Effect of Chronic Steroid Use on Postoperative Wound Complications in Patients Undergoing Arterial Bypass Surgery for Lower Extremity Peripheral Arterial Disease.

BACKGROUND: While existing literature reports adverse effects of chronic steroid use on surgical wound outcomes, there remains lack of data exploring the effect of steroids on postoperative outcomes following lower extremity arterial bypass surgery. This study aims to explore the effect of chronic steroid use on surgical outcomes in patients undergoing open revascularization for lower extremity arterial occlusive disease. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) files between 2005 and 2020, all patients receiving aortoiliac or infrainguinal arterial bypass for peripheral arterial disease (PAD) were identified by Current Procedural Terminology (CPT) codes. Patient characteristics and 30-day outcomes were compared using χ2 test and independent t-test, and the association of chronic steroid use with wound complications was studied using multivariable logistic regression analysis. RESULTS: A total of 44,675 patients undergoing open lower extremity revascularization (LER) were identified, of which 1,807 patients were on chronic steroids, and 42,868 patients were not on chronic steroids. On multivariable logistic regression analysis, being on chronic steroids was associated with higher rates of deep surgical site infections (SSIs) (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.03-1.83), any SSI (OR 1.22, 95% CI 1.04-1.43), and wound dehiscence (OR 1.42, 95% CI 1.03-1.96). Chronic steroid users also had significantly increased odds of developing sepsis (OR 1.56, 95% CI 1.19-2.04), pneumonia (OR 1.44, 95% CI 1.08-1.91), urinary tract infection (UTI) (OR 1.54, 95% CI 11.13-2.09), deep vein thrombosis (DVT) (OR 1.60, 95% CI 1.01-2.53), 30-day readmission (OR 1.30, 95% CI 1.12-1.50), reoperation (OR 1.17, 95% CI 1.01-1.37), and mortality (OR 1.33, 95% CI 1.01-1.76) compared with nonchronic steroid users. CONCLUSIONS: This study confirms that chronic corticosteroid use is associated with higher risk of SSIs in patients undergoing lower extremity arterial bypass surgery. These patients typically have various underlying health issues, emphasizing the need for personalized treatment and management to reduce steroid-related postoperative complications and improve survival.

Thromboembolectomy for acute lower limb ischemia: Contemporary outcomes of two surgical methods from a single tertiary center.

OBJECTIVES: The current treatment of acute lower limb ischemia (ALLI) includes open surgical and percutaneous pharmaco-mechanical thromboembolectomy (TE). We hereby report our results with open surgical TE over a 10-year period and compare our outcomes using routine fluoroscopic assisted TE (FATE) with blind and selective on demand fluoroscopic-assisted TE (BSTE). METHODS: This is a retrospective analysis of all patients who underwent open surgical TE for acute lower limb ischemia at a single tertiary center between 2008 and 2018. Patients were divided into a group who underwent BSTE and another who underwent routine FATE. Data on presentation, medical history, surgery performed, and short-term outcomes were retrieved from medical record. Comparison between baseline characteristics and outcomes of both groups were made using t-test and chi-square analysis. RESULTS: Over 10 years, 108 patients underwent surgical TE. Thirty-day mortality rate and 30-day major lower extremity amputation rate in the cohort were 12.0% and 6.5%, respectively. On subgroup analysis, 53 patients were treated by BSTE and 55 patients by FATE. There was no significant difference in 30-day mortality rate (11.3% vs 12.7%, p-value = .82) and 30-day major amputation rate (9.4% vs 3.6%, p-value = .454) between the two groups. Local anesthesia was more frequently performed in patients undergoing FATE (58.2% vs 24.5%, p-value < .001). More than one arteriotomy was more frequently required in patients undergoing BSTE (2.6% vs 45.5%, p-value < .001). Patients with infrapopliteal involvement undergoing FATE required less further interventions such as patch angioplasty (2.6% vs 36.4%, p-value < .001) and bypass (2.6% vs 22.7%, p-value = .01). CONCLUSION: ALLI remains a disease of high morbidity and mortality. Open surgical TE offers an effective approach to treat ALLI. The addition of fluoroscopy to the conduction of TE could be associated with valuable benefits, especially in patients with infra-popliteal involvement. Randomized controlled trials are needed to objectively assess the therapeutic potential of FATE.

Lower limb amputation following venous cannulation for VA-ECMO: a case report.

