Connaissances et pratiques des étapes préalables à la stérilisation des dispositifs médicaux thermorésistants : Etude au Centre Hospitalo-Universitaire Sahloul, Sousse-Tunisie - 2022

OBJECTIVES

The standard process of central sterilization is crucial for the optimal functioning of the operating room. The outcome of this process is closely linked to the steps preceding the steps prior to the sterilization step itself. These steps include pre-disinfection carried out in the operating rooms and other stages, namely washing, drying and packaging, which must be performed in the central sterilization unit. In this context, this study aimed to describe the knowledge of the staff in the operating rooms and the central sterilization unit at Sahloul University Hospital in Sousse (Tunisia) in 2022, regarding the steps prior to the sterilization of reusable thermoresistant medical devices and to describe their practices in terms of compliance with these steps.

METHOD

A descriptive study was conducted from January 2022 to June 2022 with the aforementioned staff, using a self-administered questionnaire to assess their knowledge of the pre-sterilization steps and a direct observation audit of their practices with regard to these steps. Both measurement instruments were pre-tested.

RESULTS

Out of 102 self-administered questionnaires (knowledge assessment) distributed to the staff concerned, only 80 were returned and correctly filled out, giving a response rate of 78.4%. Participants' responses regarding the order of steps prior to the sterilization were incorrect in 64% of cases. With regard to the evaluation of professional practices, 224 observations were made in the study area (practice audit). In 82% of these observations, the pre-disinfection step was confused with the washing step. The use of Betadine brushes and scrubbing pads for device washing was noted in 89.3%, along with the absence of swabbing of the canals and hollow parts in 9.4% of cases and the absence of drying of the canals with compressed air.

CONCLUSION

Mastery of the steps prior to sterilisation of reusable thermoresistant medical devices was insufficient in our institution, suggesting the importance of reinforcing the implementation of the procedure through a continuous training program followed by action plans.

[Premenstrual dysphoric disorder (PMDD): Drug and psychotherapeutique management, a literature review]

INTRODUCTION

Premenstrual Dysphoric Disorder (PMDD) was first recognised in July 2013 in the DSM-5 after a long journey to identify its existence. It was not until 1983 that the US National Institute of Mental Health determined research criteria for the study of PMS. In 1994, the term "premenstrual dysphoric disorder" (PMDD) replaced this term in the 4th edition of the Diagnostic System Manual (DSM). It was listed in the section "Mood Disorder Not Otherwise Specified" and remained under consideration until the DSM-5, in which it appeared in the depressive disorders section. The legitimisation of the psychiatric diagnosis as well as the determination of clear symptomatology criteria in 2013 opened up possibilities for management, development of clinical, pathophysiological, therapeutic and psychotherapeutic studies. This disabling disorder can affect personal, social, family and professional life. In 2019, the ICD-11 in turn introduced the diagnosis of premenstrual dysphoric disorder, which solidifies the recognition of the disorder.

OBJECTIVE

(I) to review the existing treatments, both medicinal and psychotherapeutic, and (II) to review their effectiveness. At the end of this work we will formulate recommendations for the management of these patients.

METHODOLOGY

A bibliographic search was carried out from 7 June 2021 to 7 July2021 on the databases (bases de données) Psychinfo APA, Scopus, PubMed, as well as the bases de données of the Cochrane organisation and the recommendation documents of the Haute Autorité de la santé. After an initial selection based on keywords, the full text of all articles were read to arrive at the final selection of 32 articles.

RESULTS

Antidepressants and Cognitive Behavioural Therapies (CBT) appear to be the most commonly recommended treatments for PMDD. Other research shows the effectiveness of oral contraceptives including drospirenone. Selective serotonin reuptake inhibitors (SSRIs) were identified as an effective treatment for PMDD. These data are consistent with the current etiological hypothesis of PMDD which has a negative impact of natural hormonal fluctuations on certain neurotransmitters. CBT showed positive results in reducing the functional impact of PMDD.

DISCUSSION

Selective serotonin reuptake inhibitor (SSRI) antidepressants were reported to be first-line treatments for PMDD (sertraline 50-150 mg/d, fluoxetine 10-20 mg/d, escitalopram 10-20 mg/d, paroxetine 12.5-25 mg/d). Drospirenone (EE 3 mg and EE 20 mg/d 24 days of hormonal pills, 4 days inactive) appears to have been a first or second line treatment depending on the articles. Current results clearly point to the effectiveness of CBT in helping to reduce: functional impairment, depressed mood, feelings of hopelessness, anxiety, mood swings, sensitivity, irritability, insomnia, conflict with others, impact of premenstrual symptoms on daily life, intensity of symptoms experienced, and symptom handicap. CBTs could also become a first-line treatment if there were to be more evidence of their effectiveness. In the future, it would seem useful to offer a psychotherapeutic treatment that can be reproduced and to multiply research with a high level of scientific comparability in order to clarify the place of CBT in the management of PMDD. Research on the etiopathology of the disorder and the optimal drug regimen is still ongoing. There is a need to develop appropriate psychotherapeutic techniques to support and accompany these patients.

CONCLUSION

In order to better evaluate treatments for PMDD, there is a need to homogenise studies on the subject at several levels: design, treatment doses, psychotherapeutic techniques, and evaluation measures. At present, some studies include both premenstrual syndrome (PMS) and PMDD patients. PMS and PMDD do not include the same symptoms, nor the same severity and potentially the same aetiology in the patients studied. In order to propose rigorous research that evaluates the effectiveness of treatments for PMDD and to properly support people with both these disorders, it seems essential to distinguish the two conditions. The role of the health practitioner is to be able to identify PMDD by differentiating it from other clinically related disorders. The patient must then be accompanied to make a choice of treatment adapted to her symptoms, their severity, her history, her plans for procreation, contraindications and her preferences. In 2021, the French National Authority for Health did not offer any guidelines or recommendations for the management of premenstrual dysphoric disorder. There is a need to develop research in France.

[Update on targeted biopharmaceuticals in systemic sclerosis!]

Systemic sclerosis (SSc) is a rare connective tissue disease characterized by inflammation, fibrosis, and autoimmunity. Despite few clinical trials when compared to other autoimmune diseases, SSc has benefited from renewed interest over the past ten years and a large number of clinical trials have been performed or are underway. We present here the results of the trials published in the last 5 years in ScS according to the chosen endpoint criteria and describe the trials in progress or expected in the years to come.

[Early post-exposure and curative therapeutic strategies against COVID-19]

INTRODUCTION

There now exist preventive and curative treatments available for both early and advanced stages of COVID-19 management.

CURRENT KNOWLEDGE

Antibiotics have no place in the initial therapeutic management of Sars-Cov-2 pneumonia. On the other hand, corticosteroids are recommended for patients requiring oxygen therapy≥2L/min. According to the latest recommendations, nirmatrelvir/ritonavir is indicated as an early treatment for adults not requiring oxygen therapy but at high risk of developing a severe form of COVID-19. In case of contraindication, remdesivir is an alternative therapy.

PERSPECTIVES

Although there is no indication for convalescent plasma outside of clinical trials, it seems promising for immunocompromised patients, particularly those with B lymphopenia. It is noteworthy that currently, with the predominance of the Omicron XBB.1.5 variant, monoclonal antibodies are no longer recommended as therapy except for sotrovimab, which still has partial efficacy and could be considered after expert opinion as salvage therapy in a previously well-established program.

