L’évaluation du raisonnement clinique des résidents en hématologie par l’approche de concordance de script

La pratique de l’hématologie, comme celle de toute profession, implique l’acquisition d’un raisonnement adéquat. Se basant sur une théorie de psychologie cognitive, le test de concordance de script (TCS) a été développé et validé comme un instrument permettant d’évaluer le raisonnement clinique dans diverses spécialités médicales. Le but de cette étude était d’examiner l’utilité et les paramètres psychométriques d’un TCS en hématologie. Nous avons construit un TCS composé de 60 questions que nous avons administré à 15 résidents juniors (R1 à R3 en médecine interne), 46 résidents séniors (R4, R5 et R6 en hématologie) et 17 hématologues à travers le Canada. Après optimisation, le TCS comptait 51 questions. Sa consistance interne mesurée par le coefficient de Cronbach alpha était 0.83. Le test était en mesure de discriminer entre les résidents selon leur niveau de formation. Les questions contenant des images (n=10) semblaient avoir un potentiel discriminatoire plus élevé. Les scores obtenus par les résidents séniors corrélaient modéremment avec ceux obtenus à un test conventionnel d’hématologie composé de questions à choix multiples et à courte réponse (r de Pearson = 0.42; p=0.02). Le TCS a été complété en 36 minutes en moyenne et a été bien reçu par les participants. Le TCS est un instrument d’évaluation utile et valide en hématologie. Il peut être utilisé à des fins formatives en aidant au suivi de la progression des résidents. Il pourrait aussi être combiné à d’autres instruments d’évaluation à des fins sanctionnelles, ou encore, en éducation médicale continue.The practice of hematology, like any other profession, requires the acquisition of adequate judgment. Based on cognitive psychology theory, the script concordance test (SCT) has been developed and validated as an instrument capable of evaluation clinical judgement in various medical specialties. The goal of this study was to examine the usefulness and the psychometric qualities of the SCT in hematology. We constructed a SCT composed of 60 questions and we administered it to 15 junior residents (R1 to R3 in internal medicine), 46 senior residents (R4, R5 and R6) and 17 hematologists from across Canada. After item optimization, the test comprised 51 questions. Its internal consistency measured by Cronbach alpha was 0.83. The test was able to discriminate between residents according to their year of training. Questions containing an image (n=10) seemed to offer a stronger discriminative potential. Scores obtained by the senior residents correlated moderately with those obtained on a conventional hematology exam made of multiple choice questions and short-answers (Pearson r: 0.42; p=0.02). The SCT was completed in an average of 36 minutes and was well received by participants. The SCT is a useful and valid evaluation instrument in hematology. It may be used during training to monitor resident progression. It may also be combined to other evaluation tools and used for summative purposes or in continuing medical education

Access Now: Improving Access to Specialty Healthcare for the Low-income Uninsured

Seventeen percent of non-elderly Americans were uninsured in 2007. Sixty-five percent of the uninsured have a family income below 200 percent of the federal poverty level. The uninsured receive less preventive care, fewer diagnostic services, less therapeutic care, and are usually more severely ill at presentation. The uninsured have poorer disease-specific and general mortality and morbidity, which is partially explained by decreased access to care and medical care use. Thus, the physical and emotional health of the uninsured suffers due to decreased use of and access to medical services. Lack of insurance affects also burdens families and communities. Families without health insurance are twice as likely to spend over five percent of their income on out-of-pocket health care. In 2005, approximately $43 billion was spent on uncompensated medical care for the uninsured. An estimated$65 to $130 billion is lost annually due to the uninsured's poorer health and reduced lifespans. Thus, the health consequences of uninsurance present a significant burden to patients, family, and communities. The burden of care for the uninsured further falls disproportionately on primary care providers. In minority populations, 45.6 percent of low-income uninsured physician visits are with family physicians. In comparison, 30.1 percent of insured physician visits are with family physicians. Since the uninsured present more severely ill and advanced disease, family physicians are caring for sicker patients that often would be better served by more specialized care. In a study of children with a chronic condition or disability, Kuhlthau and colleagues found that 16.9 percent of the uninsured saw a specialist while 28.3 percent of the privately insured saw a specialist. Szilagyi and colleagues found a 5-fold increase in specialty visits after patient enrollment in an insurance program. Uninsured dialysis patients are three times more likely to be referred late to nephrologists than their insured counterparts. The uninsured's decreased access to specialists leads to worse outcomes for patients with hypertension, heart attacks, cancer, trauma, ruptured appendices, liver disease, and patients on ventilator support. Many communities have safety nets that are intended to provide care for their low-income uninsured. Generally, this includes some combination of emergency departments, health departments, free clinics, and charity care from other private providers. Safety nets are mainly composed of primary care providers and lack specialty care providers. While the specialty needs of the uninsured are known, few models to address this problem are described in the medical literature. In this program plan and evaluation paper, I first explore what models exist to address the lack of specialty care for the uninsured. I then describe a recently begun program in Richmond, Virginia and outline a plan for its growth and evaluation.Master of Public Healt

Increased systemic inflammation is associated with cardiac and vascular dysfunction over the first 12 weeks of antiretroviral therapy among undernourished, HIV-infected adults in Southern Africa.

