Prise en charge des méningites postopératoires

Postoperative meningitis are rare but severe complications of neurosurgery. Their incidence varies from 0.3 to 1.5% after craniotomy. Aseptic meningitis are twice as more frequent than bacterial meningitis and have a constantly favorable outcome without antibiotic treatment. Physiopathology of aseptic meningitis remains debated between a bacterial origin with a low inoculum or a local inflammatory reaction to blood breakdown products, sutures, tissue breakdown products, etc. Clinical presentation and characteristics of cerebrospinal fluid (CSF) are similar between the two entities. Only negative CSF direct examination and CSF culture in the absence of antibiotic exposure previous to lumbar puncture allows the diagnostic of septic meningitis. There now is a consensus to systematically treat with antibiotics according to local ecology any patient with symptoms suggestive of postoperative meningitis with a CSF yielding more than 100 leukocytes/mm³. Antibiotic should be stop after 72 hours if CSF cultures remain sterile; if culture is positive, empirical treatment should be adapted accordingly. The efficiency of this approach was demonstrated in a prospective study and allowed a significant reduction in the duration of antibiotic treatment in patients with postoperative meningitis with a favorable clinical outcome.     

Handiness and acceptability of the new Abak bottle in chronically treated patients. A cross-sectional, retrospective and multicentre study

Background

Difficulty of use of eyedrops is a factor associated with poor patient compliance that reduces treatment efficacy. The aim of this study was to evaluate the handiness and global acceptability of the new Abak^® timolol bottle (multidose preservative-free eyedrops) in comparison with that of other administration systems (classical multidose eyedrops or single-doses) in patients treated for glaucoma or ocular hypertension.

Methods

Cross-sectional, retrospective and multicentre study involving 41 ophthalmologists in France. Selected patients were those who had been treated with the new Abak^® bottle since at least two months, as a replacement for other beta-blocker eyedrops. Handiness and acceptability of the new Abak^® bottle in comparison with other delivery systems were evaluated using a questionnaire filled by the investigator.

Results

Almost all the patients were unanimous regarding the handiness of the new Abak^® bottle: easy to open for 96.5% of them, easy to handle for 96.0%, and easy to get drops for 91.1%. For all these criteria and in a general manner, patients preferred the new Abak^® bottle in comparison with the previous eyedrop container. These results were confirmed in the oldest patients.

Conclusion

The new Abak^® bottle had a greater acceptability compared to preserved multidose eyedrops or to single-doses. Its handiness and the absence of preservative which may improve local tolerance are in favor of a greater compliance in chronically treated patients.     

Ulcerative colitis: exceptional consequence after rituximab therapy

Introduction

Possible adverse complications related to rituximab (RTX) are low, some of which are extremely rare. The authors describe one situation visibly waning exceptional treatment with RTX for SLE refractory to conventional therapies.

Comment

The authors report a patient of 34 years followed for months for an illness in its bullous lupus, with cutaneous, articular, hematologic and immunologic. Given a corticosteroid resistance, several therapeutic background based hydroxychloroquine, cyclophosphamide and methotrexate, were initiated without any improvement. Immunomodulatory therapy type RTX was introduced to this form refractory at a rate of 375 mg/m²/week. The waning of the second infusion, the patient presented a sudden intense abdominal pain syndrome, revealing an acute catarrhal appendicitis. At distance from the appendectomy, the consequences of which were favorable, treatment with RTX was resumed. In the aftermath of the third infusion, the patient presented in table tract marked by profuse watery diarrhea whose explorations reveal a morphological endoscopic appearance of erythematous, ulcerative colitis, reversible upon discontinuation of treatment. Histological data revealed important infiltrates composed mainly of CD8 T lymphocytes.

Conclusion

Gastrointestinal immunological consequences to the requirements of the targeted therapies deserved very careful and rigorous monitoring. However, at the slightest sign of digestive, a detailed morphological exploration is essential, to avoid in particular surgical emergency, evolution without treatment could engage in short-term vital prognosis.     

Retinal drug targets

Retinal effects of systemically administered drugs are rare due to the hematoretinal barriers that protect the retina from circulating active principles. However, some compounds may have direct or indirect toxic effects on the retina through direct interaction with a specific receptor or due to their accumulation within pigment of uveal cells. In the latter case, toxicity is dose-dependent and may be observed years after cessation of medication, as observed with antimalarial drugs. Anti-infective and anti-inflammatory agents, particularly glucocorticoids, are currently injected peri- or intraocularly. The mechanisms and the exact toxicity of glucocorticoids on the retina remain poorly understood. More recently, anti-VEGF has been specifically developed for the treatment of retinal diseases. However, the long-term blockade of VEGF on normal retinal physiology should be determined taking into account VEGF and VEGF receptors expression in the normal and pathologic retina. Whilst enormous advances are made in the treatment of retinal diseases, basic research is still required to define more accurately the molecular targets of drugs to improve their benefits and reduce their potential side effects.     

Novel strategy in lupus therapy: from the peptide P140 to Lupuzor™

Autoimmune diseases are illnesses that occur when the body's tissues are attacked by its own immune system. This review describes the path between the discovery of a synthetic peptide able to delay the development of lupus in mouse models that spontaneously develop lupus-like disease, and the results of multicenter phase IIb clinical trials including lupus patients. If the 2nd phase IIb and phase III results confirm the 1st phase IIb clinical trial, this therapeutic peptide could have a major impact in the treatment of patients with lupus, an autoimmune disease affecting at least five million patients in the world, in majority young women for whom there is no specific treatment today.     

