[Medication reconciliation in a department of internal medicine and infectious and tropical diseases: Feedback after one year practice]

Since April 2015, medication reconciliation is performed in our Department. The objective of this study is to assess the impact of this activity on patients' care after one year of practice.

METHODS

All patients who received medication reconciliation between April-October 2015 and June-December 2016 were included in this retrospective study. Undocumented unintentional discrepancies (DNIND) which result from the comparison between the patient's usual treatments and the medication prescribed at admission were collected. Then, a multidisciplinary discussion was initiated to correct them. The gravity of each DNIND was determined a posteriori.

RESULTS

A statistical comparison between the two studies (2015 vs. 2016) showed the following significant results: decrease in DNIND (0.9 vs. 0.43), in percentage of patients with at least one DNIND (43% vs 31% P <5.10^-6), in reconciliation time (43min vs. 23min) and no significant difference in the distribution of DNIND typology. The main therapeutic classes are: metabolism-diabetes-nutrition (21%), cardiology (18%), pneumology (17%) and neurology-psychiatry (15%). Drugs mainly concerned with DNIND are inhaled anti-asthmatics (13% of the medicines with DNIND), vitamins (8% of DNIND) and the levetiracetam antiepileptic drug (5% of DNIND).

CONCLUSION

The implementation of the reconciliation medication allowed a significant reduction of the DNIND that permits to improve the patient healthcare pathway.

The combination of micro-resonators with spatially resolved ferromagnetic resonance

We present two new and complementary approaches to realize spatial resolution for ferromagnetic resonance (FMR) on the 100 nm-scale. Both experimental setups utilize lithographically fabricated micro-resonators. They offer a detection sensitivity that is increased by four orders of magnitude compared with resonator-based FMR. In the first setup, the magnetic properties are thermally modulated via the thermal near-field effect generated by the thermal probe of an atomic force microscope. In combination with lock-in detection of the absorbed microwave power in the micro-resonator, a spatial resolution of less than 100 nm is achieved. The second setup is a combination of a micro-resonator with a scanning transmission x-ray microscope (STXM). Here a conventional FMR is excited by the micro-resonator while focused x-rays are used for a time-resolved snap-shot detection of the FMR excitations via the x-ray magnetic circular dichroism effect. This technique allows a lateral resolution of nominally 35 nm given by the STXM. Both experimental setups combine the advantage of low-power FMR excitation in the linear regime with high spatial resolution to study single and coupled nanomagnets. As proof-of-principle experiments, two perpendicular magnetic micro-stripes (5 μm × 1 μm) were grown and their FMR excitations were investigated using both setups.

[Modifications of immunity in obesity: The impact on the risk of infection]

Incidence of obesity is constantly rising all over the world; obesity has developed into an important problem of public health. Clinical experience, supported by many clinical trials, shows that obesity constitutes a risk factor for numerous cardiovascular, metabolic, cancer and even infectious diseases. In this revue we summarize the present knowledge on immunological properties and functions of adipose tissue and their modifications in obese subjects, with a bending to a potentially deleterious chronic inflammatory state. We will discuss the negative impact of this chronic inflammation on physiological acute inflammatory reaction during infectious episodes. However, the modifications of anti-infectious immune response in obese subjects are not well known at present and need further investigations.

Prevalence and pathogenicity of binary toxin-positive Clostridium difficile strains that do not produce toxins A and B

Clostridium difficile causes antibiotic-associated diarrhoea and pseudomembranous colitis. The main virulence factors of C. difficile are the toxins A (TcdA) and B (TcdB). A third toxin, called binary toxin (CDT), can be detected in 17% to 23% of strains, but its role in human disease has not been clearly defined. We report six independent cases of patients with diarrhoea suspected of having C. difficile infection due to strains from toxinotype XI/PCR ribotype 033 or 033-like, an unusual toxinotype/PCR ribotype positive for CDT but negative for TcdA and TcdB. Four patients were considered truly infected by clinicians and were specifically treated with oral metronidazole. One of the cases was identified during a prevalence study of A(-)B(-)CDT(+) strains. In this study, we screened a French collection of 220 nontoxigenic strains and found only one (0.5%) toxinotype XI/PCR ribotype 033 or 033-like strain. The description of such strains raises the question of the role of binary toxin as a virulence factor and could have implications for laboratory diagnostics that currently rarely include testing for binary toxin.

