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

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

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

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

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

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

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

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

Consistency of safety profile of new oral anticoagulants in patients with renal failure.

BACKGROUND: The use of new oral anticoagulants (NOACs) in patients with impaired renal function has raised major concerns, in particular the possibility of an increased risk of bleeding due to accumulation. The aims of this work were to assess the safety of NOACs in patients with renal failure and describe the relationship between clinical events and drug renal excretion magnitude. METHODS: All phase III trials comparing NOACs with vitamin K antagonists (VKAs) in patients with estimated glomerular filtration (eGFR) rate < 50 mL min(-1) were eligible. The main safety and efficacy outcomes were major bleeding and thrombosis. A meta-regression was performed to estimate the correlation between the treatment effect estimate and the percentage of renal excretion. RESULTS: Nine studies (12 272 patients) were included. A significantly greater relative reduction in major bleeding was seen for NOACs with renal excretion <50% (RR, 0.61; CI, 0.51-0.74) than for those with high renal excretion (RR, 0.96; CI, 0.85-1.07) (interaction test, P < 0.0001). A linear relationship between the relative risk of major bleeding and the magnitude of renal excretion was found by meta-regression (R(2)  = 0.66, P = 0.03). For thrombosis, a greater treatment effect of NOA vs. INR-adjusted VKA was observed in patients with eGFR < 50 mL min(-1) (RR 0.78, CI 0.67-0.92), but no correlation between treatment effect and renal excretion was found. CONCLUSIONS: New oral anticoagulants were at least as effective as VKAs, with reduced risks of major bleeding and thrombosis in patients with eGFR < 50 mL min(-1) . The renal excretion of these new drugs seemed to modify the safety profile, contrary to the efficacy.

Identification of the in vivo elastic properties of common carotid arteries from MRI: a study on subjects with and without atherosclerosis.

The stiffness of the arterial wall, which is modified by many cardiovascular diseases such as atherosclerosis, is known to be an indicator of vulnerability. This work focuses on the in vivo quantification of the stiffness of the common carotid artery (CCA) by applying the Magnitude Based Finite Element Model Updating (MB-FEMU) method to 13 healthy and diseased volunteers aged from 24 to 76 years old. The MB-FEMU method is based on the minimisation of the deviation between the image of a deformed artery and a registered image of this artery deformed by means of a finite elements analysis. Cross sections of the neck of each subject at different times of the cardiac cycle are recorded using a Phase Contrast cine-MRI. Applanation tonometry is then performed to obtain the blood pressure variations in the CCA throughout a heart beat. First, a time averaged elastic modulus of each CCA between diastole and systole is identified and a stiffening of the artery with age and disease is observed. Second, four elastic moduli are identified during a single heart beat for each artery, highlighting the nonlinear mechanical behaviour of the artery. A stiffening of the artery is observed and quantified at systole in comparison to diastole.

[Screening strategies for the diagnosis of asymptomatic arterial lesions in patients with atherothrombosis]. / Méthodes de dépistage des localisations artérielles asymptomatiques chez le patient athérothrombotique.

Atherosclerosis is a ubiquitous inflammatory disease. Patients presenting an acute atherothrombotic event (acute coronary syndrom, stroke, aortic aneurysm, ...) have an increased risk of events in remote arterial territories affected by atherosclerosis. These patients could benefit from systematic screening of asymptomatic atherosclerotic lesions to avoid these complications. For each atherosclerotic territory (coronary artery, carotid artery, aorta, peripheral arteries including renal arteries), we review the methods for screening asymptomatic atherothrombotic lesions which could justify specific treatments: coronary artery stenosis > or = 50%, carotid artery stenosis > or = 60%, renal artery stenosis > or = 50%, and abdominal aortic aneurysm > or = 30 mm. This review shows that non invasive methods (ie, echography, tomodensitometry) are widely available for diagnosis of asymptomatic lesions in carotid and renal arteries, and in the aorta. Despite its invasive caracteristic, coronarory angiography remains the gold-standard for the diagnosis of coronary artery disease. However, cardiac multi-slices CT-scan appears a promising technique for asymptomatic patients.