Lower limb amputation following arterial cannulation for VA-ECMO has been described in the literature. Limb ischemia however following venous cannulation is very rare and not quite understood. We present a case of limb ischemia following venous cannulation. A combination of venous congestion, compartment syndrome and subsequent arterial insufficiency is the proposed pathophysiology. Shock and use of vasopressors are compounding factors. Limb ischemia can be transient and reversible if diagnosed immediately and treated by early removal of the cannula. Our patient was unstable and ECMO dependent, and removal of the cannula was not an option. This resulted in limb loss and eventual above knee amputation. Use of the smallest appropriate venous cannula and early fasciotomy, in addition to hemodynamic optimization are measures that could help in preventing major amputation.

Cognitive functions of patients treated with chemotherapy: A comparative study.

OBJECTIVES: Chemobrain is a well-established clinical syndrome that has become an increasing concern because of the growing number of long-term cancer survivors. It refers to the post-chemotherapy related cognitive dysfunction. The aim of this study was to objectively assess the impact of cancer treatment on the cognition of cancer patients. METHODS: This was a convenience sample comparative study conducted at the Hematology and Oncology Department of Hôtel Dieu de France University Hospital in Beirut, Lebanon. It included cancer patients (G1) aged under 65 years who had already been treated for cancer compared to two control groups. The first control group (G2) consisted of treatment-naïve cancer patients aged under 65, and the second group (G3) was recruited from a pool of healthy controls aged between 40 and 65 years. All participants were asked to complete the part B of the trail making test (TMT) and the digital symbolic substitution test (DSST). RESULTS: In the bivariate analysis, patients in G1 had significantly higher scores than patients in G2 (P=0.017) and G3 (P<0.001) on the TMT-B. However, patients in G1 only had lower scores on DSST when compared with G3 (P=0.017). In the logistic regression taking different groups two-by-two as the dependent variable, the only significant difference was found in the comparison between G2 and G3 with higher TMT-B scores more in favor of belonging to G2 (OR=0.946; P=0.003). CONCLUSIONS: Our results suggest that, after controlling for anxiety and depression symptoms, patients treated with chemotherapy have significantly poorer outcomes on the DSST and TMT-B than treatment-naïve cancer patients and healthy controls. However, when taking confounding factors into account, the difference only persisted between patients undergoing chemotherapy and healthy controls. These findings are in favor of a multifactor cognitive impairment in patients with cancer partially related to chemotherapeutic treatment.

Major lower extremity amputations in a developing country: 10-Year experience at a tertiary medical center.

BACKGROUND: Lower extremity amputation (LEA) is a major surgical procedure with a high risk of significant morbidity and mortality. The objective of this study was to describe mortality and functionality outcomes following this procedure in a developing country. METHODS: This is a retrospective study of all patients undergoing LEA for non-traumatic etiology between 2007 and 2017. Medical records were used to retrieve demographics, comorbidities, and perioperative complications of identified patients. Patients were contacted to follow-up on their medical, postoperative care, and ambulatory status. Mortality and postoperative functionality rates were analyzed. RESULTS: The study included 78 patients. Median follow-up duration was 24 months. Hypertension (81%) and diabetes (79%) were the most common comorbidities. Mortality rates at 30 days, 1, and 5 years were 10.3, 29.2, and 65.5%, respectively. Mortality was significantly associated with age > 70 at amputation (p = 0.042), hypertension (p = 0.003), chronic kidney disease (p = 0.031), and perioperative sepsis (p = 0.01). Only 1.6% of patients were discharged into a specialized care center, and only 27% of patients were ambulatory postoperatively, although 90.5% were fitted with a prosthesis. CONCLUSIONS: Survival following major amputation in a developing country is currently comparable to more developed regions of the world. Major discrepancy seems to exist in ambulatory status following the procedure. Discharge placement policies should be properly set, and rehabilitation centers funding should be increased. Awareness may also be warranted to educate patients and families about the value and positive impact of rehabilitation centers.

Bilateral Carotid Patch Infection Occurring 12 years Following Endarterectomy.