Ocular toxicity of benzalkonium

In order to meet the requirements of the pharmacopeia, ophthalmic preparations have to be manufactured in conditions that can secure their sterility before use and can prevent the development of micro-organisms after opening of the vial. The addition of an appropriate preservative is a way to meet this requirement. However, in addition to their lack of efficacy in certain conditions, they can be problematic in terms of formulation, stability and interaction with the packagings. Furthermore, their daily and repeated use in chronic pathologies such as glaucoma, dry eye or allergy has revealed their nuisance. Moreover, the recognition of certain parameters such as life quality and therapeutic observance has strengthened the proofs that have already been clinically shown. The review of the experimental and clinical data already published about the toxicity of the preservatives shows that almost every ocular structure is affected to various extents. From the first assumption data to preclinical and clinical proofs, this article highlights the evolution of the understanding process towards the toxic role of preservatives.     

Grippe A (H1N1) 2009. Revue générale

Influenza A(H1N1) 2009 is an acute contagious respiratory infection caused by influenza A virus subtype H1N1 appeared in 2009 and responsible for a pandemic. The new virus, different from the avian virus H5N1, is a variant containing genes from several known viruses from porcine, avian and human origin. Appeared originally in the northern hemisphere, the epidemic wave reached early most countries, and up to 24% of the population in metropolitan France. It is characterized by a low mortality estimated at 0.04 to 0.2%, and by a benign, or even asymptomatic presentation. However, more severe clinical expression has been observed in some subgroups, carrying or not risk factors (young, pregnant women). The preexisting immunity in a significant proportion of the population, the remarkable stability of the virus, determination of early antigenic characteristics of the virus, the development and rapid availability of suitable vaccines, the efficacy of antiviral drugs, and health care system contributed to the control the morbidity and mortality of the first pandemic wave. Other virological, clinical and epidemiological investigations, are needed to identify all potential risk factors for severity and determine the role of mutation and the diffusion of pandemic and seasonal viruses, which may alter the virulence and transmissibility of influenza A(H1N1)v 2009.     

Efficacity of rituximab in hemolytic anemia with cold autoantibodies case

Introduction

Autoimmune hemolytic anemia with cold autoantibodies or cold agglutinin disease is a rare chronic disorder in which no treatment has, until now, evidence of its effectiveness.

Clinical case

We report a patient who successfully responded to rituximab for a cold agglutinin disease refractory to conventional therapy with very good tolerance and a complete remission.

Conclusion

There are only few observations that have been reported in the literature regarding the efficacity of rituximab in the treatment of cold agglutinin disease. This promising therapy could, in the future, constitute a real alternative.     

Proposal of a costing method for the provision of sterilization in a public hospital

Introduction

To refine the billing to institutions whose operations of sterilization are outsourced, a sterilization cost approach was developed. The aim of the study is to determine the value of a sterilization unit (one point “S”) evolving according to investments, quantities processed, types of instrumentation or packaging.

Materials and methods

The time of preparation has been selected from all sub-processes of sterilization to determine the value of one point S. The time of preparation of sterilized large and small containers and pouches were raised. The reference time corresponds to one bag (equal to one point S). Simultaneously, the annual operating cost of sterilization was defined and divided into several areas of expenditure: employees, equipments and building depreciation, supplies, and maintenance.

Results

A total of 136 crossing times of containers were measured. Time to prepare a pouch has been estimated at one minute (one S). A small container represents four S and a large container represents 10 S. By dividing the operating cost of sterilization by the total number of points of sterilization over a given period, the cost of one S can be determined.

Discussion/conclusion

This method differs from traditional costing method in sterilizing services, considering each item of expenditure. This point S will be the base for billing of subcontracts to other institutions.     

Medical devices classification: principles and quality management

Medical device market covers a large rank of references and is characterized by a lack of standardization in products naming. Using a specific classification is the first step to ensure a good analysis and a specific follow up of this market. CLADIMED is the classification for medical device used in France and Belgium. It is a five level classification, similar to the Anatomical Therapeutical Chemical classification (ATC) for drugs (WHO). CLADIMED association, gathering users and suppliers, manage this classification. A scientific committee is in charge to guarantee quality and respect of the classification principles.     

Vaccination antigrippe A (H1N1) : analyse rétrospective 2009

The occurrence of the influenza A (H1N1) pandemic was the opportunity to set an appropriate vaccination campaign, effective and well tolerated within the shortest period of time. Thanks to a strong experience in the development of seasonal influenza vaccines and recent experimental knowledge on potential vaccines against H5N1 strain, pharmaceutical companies developed a new vaccine suited for the pandemic A H1N1 California July 2009 strain. This vaccine was produced with and without adjuvant, taking into account safety controls and evolution of scientific knowledge. Nevertheless, this campaign got a poor reception from the general and medical population due to the concomitant spread of the pandemics, an insufficient communication program, organization that was felt as unsuited, too complex and not well understood. Despite that, effectiveness and tolerance of the vaccination campaign have been observed with may be a positive effect on the epidemic.