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.INTRODUCTION: Persistent systemic inflammation is associated with mortality among undernourished, HIV-infected adults starting antiretroviral therapy (ART) in sub-Saharan Africa, but the etiology of these deaths is not well understood. We hypothesized that greater systemic inflammation is accompanied by cardiovascular dysfunction over the first 12 weeks of ART. METHODS: In a prospective cohort of 33 undernourished (body mass index <18.5 kg/m2) Zambian adults starting ART, we measured C-reactive protein (CRP), tumor necrosis factor-α receptor 1 (TNF-α R1), and soluble CD163 and CD14 at baseline and 12 weeks. An EndoPAT device measured the reactive hyperemia index (LnRHI; a measure of endothelial responsiveness), peripheral augmentation index (AI; a measure of arterial stiffness), and heart rate variability (HRV; a general marker of autonomic tone and cardiovascular health) at the same time points. We assessed paired changes in inflammation and cardiovascular parameters, and relationships independent of time point (adjusted for age, sex, and CD4+ T-cell count) using linear mixed models. RESULTS: Serum CRP decreased (median change -3.5 mg/l, p=0.02), as did TNF-α R1 (-0.31 ng/ml, p<0.01), over the first 12 weeks of ART. A reduction in TNF-α R1 over 12 weeks was associated with an increase in LnRHI (p=0.03), and a similar inverse relationship was observed for CRP and LnRHI (p=0.07). AI increased in the cohort as a whole over 12 weeks, and a reduction in sCD163 was associated with a rise in the AI score (p=0.04). In the pooled analysis of baseline and 12 week data, high CRP was associated with lower HRV parameters (RMSSD, p=0.01; triangular index, p<0.01), and higher TNF- α R1 accompanied lower HRV (RMSSD, p=0.07; triangular index, p=0.06). CONCLUSIONS: Persistent inflammation was associated with impaired cardiovascular health over the first 12 weeks of HIV treatment among undernourished adults in Africa, suggesting cardiac events may contribute to high mortality in this population.This work was supported by the Vanderbilt Meharry Center for AIDS Research (NIH grant number P30 AI54999); the NIH Fogarty International Center, Office of the Director, National Institutes of Health, National Heart, Blood, and Lung Institute, and National Institute of Mental Health, through the Vanderbilt-Emory-Cornell-Duke Consortium for Global Health Fellows (grant number R25 TW009337); the National Center for Advancing Translational Sciences (CTSA award number UL1TR000445) and the European and Developing Countries Clinical Trials Partnership (grant IP.2009.33011.004)

A 12 week longitudinal study of microbial translocation and systemic inflammation in undernourished HIV-infected Zambians initiating antiretroviral therapy.

BACKGROUND: Undernourished, HIV-infected adults in sub-Saharan Africa have high levels of systemic inflammation, which is a risk factor for mortality and other adverse health outcomes. We hypothesized that microbial translocation, due to the deleterious effects of HIV and poor nutrition on intestinal defenses and mucosal integrity, contributes to heightened systemic inflammation in this population, and reductions in inflammation on antiretroviral therapy (ART) accompany reductions in translocation. METHODS: HIV-infected, Zambian adults with a body mass index <18.5 kg/m2 were recruited for a pilot study to assess the relationships between microbial translocation and systemic inflammation over the first 12 weeks of ART. To assess microbial translocation we measured serum lipopolysaccharide binding protein (LBP), endotoxin core IgG and IgM, and soluble CD14, and to assess intestinal permeability we measured the urinary excretion of an oral lactulose dose normalized to urinary creatinine (Lac/Cr ratio). Linear mixed models were used to assess within-patient changes in these markers relative to serum C-reactive protein (CRP), tumor necrosis factor-α receptor 1 (TNF-α R1), and soluble CD163 over 12 weeks, in addition to relationships between variables independent of time point and adjusted for age, sex, and CD4+ count. RESULTS: Thirty-three participants had data from recruitment and at 12 weeks: 55% were male, median age was 36 years, and median baseline CD4+ count was 224 cells/μl. Over the first 12 weeks of ART, there were significant decreases in serum levels of LBP (median change -8.7 μg/ml, p = 0.01), TNF-α receptor 1 (-0.31 ng/ml, p < 0.01), and CRP (-3.5 mg/l, p = 0.02). The change in soluble CD14 level over 12 weeks was positively associated with the change in CRP (p < 0.01) and soluble CD163 (p < 0.01). Pooling data at baseline and 12 weeks, serum LBP was positively associated with CRP (p = 0.01), while endotoxin core IgM was inversely associated with CRP (p = 0.01) and TNF-α receptor 1 (p = 0.04). The Lac/Cr ratio was not associated with any serum biomarkers. CONCLUSIONS: In undernourished HIV-infected adults in Zambia, biomarkers of increased microbial translocation are associated with high levels of systemic inflammation before and after initiation of ART, suggesting that impaired gut immune defenses contribute to innate immune activation in this population

