Characteristics of large granular lymphocyte leukemia associated with variable common immunodeficiency disorders: A study of 12 cases.

OBJECTIVES: Common Variable Immunodeficiency Disorders (CVID) and Large Granular Lymphocytes leukemia (LGLL) exhibit diverse clinical manifestations including infections, dysimmunity, and lymphoproliferation. Recent decades have seen the discovery of new genes in the lymphopoiesis pathway, such as JAK-STAT. This case series supplemented by a literature review aims to describe clinical and biological characteristics of patients with both CIVD and LGLL. METHODOLOGY: Patients were included through a call for comments to French and Belgian centers and through a literature review via PubMed. Clinical characteristics were compared to two large French cohort involving CVID and LGLL patients. RESULTS: Twelve patients were included. In all cases, CVID precedes LLGL (median diagnosis delay for LLGL was 7 years). Most cases presented with splenomegaly and autoimmune cytopenia. Ten out of 12 patients underwent splenectomy during follow up. CONCLUSIONS: Patients with LGLL and CVID differ from patients without immune deficiency in term of clinical presentation and prognosis. We suggest CVID may act as a trigger of LGL lymphocytosis, due to endogenous and exogenous antigenic pressure leading to the selection of a dominant LGL clone and stimulation of the JAK-STAT pathway. The role of splenomegaly and splenectomy in LGLL onset warrant further investigation in future studies.

Impact of a simulation-based training on the experience of the beginning of residency.

INTRODUCTION: We aimed to evaluate the impact of an immersive simulation session on the experience of the beginning of residency. METHODS: The interventional group consisted of newly recruited residents in 2019, who participated in the workshop presenting four emergency scenarios frequently encountered during night shifts; the control group comprised residents who had begun their internship in 2018, without having participated in the simulation workshop. The level of psychological stress and self-confidence were self-estimated in the simulation group before and immediately after the workshop. During the second semester of residency, stress, self-efficacy and anxiety were evaluated in both groups with the Perceived Stress Scale (PSS), General Self-efficacy Scale (GSES), and Generalized Anxiety Disorder-7 (GAD-7) scale. RESULTS: In the second semester 2020, the PSS, GSES and GAD-7 were 20.71±8.15 and 22.44±5.68 (P=0.40); 26.88±6.30 and 27.11±3.95 (P=0.87); 6.94±5.25 and 8.89±4.78 (P=0.22) for the simulation (n=17, 89.5% of participation) and control (n=9, 75%) groups, respectively. In the simulation group, the level of self-confidence had significantly improved from 1.82±0.95 before the session to 2.29±1.16 after the session (P=0.05). Interestingly, this improvement in self-confidence was significantly correlated with GAD-7 (P=0.014) and PSS (P=0.05), and tended to be correlated with GSES (P=0.09). CONCLUSION: Our study showed a significant improvement in self-confidence between before and after the simulation session. Residents who experienced an improvement in self-confidence saw their stress and anxiety levels decrease during the second semester reevaluation, in favor of a prolonged benefit from the session.

[Adult immune thrombocytopenia and thrombopoietin receptor agonist: Ten years later]. / Agonistes du récepteur de la thrombopoïétine et purpura thrombopénique immunologique de l'adulte : où en sommes-nous 10 ans après ?

Ten years after their licence in France, the use of the two thrombopoietin receptor agonists (TPO-RA), eltrombopag and romiplostim, has deeply modified the landscape of immune thrombocytopenia (ITP) treatment. In this review, we summarise data on efficacy and safety of these treatments during ITP, as well as their use in clinical practice. Their place in therapeutic strategy, the recent description of persistant remission after discontinuation of TPO-RA, and future new thrombopoietic agents are also discussed. Their use has progressively increased and early use at a newly diagnosed stage of the disease is under evaluation. However physician have to keep in mind that thromboembolism rates appear to be higher with TPO-RA treatment in ITP patients at high risk of thrombosis, and that data from "real-life" studies with very long term follow up are not available. Finally, the cost of these treatments should also be evaluated in future therapeutic strategies comparisons.