BACKGROUND: Carotid endarterectomy (CEA) is the most commonly used invasive procedure for treatment of carotid stenosis. Different methods are used to close the arteriotomy including primary closure and patch repair with a graft. Prosthetic patch infection is a rare but serious complication of patch closure, and we will present a unique case of carotid patch infection (CPI) 12 years after implantation. CASE: Patient is 76-year-old male ex-smoker with history of bilateral CEA with Dacron patch closure 12 years prior to presentation. He had a left neck draining sinus one year prior to presentation that was treated by patch excision and ICA ligation. He presented to us one year later with a right neck draining sinus tract, reaching the carotid sheath on CT scan. Surgery was done under EEG and NIRS oximetry with shunting. Excision of the patch with the involved ICA was done. CCA to distal ICA bypass was done by a reversed GSV graft. Intraoperative cultures of the patch grew Staphylococcus species coagulase negative, so the patient was discharged on antibiotics for one month. The patient had early postoperative swallowing difficulty that resolved over six weeks but no other complications. Patient was followed-up every three months and he was doing well on one-year follow-up. DISCUSSION: Carotid patch infection is a well-documented complication of CEA with a prevalence between 0.27% and 1%. It most commonly presents as a pseudoaneurysm, draining sinus or neck swelling. The highest incidence is during the first year after the operation, and especially within the first three months postop due to contamination or wound infections; however, late presentations such as our case are rare. Bacterial cultures are positive in around 80% of the cases, growing mostly gram-positive cocci. Other organisms include Pseudomonas and Enterobacter. Management of CPI is challenging; difficulties include distal ICA control, friable arteries and adhesions to cranial nerves. Debridement with ligation of the vessel stump is an option, but may not be tolerated. Best outcomes are obtained with autogenous revascularization after debridement as was done in our case on the right side. Newer endovascular techniques may provide alternatives in urgent or high-risk situations, especially as staged procedures. This case is unique in its bilaterality and the longest time till presentation in the literature.

Management of dual traumatic arterial-venous fistula from a single shotgun injury: a case report and literature review.

BACKGROUND: Traumatic arteriovenous fistula (TAVF) is an uncommon vascular entity that arises in various locations, often from penetrating injuries, with a wide spectrum of signs and symptoms. This case report highlights the importance of suspecting multiple TAVFs after a single gunshot wound, especially if it involves pellets. It also sheds light on adapting treatment, whether endovascular or open repair, to the location and characteristics of each fistula. CASE PRESENTATION: A 35-year-old male, with history of shotgun wound 5 months earlier, presented to our clinic with right lower extremity (RLE) edema and pain. Arterial duplex scan and subsequent angiogram showed two TAVFs at the popliteal and posterior tibial (PT) arteries, both of which could not be exactly localized with a computed tomography angiography (CTA) due to artifacts. The fistula connecting the posterior tibial artery (PTA) and vein was repaired endovascularly using a covered-stent, while the fistula between the popliteal artery and vein was repaired surgically. Postoperative follow-up at 3 months showed no arteriovenous fistula (AVF), patent vessels and distal stent stenosis at the PTA. CONCLUSIONS: Patients who sustain gunshot injuries with shrapnel or pellets and develop TAVF consequentially need to be followed up with the possibility of multiple AVFs in mind. Arterial duplex scan is highly sensitive to detect those AVFs, yet angiography remains gold standard, particularly with extensive metal artefacts. Endovascular repair, when feasible, should be considered first, unless the patient is unstable or has anatomical constraints that increase the risk of complications. Lastly, surgeons should be weary of deep venous thrombosis (DVT), the Branham effect and arterial aneurysmal dilation postoperatively.

Microbiological profile and antimicrobial resistance among diabetic foot infections in Lebanon.

Diabetic Foot Infection (DFI) is a challenging complication of diabetes mellitus with a high burden in the Middle East where there is a marked increase in diabetes prevalence and complications. Early detection of DFI and the infectious organisms could result in the early initiation of appropriate antibiotic therapy and improved outcomes. DFI microbiological profiles differ between countries. In our region, Western guidelines are used when initiating treatment for DFI in the absence of local guidance. The purpose of our study was to determine the microbiologic profile and antimicrobial susceptibility of the DFI admissions at a large tertiary referral centre in Beirut and review other reported series in Lebanon and our region. This is a retrospective observational study of patients with DFI admitted to the American University of Beirut Medical Centre from January 2008 to June 2017. The bacteriologic isolation and antimicrobial susceptibility tests were performed according to standard microbiological methods. Between 2008 and 2017, 319 diabetic patients with DFU were admitted to AUBMC, and deep-tissue cultures were taken for 179 patients. From 179 deep tissue cultures, 314 bacterial isolates were obtained. Fifty-four percent of patients had the polymicrobial infection. Aerobic gram-negative rods (GNR) were more prevalent than gram-positive cocci (GPC) (55%, 39%, respectively). The most common isolate was Escherichia coli (15%) followed by Enterococcus (14%) and Pseudomonas aeruginosa (11%). Staphylococcus aureus isolates accounted for 9% with 50% of them being methicillin-resistant (MRSA). Among Enterobacteriaceae, 37% of isolates were fluoroquinolone-resistant, 25% were ESBL producers, and 2% were carbapenem-resistant. Antibiotic resistance was significantly associated with prior usage of antibiotics. Anaerobes were isolated in 1% and Candida species in 5% of isolates. The sensitivity, specificity, PPV, and NPV of swab culture recovery of pathogens compared with deep tissue culture were (76%, 72%, 76%, 72%) and (94%, 81%, 91%, 86%) for gram-positive and gram-negative organisms, respectively. The microbiological profile of DFI in Lebanon is comparable to other countries in the MENA region with big differences compared with the West. Therefore, it is imperative to develop local guidelines for antimicrobial treatment. The high prevalence of GNR in DFI and the high fluoroquinolone resistance should be taken into consideration when choosing empiric antibiotics. Empiric treatment for MRSA or Pseudomonas does not appear necessary except for patients with specific risk factors.