CONCLUSION

Despite the evolution of variants, antivirals still appear to have activity and remain the first-line treatment for patients, in addition to vaccination.

[Rare tumours of the breast]

Breast tumours are the most common tumours in women but represent a very heterogeneous group. On the one hand, there are ductal and lobular carcinomas of the breast, representing 90% of tumours, whose clinicopathologic characteristics are well known. On the other hand, there are rare breast tumours, each of which represents less than 1% that limits their study through large cohorts. The objective of this work was to collect, update and synthesize knowledge on these rare tumours. A literature review was performed on the Medline and Google Scholar databases. We present here a selection of several rare tumours, providing updated data at the epidemiological, histopathological, genetic, clinical and radiographic, prognostic and therapeutic levels, taking into account the place of radiotherapy. Each tumour histology is unique and has its own characteristics, the management must therefore be adapted as much as possible and decided in a multidisciplinary meeting.

[Scleritis and episcleritis]

Scleritis and episcleritis are rare ocular inflammatory diseases but deserve to be known by internists because of their frequent association with systemic autoimmune diseases. It is important to distinguish them between because their prognosis, therapeutic management and potential complications are very different. Episcleritis represents a superficial ocular inflammation with usually benign visual prognosis, no complication with local treatment, and is associated with a systemic autoimmune disease in rare cases. In contrast, scleritis is a potentially serious ophthalmological condition that can threaten the visual prognosis in the absence of appropriate systemic treatment. It is associated with an underlying disease in 40-50% of cases, in particular a systemic autoimmune disease (25-35% of cases) or an infectious cause (5-10% of cases). Rheumatoid arthritis and systemic vasculitides, particularly antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides, are the main autoimmune causes of scleritis and episcleritis. Scleritis can reveal the underlying autoimmune disease and requires systematic etiological investigations. Aggressive, complicated, refractory forms or those associated with a systemic autoimmune disease require glucocorticoids or even immunosuppressants, and close collaboration between ophthalmologists and internists is required. The development of biologic agents offers new effective therapeutic tools in the management of these difficult cases.

2022 Recommendations of the AFU Lithiasis Committee: Medical management - from diagnosis to treatment

The morphological-compositional analysis of urinary stones allows distinguishing schematically several situations: dietary, digestive, metabolic/hormonal, infectious and genetic problems. Blood and urine testing are recommended in the first instance to identify risk factors of urinary stone disease in order to avoid recurrence or progression. The other objective is to detect a potential underlying pathology associated with high risk of urinary stone disease (e.g. primary hyperparathyroidism, primary or enteric hyperoxaluria, cystinuria, distal renal tubular acidosis) that may require specific management. Lifestyle-diet measures are the basis of the management of all stone types, but pharmacological treatments may be required. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendation (CPR) method and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) [EAU 2022] and their adaptability to the French context.

[French recommendations for malignant pheochromocytomas and paragangliomas by the national ENDOCAN-COMETE network]

Pheochromocytomas and paragangliomas are rare neuroendocrine tumors, developed respectively in the adrenal medulla and in extra-adrenal locations. Their malignancy is defined by the presence of distant metastases. Forty percent of them are inherited and can be part of different hereditary syndromes. Their management is ensured in France by the multidisciplinary expert centers of the ENDOCAN-COMETE national network "Cancers of the Adrenal gland", certified by the National Cancer Institute and discussed within multidisciplinary team meetings. The diagnostic and therapeutic work-up must be standardized, based on an expert analysis of clinical symptoms, hormonal biological secretions, genetics, morphological and specific metabolic imaging. In the context of a heterogeneous survival sometimes beyond seven to ten years, therapeutic intervention must be justified. This is multidisciplinary and relies on surgery, interventional radiology, external or internal radiotherapy and medical treatments such as sunitinib or dacarbazine and temodal chemotherapy. The personalized approach based on functional imaging fixation status and genetics is progressing despite the extreme rarity of this disease.

[Well-differentiated neuroendocrine tumors of the digestive tract: Focus on pancreatic neuroendocrine tumors]

Pancreatic neuroendocrine tumors are rare tumors showing a rising incidence. They are well-differentiated tumors, classified by grade according to their Ki67 index value (grade 1 to 3). Pancreatic neuroendocrine tumors are mainly sporadic tumors but about 10% arise within endocrine tumor syndromes such as multiple endocrine neoplasia type 1. They can be responsible for functional syndromes or non-specific clinical symptoms depending on tumor extension. However, there is also an increase of incidental diagnoses of nonfunctional pancreatic neuroendocrine tumors with the widespread use of high-quality imaging techniques. About 50 % of pancreatic neuroendocrine tumors are diagnosed at a metastatic stage, with metastases often located in the liver. Chromogranin A, CT-scan and often an abdominal MRI, and functional imaging should be performed for tumor staging and follow-up. Imaging with PET/CT with 68Ga-labeled somatostatin analogues has the highest sensitivity for the diagnosis of pancreatic neuroendocrine tumors, while 18fluorodeoxyglucose PET/CT can sometimes be useful. Overall, they are rather indolent tumors with prolonged survival. Surgery is the recommended treatment in the localized setting, with the exception of small<2cm nonfunctional tumors that can be monitored with imaging techniques. For advanced tumors, there are several available treatments such as somatostatine analogues, chemotherapy, targeted therapies (sunitinib, everolimus), locoregional ablative therapies and Peptide Receptor Radiolabelled Therapy. The treatment strategy will depend on the initial tumor staging, tumor grade, aggressiveness and patient's choice.

French National Diagnostic and Care Protocol for antiphospholipid syndrome in adults and children

Antiphospholipid syndrome (APS) is a chronic autoimmune disease involving vascular thrombosis and/or obstetric morbidity and persistent antibodies to phospholipids or certain phospholipid-associated proteins. It is a rare condition in adults and even rarer in children. The diagnosis of APS can be facilitated by the use of classification criteria based on a combination of clinical and biological features. APS may be rapidly progressive with multiple, often synchronous thromboses, resulting in life-threatening multiple organ failure. This form is known as "catastrophic antiphospholipid syndrome" (CAPS). It may be primary or associated with systemic lupus erythematosus (associated APS) and in very rare cases with other systemic autoimmune diseases. General practitioners and paediatricians may encounter APS in patients with one or more vascular thromboses. Because APS is so rare and difficult to diagnosis (risk of overdiagnosis) any suspected case should be confirmed rapidly and sometimes urgently by an APS specialist. First-line treatment of thrombotic events in APS includes heparin followed by long-term anticoagulation with a VKA, usually warfarin. Except in the specific case of stroke, anticoagulants should be started as early as possible. Any temporary discontinuation of anticoagulants is associated with a high risk of thrombosis in APS. A reference/competence centre specialised in autoimmune diseases must be urgently consulted for the therapeutic management of CAPS.