Adult-onset Still's disease revealed by perimyocarditis and a concomitant reactivation of an EBV infection

We describe a 17-year-old patient presenting perimyocarditis as the initial manifestation of the adult-onset Still's disease. Corticotherapy was rapidly successful but induced major acute hepatitis in relation with Epstein-Barr virus reactivation. After 1 year, even if the global outcome is favourable, a slightly lowered ejection fraction still persists. Former case reports and differential diagnosis with reactive haemophagocytic syndrome would be discussed.

Concomitant axillary mycobacteriosis and neuro-sarcoidosis: diagnostic pitfalls

There are many similarities between mycobacteriosis, in particular, tuberculosis, and sarcoidosis such as predominant intrathoracic localisation (even if all organs and tissues may be concerned), great variability of phenotypic expression, and granulomatous inflammatory reaction, caseous necrosis not being an absolute criterion of tuberculosis. Moreover, microbial (or mycobacterial?) agents may play a role in the pathogenesis of sarcoidosis which remains a diagnosis of exclusion particularly in atypical cases. The authors report a case of a non-immunocompromised female patient who presented, simultaneously, isolated axillary tubercular adenitis and neuro-sarcoidosis without any other localisation. This case illustrates the difficulty to distinguish between both of these two diseases and thus to choose an adequate treatment when diagnosis is not proven. Moreover, our patient (human leucocyte antigen B27 positive) presented symptoms of spondylarthritis which also may have a nosological link with tuberculosis or sarcoidosis.

Visualization of spin dynamics in single nanosized magnetic elements

The design of future spintronic devices requires a quantitative understanding of the microscopic linear and nonlinear spin relaxation processes governing the magnetization reversal in nanometer-scale ferromagnetic systems. Ferromagnetic resonance is the method of choice for a quantitative analysis of relaxation rates, magnetic anisotropy and susceptibility in a single experiment. The approach offers the possibility of coherent control and manipulation of nanoscaled structures by microwave irradiation. Here, we analyze the different excitation modes in a single nanometer-sized ferromagnetic stripe. Measurements are performed using a microresonator set-up which offers a sensitivity to quantitatively analyze the dynamic and static magnetic properties of single nanomagnets with volumes of (100 nm)(3). Uniform as well as non-uniform volume modes of the spin wave excitation spectrum are identified and found to be in excellent agreement with the results of micromagnetic simulations which allow the visualization of the spatial distribution of these modes in the nanostructures.

[Hypokalemia induced quadriparesis as the presenting manifestation of Gougerot-Sjögren's syndrome]

We report a 30-year-old woman who presented with a hypokaliemia-related subacute quadriparesis. The various causes of hypokalemia induced paresis were discussed but the association of hypokalemia with metabolic acidosis and normal anion gap was diagnostic of distal renal tubular acidosis. The renal tubulopathy was the presenting manifestation of a primary Sjogren's syndrome. Distal renal tubular acidosis concerns a third of the patients affected by this auto-immune disease.

[Ovarian and peritoneal sarcoidosis mimicking an ovarian cancer]

Ovarian and peritoneal sarcoidosis is a very rare condition, with an atypical clinical presentation close to that of ovarian cancer. An erroneous diagnosis could induce a definitive castration. A 38-year-old woman was admitted because of ascites and weight loss. A computerized tomography scan revealed multiple soft tissue nodules in the pelvis, on the ovaries as well as peritoneal deposits. Histological examination after laparoscopic biopsy was indicative of sarcoidosis. Corticosteroids were given to the patient and the symptoms quickly subsided. This case with its clinical presentation is discussed in comparison with previously reported cases.

Phase II study of leucovorin, 5-fluorouracil and gemcitabine for locally advanced and metastatic pancreatic cancer (FOLFUGEM 2)

AIM

FOLFUGEM 1 (leucovorin 400 mg/m2 combined with 5-flurorouracil (FU) bolus 400 mg/m2 then 5-FU 2-3 g/m2/46 hours and gemcitabine 1000 mg/m2 in 30 min) in patients with locally-advanced and metastatic pancreatic adenocarcinoma appeared to be toxic (neutropenia and alopecia). The aims of this phase II multicentric study were to evaluate the response rate, clinical benefit and tolerance of a new scheme of combined leucovorin, 5-FU and gemcitabine (FOLFUGEM 2).