[Vascular resistances in lower limb arterial disease used to evaluate the quality of peripheral arteries. Preliminary study]. / Apport de la mesure des résistances périphériques dans l'évaluation du lit d'aval jambier chez l'artériopathe. Etude préliminaire de faisabilité.

UNLABELLED: Peripheral resistance of lower limb arteries is not a common clinical measurement despite easy-to-apply non-invasive techniques. The aim of our trial has been to test this new parameter as a marker of arterial lesions. MATERIAL AND METHODS: In this prospective study, hemodynamic data acquired non-invasively [Ankle brachial index (ABI), peak systolic velocity (PSV), end-diastole velocity (VTD) and peripheral artery quality] in patients with lower limb arterial disease were compared with the resistance index measured in the common femoral artery (Arbeille index: IR=VTD/PSV). RESULTS: Between February 1, 2003 and April 30, 2003, 150 measurements of resistance index were made in 99 individuals with ischemia following a strain (69% men, 31% women, average age 64.8+/-15.2 years). Forty-one of the resistance measurements (27%) were also made in patients with arterial disease factors (diabetics, renal replacement therapy). The resistance index was closely associated with end-diastole velocity. (r=-0.76; DDL=148; p<0.01) as well as peripheral artery quality (r=0.81; DDL=148; p<0.01); on the contrary the resistance index was not affected by the arterial disease factors (0.3+/-0.1 vs 0.33+/-0.12; p=NS). CONCLUSION: These findings suggest that the hemodynamic impact might be evaluated more precisely diabetics and renal replacement therapy patients whose hemodynamic parameters are difficult to assess due to their arterial disease factors. Prospective studies are needed to determine the role of the resistance index in the follow up of these patients, and its contribution in comparison with the measurement of end-diastole velocity.

[Validation of a French translation of the Edinburgh claudication questionnaire among general practitioners' patients]. / Validation d'une traduction française du questionnaire d'édimbourg au sein d'une population de consultants en médecine générale.

OBJECTIVES: Intermittent claudication is one of the clinical symptoms of peripheral arterial disease (PAD). The presence of PAD is a high risk marker of cardiac events and stroke. The PAD screening can be enhanced by the use of questionnaires. The Edinburgh Questionnaire presents in its English version better diagnostic performances compared to the Rose (WHO) Questionnaire. The aim of this study is to precise the performances of the French version of the Edinburgh Questionnaire among a population consulting general practitioners. METHODS: Four centers instructed 10 general practitioners each to the measurement of ankle pressure with a Doppler stethoscope. The physicians administrated the Questionnaire to 10 consecutive consultants in a same day, and measured the pressure on posterior tibial, dorsalis pedis and humeral arteries. With a second questionnaire they collected data concerning age, weight, height, and the presence of major risk factors. The same protocol was repeated a second day on new patients. The diagnosis of PAD was based on an ankle-arm index lower than 0.85 for at least on limb. RESULTS: The population studied consisted of 727 subjects (351 females and 376 males). The mean age was at 58.3 +/- 16.1 years (ranging from 18 to 83.3 years). The sensitivity of the Questionnaire is at 47% (95% CI: 32.3-61.7%), the specificity at 98.8% (95% CI: 97.5-99.4%), the positive and negative predictive values are respectively at 73.3% (95% CI: 54.1-87.7%) and 94.8% (95% CI: 94.7-97.6%). Among this population of general practitioners consultants, the prevalence of a low ankle-arm index under 0.85 is at 6.7%. DISCUSSION: The French version of the Edinburgh Questionnaire maintains the very good specificity of the English version. The lower sensitivity could be explained by the choice of the gold standard, namely the ankle-arm index which includes asymptomatic patients with authentic PAD. The use of this Questionnaire can be recommended for the screening of this disease as well as in epidemiological studies.

[Silent myocardial ischemia in type 2 diabetes. Predictive value of intima-media thickness]. / Ischémie myocardique silencieuse chez le diabétique de type 2. Valeur prédictive de l'épaisseur intima-media.