French national diagnostic and care protocol for Sjögren's disease

Sjögren's disease (SD), also known as Sjögren's syndrome (SS) or Gougerot-Sjögren's syndrome in France, is a rare systemic autoimmune disease in its primary form and is characterised by tropism for the exocrine glandular epithelia, particularly the salivary and lacrimal glands. The lymphocytic infiltration of these epithelia will clinically translate into a dry syndrome which, associated with fatigue and pain, constitutes the symptom triad of the disease. In about one third of patients, SD is associated with systemic complications that can affect the joints, skin, lungs, kidneys, central or peripheral nervous system, and lymphoid organs with an increased risk of B-cell lymphoma. SD affects women more frequently than men (9/1). The peak frequency is around the age of 50. However, the disease can occur at any age, with paediatric forms occurring even though they remain rare. SD can occur alone or in association with other systemic autoimmune diseases. In its isolated or primary form, the prevalence of SD is estimated to be between 1 per 1000 and 1 per 10,000 inhabitants. The most recent classification criteria were developed in 2016 by EULAR and ACR. The course and prognosis of the disease are highly variable and depend on the presence of systemic involvement and the severity of the dryness of the eyes and mouth. The current approach is therefore to identify at an early stage those patients most at risk of systemic complications or lymphoma, who require close follow-up. On the other hand, regular monitoring of the ophthalmological damage and of the dental status should be ensured to reduce the consequences.

[Overview of care management principles in functional neurological disorders]

After more than twenty years of academic research on functional neurological disorders (FND) throughout the world, a standardized care management strategy has emerged to allow a more adapted care offer to patients with FND, as close as possible to their experience and their needs. With regard to this special issue on FND in collaboration with L'Encéphale and at the initiative of the Neuropsychiatry section of the AFPBN (French Association of Biological Psychiatry and Neuropsychopharmacology), we would like to suggest a summary of all topics discussed in more detail in each article of this special issue, in order to facilitate its reading. We therefore cover the following themes: the initial contact with a patient with FND, the diagnostic process in favor of a positive diagnosis, the physiological, neural and psychological basis of FND, the diagnostic announcement (and its intangibles), the therapeutic patient education in FND, the general principles of therapeutic management through a personalized and multidisciplinary care program, and the validated therapeutic tools available according to the symptoms identified. This article is designed to be of broad interest on FND, supported by tables and figures showing the key points of all these steps, to keep an educational purpose at most. We hope that through this special issue, each health professional will be able to grasp this knowledge and this framework of care as easily and quickly as possible, in order to participate in the standardization of the care offer.

[Validated care programs for patients with functional neurological disorders]

Functional neurological disorder (FND) is a common cause of persistent and disabling neurological symptoms. Diagnostic delay may lead to no treatment, inappropriate treatment or even iatrogenic symptoms. Yet, several treatments significantly reduce physical symptoms and improve functioning in FND patients even though not all patients respond to the currently available treatments. This review aims to describe the range of evidence-based rehabilitative and/or psychological therapeutic approaches available for FND patients. The most effective treatments are multidisciplinary and coordinated; using an outpatient or inpatient setting. Building a network of FND-trained healthcare professionals around the patient is an essential aspect of optimal patient management. Indeed, a supportive environment coupled with a collaborative therapeutic relationship improves understanding of FND and appears to help patients engage in appropriate treatments. Patients need to be invested in their own care and have to understand that recovery may depend on their commitment. The conventional treatment combines psychoeducation, physical rehabilitation and psychotherapy (cognitive and behavioral therapy, hypnosis, psychodynamic interpersonal therapy). Early referral of patients to physical therapy is recommended; however, the optimal parameters of treatment, duration and intensity are unknown and seem to vary with the severity and chronicity of symptoms. The goal is to minimize self-awareness by diverting attention or by stimulating automatically generated movements with non-specific and gradual exercises. The use of compensatory technical aids should be avoided as much as possible. Psychotherapeutic management should encourage self-evaluation of cognitive distortions, emotional reactions and maladaptive behaviors while empowering the patient in managing symptoms. Symptom management can use anchoring strategies to fight against dissociation. The aim is to connect to the immediate environment and to enrich one's sensoriality. The psychological interventions should then be adapted to the individual psychopathology, cognitive style and personality functioning of each patient. There is currently no known curative pharmacological treatment for FND. The pharmacological approach rather consists of progressively discontinuing medication that was introduced by default and that could lead to undesirable side effects. Finally, neurostimulation (transcranial magnetic stimulation, transcranial direct current stimulation) can be effective on motor FND.

French national diagnostic and care protocol for Kawasaki disease

Kawasaki disease (KD) is an acute vasculitis with a particular tropism for the coronary arteries. KD mainly affects male children between 6 months and 5 years of age. The diagnosis is clinical, based on the international American Heart Association criteria. It should be systematically considered in children with a fever, either of 5 days or more, or of 3 days if all other criteria are present. It is important to note that most children present with marked irritability and may have digestive signs. Although the biological inflammatory response is not specific, it is of great value for the diagnosis. Because of the difficulty of recognising incomplete or atypical forms of KD, and the need for urgent treatment, the child should be referred to a paediatric hospital as soon as the diagnosis is suspected. In the event of signs of heart failure (pallor, tachycardia, polypnea, sweating, hepatomegaly, unstable blood pressure), medical transfer to an intensive care unit (ICU) is essential. The standard treatment is an infusion of IVIG combined with aspirin (before 10 days of fever, and for a minimum of 6 weeks), which reduces the risk of coronary aneurysms. In case of coronary involvement, antiplatelet therapy can be maintained for life. In case of a giant aneurysm, anticoagulant treatment is added to the antiplatelet agent. The prognosis of KD is generally good and most children recover without sequelae. The prognosis in children with initial coronary involvement depends on the progression of the cardiac anomalies, which are monitored during careful specialised cardiological follow-up.

[Guidelines of the French National ENDOCAN-COMETE, Association of Endocrine Surgery, Society of Urology for the management of adrenocortical carcinoma]

The adrenocortical carcinoma (ACC) is a primary malignant tumor developed from the adrenal cortex, defined by a Weiss score≥3. Its prognosis is poor and depends mainly on the stage of the disease at diagnosis. Care is organized in France by the multidisciplinary expert centers of the national ENDOCAN-COMETE "Adrenal Cancers" network, certified by the National Cancer Institute. This document updates the guidelines for the management of ACC in adults based on the most robust data in the literature. It's divided into 11 chapters: (1) circumstances of discovery; (2) pre-therapeutic assessment; (3) diagnosis of ACC; (4) oncogenetics; (5) prognostic classifications; (6) treatment of hormonal hypersecretion; (7) treatment of localized forms; (8) treatment of relapses; (9) treatment of advanced forms; (10) follow-up; (11) the particular case of ACC and pregnancy. R0 resection of all localized ACC remains an unmet need and it must be performed in expert centers. Flow-charts for the therapeutic management of localized ACC, relapse or advanced ACC are provided. It was written by the experts from the national ENDOCAN-COMETE network and validated by all French Societies involved in the management of these patients (endocrinology, medical oncology, endocrine surgery, urology, pathology, genetics, nuclear medicine, radiology, interventional radiology).

[Neurological involvement of sarcoidosis: current diagnostic and therapeutic strategies]

Neurosarcoidosis (NS) is a rare but severe form of sarcoidosis. NS is associated with significant morbidity and mortality. Mortality is about 10% at 10 years with more than 30% of patients who have a significant disability. The most frequent features are cranial neuropathy (the facial and optic nerve most commonly affected), cranial parenchymal lesions, meningitis, spinal corn abnormalities (20-30%) and more rarely peripheral neuropathy (approximately 10-15%). The challenge of diagnosis is to eliminate other diagnoses. Atypical presentations should make to discuss the need for cerebral biopsy in order to highlight the presence of granulomatous lesions while eliminating alternative diagnosis. Therapeutic management is based on corticosteroid therapy and immunomodulators. There are no comparative prospective study to allow us to define the first-line immunosuppressive treatment and the therapeutic strategy in refractory patients. Conventional immunosuppressants such as methotrexate, mycophenolate mofetil and cyclophosphamide are commonly used. Data on the efficacy of anti-TNFα (including infliximab) in refractory and/or severe forms are increasing during the last ten years. Additional data is necessary to assess their interest in first line in patients with severe involvement and a significant risk of relapse.