The natural history of latent rheumatic heart disease in a 5 year follow-up study: a prospective observational study

BackgroundLatent rheumatic heart disease (RHD) occurs in asymptomatic individuals with echocardiographic evidence of RHD and no history of acute rheumatic fever. The natural history of latent RHD is unclear but has important clinical and economic implications about whether these children should receive penicillin prophylaxis or not. We performed a 5-year prospective study of this question.MethodsIn August 2013 through September 2014, we conducted a follow-up study of latent RHD among school pupils using the World Heart Federation (WHF) echocardiographic criteria. Contingency tables were used to assess progression, persistence or regression of latent RHD.ResultsForty two borderline and 13 definite cases of RHD (n 55) were identified, 44 (80%; mean age 13.8 ± 4.0years; 29 (65.9%) female) of whom were available for echocardiographic examination at a median follow-up of 60.8months (interquartile range 51.3-63.5). Over the follow-up period, half the participants (n = 23; 52.3%) improved to normal or better WHF category (regressors), a third (n = 14, 31.8%) remained in the same category (persistors), while seven others (15.9%) progressed from borderline to definite RHD (progressors). In total, 21 subjects (47.7%) reverted to a normal status, nine (20.4%) either improved from definite to borderline or remained in the borderline category, and 14 (31.8%) either remained definite or progressed from borderline to a definite status. Two cases (20%) progressed to symptomatic disease.ConclusionsLatent RHD has a variable natural history that ranges from regression to normal in nearly half of cases, to persistence, progression or development of symptoms in the remainder of subjects

Epstein-Barr virus myelitis and Castleman's disease in a patient with acquired immune deficiency syndrome: a case report

<p>Abstract</p> <p>Introduction</p> <p>Few cases of Epstein-Barr virus myelitis have been described in the literature. Multi-centric Castleman's disease is a lymphoproliferative disorder that is well known for its associations with the human immunodeficiency virus, human herpes virus 8, and Kaposi's sarcoma. The concurrent presentation of these two diseases in a patient at the same time is extremely unusual.</p> <p>Case Presentation</p> <p>We describe the case of a 43-year-old Caucasian man with acquired immune deficiency syndrome who presented with fever, weight loss and diffuse lymphadenopathy, and was diagnosed with multi-centric Castleman's disease. He presented three weeks later with lower extremity weakness and urinary retention, at which time cerebrospinal fluid contained lymphocytic pleocytosis and elevated protein. Magnetic resonance imaging demonstrated abnormal spinal cord signal intensity over several cervical and thoracic segments, suggesting the diagnosis of myelitis. Our patient was ultimately diagnosed with Epstein-Barr virus myelitis, as Epstein-Barr virus DNA was detected by polymerase chain reaction in the cerebrospinal fluid.</p> <p>Conclusion</p> <p>To the best of our knowledge, this is the first case of multi-centric Castleman's disease followed by acute Epstein-Barr virus myelitis in a human immunodeficiency virus-infected patient. Clinicians caring for human immunodeficiency virus-infected patients should be vigilant about monitoring patients with increasing lymphadenopathy, prompting thorough diagnostic investigations when necessary.</p

Thiamine : comment l’utiliser dans la prévention et le traitement de l’encéphalopathie de Wernicke?

Résumé La thiamine est indiquée dans la prévention et le traitement de l’encéphalopathie de Wernicke. Elle est utilisée à cet effet depuis plusieurs années déjà. Mais connaît-on vraiment la dose, la voie ainsi que la durée d’administration optimales recommandées lorsqu’un patient se présente avec des facteurs de risque ou des symptômes suggérant une encéphalopathie de Wernicke? En juillet 2003, le CMDP du CHUM a émis des directives malgré l’absence de lignes directrices claires dans la littérature. Ce texte vise à faire le point dans le contexte actuel des choses

Le test de concordance de script comme outil d’enseignement et d’apprentissage : un projet-pilote pour les étudiants de première année de médecine

Contexte : Les étudiants en médecine peuvent éprouver de la difficulté à organiser leurs connaissances théoriques d’une façon qui soit adaptée à la pratique clinique. Méthodes : Le test de concordance de script (TCS), outil habituellement utilisé pour évaluer le raisonnement clinique, a été employé dans un but pédagogique pour amener les étudiants à utiliser en contexte clinique les connaissances qu’ils viennent d’acquérir. L’activité de petit groupe a été réalisée pour les étudiants de première année à la fin du cours de Sciences Hématologiques à l’Université de Montréal. Un questionnaire anonyme demandant aux étudiants de décrire les points forts et les points faibles de l’activité a été administré à la fin de l’activité. Résultats : L’activité a été appréciée à la fois par les étudiants et par les tuteurs. Les points forts identifiés par les étudiants incluent l’occasion de discuter et réviser les notions apprises, d’intégrer leurs connaissances et de développer le raisonnement clinique. Conclusion : Le TCS peut être employé de façon formative pour des étudiants n’ayant que peu d’expérience clinique. Les réflexions et discussions induites par le format des questions semblent favoriser l’intégration des connaissances