Identifying isoniazid resistance markers to guide inclusion of high-dose isoniazid in tuberculosis treatment regimens.

OBJECTIVES: Effective use of antibiotics is critical to control the global tuberculosis pandemic. High-dose isoniazid (INH) can be effective in the presence of low-level resistance. We performed a systematic literature review to improve our understanding of the differential impact of genomic Mycobacterium tuberculosis (Mtb) variants on the level of INH resistance. The following online databases were searched: PubMed, Web of Science and Embase. Articles reporting on clinical Mtb isolates with linked genotypic and phenotypic data and reporting INH resistance levels were eligible for inclusion. METHODS: All genomic regions reported in the eligible studies were included in the analysis, including: katG, inhA, ahpC, oxyR-ahpC, furA, fabG1, kasA, rv1592c, iniA, iniB, iniC, rv0340, rv2242 and nat. The level of INH resistance was determined by MIC: low-level resistance was defined as 0.1-0.4 µg/mL on liquid and 0.2-1.0 µg/mL on solid media, high-level resistance as >0.4µg/mL on liquid and >1.0 µg/mL on solid media. RESULTS: A total of 1212 records were retrieved of which 46 were included. These 46 studies reported 1697 isolates of which 21% (n = 362) were INH susceptible, 17% (n = 287) had low-level, and 62% (n = 1048) high-level INH resistance. Overall, 24% (n = 402) of isolates were reported as wild type and 76% (n = 1295) had ≥1 relevant genetic variant. Among 1295 isolates with ≥1 variant, 78% (n = 1011) had a mutation in the katG gene. Of the 867 isolates with a katG mutation in codon 315, 93% (n = 810) had high-level INH resistance. In contrast, only 50% (n = 72) of the 144 isolates with a katG variant not in the 315-position had high-level resistance. Of the 284 isolates with ≥1 relevant genetic variant and wild type katG gene, 40% (n = 114) had high-level INH resistance. CONCLUSIONS: Presence of a variant in the katG gene is a good marker of high-level INH resistance only if located in codon 315.

Raising rare disease awareness using red flags, role play simulation and patient educators: results of a novel educational workshop on Raynaud phenomenon and systemic sclerosis.

BACKGROUND: As lack of awareness of rare diseases (RDs) among healthcare professionals results in delayed diagnoses, there is a need for a more efficient approach to RD training during academic education. We designed an experimental workshop that used role-play simulation with patient educators and focused on teaching "red flags" that should raise the suspicion of an RD when faced with a patient with frequently encountered symptoms. Our objective was to report our experience, and to assess the improvement in learners' knowledge and the satisfaction levels of the participants. RESULTS: The workshop consisted of 2 simulated consultations that both started with the same frequent symptom (Raynaud phenomenon, RP) but led to different diagnoses: a frequent condition (idiopathic RP) and an RD (systemic sclerosis, SSc). In the second simulated consultation, the role of the patient was played by a patient educator with SSc. By juxtaposing 2 seemingly similar situations, the training particularly highlighted the elements that help differentiate SSc from idiopathic RP. When answering a clinical case exam about RP and SSc, students that had participated in the workshop had a higher mean mark than those who had not (14 ± 3.7 vs 9.6 ± 5.5 points out of 20, p = 0.001). Participants mostly felt "very satisfied" with this training (94%), and "more comfortable" about managing idiopathic RP and SSc (100%). They considered the workshop "not very stressful" and "very formative" (both 71%). When asked about the strengths of this training, they mentioned the benefits of being put in an immersive situation, allowing a better acquisition of practical skills and a more interactive exchange with teachers, as well as the confrontation with a real patient, leading to a better retention of semiological findings and associating a relational component with this experience. CONCLUSIONS: Through the use of innovative educational methods, such as role-play simulation and patient educators, and by focusing on teaching "red flags", our workshop successfully improved RP and SSc learning in a way that satisfied students. By modifying the workshop's scenarios, its template can readily be applied to other clinical situations, making it an interesting tool to teach other RDs.