[Latest updates on immunotactoid glomerulopathy and fibrillary glomerulonephritis]

Various hematologic malignancies can lead to renal complications. The most common of these hemopathies to affect the kidney is multiple myeloma, however an increasing number of kidney diseases are associated with other monoclonal gammopathies. It is recognized that clones in small abundance can be responsible for severe organ damage, thus the concept of monoclonal gammopathy of renal significance (MGRS) has emerged. Although the hemopathy in these patients is more consistent with monoclonal gammopathy of undetermined significance (MGUS) than with multiple myeloma, the diagnosis of a renal complication changes the therapeutic management. Preservation and restoration of renal function is possible with treatment targeting the responsible clone. In this article, we take as an example immunotactoid and fibrillary glomerulopathies, two distinct entities with different etiologies and consequently different management. Immunotactoid glomerulopathy is most often associated with monoclonal gammopathy or chronic lymphocytic leukemia, the deposits on renal biopsy are monotypic, and treatment is therefore based on clone targeting. Fibrillary glomerulonephritis, on the other hand, is caused by autoimmune diseases or solid cancers. Deposits on renal biopsy are in the vast majority polyclonal. There is a specific immunohistochemical marker, DNAJB9, and treatment is less well established.

Preliminary study of elastic-tension digital neoprene orthoses for proximal interphalangeal joint flexion contracture

Flexion contracture of the proximal interphalangeal joint (PIPJ) is one of the most frequent complications in finger trauma. Orthoses are the most widely used method to optimize total end-range time (TERT). No previous studies showed that an elastic tension orthosis could be applied for longer than 12 h. We aimed to demonstrate that the elastic-tension digital neoprene orthosis (ETDNO) can achieve higher TERT and therefore better range of motion than other elastic-tension orthoses (ETO) described in the literature. A prospective study of treatment of PIPJ flexion contracture included 10 PIP joints in 8 patients who met the selection criteria. They were instructed to use the ETDNO for around 23 h per day as far as possible, during a period of 3 weeks. Patients reported a mean TERT of 20.6 h a day. PIPJ contracture improved by a mean Torque Range of Motion (TROM) of 23.5° at 500 g and 22.9° at 800 g of passive extension force during the 3-week treatment. Based on the results of this study, the ETDNO appears to offer a highly effective approach for improving PIPJ flexion contracture, increasing range of motion in extension. ETDNO's efficacy probably lies in the significantly improved comfort and low-profile design, enabling excellent compliance and thus optimizing TERT. LEVEL OF EVIDENCE: Level III.

[Ocular surface disease in glaucoma patients: Expert opinion and management algorithm in Algeria]

INTRODUCTION

The main goal of treatment for any glaucoma patient is to reduce the intraocular pressure. Unfortunately, the long-term use of glaucoma medications causes deleterious effects on the ocular surface, leading to impaired quality of life and failed glaucoma surgery. In addition, adverse effects of medications are a barrier to adherence and compliance, and this directly affects efficacy. It is therefore essential to regularly assess the ocular surface of glaucoma patients in order to detect any signs of damage early and act accordingly. Although the TFOS DEWS 2 now offers a strategy for diagnosing ocular surface pathologies, some examinations are unfortunately not feasible in Algeria due to lack of time and/or knowledge on the part of some ophthalmologists or are simply inaccessible to others.

METHODS

Algerian experts (members of the ACOS club) met for the purpose of proposing an algorithm for the management of Algerian glaucoma patients, based on the recommendations of the DEWS, their own practice and the results of a preliminary national survey of ophthalmologists.

RESULTS

The proposed algorithm allows evaluation of the ocular surface of the glaucoma patient in current practice by any Algerian ophthalmologist.

CONCLUSION

Management of glaucoma patients should include a systematic examination of the ocular surface. The choice of treatment should be determined by the ocular surface condition of the glaucoma patient.

[Treatment Results Of Diaphyseal Humerus Open Fractures In Adult: Study Of 16 Cases]

AIM

To evaluate the initial results of our different treatments of open humeral shaft fractures.

METHOD

This was a retrospective study conductecd in Abidjan (Ivory Coast) over a period of 10 years, involving 16 open humeral shaft fractures. It included 10 men and six women with a mean age of 32.8 years (Extremes: 21 and 61). The skin opening was classified according to Cauchoix and Duparc. Fractures were either treated by trimming followed by a brachial-ante-brachial cast, or treated with a screwed plate or external fixator. Patients were followed according to a strict protocol. Overall results were assessed by Stewart and hundley functional scoring.

RESULTS

At a minimum follow-up of 24 months, all patients had consolidated. There was one case of local infection, three cases of elbow stiffness and four reversible cases of radial nerve palsy. The functional results according to the Stewart and Hundley score were very good in 11 cases, good in four cases and fair in one case, with no poor result.

CONCLUSION

Depending on the therapeutic indications, the initial results are satisfactory both clinically and functionally.

Approche thérapeutique des maladies de Castleman : l’émergence des thérapies ciblées

The spectrum of Castleman disease encompasses several different disorders. Nowadays three different forms of the disease are individualized: unicentric Castleman disease, multicentric HHV-8 associated Castleman disease and idiopathic multicentric Castleman disease. In the latter a severe form called TAFRO syndrome (thrombocytopenia, anasarca, myelofibrosis, renal dysfunction, and organomegaly) tend to be individualized. Improvement in the classification and understanding of the physiopathology of CD have allowed improvement in treatment strategies. Treatment of rare but often severe manifestations, such as paraneoplastic pemphigus and bronchiolitis obliterans in unicentric CD and hemophagocytic syndrome and/or Kaposi' sarcoma in HHV8 associated CD, are better adapted. Most of current treatment strategies are based on retrospective and very few prospective studies. Both anti-IL6/6R and anti-CD20 biotherapies have greatly improved the management of certain forms of the disease. We report in this review the most relevant studies and national or international expert consensus statements for the treatment in the different types of CD. © 2022 Published by Elsevier Masson SAS on behalf of Société nationale française de médecine interne (SNFMI).

[Cardiac amyloidosis: State of art in 2022]

The 3 main types of cardiac amyloidosis are linked to two protein precursors: AL amyloidosis secondary to free light chain deposits in the context of monoclonal gammopathy (mainly of undetermined significance or myeloma) and transthyretin amyloidosis (ATTR), comprising wild-type transthyretin amyloidosis (ATTRwt for wild type) and hereditary transthyretin amyloidosis (ATTRv for variant). These diseases are underdiagnosed and highly prevalent in common cardiac phenotypes in recent studies (heart failure with preserved ejection fraction, severe aortic stenosis, hypertrophic cardiomyopathy). Myocardial amyloid infiltration affects all cardiac structures and clinically promotes predominantly heart failure, conductive disorders and cardioembolic events. The search for extracardiac signs makes it possible to arouse diagnostic suspicion. Electrocardiogram, echocardiography and cardiac MRI can suspect cardiac amyloidosis. The diagnostic confirmation follows a simple algorithm including a systematic search for monoclonal gammapathy and a disphosphonate scintigraphy. Histological proof is necessary in case of AL or ATTR amyloidosis with concomitant monoclonal gammopathy in order to initiate specific treatment. Due to the late disease onset in ATTRv, genetic testing must be routine in all cases of ATTR. These diseases are no longer perceived as incurable since recent therapeutic innovations. A better knowledge of the disease is more than ever necessary.

