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.

Role for vascular investigations in giant cell arteritis.

Giant cell arteritis is characterized by diffuse arterial inflammation that selectively involves the superficial temporal arteries but can occur in larger arteries. Various vascular investigations can assist in diagnosing and evaluating the extent of giant cell arteritis. Imaging techniques, mainly Doppler ultrasonography of the superficial temporal arteries, seem less reliable for the diagnosis than temporal artery biopsy, which is safe and remains indispensable. Investigations of larger arteries can detect asymptomatic stenotic lesions, which are common, particularly in the axillary and subclavian arteries. Involvement of the aorta can cause life-threatening dissection or aneurysmal rupture. Imaging techniques useful for diagnosing aortic involvement include ultrasonography, computed tomography, magnetic resonance imaging, and aortography. Although there is no standardized strategy for aortic lesion detection, helical computed tomography may be valuable.

[Simple Horton's syndrome: modalities of treatment]. / La maladie de Horton simple: modalités thérapeutiques.

IN GENERAL: Corticosteroids remain the basis of treatment of Horton's syndrome, with prednisone the molecule of choice, since they improve the symptoms and considerably reduce the risk of blindness. Several clinical forms of the disease must be distinguished in order to specify the modalities of corticosteroid treatment and any eventual associated treatments. SIMPLE HORTON'S SYNDROME: The simple forms of the disease are defined by the absence of ocular involvement, the absence of clinical involvement of the large arteries, the absence of corticosteroid resistance and the absence of corticosteroid dependence (simple forms subsequently complicated). MODALITIES OF CORTICOSTEROID THERAPY: These simple forms justify an attack treatment with 0.7 mg/kg/d of prednisone although cortisone assaults do not have a specific justification. Initiation with lower daily doses of prednisone at 0.5/mg/kg or even less appear to expose the patient to a higher risk of progression of the disease, but merit assessment. SATELLITE QUESTIONS: The iatrogeneity of corticosteroids raises problems in corticosteroid dependent patients and those receiving prolonged attack treatment. The risk of cortisone-induced osteoporosis is particularly high during Horton's syndrome. There is still no prospective study specifying the indications for treatment of the disease with anticoagulants or platelet antiaggregants.

[Complicated Horton's syndrome: therapeutic modalities]. / La maladie de Horton compliquée: modalités thérapeutiques.

FORMS THAT RAISE THERAPEUTIC PROBLEMS: The complicated forms of Horton's syndrome regroup various situations: ocular involvement at the start, large vein involvement, corticosteroid resistance (rare), corticosteroid dependence preventing the reduction in the daily dose of prednisone to less than 15 mg, high rate of morbidity with prolonged corticosteroid therapy. GENERAL PRINCIPLES: The ocular forms and those with large vein involvement, require a minimal attack treatment with 1mg/kg/d of prednisone. Cortisone assaults are often prescribed despite the fact that their efficacy remains to be demonstrated. Curative treatment with heparin (calcic or of low molecular weight) should be prescribed for 5 to 7 days with later relay to a platelet anti-aggregant, without any randomised study having validated this proposition. THE CASE OF CORTICOSTEROID-DEPENDENCE: The iatrogenic risk of corticosteroids is high and alternative treatments should be proposed: azathioprine, methotrexate, dapsone or hydroxychloroquine. Osteoporosis is the most frequent complication of corticosteroid therapy and must be avoided by the administration of a biphosphonate.

Giant cell arteritis with or without aortitis at diagnosis. A retrospective study of 22 patients with longterm followup.

OBJECTIVE: Studies have shown that aortitis may be present in half the patients with recent-onset giant cell arteritis (GCA). We assessed whether aortitis at diagnosis affects longterm outcome in patients with GCA. METHODS: We retrospectively analyzed the longterm outcome of a prospective cohort of 22 patients with biopsy-proven GCA who all had aortic computed tomography (CT) evaluation at the time of diagnosis of GCA between May 1998 and November 1999. Longterm outcome, especially vascular events such as aortic aneurysm, mortality, relapses of GCA, and requirement for steroids, was assessed in 2011 by chart review and patient/physician interviews. RESULTS: At disease onset, 10/22 patients had aortitis on CT scan. Patients with and without aortitis had similar baseline characteristics, including cardiovascular risk profile. At the time of the study, 12/22 (57%) patients had died. Vascular causes of death were more frequent in patients with aortitis (5/7 vs 0/5; p = 0.02). A higher number of vascular events was noted in patients with aortitis (mean events per patient 1.33 vs 0.25; p = 0.009). Stroke was more frequent in patients with aortitis. These patients seemed to exhibit a more chronic or relapsing disease course, and they were less likely to completely discontinue steroid therapy (p = 0.009, log-rank test). CONCLUSION: Our study suggests for the first time that inflammatory aortic involvement present at onset of GCA could predict a more chronic/relapsing course of GCA, with higher steroid requirements and an increased risk for vascular events in the long term.