PATIENTS AND METHODS

FOLFUGEM 2 associated leucovorin 400 mg/m2 in 2 hours followed by 5-FU 1000 mg/m2 in 22 hours, then gemcitabine 800 mg/m2 (10 mg/m2/min) with cycles every 14 days. Gemcitabine dose could be increased (1000 then 1250 mg/m2) when NCI/CTC toxicity was < or = grade 2.

RESULTS

Fifty-eight patients were included (locally-advanced tumor: N = 13 and metastatic: N = 45). Among the 39 patients with measurable disease, 11 had partial response (28.2%, 95% confidence interval: 14-42%) and 11 had stable disease (28.2%). On an intent-to-treat analysis, the objective response rate was 19% (95% confidence interval: 9-29%). Clinical benefit rate was 46%. Median progression-free survival and median overall survival were 3.1 and 7.2 months, respectively. There were 13% grade 3-4 neutropenia and 36% complete alopecia.

CONCLUSION

FOLFUGEM 2 schema has an antitumoral effect in advanced pancreatic cancer and has an acceptable toxicity which appears to be less than that of FOLFUGEM 1.

Population dynamics of an introduced bacterium degrading chlorinated benzenes in a soil column and in sewage sludge

The capacity of the beta-Proteobacterium Pseudomonas sp. strain P51, which degrades chlorinated benzenes, to metabolize 1,2,4-trichlorobenzene (TCB) under environmental conditions was tested by its release into two experimental systems. The first system consisted of laboratory scale microcosms which were operated with and without the addition of TCB and which were inoculated with sludge from a wastewater treatment plant. The second system consisted of a non sterile, water saturated soil column. We determined survival of strain P51 after its introduction and its ability to degrade TCB. The population dynamics was followed by selective plating and applying the polymerase chain reaction (PCR) to detect strain P51 and the chlorobenzene (tcb) genes on catabolic plasmid pP51. The results showed a completely different behaviour of strain P51 in the two habitats under the applied conditions. In the soil column the P51 bacteria inoculated the entire area and their population reached 2 x 10(6) cells/g soil. The population remained active since TCB was degraded to concentrations below the detection limit of 30 micrograms/l. In the sludge microcosms, the number of strain P51 cells immediately decreased from 4 x 10(7) cells/ml to 10(5) cells/ml over a period of 2 days after inoculation, and then the strain disappeared to levels below our detection limit (10(3)-10(4) cells/ml). In the reactor without TCB the population of P51 maintained a stable value of 10(5) cells/ml during 8 days but then also decreased to levels below the detection limit. In addition, no significant TCB degradation was found in the sludge reactors. The influence of presence of TCB on maintenance of strain P51 in the two habitats is discussed. This work demonstrates the possibility to successfully apply preselected strains to degrade otherwise poorly degradable substances in complex mixed microbial communities. However, survival and activity may depend strongly on the type of system into which the strain is introduced.

Quantification of bacterial mRNA involved in degradation of 1,2,4-trichlorobenzene by Pseudomonas sp. strain P51 from liquid culture and from river sediment by reverse transcriptase PCR (RT/PCR)

Competitive reverse transcriptase polymerase chain reaction (RT/PCR) was used to quantify the mRNA of the tcbC gene of Pseudomonas sp. strain P51. The tcbC gene encodes the enzyme chlorocatechol-1,2-dioxygenase involved in 1,2,4-trichlorobenzene (TCB) degradation. The mRNA content per cell was monitored in a batch culture growing on 1,2,4-TCB. No mRNA could be detected in the first 2 days of the lag phase. mRNA production became maximal with 20 molecules per cell in the early exponential growth phase but then decreased to less than 10 molecules per cell. When TCB was depleted and the cells entered the stationary phase, the mRNA content decreased slowly below the detection limit within 4 days. In order to compare detection of tcbC mRNA in pure culture and in river sediment, cells of strain P51 pregrown on TCB were added to sediment and RNAs extracted. In sediment samples containing 5 x 10(8) cells per gram the tcbC mRNA was quantifiable by RT/PCR. The mRNA recovery was about 3% as compared to the inoculum. The detection limit of the RT/PCR method was about 10(7) mRNA molecules per gram sediment or 10(6) copies per ml culture medium which corresponded in our case to 10(5) molecules per reaction vial.