[Introduction to debriefing for internists: how to transform real or simulated clinical situations into learning moments]. / Initiation au débriefing pour les internistes : état des connaissances et mise en pratique pour transformer des situations cliniques réelles ou simulées en moments d'apprentissage.

Debriefing is a phase of synthesis and reflection that immediately follows a real-life or simulated situation. It is an essential educational step that forces the learners to reflect upon the thought processes that underlie their actions. Debriefing encourages a personal and collective reflection in order to remodel erroneous mental schemas and rectify actions done in context. Debriefing cannot be improvised; it requires a sound structure and regular practice in order to be truly effective. The debriefer must be considerate, choose appropriate learning objectives and dedicate ample time to the learners. Debriefing is focused on learning acquired in context-in other words, on the actions that were performed within a real-life or simulated clinical practice situation-and immediately follows the situation. After an initial phase of emotional release, the debriefer will help learners analyse their actions to identify their underlying rationale (contextualization), extract the overarching principles related to the lived situation in order to modify the rationale if needed (decontextualization) and assist the transfer of learning to real life (in the case of simulation) and to similar situations (recontextualization). A final summary of learning achieved during the training session concludes the debriefing. Debriefing is useful in any learning situation, including in internal medicine. Even if simulation is still underused in internal medicine, post-event debriefing can be implanted in our clinical services. Indeed, training our students and shaping them into healthcare professionals rest in no small part on hospital rotations where the intern is confronted with real-patient situations that are suitable to learning. Some in-hospital clinical encounters can be actively transformed into learning opportunities thanks to post-event debriefing, but can also passively morph into bad daily practice if no supporting action is implemented. Debriefing can thus provide an opportunity to develop non-technical skills in critical situations, or doctor-patient communication skills, within a team or between colleagues. These competencies are the hallmark of well-trained interns and are indispensable for the proper functioning of a care team. We will not develop the emotional and psychological management of debriefing in this article. We hope we will helpfully introduce as many of our colleagues as possible to the art of debriefing in most circumstances.

Aging in the Syrian hamster testis: Inflammatory-oxidative status and the impact of photoperiod.

Testicular aging is linked to histological, morphological and functional alterations. In the present study, we investigated whether aging affects the inflammatory and oxidative status in the testis by comparing young adult, middle-aged adult and aged hamsters. The Syrian hamster, a thoroughly studied seasonal breeder, was chosen as the experimental model since it allows further investigations on the role of photoperiod and melatonin in testicular aging with a minimal impact of the experimental intervention on the animal well-being and the subsequent results achieved. In testes of aged hamsters, we found a decrease in melatonin concentration, a thickening of the wall of the seminiferous tubules as well as a significant increase in IL-1ß, NLRP3 and cyclooxygenase 2 expression, PGD2 production, macrophages numbers, lipid peroxidation and anti-oxidant enzyme catalase levels. Interestingly, when aged hamsters were transferred from a long day (LD) to a short day (SD) photoperiod for 16 weeks, testicular melatonin concentration increased while local inflammatory processes and oxidative stress were clearly reduced. Overall, these results indicate that melatonin might display anti-inflammatory and anti-oxidant capacities in the aged testes.

[Reliability and validity of a workbook for assessment of professional competencies of internal medicine residents]. / Évaluation multicentrique de la reproductibilité et de la validité d'un carnet d'évaluation des compétences professionnelles des internes de médecine interne.

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.

[Analysis of the discrimination of the final marks after the first computerized national ranking exam in Medicine in June 2016 in France]. / Analyse de la discrimination des notes aux ECN informatisées de 2016.