[Uremic calciphylaxis]

Uremic calciphylaxis is a rare disease that affects patients with chronic end-stage renal disease. It is a pathology of the microvessels of the dermis and hypodermis which are calcified and whose thrombosis leads to skin necrosis. Calciphylaxis lesions can be distal and axial. They lead to pain, infection and are associated with denutrition and in high mortality rate (40-80% at 1 year). This general review describes the clinical and para-clinical presentations of calciphylaxis. It summarizes the current knowledge on its pathogenesis and the therapeutical options that can be proposed to improve the management and attempt to reduce the mortality of patients with uremic calciphylaxis.

Carpal tunnel syndrome: Does preoperative disease severity influence the outcome of mini-open surgery?

In the practice of carpal tunnel surgery, open decompression of the median nerve in carpal tunnel syndrome (CTS) is recognized as the therapeutic priority. However, the speed and completeness of postoperative recovery of sensitivity and function depend on the initial clinical manifestations of the disease and the severity of the electrophysiological disorder. The aim of this study was to investigate the influence of preoperative clinical and electrophysiological factors on the outcome of surgical treatment of patients with CTS of varying severity. One-hundred and eighty-nine open decompressions of the median nerve via a mini-open incision were performed in 161 patients with idiopathic CTS. Clinical observations were classified in 5 groups, according to severity. Treatment results were evaluated per group at 6 weeks and 3, 6 and 12 months after surgery. In all cases, there was improvement and positive dynamics according to clinical and electroneuromyographic data. Open decompression of the median nerve via mini-open incision can achieve significant clinical and functional improvement in the majority of patients with CTS. However, the most favorable results were mainly seen in patients with initial severity classified in the first, second and third (lower severity) groups.

[Management of women with abnormal uterine bleeding: Clinical practice guidelines of the French National College of Gynecologists and Obstetricians (CNGOF)]

OBJECTIVE

To provide French guidelines for the management of women with abnormal uterine bleeding (AUB).

DESIGN

A consensus committee of 26 experts was formed. A formal conflict-of-interest (COI) policy was developed at the beginning of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, or medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.

METHODS

The last guidelines from the Collège national des gynécologues et obstétriciens français (CNGOF) on the management of women with AUB was published in 2008. The literature seems now sufficient for an update. The committee studied questions within 7 fields (diagnosis; adolescent; idiopathic AUB; endometrial hyperplasia and polyps; fibroids type 0 to 2; fibroids type 3 and more; adenomyosis). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 36 recommendations. Among the formalized recommendations, 19 present a strong agreement and 17 a weak agreement. Fourteen questions did not find any response in the literature. We preferred to abstain from recommending instead of providing expert advice.

CONCLUSIONS

The 36 recommendations made it possible to specify the diagnostic and therapeutic strategies of various clinical situations managed by the practitioner, from the simplest to the most complex.

[Spontaneous pneumomediastinum]

INTRODUCTION

Pneumomediastinum, which can be spontaneous or secondary, is defined by the presence of free air in the mediastinum as shown on a chest X-ray and/or chest CT, with or without subcutaneous emphysema. Secondary pneumomediastinum develops in various contexts (thoracic traumatism, perforation of central airway or digestive tract, pneumothorax, barotraumatism complicating mechanical ventilation…). Spontaneous pneumomediastinum , which will be the focus of this review, develops without any of the above-mentioned conditions.

STATE OF ART

Spontaneous pneumomediastinum is a rare entity which usually occurs in young people either without medical history or with an history of asthma. A trigger event is detected in 40% to 60% of cases. Positive diagnosis is made on chest radiographt but thoracic CT is more sensitive. Distinction between spontaneous pneumomediastinum and secondary pneumomediastinum is in general easy but may sometimes be more difficult, particularly in case of oesophageal perforation. The evolution of spontaneous pneumomediastinum is most often benign but, rare complications may occur. Management is most often conservative.

PERSPECTIVES

There is no consensual management of spontaneous pneumediastinum because of the lack of randomized prospective studies. This may be explained by the rarity of the disease. The actual trend is to offer to the patients a conservative treatment, which could be ambulatory in some cases.

CONCLUSIONS

Spontaneous pneumomediastinum is a rare entity developing mainly in young subjects. The evolution is in general benign, justifying a conservative approach.

[D-CBP study: Evaluation of lung cancer management times]

INTRODUCTION

Lung cancer is the leading cause of cancer-related death. Delays may have an impact on patient survival. The objective of this study was to evaluate the diagnostic and therapeutic management times for patients admitted for lung cancer treatment in the Respiratory Department of CHU de Caen Normandie.

MATERIALS AND METHODS

This is a retrospective, single-center and observational study, conducted on all patients treated for lung cancer from June 2017 to January 2018 in our department of pneumology in the Caen Normandie CHU. The main median times were investigated were: Global Time (abnormal imaging-treatment), Diagnosis time (abnormal imaging-diagnosis) and Treatment Time (diagnosis-treatment).

RESULTS

One hundred and twenty-seven (127) patients were included. Median global time was 55.5 days [31,25; 393], median diagnosis time was 22 days [13; 49], and median treatment time was 24.5 days [12,25; 45].

DISCUSSION

Our treatment times are consistent with those previously published. Areas for improvement are being developed in accordance with the 2014-2019 cancer plan, in particularly the creation in our institution of a specific care pathway for patients with lung cancer.

[Radiation-induced sexual toxicity]

Oncosexuality has recently become a new supportive care mission. Sexual morbidity is, routinely, underestimated and must be questioned. We report here the most frequent disorders for men and for women, how to prevent them and how to treat them.

[Diversity of hospital care for anorexia nervosa in psychiatry in France]

BACKGROUND

Hospitalization is rare in anorexia nervosa (AN) and local application of indications is heterogeneous. However, no study has evaluated the effect of these different treatment modalities on the mean length of stay. Our objective was to describe the context and modalities of a wide range of hospital care programs offered to patients with anorexia nervosa in eleven specialized French psychiatric centers for patients from childhood to adulthood. This work was carried out within the framework of the EVHAN (Evaluation of Hospitalization for AN, Eudract number: 2007-A01110-53, registered in Clinical trials) research program. The EVHAN program comprises five main lines: weight objectives at discharge, the practice or not of a separation period, the use of clear nutritional dietary objectives (cognitive/behavioral), the intensity of family involvement in treatment, and the existence or absence of a stabilization phase before ending inpatient treatment. These main lines will make it possible to study the impact of treatment modalities on the future of patients in the short and medium term (at discharge and at 1-year follow-up).

METHODS

The eleven centers are located in France (Bordeaux, Nantes, Paris and Ile-de-France, Rouen and Saint-Étienne). Various staff members (psychiatrists, somatic doctors, nurses, dieticians, psychologists) from each center were interviewed using a semi-structured questionnaire. Data on operating modalities and context of care were collected and analyzed.