CONTEXT: The carotid intima-media thickness (CIT) is correlated with the prevalence of cardiovascular diseases. We studied the relationship between the thickness of the carotid intima-media and the existence of myocardial ischemia, detected by scintigraphy in a population of type 2 diabetic patients without coronary antecedents. METHODS: We conducted repeated Doppler measurements of the CIT of primitive carotid arteries in 52 diabetic patients aged 49 to 75. All these asymptomatic patients, without coronary antecedents, diabetic for more than 10 years and exhibiting at least one cardiovascular risk factor, had undergone myocardial scintigraphy. RESULTS: The CIT was greater in the group with positive scintigraphies and is the best predictive factor of the presence of ischemia. For a CIT value < 0.55 mm, the negative predictive value of the CIT was of 77% with 80% sensitivity; in non-smokers the predictive negative value increased to 92% with 95% sensitivity. CONCLUSIONS: Reliable and reproducible, measurement of CIT correlates well with myocardial scintigraphy and could be an interesting alternative screening policy in asymptomatic, type 2 diabetic patients.

Quantitation of chemokines (MDC, TARC) expression in mucosa from Crohn's disease and ulcerative colitis.

Chemokines and their receptors are involved in the migration of different mononuclear cells. Among them macrophages-derived chemokines (MDC) and thymus-and activation regulated chemokine (TARC) belong to a new cluster of genes involve in Th2 lymphocytes homing. Cytokines appear to play a significant role in pathogenesis of inflammatory bowel diseases with an excessive Th1 response in chronic lesions of Crohn's disease (CD) and a Th2 pattern in both earlier mucosal CD lesions and in mucosa of ulcerative colitis (UC). Here we demonstrate that RNAm coding for MDC and TARC are expressed in mucosa from CD and UC patients. Using real-time fluorescent RT-PCR, MDC and TARC mRNA were increased in CD inflamed mucosa. Moreover MDC and TARC transcripts were increased in inflamed CD specimen compared to non-involved CD mucosa. These differences both discriminate CD from UC patients. Additionally, MDC protein was produced in isolated mononuclear cells from peripheral blood (PBMC) or mucosa (LPMC) from UC and CD patients: spontaneously, MDC production from PBMC was increased in CD compared to UC patients. MDC production from CD PBMC was also higher than that found in healthy controls. Together, these data indicate that MDC should be involved in the lymphocytes homing in mucosa from CD patients.

[Diabetic arteriopathy. Microcirculation, an inevitable therapeutic objective]. / Artériopathie diabétique. La microcirculation, un objectif thérapeutique incontournable.

The most severe stages of arteriopathy often involve multifocal macrovascular lesions leading to defective perfusion of the distal tissues and subsequent dysfunction of the microcirculation. Diabetic autonomous neuropathy facilitates and aggravates this endothelial dysfunction. Loss of vasomotricity, platelet and white cell activation, and cytokine release lead to an obstruction of the capillaries and alteration or even destruction of the endothelium. At this stage, the lesions are irreversible and tissue vitality is definitively compromised. The goal of medical treatment is to delay the development of dysfunction and subsequent destruction of the microcirculation before, during and after restoration of sufficient flow through the macrocirculation lesions by angioplasty and/or surgery. Extrapolating from in vitro and animal studies, two mediators, EDRF (NO) and prostacycline, could theoretically inactivate inappropriate activated cells and re-establish flow. Besides their vasodilator proprieties, NO and prostacycline have a synergetic inhibitory effect on platelet and leukocyte activation. The role of platelet antiaggregates and heparins in this stage of severe chronic ischemia remains to be determined. The relative failures of therapeutic drug trials conducted since the end of the eighties demonstrates the importance of intervening before the microcirulation disorders become too severe. Until new compounds are developed, therapeutic progress can be achieved by more precise and earlier detection of alterations in the microcirculation to enable optimal management of arteriopathy of the lower limbs with surgery or angioplasty.

Comparison of color duplex ultrasound and computed tomography scan for surveillance after aortic endografting.

Endovascular repair of abdominal aortic aneurysms (AAA) requires regular surveillance for early detection of endograft failure. CT scanning is the gold standard surveillance procedure. The purpose of this study was to assess the reliability of color duplex ultrasound (CDU) in comparison to CT scanning for detection of endoleaks and changes in aneurysmal diameter. From November 1996 to September 1999, a total of 41 patients treated by aortic endografting underwent regular surveillance with both CT scanning and CDU. There were 39 men and 2 women with a mean age of 71 years (range, 50-83). Endovascular treatment involved deployment of a straight aorto-aortic stent in 6 cases, bifurcated stent in 33, and aorta-to-unilateral iliac artery stent in 2. Stent deployment failed in one case; the procedure was conversion to open surgery. Primary or secondary endoleaks were detected in 17 patients (42%). Our findings indicated that CDU is less reliable than the CT scan for detection of endoleaks, but that reliability of CDU for surveillance of aneurysmal diameter is fair.