Apprentissage de l'aide au sevrage tabagique dans les formations médicales au Liban.

INTRODUCTION: Tobacco use is a major public health problem in our societies today. Nevertheless, effective smoking cessation interventions can reduce tobacco-related morbidity and mortality. AIM: The aim of this study was to develop, implement, and evaluate a Competency-Based Approach (CBA) training program for residents in Lebanon aiming to improve their skills in counseling patients about smoking cessation. METHODS: We followed a systematic educational planning starting by identification of professional tasks and competencies to acquire. A cross-sectional descriptive study was conducted for 16 residents to analyze learning needs and determine learning objectives. The workshop was chosen as a learning method. A pre-post intervention analysis made it possible to evaluate the progress. RESULTS: Pre-intervention analysis showed that residents lacked skills and faced barriers in smoking cessation interventions (score of the items "General Knowledge": 7.1/10; "Practices": 6.5/10; "Skills": 3.8/10; "Barriers": 5.6/10). There were statistically significant improvements in all scores as well as significant decrease in barriers post-intervention (score of the items "General Knowledge": 9.4/10; "Practices": 9.2/10; "Skills": 8.3/10; "Obstacles": 2.1/10). The evaluation of the workshop was overwhelmingly positive. CONCLUSION: A CBA workshop can improve residents' skills and effectiveness in counseling patients about smoking cessation. It should be integrated into the medical curriculum and delivered to every physician especially in a country with one of the highest rate of smoking and the weakest tobacco control strategies.

[Smoking cessation support workshops in medical training programs in Lebanon]. / Apprentissage de l'aide au sevrage tabagique dans les formations médicales au Liban.

INTRODUCTION: Tobacco use is a major public health problem in our societies today. Nevertheless, effective smoking cessation interventions can reduce tobacco-related morbidity and mortality. AIM: The aim of this study was to develop, implement, and evaluate a Competency-Based Approach (CBA) training program for residents in Lebanon aiming to improve their skills in counseling patients about smoking cessation. METHODS: We followed a systematic educational planning starting by identification of professional tasks and competencies to acquire. A cross-sectional descriptive study was conducted for 16 residents to analyze learning needs and determine learning objectives. The workshop was chosen as a learning method. A pre-post intervention analysis made it possible to evaluate the progress. RESULTS: Pre-intervention analysis showed that residents lacked skills and faced barriers in smoking cessation interventions (score of the items “General Knowledge”: 7.1/10; “Practices”: 6.5/10; “Skills”: 3.8/10; “Barriers”: 5.6/10). There were statistically significant improvements in all scores as well as significant decrease in barriers post-intervention (score of the items “General Knowledge”: 9.4/10; “Practices”: 9.2/10; “Skills”: 8.3/10; “Obstacles”: 2.1/10). The evaluation of the workshop was overwhelmingly positive. CONCLUSION: A CBA workshop can improve residents’ skills and effectiveness in counseling patients about smoking cessation. It should be integrated into the medical curriculum and delivered to every physician especially in a country with one of the highest rate of smoking and the weakest tobacco control strategies.

Immunotherapy: last bullet in platinum refractory germ cell testicular cancer.

Testicular germ cell tumors are chemosensitive with very high cure-rates even in the metastatic setting. However, patients with platinum-refractory and relapsing tumors after autologous stem cell transplant have very poor outcomes despite salvage treatments, and with no effective alternative therapies. Immunotherapy, notably with PD-1 inhibitors, has proven to be very effective in treating various solid tumors. This review summarizes the experience with anti-PD-1 agents (pembrolizumab, nivolumab) in the treatment of testicular germ cell tumor relapsing after multiple lines of treatment, and exposes future trials evaluating newer checkpoint inhibitors in this setting.