RESULTS

Four of the eleven centers were exclusively child/adolescent centers, and seven of 11 were adolescent (from 11, 13 or 16 years) and young adult centers. All centers offered a graduated approach from outpatient to full hospitalization. The majority had a number of beds allocated for patients with eating disorders. The criteria for hospitalization were homogeneous with respect to somatic and/or psychic severity prefiguring the consensus criteria defined by the French Health Authority (HAS) in 2010. Child/adolescent units used the weight curve to set weight objectives at discharge (between the 10th and 50th percentiles). Most adult units used weight objectives at discharge corresponding to a body mass index between 17 and 20kg/m². Nine centers used a written or oral care contract. One unit did not separate the patient from her/his usual environment, the others had a practice gradient of partial separation and total separation times. These were either short, lasting a maximum of 3 weeks, or long, lasting more than 3 weeks. Conversely, patients were not isolated within the unit, and benefited from a rich social life, depending on her/his physical condition. The patient's family was in contact with the team and fully supported. The longest periods of separation involved adolescents and adults. Nutritional support varied from a group approach (meals in the dining room, standardized meals of the care center) to very individualized approaches within a specific framework. All the units reported meeting with families at least once during the hospitalization; with the patient's parents for child/adolescent patients and/or unmarried patients and with the husband/wife for married patients. The majority of the centers requested a phase of weight stabilization, whatever the age before hospital discharge.

CONCLUSION

There is international and national consensus regarding the indications for hospitalization, and the main lines of multidisciplinary care to be developed within this framework. However, local application of these indications was heterogeneous resulting in diverse modalities of hospital care for anorexia nervosa in France. Specialized teams have developed management strategies arising from their "team culture". The complexity of the anorexic pathology, due to the psyche-soma intrication and the diversity of age groups, highlights the complexity of care available. The impact of this diversity of hospital care on patient outcomes will be studied as a result of this work.

[Renal involvement in sarcoidosis: Prognostic and predictive factors]

INTRODUCTION

Sarcoidosis is a systemic granulomatous disease that primarily affects the respiratory system and lymphatic vessels. Renal involvement is rare, poorly studied and found in less than 10% of cases. The objective of our study was to identify factors of poor renal prognosis and predictive factors of renal involvement during sarcoidosis.

METHODS

It's a retrospective study including patients hospitalized in our department for sarcoidosis with renal involvement over a period of 40 years. To study renal survival, we identified two groups of patients with renal manifestations of sarcoidosis by following their evolution: group A (n=26) represents those with renal remission or deterioration of renal function but without progression to end-stage renal disease and group B (n=8) those with progression to end-stage renal disease. To detect the predictive factors of end-stage renal disease in patients with sarcoidosis, we compared the clinical and paraclinical characteristics of our patients (group 1) to those of 44 patients with sarcoidosis without renal impairment followed in our department during the same period (group 2).

RESULTS

Renal involvement was observed in 34 patients hospitalized for sarcoidosis (43.6%). There were 28 women and 6 men with a sex ratio of 0,21. The mean age at diagnosis of sarcoidosis was 47.1 years. The median time from sarcoidosis diagnosis to renal disease was 2 months (range 1-72). Tubulointerstitial nephropathy was the most frequent renal manifestation observed in 24 patients (70.6%). Hypercalcemia and hypercalciuria were found in 52.9% and 46.4% respectively. Renal failure was noted in 25 patients (73.5%). Corticosteroid therapy was initiated in 33 patients (97%) associated with immunosuppressive therapy in 3 cases. Predictive factors of end-stage renal disease were advanced age at diagnosis of nephropathy (P=0.007), comorbidities (P=0.002), multi-organ involvement (P=0.041), initial renal failure (P=0.013), interstitial fibrosis (P=0.006) and renal granulomas (P=0.007). Predictive factors of renal impairment during sarcoidosis were multi-organ involvement, inflammatory syndrome and hypercalcemia.

CONCLUSION

Renal envolvement, although rare during sarcoidosis, can influence the prognosis hence the great interest of its early detection to prevent progression to end-stage renal failure.

Vesico-vaginal fistula in Tunisia: Epidemiology and risk factors of treatment failure

INTRODUCTION

Vesico-vaginal fistula (VVF) is a global healthcare problem that has a high prevalence in developing countries. The aim of this work is to study the epidemiological, clinical and therapeutic characteristics of VVF post-obstetric and gynecologic procedures in order to identify the predictive factors of surgical treatment failure.

METHODS

Data were collected from 132 VVF patients in our institution between 1985 and 2017. VVF was classified according to Zmerli's classification. Patients underwent surgical treatment and were evaluated after a follow-up period of 6 months. Successful treatment was defined as the absence of urine leakage whereas recurrence was defined as the presence of urine leakage immediately after the surgery or after a period of dryness with a confirmed VVF. Risk factors of surgical treatment failure were identified.

RESULTS

The average age of patients was 44 years. The patients were multiparous in 62% of cases. VVF was consecutive to hysterectomy in 62.1% of cases, and after childbirth in 34%. VVF was retro-trigonal in 99 cases (75%) and trigonal in 33 cases (25%). The average size of the fistula was 1cm (0.3-2cm). VVF repair was performed by vaginal approach in 68% of cases and abdominal approach in 32% of cases. Treatment failure was noted in 36 patients (27%). Predictive factors of treatment failure were: vaginal fibrosis (P<0.001); trigonal location of the fistula (P<0.001); large diameter of the VVF>1cm (P<0.001); and complex and complicated fistulas (P=0.02).

CONCLUSION

Although Tunisia is a developing country, the main cause of VVF was not obstetrical. Treatment failure, noted in almost one third of cases, was, in our series, correlated with the quality of the vaginal tissue, the size and the location of the fistula, and its complexity.

LEVEL OF PROOF

4.

[Oral chemotherapy (sonigegib) of extensive basal cell carcinoma, about 4 cases]

Basal cell carcinoma (BCC) is the most frequent cutaneous carcinoma. Its incidence is constantly increasing, primarily due to sun exposure during the two first decades of life. The lower lid and medial canthus are the most common locations. In the majority of cases, surgery with sufficient margins is the first-line treatment. In the case of inoperable tumors (extensive lesions, poor general health, high surgical morbidity, unacceptable cosmetic sequelae), oral chemotherapy can be suggested. We report the follow-up of 4 patients with advanced non-metastatic basal cell carcinoma (BCC) treated with oral chemotherapy (sonigegib). All patients were female with a mean age of 80years. The first patient had an infiltrative BCC of the right lower lid with orbital invasion, the second a nodular BCC of the right inferior lid with massive cutaneous and orbital invasion extending to the controlateral medial canthal angle, the third an advanced infiltrative BCC invading both orbits and nasal cavities, and the fourth, an infiltrative BCC with extension to the ipsilateral skin of the face. The diagnosis of BCC was confirmed by multiple biopsies in our four patients prior to starting chemotherapy. Because of the locally advanced lesions, surgery was contraindicated in all cases, chemotherapy was undertaken (sonidegib 200mg daily), and ophthalmological and dermatological examinations were performed every 3months. In all 4 patients, the outcome was very favorable, with one clear regression in tumor size and infiltration and 3 partial regressions. Many side effects were noted, including nausea, muscle cramping, dysgeusia resulting in significant weight loss, and malnutrition in the elderly patients. The treatment had to be discontinued after 11months in the patient with total macroscopic regression because of major side effects. The treatment is still underway for the other patients and will be continued as long as a clinical benefit is observed. The treatment will be discontinued if intolerable side effects develop. Oral chemotherapy (sonidegib) is an effective alternative treatment when surgery cannot be realized, especially in the case of extensive infiltrative non-metastatic BCC.