INTRODUCTION: The first computerised national ranking exam (cNRE) in Medicine was introduced in June 2016 for 8214 students. It was made of 18 progressive clinical cases (PCCs) with multiple choice questions (MCQs), 120 independent MCQs and 2 scientific articles to criticize. A lack of mark discrimination grounded the cNRE reform. We aimed to assess the discrimination of the final marks after this first cNRE. METHODS: A national Excel® file gathering overall statistics and marks were transmitted to the medical faculties after the cNRE. The mean points deviation between two papers and the percentage of points ranking 75% of students allowed us to analyse marks' discrimination. RESULTS: The national distribution sigmoid curve of the marks is superimposable with previous NRE in 2015. In PCCs, 72% of students were ranked in 1090 points out of 7560 (14%). In independents MCQs, 73% of students were ranked in 434 points out of 2160 (20%). In critical analysis of articles, 75% of students were ranked in 225 points out of 1080 (21%). The above percentages of students are on the plateau of each discrimination curve for PCCs, independent MCQs and critical analysis of scientific articles. CONCLUSION: The cNRE reduced equally-ranked students compared to 2015, with a mean deviation between two papers of 0.28 in 2016 vs 0.04 in 2015. Despite the new format introduced by the cNRE, 75% of students are still ranked in a low proportion of points that is equivalent to previous NRE in 2015 (between 15 et 20% of points).

[Educational assessment of the first computerized national ranking exam in France in 2016: Opportunities for improvement]. / Analyse docimologique des premières Épreuves classantes nationales informatisées (ECNi) de 2016 : propositions d'amélioration.

In June 2016, 8124 medical students in their sixth year of graduation passed the first computerized national ranking exam (CNRE) in France after which they will have to choose what medical specialty they will be practicing all their life. We conducted the first educational assessment of this CNRE according to two criteria: the relevance of the questions and the cognitive domain mainly required to answer these questions. We propose two improvements for the future CNRE: promote student reasoning in the multiple choices questions, reduce to 10 the number of multiple choice questions in the progressive clinical cases and increase by 9 their total number (from 18 to 27), and use a majority of mini-clinical cases for isolated multiple choice questions in order to focus students on reasoning instead of simple knowledge restitution.

Pressure-induced switching properties of the iron(iii) spin-transition complex [FeIII(3-OMeSalEen)2]PF6.

We investigated the effect of an externally applied pressure on the iron(iii) Schiff-base compound [Fe(3-OMeSalEen)2]PF6 (H-3-OMeSalEen, condensation product of 3-methoxy-substituted salicylaldehyde and N-ethylethylenediamine), which at ambient pressure displays a thermal spin transition with a 3 K wide hysteresis loop centered at 164 K. Raman spectrometry revealed the occurrence of a complete spin-state switching process for a pressure of P1/2 = 8-9 kbar at room temperature. The evolution of lattice parameters as a function of pressure was followed by X-ray diffraction measurements on single crystals, highlighting the important microscopic aspects at the origin of the pressure-induced transition, i.e. an anisotropic response and a high compressibility of the HS molecular lattice. Variable temperature magnetic susceptibility measurements at different applied pressures revealed the smoothening of the spin transition curves and a linear increase of the transition temperatures by ca. 16.4 (1.0) K kbar-1, in good agreement with the Clausius-Clapeyron law. The non-negligible influence of the pressure transmitting oils on the intrinsic transition properties was also evidenced and attributed to mechanical interactions between the particles and the solidified matrix.

Comparison of structural dynamics and coherence of d-d and MLCT light-induced spin state trapping.

Light-induced excited spin state trapping (LIESST) in FeII spin-crossover systems is a process that involves the switching of molecules from low (LS, S = 0) to high spin (HS, S = 2) states. The direct LS-to-HS conversion is forbidden by selection rules, and LIESST involves intermediate states such as 1,3MLCT or 1,3T. The intersystem crossing sequence results in an HS state, structurally trapped by metal-ligand bond elongation through the coherent activation and damping of molecular breathing. The ultrafast dynamics of this process has been investigated in FeN6 ligand field systems, under MLCT excitation. Herein, we studied LIESST in an FeIIN4O2 spin-crossover material of lower symmetry, which allowed for quite intense and low-energy shifted d-d bands. By combining ab initio DFT and TD-DFT calculations and fs optical absorption measurements, we demonstrated that shorter intermediates enhanced coherent structural dynamics, and d-d excitation induced faster LS-to-HS switching, compared to MLCT.

Spatially controlled positioning of coordination polymer nanoparticles onto heterogeneous nanostructured surfaces.