Lung cancer and immunotherapy: a real-life experience from second line and beyond.

Aim: This study assessed the efficacy of anti-PD-1/PD-L1 agents in real life when used in second line or beyond. Materials & methods: Patients with advanced non-small-cell lung cancer progressing after standard chemotherapy and receiving immunotherapy in the second line or beyond were included. Results: One hundred and ten patients were included with PD-L1 expression above 50%, between 1-49 and <1% in 38.6, 27.3 and 34.1% of patients, respectively. Checkpoint inhibitors were used as second, third and fourth line in 74.7, 21.8 and 3.5%, respectively. Partial response was observed in 25.6% of patients. Median progression-free survival was 4 months and median overall survival was 8.1 months. Conclusion: Immunotherapies are emerging as important tools in the oncologic field with good responses in real-life practice.

An insight into Clostridium difficile infection: a single-center retrospective case-control study.

BACKGROUND: Clostridium difficile infection (CDI) has become a worldwide health problem in view of its significant incidence and medical and economic impact on the health system. Prior studies have been undergone about risk factors and disease characteristics. We wanted to study the characteristics, prognostic factors associated with CDI at our institute, as well as a new prognostic factor. METHODS: Our study aimed at describing the risk factors, patient characteristics, and outcomes associated with healthcare facility-acquired CDI (HCFA-CDI) and community-acquired CDI (CA-CDI). We intended to identify the factors associated with worse outcomes. We evaluated the characteristics associated with CDI over 3 years. We also evaluated a simple neutrophil-lymphocyte ratio (NLR) and its predictive value for worse outcomes. RESULTS: Six hundred patients were enrolled (333 in a control group; 171 in the HCFA-CDI group and 96 in the CA-CDI group). NLR > 5 predicted increased mortality and intensive care unit transfer in all CDI if done as early as day 2 after CDI diagnosis. In HCFA-CDI, NLR > 5 predicted a higher ICU transfer if done as early as day 1 post-diagnosis and with increased mortality as early as day 2 post-diagnosis. In CA-CDI, NLR > 5 predicted a higher mortality and ICU transfer if done at least 4 days after diagnosis. Moreover, every 10-unit increase in NLR was associated with a significant increase in mortality and ICU transfer in patients with CDI. CONCLUSION: A timely use of NLR can be used as a mean to predict worse outcomes, namely ICU transfer and mortality, in patients with CDI.

Transcutaneous embolisation of an axillary artery aneurysm in a child with Takayasu arteritis.

We report the case of a 10-year-old girl with Takayasu arteritis who developed acute onset wrist drop diagnosed with a large right axillary artery aneurysm compressing the surrounding structures. Our case is unique because it describes a rare presentation of Takayasu arteritis (axillary aneurysm) in a child that was treated successfully in an unconventional manner by transcutaneous embolisation following failure of trans-arterial approach.

The merit of tyrosine kinase inhibitors in the adjuvant setting of high-risk renal cell carcinoma: a meta-analysis.

AIM: As no meta-analyses have evaluated tyrosine kinase inhibitors in the adjuvant setting of high-risk renal cell carcinoma (RCC), the aim was to evaluate the benefit of sunitinib and pazopanib in the adjuvant setting. METHODS: This meta-analysis included all Phase III randomized controlled trials evaluating adjuvant sunitinib and pazopanib in high-risk RCC. Primary outcome was the comparison of disease-free survival (DFS) between tyrosine kinase inhibitors and placebo. RESULTS: There was a tendency for significant overall effect of both sunitinib and pazopanib on DFS (hazard ratio: 0.85; 95% confidence interval: 0.72-1.01; p = 0.06). There was no significant difference between the effect of sunitinib and pazopanib on DFS (p = 0.51;  I2 = 0%). CONCLUSION: Pazopanib and sunitinib could prolong DFS in the adjuvant treatment of high-risk RCC and seem equally effective in this setting.