Relationship between OSDI score and biomicroscopic ocular surface damages in glaucomatous patients treated with preserved antiglaucomatous eye drops

PURPOSE

Our goal was to identify factors that may influence the OSDI score, in particular, ocular surface damage in patients on preserved glaucoma eye drops.

METHODS

This was a cross-sectional study of 155 glaucoma patients treated with preserved glaucoma eye drops. They all completed the "Ocular Surface Disease Index" (OSDI) questionnaire and underwent complete ophthalmological examination with precise evaluation of the status of the ocular surface. The assessment included Shirmer I testing, tear break up time (TBUT), eyelid, conjunctival and corneal examination with fluorescein and lissamine green staining. We analyzed factors that may influence the OSDI score and its relationship with the biomicroscopic signs.

RESULTS

Benzalkonium chloride (BAK) was used in 80% of cases. The OSDI score was≥13 in 61.3% of cases and classified as severe in 22.6% of cases. The biomicroscopic signs of ocular surface disease were at least minimal in 87.1% of cases. The severity of the OSDI score was statistically associated with patient age (P<0.001), treatment duration (P<0.001), multiple medications (P=0.011), and use of BAK (P=0.004). Blepharitis (P=0.013), Meibomian gland dysfunction (P=0.039), corneal neovascularization (P=0.025) and superficial punctate keratitis (SPK) (P=0.044) were retained as predictors of a pathological OSDI score. A disparity between the severity of symptoms and biomicroscopic signs was noted.

CONCLUSION

Symptoms and clinical signs are complementary for assessment of the various aspects of ocular surface disease. OSDI score is correlated with ethnicity, glaucoma treatment duration, number of medications, BAK use and clinical ocular surface changes, especially SPK.

[Meningiomas: A review of current knowledge]

Meningiomas are the most frequent among intracranial tumors, and represent more than 30% of primitive central nervous system neoplasms. Arising from the meninges, they are generally benign lesions and can be treated by either radio-clinical follow-up or surgical resection with excellent outcome. However, more than 20% of meningiomas harbor atypical or malignant features and represent challenges for both prognostic evaluation and therapeutic strategy. The discovery of the genetic and epigenetic landscapes of meningiomas enabled the identification of new prognostic markers and potential therapeutic targets for refractory meningiomas. This review summarizes current epidemiology, histological and molecular characteristics, diagnosis and treatments for meningiomas, and highlights the close relationship between the development of meningiomas and hormonal intake, as illustrated by recent recommendations of the "Agence Nationale de Securité du Medicament", the French national drug safety agency.

[Treatments for depression in consultation-liaison psychiatry: From theory to practice]

Treatments for depression include an adapted lifestyle, physical activity, psychotherapies, antidepressant and mood stabilizing drugs, neuromodulation, chronotherapy, spa treatments. Drug treatments used for major depressive episode are antidepressants and mood stabilizers. For a mild episode, psychotherapy is indicated. It should be combined with an antidepressant (serotonin reuptake inhibitor) for moderate and severe episodes. Suicide risk assessment is essential throughout the depressive episode. It is recommended to monitor at the start of antidepressant treatment for suicidal behavior, a change in mood suggesting an underlying bipolar disorder. The effectiveness of the treatment is evaluated after 4 to 8 weeks. The total duration of antidepressant treatment for an EDC is between 6 months and 1 year after remission, in order to prevent relapses. The use of liaison psychiatry, a real healthcare system within the general hospital, is strongly recommended for better screening and treatment of depression, thus reducing the length of hospital stays, improving the prognosis of depression. The aim of this article is to provide clinicians with a summary of validated data on the efficacy/tolerance of treatment for depression, and to suggest practical action to be taken on the main daily clinical situations: treating comorbid conditions, taking into account interactions drugs, manage the serotonin syndrome, lead to withdrawal from antidepressants, manage treatment in the elderly.

Functional and/or hygienic surgery of the hypertonic upper limb

Neuro-orthopedic complications of the upper limb affect all of its joints and lead to a multitude of clinical pictures. The clinical assessment, which should be multidisciplinary, will have to answer basic questions to define the goal(s) and the appropriate surgical strategy. What is the patient's and family's complaint? What is the possible utility of the deformities? What is the type of deformity? Is it reducible or not? What is the contribution of the upper limb deformities versus that of any associated injuries to the discomfort? Several difficulties exist in the clinical assessment: evaluation of the antagonists especially the wrist extensor muscles; the intrinsic deformity component, which can be masked by the extrinsic component when retracted, the muscles responsible for a wrist flexion contracture and the complex shoulder deformities. Many patients have multiple deformities, which creates a problem for the hierarchy of corrections depending on the objectives. The answer to these questions helps to define a clear objective that will be formalized in a contract with the patient and subsequently to define the surgical strategy. Surgery is based on a simple principle: relax the muscles on the side of the deformity, either by selective neurotomy if there is a simple hypertonia, or by a tendon procedure if the muscle is retracted; compensate for the antagonists if they are deficient, and potentially stabilize the joint. Conservative procedures are preferred to preserve the possibility of functional recovery in the future. The wide range of medical and surgical solutions allows the patient's care to be personalized. In the upper limb, the results are better for hygienic, positioning, and analgesic objectives. They remain more difficult to obtain for functional objectives, due to the biomechanical complexity of gripping.

[Treatment of exudative age-related macular degeneration: Consensus of French experts for first-line treatment selection and the importance of long-term risk/benefit ratio]

Choosing a first-line treatment to optimize long-term outcomes is a major challenge for treating patients with neovascular age-related macular degeneration (AMD). The development of several new molecules makes it critical to identify the relevant factors to consider so as to provide an optimal risk-benefit ratio when initiating a treatment in naïve patients with neovascular AMD. This paper proposes a consensus established with the Delphi method (which includes a gradation in a consensus based on an analysis of the convergence rate of answers) to provide criteria that guide the ophthalmologist's decision for treatment initiation and follow-up in neovascular AMD patients. Fourteen questions were submitted to 93 French retina experts. Thirteen (93%) of the questions reached a consensus (≥50% of answers consensual). The criteria recommended to take into account were both efficacy and onset of action of the molecules, their safety, and the ability to decrease injection frequency. The primary criterion of expected efficacy of a molecule is a combination of the gain in visual acuity and resorption of retinal fluid. With regard to safety, experts recommend tighter follow-up for molecules currently in development, and at every scheduled visit, patients should be screened to identify early any potential adverse effects such as intraocular inflammation, retinal vasculitis or vascular occlusion. Experts also emphasize the importance of the packaging of the biological, with a preference toward prefilled syringes. Injection frequency is a key factor, and the authors recommended aiming for a maximal injection interval of 12 to 16 weeks. The stability of that maximum interval is also an important factor to consider in treatment selection.

[Cesarean scare niche: Definition, diagnosis, risk factors, prevention, symptoms, adverse effects, and treatments]

OBJECTIVES

To review the definitions, diagnostic methods, risk factors, symptoms, and treatments for caesarean scar niche.

METHODS

Review of the literature, critical reflection, and pragmatic advice.

RESULTS

There is no consensus on the definition of caesarean scar niche. Some suggest an indentation≥2mm of the myometrium of the caesarean scar, but this is present in more than half of women with caesarean history and takes no account of woman's symptoms. The most popular diagnostic method is ultrasound±hysterosonography. Risks factors for niche are multiple Caesareans, Cesarean during labor with too low incision, and retroverted uterus. Symptoms include abnormal gynaecologic bleeding and pelvic pain, and their presence establish the "Caesarean scar syndrome". The risks of pregnancy with niche is poorly studied, but pregnancy is not contraindicated, even if the niche is untreated. The treatment of caesarean scar niche is mainly surgery and conservative. The former should be reserved for symptomatic patients, and those with secondary infertility and fertility treatment failure. Patients with residual myometrium thickness≥2.5mm may benefit from first-line hysteroscopic treatment, whereas a laparoscopic or vaginal approach could be offered in other cases.