[Abdominal aortic involvement in active giant cell (temporal) arteritis: a study of 20 patients by Doppler ultrasonography and computed tomographic angiography]. / Fréquence de l'atteinte de l'aorte abdominale au diagnostic de maladie de Horton : étude de 20 patients par échographie-Doppler et angiotomodensitométrie.

OBJECTIVE: This study used Doppler ultrasonography and computed tomographic angiography (CTA) to assess the prevalence of abdominal aortic lesions that suggested abdominal aortitis at diagnosis of giant-cell or temporal arteritis (GCA). We also evaluated the contribution of these 2 techniques to diagnosis. METHODS: This single-center study included patients admitted to the internal medicine department of the Nantes (France) University Hospital, between May 1999 and May 2002 at the time of their diagnosis with biopsy-proven GCA. In the 8 weeks after diagnosis, patients underwent a thorough workup, including the collection of clinical and laboratory data. Imaging tests for each patient included Doppler ultrasonography and a CTA scan of the abdominal aorta, looking for aneurysms, ectasia, and thickening of the aortic wall. RESULTS: This study included 20 patients (17 women, mean age 73.9+/-7.2 years, mean CRP=116+/-75.9mg/L). Doppler ultrasonography suggested aortitis in 8 cases (40%): 7 patients (35%) had a hypoechoic halo, 3 (15%) a small aneurysm (diameter < 30mm), and 2 (10%) both. CTA scans of the aorta showed aortitis in 5 cases (25%), all with abnormal thickening of the aortic wall. CTA did not identify any aneurysms. Overall, abdominal aortitis was suspected in 10 patients (50%). CONCLUSION: At the time of GCA diagnosis, both Doppler ultrasonography and CTA can detect morphological abnormalities of the abdominal aorta. Here they suggested asymptomatic abdominal aortitis in half the patients. Doppler ultrasonography appears more effective for detecting aortic aneurysms, while CTA seems helpful for the diagnosis of parietal thickening. The risk factors associated with abdominal aortitis in GCA remain to be identified.

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.

Silent versus cranial giant cell arteritis. Initial presentation and outcome of 50 biopsy-proven cases.

BACKGROUND: The objective of the present study was to compare the silent form of giant cell arteritis (GCA) to the classic cephalic form of the disease. METHODS: We conducted a retrospective study based on a chart review of 50 consecutive, biopsy-proven GCA, recorded at a department of internal medicine. We sought to distinguish a silent form, defined by a prolonged inflammatory syndrome or fever of unknown origin with the absence of cephalic signs, polymyalgia rheumatica, or large artery involvement, from an overt "classic" cranial temporal arteritis. RESULTS: The prevalence of the silent form of GCA was 46% in our study. Abnormal temporal arteries were more frequent in the cephalic group. The silent GCA group had higher C-reactive protein levels (p<0.05), a higher platelet count (p<0.05), and lower serum albumin (p<0.05). There was no significant difference in temporal artery specimens in the two groups. Clinical relapses tended to be more frequent, and patients free of corticosteroids tended to be less frequent, in the cephalic group, though the difference was not statistically significant. CONCLUSIONS: The silent and cephalic forms of GCA could have distinct clinical and biological patterns and different outcomes. The limitation of our study was its retrospective design. Further studies are required to determine if this distinction is useful in treating GCA patients.

[Giant cell arteritis after the age of 75]. / Maladie de Horton chez le sujet âgé de plus de 75 ans.

Despite its increasing incidence giant cell arteritis is not well detected in the elderly. Response to corticosteroid treatment is the same before and after the age of 75, but there are many steroid-induced side effects, particularly bone fractures, in the elderly. Therefore, it is important to reduce the corticosteroid load in elderly and frail people. In this cases, 0.3 to 0.5mg/kg, or 15 to 25mg daily prednisone-equivalent dose at start seems to be enough to prevent blindness in simple forms. This dose has to be rapidly reduced whenever the C-reactive protein remains moderately elevated. Moreover, an anti-agregant or anticoagulant treatment must be associated at the beginning of steroid treatment to prevent ischemic complications, as well as biphosphonates, which could prevent corticosteroid-induced osteoporosis.