Switching temporary hemodialysis catheters to long-term catheters: exchange versus de-novo placement, any difference in line infection?
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BACKGROUND: Shifting from a short-term catheter to a long-term one is done either by removing the old catheter and placing a new long-term one via fresh new puncture site, or by replacing the old catheter with a long-term one over a guidewire. AIM: We aimed to describe our technique in changing a temporary line to a long-term catheter (LTC) over a guidewire and to determine the incidence of line-related infections following this procedure. MATERIALS AND METHODS: A retrospective pilot study was conducted between 2005 and 2010 at the American University of Beirut Hospital. We compared the first group (A), which consisted of 20 patients who underwent exchange of a short-term dialysis catheter with a tunneled one over a guidewire using our technique, to a second group (B) of 60 patients who underwent de-novo LTC placement. The two groups were matched by age, with a follow-up of at least 1 month. RESULTS: The technical success rate of the catheter-conversion procedure was 100%. Our results revealed no significant difference of catheter duration between the two groups, with median duration of 6.5 vs. 4.0 days for group A and group B, respectively (p = 0.21). Moreover, there was also no significant mean time difference between any infection and long term catheter (LTC) insertion among the two groups (p = 0.31). Furthermore, there was no difference of catheter infection between the two groups (p = 0.1). CONCLUSION: We concluded that there was no difference in terms of side effects or risk of infection in the guidewire group when compared to standard technique.
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Central Macular Thickness Monitoring after a Taxane-Based Therapy in Visually Asymptomatic Patients.

BACKGROUND: Taxanes are drugs used in various chemotherapeutical protocols to treat solid tumors. They have multiple systemic adverse effects, such as bone marrow suppression, alopecia, nausea, and vomiting, and may rarely cause ocular symptoms. In the past decade, a few reported cases have shown the occurrence of a cystoid macular edema with significant visual loss after the use of a taxane-based chemotherapy. The aim of this study was to compare the central macular thickness (CMT) before and after the initiation of a taxane-based therapy in visually asymptomatic patients and to elucidate the possible impact of these drugs on the vision of cancer patients. METHODS: Patients with a confirmed diagnosis of a solid tumor were screened for any ophthalmic disease before inclusion and had a baseline macular spectral domain optical coherence tomography (OCT; RTVue-100; Optovue Inc., Fremont, CA, USA) before the initiation of a taxane-based chemotherapy according to different protocols, such as 4EC-4T, 3FEC/3T, or 4TC. OCT was repeated after 4 cycles (or 3 months) of treatment, and CMT was compared to baseline. Patients presenting diabetic retinopathy, age-related macular degeneration or any condition that causes macular edema confirmed by ophthalmic examination were excluded. RESULTS: Fifty eyes of 25 patients were included; 92% of the subjects were female with a mean age of 48.52 years, 88% were diagnosed with breast cancer, 8% with esophageal cancer, and 4% with ovarian cancer. Docetaxel was the taxane administered to 92% of the patients. The received dose of docetaxel ranged between 110 and 160 mg. The other patients had paclitaxel in their protocols. No significant macular edema or drop in visual acuity were noted in any patient. Nevertheless, the mean CMT was found to be increased, particularly in the parafoveal and perifoveal areas (mean difference of +2.22 µm; p = 0.001). CONCLUSION: Taxane-based chemotherapy regimens seem to increase macular thickness, with a relative sparing of the fovea, in patients without significant macular edema. Further research is required to better explain the pathophysiology and possible impact of this phenomenon.

Using the Script Concordance Test to Evaluate Clinical Reasoning Skills in Psychiatry.

OBJECTIVES: Although clinical reasoning is a major component of psychiatric training, most evaluating tools do not assess this skill properly. Clinicians mobilize networks of organized knowledge (scripts) to assess ambiguous or uncertain situations. The Script Concordance Test (SCT) was developed to assess clinical reasoning in an uncertainty context. The objective of this study was to test the usefulness of the SCT to assess the reasoning capacities of interns (7th year medical students) during the psychiatry training. METHODS: The authors designed a SCT for psychiatry teaching, adapted to interns. The test contained 20 vignettes of five questions each. A reference panel of senior psychiatrists underwent the test, and we used their scoring as a reference for the student group. The SCT assessed the competence of students at the beginning and the end of their training in psychiatry. RESULTS: A panel of 10 psychiatrists and 47 interns participated to this study. As expected, the reference panel performed significantly (p<0.001) better (79.4±5.1) than the students on the SCT. Interns improved significantly (p<0.001) their scores between the beginning (58.5±6.2) and the end (65.0±5.3) of their psychiatry rotation. The students improved significantly (p<0.001) their scores between the beginning and the end of the training (6.4±4.8). CONCLUSIONS: This is the first study using the SCT in psychiatry. This study shows the feasibility of this procedure and its utility in the field of psychiatry for evaluating medical students in their clinical reasoning competence. It can provide a valid alternative to classical evaluation methods.