Meningococcal disease in a kidney transplant recipient with mannose-binding lectin (MBL) deficiency

Background: There is an increasing amount of data associating MBL deficiency with a higher susceptibility to meningococca[ disease. In addition, meningococca[ disease has been reported in patients with various immunosuppressive conditions. However, to our knowledge, only three cases of meningococca[ disease have been reported in solid organ recipients (SOT). Methods & Results: A 32 year-old male patient underwent cadaveric kidney transplantation for endstage renal disease of unknown origin. On day 71 post-transplantation he developed fever (39.6°C), shaking chilis, and tachycardia without hypotension. At this time, immunosuppression consisted of tacro[imus, prednisone 10mg daily and mycopheno[ ate mofeti[ 2 g daily. Physical examination on admission was normal, except for two small petechia[ lesions on the forearm. No meningeal signs were present. Three sets of blood cultures grew Neisseria meningitidis group C susceptible to ceftriaxone (MIC=0.003mg/[). Antibiotic therapy consisted in intravenous ceftriaxone 2 g per day for a total duration of 7 days. Serum immunog[obu[in levels, C3, C4 and CHS0 were normal However, using a method to screen for the functional activity of a[[ three pathways of complement (Wies[ab, Lund, Sweden), no activation via the MBL pathway could be detected (0%). A subsequent quantification of MBL pathway components revealed normal levels of MASP 2 but undetectab[e amounts of MBL (below 10 ng/m[, normal range: >500 ng/m[). Conclusion: Since the exact incidence and the possible relationship between meningococca[ disease and organ transplantation is not we[[ understood, we strongly encourage transplantation centers to report additional cases. The potential clinical usefu[ ness of screening SOT candidates for MBL deficiency in relation to infectious complications after transplantation remains to be determined.

Severe stroke: patient profile and predictors of favorable outcome.

Summary.  Background:  Severe stroke carries high rates of mortality and morbidity. The aims of this study were to determine the characteristics of patients who initially presented with severe ischemic stroke, and to identify acute and subacute predictors of favorable clinical outcome in these patients. Methods:  An observational cohort study, Acute Stroke Registry and Analysis of Lausanne (ASTRAL), was analyzed, and all patients presenting with severe stroke - defined as a National Institute of Health Stroke Scale score of ≥ 20 on admission - were compared with all other patients. In a multivariate analysis, associations with demographic, clinical, pathophysiologic, metabolic and neuroimaging factors were determined. Furthermore, we analyzed predictors of favorable outcome (modified Rankin scale score of ≤ 3 at 3 months) in the subgroup of severe stroke patients. Results:  Of 1915 consecutive patients, 243 (12.7%) presented with severe stroke. This was significantly associated with cardio-embolic stroke mechanism (odds ratio [OR] 1.74, 95% confidence interval [CI] 1.19-2.54), unknown stroke onset (OR 2.35, 95% CI 1.14-4.83), more neuroimaging signs of early ischemia (mostly computed tomography; OR 2.65, 95% CI 1.79-3.92), arterial occlusions on acute imaging (OR 27.01, 95% CI 11.5-62.9), fewer chronic radiologic infarcts (OR 0.43, 95% CI 0.26-0.72), lower hemoglobin concentration (OR 0.97, 95% CI 0.96-0.99), and higher white cell count (OR 1.05, 95% CI 1.00-1.11). In the 68 (28%) patients with favorable outcomes despite presenting with severe stroke, this was predicted by lower age (OR 0.94, 95% CI 0.92-0.97), preceding cerebrovascular events (OR 3.00, 95% CI 1.01-8.97), hypolipemic pretreatment (OR 3.82, 95% CI 1.34-10.90), lower acute temperature (OR 0.43, 95% CI 0.23-0.78), lower subacute glucose concentration (OR 0.74, 95% CI 0.56-0.97), and spontaneous or treatment-induced recanalization (OR 4.51, 95% CI 1.96-10.41). Conclusions:  Severe stroke presentation is predicted by multiple clinical, radiologic and metabolic variables, several of which are modifiable. Predictors in the 28% of patients with favorable outcome despite presenting with severe stroke include hypolipemic pretreatment, lower acute temperature, lower glucose levels at 24 h, and arterial recanalization.

L'apport du patient simulé dans l'apprentissage de la relation médecin-malade: résultats d'une évaluation préliminaire

Contexte : Les étudiants de 4° année des études de médecine à la faculté de biologie et de médecine de Lausanne bénéficient d'un enseignement des habiletés à la communication médecin-malade, ayant recours à un patient simulé joué par un comédien. But : Évaluer la pertinence de cette méthode active dans l'optique de renforcer cet enseignement dans le curriculum. Méthodes : Un questionnaire demande aux étudiants d'apprécier leurs apprentissages, ainsi que le dispositif d'enseignement. Un autre questionnaire évalue les compétences de l'étudiant qui mène l'entretien par l'étudiant lui-même (étudiant actif), par les étudiants observateurs, par l'enseignant et par le patient simulé. Résultats : Ce dispositif d'enseignement est apprécié des étudiants et permet aux étudiants qui ont mené l'entretien et aux étudiants observateurs d'en tirer un bénéfice. Les étudiants actifs ont tendance à évaluer leurs compétences d'entretien plus négativement que ne le font l'enseignant, le comédien et les étudiants observateurs .Conclusion : Ce dispositif d'enseignement est perçu comme pertinent par l'ensemble des participants, mais devrait être renforcé pour donner à chaque étudiant l'occasion de participer activement à l'entrevue simulée. -- Context: 4th year medicine students at the Faculty of Biology and Medicine of Lausanne were taught to develop patient-doctor communication skills, using a simulated patient played by an actor. Objective: To assess the relevance of this active method in the perspective of reinforcing this teaching approach in the curriculum. Method: This new form of teaching was assessed by questionnaires filled by all participants, i.e. students involved in the communication (active student), students who were bystanders (observer students), the tutor, as well as the actor. Results: This teaching approach was appreciated from all students, active and observer, allowing them to gain benefit from the interview on communication skills acquirement. The active students assessed their communication skills more negatively than did the teacher, the actor and the observer students. Conclusion: This teaching method seems to be relevant for all participants and should be reinforced to give the opportunity for each student to participate as an active student.