Grazing of Tetrahymena sp. on adhered bacteria in percolated columns monitored by in situ hybridization with fluorescent oligonucleotide probes

Predation of attached Pseudomonas putida mt2 by the small ciliate Tetrahymena sp. was investigated with a percolated column system. Grazing rates were examined under static and dynamic conditions and were compared to grazing rates in batch systems containing suspended prey. The prey densities were 2 x 10(8) bacteria per ml of pore space and 2 x 10(8) bacteria per ml of suspension, respectively. Postingestion in situ hybridization of bacteria with fluorescent oligonucleotide probes was used to quantify ingestion. During 30 min, a grazing rate of 1,382 +/- 1,029 bacteria individual-1 h-1 was obtained with suspended prey; this was twice the grazing rate observed with attached bacteria under static conditions. Continuous percolation at a flow rate of 73 cm h-1 further decreased the grazing rate to about 25% of the grazing rate observed with suspended prey. A considerable proportion of the protozoans fed on neither suspended bacteria nor attached bacteria. The transport of ciliates through the columns was monitored at the same time that predation was monitored. Less than 20% of the protozoans passed through the columns without being retained. Most of these organisms ingested no bacteria, whereas the retained protozoans grazed more efficiently. Retardation of ciliate transport was greater in columns containing attached bacteria than in bacterium-free columns. We propose that the correlation between grazing activity and retardation of transport is a consequence of the interaction between active predators and attached bacteria.

High dose chemotherapy with ABMT in soft tissue sarcomas: a report of 22 cases

Twenty-two patients with locally advanced or metastatic soft tissue sarcomas received high dose chemotherapy with autologous bone marrow graft. Eleven patients receiving melphalan also received fractionated total body irradiation. Six patients (four in CR and two in PR) were intensified after first line therapy. Thirteen patients were grafted after chemosensitive relapse: seven in second CR, one in third CR, one in first PR, three in second PR and one in fourth PR. Three patients with primary refractory disease were intensified. The overall response rate in 66% in nine evaluable patients. The overall median survival and disease-free survival were 19 and 15 months, respectively. The actuarial survival rates at 2 and 5 years were 40% and 32% respectively. There was one treatment-related death due to infection. We conclude that high dose chemotherapy is feasible and provides reasonable response rates in patients with advanced soft tissue sarcomas.

Treatment of poor prognosis Burkitt's lymphoma in adults with the Société Française d'Oncologie Pédiatrique LMB Protocol--a study of the Federation Nationale des Centres de Lutte Contre le Cancer (FNLCC)

14 adult patients between 16 and 50 years old with small non-cleaved cell lymphoma (Burkitt's lymphoma) were prospectively treated from 1982 to 1990 with the LMB protocols of the Société Française d'Oncologie Pédiatrique (SFOP). No HIV-positive patients were included. All patients had extensive disease with bad prognosis factors, i.e. 10 patients had Murphy stage III and 4 had stage IV with bone marrow involvement. The LMB protocols were characterised by high-dose fractionated cyclophosphamide, high-dose methotrexate (HD-MTX), and cytosine arabinoside. No local or central nervous system irradiation was used. Treatment duration ranged from 5 (LMB 84) to 12 (LMB 81) months. There were no therapy-related deaths. All patients achieved complete remission (CR). 6 patients relapsed between 2 and 30 months following CR. 8 of the 14 patients (57%) are still alive and disease-free after treatment by LMB protocol alone. 2 patients were salvaged with bone marrow transplantation after relapse and a total of 10 out of 14 patients (71%) are disease-free at the time of this report. Our results showed the high curability of advanced Burkitt's lymphoma using a paediatric protocol, even in adult patients. The LMB protocol may be applied to adult patients but requires intensive care during the induction period.