[Teaching targets in vascular medicine]. / Objectifs pédagogiques en médecine vasculaire.

The reference list presented here is a selection of educative objectives performed by the French "Collège des Enseignants de Médecine Vasculaire" for the different levels of the medical initial education course. It was produced through a collective procedure, after selecting the most relevant topics and setting up writing rules based upon docimology, and favoring practical rather than theoretical objectives. The main topics are peripheral obstructive arterial disease, polyatherosclerosis, atherosclerosis risk factors, venous thromboembolic disease, thrombophilia, chronic venous insufficiency, lymphatic insufficiency, leg ulcers, vascular acrosyndromes, cerebrovascular diseases and connective tissue diseases, vascular occupational diseases, vascular adverse effects of drugs, diabetic vascular disease, the vascular consequences of hypertension, vascular malformations and angiodysplasia, inflammatory arterial diseases, and vascular explorations. As a whole they include about 300 objectives for the five teaching levels. We hope that this list will help stimulate production of training courses and documents strongly needed in this field.

[Raynaud's phenomenon and connective tissue diseases]. / Phénomène de Raynaud et connectivites.

Connective tissue diseases are the most important organic causes of Raynaud's phenomenon, and systemic sclerosis is the most frequent one. Careful history taking and clinical examination eventually lead to further investigations where capillaroscopy and specific autoantibodies tests have the best performances to reach diagnosis. Our understanding of local regulation of blood flow has been improved discovery of new neuromediators and local substances derived from endothelium. These compounds have direct implications for medical therapy and represent new hopes for the treatment of Raynaud's phenomenon which, however, remains difficult and incomplete for most patients.

[Medical treatment of arm embolisms]. / Traitement médical des embolies du membre supérieur.

Emboli in the upper limb occur much less often than in other territories. They usually cause subacute ischaemia due to the importance of the arterial anastomotic network. Medical treatment is thus often sufficient. An analysis of the data in the literature show that medical treatment can give results comparable to surgery. Medical management should only be proposed as a complementary treatment when acute sensitivomotor acute ischaemia threatens the upper limb since priority must be placed on immediate restoration of the arterial flow.

[Diagnosis of sclerotic arterial diseases of the lower limbs]. / Diagnostic des artériopathies scléreuses des membres inférieurs.

Diagnosis and treatment of lower limbs arterial disease do not depend exclusively on functional staging. Fontaine's classification has to be replaced by a classification based on clinical and complementary investigations to understand better the evolutive risks, and guide management. Distal systolic pressures along with symptom analysis and clinical examination allow a more precise diagnosis. Complementary investigations aim at assessing, the localization and extension of atherosclerotic lesions; the severity of tissue ischaemia. The concept of critical ischaemia has tried to insure greater diagnostic homogeneity for patients with rest ischaemia. The role of complementary investigation can only increase for the diagnosis and management sclerotic arterial disease. The detection of the other localizations of atherosclerosis and arteriosclerosis are essential to prevent complications which are responsible for the prognosis of the disease. Sclerotic arterial diseases represent approximately 90 to 95% of the causes of arterial diseases. Identification of these other causes remains, however, essential as it can greatly influence prognosis.

[Medical treatment of sclerotic arteriopathies of the lower limbs]. / Traitement médical des artériopathies scléreuses des membres inférieurs.

The medical treatment of sclerotic arterial disease in the lower limbs is only one facet in the management of generalized arterial disease. Clinical and ancillary investigations estimate not only the severity of arterial insufficiency, but also the diffusion of arterial disease and the existence of threatening lesions. Medical treatment has 2 essential aims: to limit the progression of lesions by risk factor control and antithrombotic drugs; to improve arterial insufficiency using adapted rehabilitation and, if necessary, drugs with vasodilatating or haemorrheological properties.