Prussian Blue Analog (PBA) nanoparticles were formed on a heterogeneous nanostructured surface made of an ordered nanoperforated titanium oxide thin film deposited on a gold layer. The study of the nanocomposite film by grazing-incidence wide angle X-ray scattering, infrared spectroscopy, scanning electron microscopy and atomic force microscopy shows that the PBA particles are precisely positioned within all the perforations of the oxide film over very large surface areas. Further investigation on the formation of the PBA particles demonstrates a decisive role of a heterogeneous nucleation of the coordination polymer driven by well-adjusted surfaces energies and reactant concentrations in the spatial positioning of the PBA particles. Thanks to the well-controlled positioning of the particles within the ordered nanoperforations, the latter were successfully used as nano crucibles for the local transformation of PBA into the corresponding metal alloy by heat treatment. The thin film heterostructure thus obtained, made of ferromagnetic islands isolated by diamagnetic walls, opens interesting perspectives for the design of magnetic storage devices.

Nanocrystals of Fe(phen)2(NCS)2 and the size-dependent spin-crossover characteristics.

We report on the size reduction of the neutral Fe(phen)2(NCS)2 prototypical compound exhibiting a cooperative spin-crossover associated with a first-order phase transition (at ca. 176 K). We use the [Fe(phen)3](NCS)2 ionic precursor and the solvent-assisted precipitation technique to prepare an array of crystalline objects with sizes varying over two orders of magnitude (from 15 up to 1400 nm). TEM, X-ray diffraction and IR measurements provide evidences for the formation of particles of neutral and ionic species, which results from the interplay between the relevant chemical equilibrium and the reaction kinetics (ligand extraction, complex precipitation), and the modulation of the latter by physico-chemical parameters. A thermal transformation of diamagnetic nanocrystals of [Fe(phen)3](NCS)2 leads to spin-crossover particles of Fe(phen)2(NCS)2 of a comparable size. Powders of nano-, micro- and polycrystals of Fe(phen)2(NCS)2 present X-ray diffractograms typical of the so-called polymorph II. The importance of size effects on the cooperative spin-crossover process was probed with magnetic, Mössbauer, Raman and IR spectroscopic measurements. Each sample exhibits spin-state switching of the Fe(ii) ions. The salient features are: a cooperativity preserved at the micrometric scale, a very limited downshift of the transition temperature and an asymmetric spreading of the thermal process (over ca. 100 K) with the size reduction. At temperatures close to room temperature, the process appears to be quasi complete whatever the size of the samples. This result, extracted from Raman data, was confirmed by Mössbauer measurements in the case of the largest objects (LS residue <5-10% for bulk and microparticles). Below 150 K, a very efficient low-spin to high-spin photoexcitation was induced by the Raman laser beam in all the samples which prevents the extraction of the high-spin fraction in this temperature range. However variable temperature IR spectra of the 29 nm particles indicate that the HS residue, that is close to zero in the case of microparticles, does not drastically increase (<30%) for the smallest particles. The processing of a number of related spin-crossover compounds in the form of nanoparticles may be achieved with this general approach.

[Practical conduct for patients with a lonely hypoxemia at rest or during exercise]. / Démarche diagnostique d'une hypoxémie « nue ¼ de l'adulte.

INTRODUCTION: Hypoxemia is a decrease in blood oxygen partial pressure. This work aims at presenting a practical conduct for patients with a lonely hypoxemia at rest or during exercise, defined by the absence of dyspnea at rest, obvious clinical or radiographic abnormality. STATE OF THE ART: Diagnostic tools available to the clinician are clinical examination, CT scan, echocardiography, hyperoxia test, trans cranial ultrasound and lung scintigraphy. This work proposes a practical diagnostic approach, with a main role of chest CT. PERSPECTIVES: Work is underway to determine more precisely the place of echocardiography for the diagnosis of intra or extra cardiac shunts. CONCLUSIONS: The finding of a lonely hypoxemia requires careful diagnostic approach to quickly rule out potentially serious causes and not to disregard the rare causes.