to a pejorative prognosis. Moreover general and local treatment must be given early (at the inflammatory stage). After this stage, the local treatments are difficult and not efficient.

[Empirical treatment of granulomatous hepatitis of unknown origin: practice investigation in the French National Society of Internal Medicine]

PURPOSES

Ten to fifteen percent of granulomatous hepatitis are idiopathic. If symptoms like prolonged fever are present, empirical treatment is discussed. The goal of this study is to describe the empirical treatment proposed in this situation by French specialists of internal medicine.

METHODS

We conducted a practice investigation among the French national society of internal medicine (SNFMI), using an anonymous questionnaire that related a case of idiopathic granulomatous hepatitis. This questionnaire was proposed to all French internists present at the SNFMI congress in June and December 2004. French specialists of internal medicine had to answer if they would prescribe an empirical treatment and if so, to specify this treatment.

RESULTS

Thirty-six French specialists of internal medicine answered to the questionnaire. In the proposed situation, 89% of them initiate an empirical treatment. In 18/36 cases (50%), a first-line anti-tuberculosis empirical treatment is proposed (quadritherapy in 11 cases). In 7 cases (19%), an empirical treatment with prednisone, 0.4 mg/kg/d (N=1) and 1 mg/kg/d (N=6), would be prescribed. Seven internists (19%) would prescribe an empirical treatment with cyclins at the dose of 100 to 400 mg/d. Median duration of the empirical treatment would be 28 days (range: 8-252d). The evaluation parameters mentionned are: fever (69%), weight (59%), seric level of C-reactive protein (59%), and liver biology (53%). In case of failure of first-line empirical treatments, 69% of all questionned internists prescribe a second-line treatments: prednisone at the dose of 0.4 to 2 mg/kg/d (72%), anti-tuberculosis treatments (16%), cyclins 200 mg/d (12%), with a median duration of 28 days. Seven internists (19%) propose to combine two empirical treatments.

DISCUSSION

Faced with a problem of idiopathic granulomatous hepatitis, French internists questionned propose four therapeutics options: no treatment, anti-tuberculosis treatment, cyclins or steroids treatment. First-line anti-tuberculosis treatment is a coherent proposition regarding to the high prevalence of tuberculosis. There are only few data available concerning empirical treatment with steroids or cyclins. Specific proposition of such empirical treatments should be defined.

CONCLUSIONS

The management of idiopathic granulomatous hepatitis is difficult. Our study shows that therapeutics practices of French internists are heterogenous. The main proposition consists in a first-line anti-tuberculosis empirical treatment, that has to be evaluated after four weeks, and switched with steroids (prednisone, 1 mg/Kg/d) in case of failure. This study is not an expert proposition but contributes to suggest clinical practice guidelines for a rare, complex, heterogenous, and typically internist situation.