CONCLUSIONS

A pragmatic definition of caesarean scar niche as a disease including symptoms is the necessary prerequisite for the management of women. The treatment is mainly surgical, or conservative depending on the desire for subsequent pregnancy.

[SARS-CoV-2 infection: Available data on 15th April 2021]

INTRODUCTION

Since January 2020, when the first cases of SARS-CoV-2 infection were diagnosed in France, pulmonologists have been at the heart of the crisis and should be responsible for the management of acute COVID-19 (and any possible sequelae) BACKGROUND: Many drugs have been evaluated or are currently under evaluation as possible specific treatment for SARS-CoV-2. Nevertheless, as of April 15, 2021, the only recommended treatment in current practice is the "standard of care", i.e. the symptomatic management of infection with SARS-CoV-2. This review presents the state of knowledge on COVID-19 in the acute phase (virological, immunological, epidemiological and therapeutic data) available on 15th April, 2021.

OUTLOOK

A large number of clinical trials are currently ongoing. It is important to propose to patients the opportunity to participate in clinical trials and to structure the research in order to complete the studies.

CONCLUSION

Current management is based on oxygen therapy, thromboprophylaxis and in some cases corticosteroids. No antiviral therapy is currently recommended. These data are constantly evolving.

[Breast cancer-related thrombotic microangiopathy: A review]

Thrombotic Microangiopathies (TM) have been described since the 1960s. They are characterized by presence of mechanical haemolytic anemia associated with peripheral thrombocytopenia. TM in cancer can be related to several causes, whose cancer himself: cancer-related microangiopathic haemolytic anaemia (MAHA). Incidence of cancer related MAHA remains unknown. Cancer-related MAHA are mainly observed in mucin-producer adenocarcinomas, such as gastric (half of reported cases) and breast cancer. We conducted a review of all original published cases of TM reported in breast cancer, and we specifically investigated BC-MAHA cases. A Medline search identified 158 MAHA cases including 118 BC-MAHA, and 40 drug-related MAHA. Most of BC-MAHA occur in disseminated cancers, mainly with medullar involvement, and/or bone metastasis. Patients typically suffer from poor general state, bone pain, and/or dyspnea. Laboratory abnormalities such as myelemia or erythromyelemia in peripheral blood are frequently observed. Incidence of coagulation disorders is increased, compared to other MAHA causes. BC-MAHA prognosis is dramatically poor. Treatments classically used in other MAHA causes, such as plasmapheresis or immunoglobulins, are inefficient. Urgent anti-neoplastic therapy may be the only effective treatment, associated to symptomatic therapies (transfusions, blood pressure control).

[Hairy cell leukemia: What are the best treatment options for relapsed or refractory patients?]

Hairy cell leukemia is a rare form of leukemia: three hundred new cases are diagnosed each year in France. The diagnosis is based on: (1) morphological examination of the blood and bone marrow smear, (2) analysis by flow cytometry of hairy cells, which express three or the four following markers: CD11c, CD25, CD103 and CD123, (3) identification of the BRAF^V600E mutation, a true molecular marker of the disease. The management of treatment has evolved considerably in recent years. As of today, the purine analogues remain the standard treatment in the first line. Relapses are however observed in about 40% of cases. In the event of a first relapse, the preferred option is treatment with immunochemotherapy i.e. a combination of cladribine plus rituximab. Subsequent relapses are treated with moxetumomab pasudotox or BRAF inhibitors which provide indisputable benefits if third-line treatment is required. We will discuss in patients with relapsed/refractory hairy cell leukemia the needs for personalized medicine and the advantages and disadvantages of each treatment modality. The good prognosis for LT requires treatments that are not immunosuppressive, non-myelotoxic, and do not increase the risk of secondary cancers.

[French Urological Association (AFU) guidelines for Peyronie's disease assessment and treatment]

INTRODUCTION

Peyronie's disease is a common cause for consultation in urology. Many controversies surround its treatment. No French Guidelines have been published so far. The Committee of Andrology and Sexual Medicine of the French Association of Urology therefore offers a series of evidence-based recommendations.

MATERIALS AND METHODS

These recommendations are made according to the ADAPTE method, based on European (EAU, ESSM), American (AUA, ISSM) and Canadian (CAU) recommendations, integrating French specificities due to the availability of treatments, and an update of the recent bibliography.

RESULTS

The assessment of the disease is clinical. Patients with functional impairment or significant psychological repercussions may be offered treatment. The benefits and drawbacks of each treatment should be explained to the patient. Regarding non-surgical treatments, no available treatment has market authorization in France. Vitamin E is not recommended. Analgesic (oral or low-intensity shock waves) or proerectile treatments may be offered as needed, as well as traction therapy. Due to the unavailability of collagenase injections, verapamil injections may be offered. Surgical treatments are to be considered in the stabilized phase of the disease, and consist of performing a plication, an incision-graft or the placement of a penile implant according to the patient's wishes, the curvature and the penis size, as well as erectile function. Combination treatments can be offered.

CONCLUSION

The management of Peyronie's disease is complex, and the levels of evidence for treatments are generally low. The success of treatment will depend on the quality of the initial assessment, the patient's information and understanding of the expected effects, and the practitioner's experience.

[Hypersensitivity Pneumonitis: An update]

Hypersensitivity Pneumonitis (HP) is a common immune-mediated interstitial lung disease (ILD) induced by repeated exposure to environmental antigens in susceptible individuals. The most commonly known forms are bird fancier's disease and farmer's lung. However, the antigens involved are widely diverse. Therefore, the list of causes of HP is frequently expanding. HP seems to be under-diagnosed owing to its highly heterogeneous presentation in both the non-fibrotic and fibrotic subtypes and could represent up to 15% of all ILDs encountered in clinical practice. However, the recognition of HP cases is essential to ensure appropriate therapy for the patient. Home health care workers' intervention is sometimes critical in this context. In case of confirmed exposure, the diagnosis could be considered with high confidence if the high-resolution computed tomography (HR-CT) shows a typical HP pattern associated with a lymphocytosis over 30% in the broncho-alveolar lavage (BAL). In all other situations, the patients should undergo further investigations and additional histopathological sampling should be considered and submitted to a multidisciplinary team discussion. After diagnosis, antigenic eviction is the rule whenever possible. Corticosteroid treatment is the first-line medical treatment for severe forms and aims to prevent the development of fibrosis. Anti-fibrotic therapy is now an option for patients with progressive ILD and failure of immunomodulatory/immunosuppressive therapies.

[An updated synthesis of the international recommendations about the use of non-pharmacological interventions in the treatment of fatigue]

INTRODUCTION

Fatigue is a frequent and disturbing symptom in oncology but remains undertreated. Given the absence of effective drug treatment, non-pharmacological interventions have a prominent place in the treatment of fatigue. However, they are relatively unknown by professionals who lack of clear points of reference to refer patients with confidence. This article aims to improve the knowledge about this therapeutic field through an updated synthesis of the levels of recommendations and available evidence.

METHODS

A three-step approach was conducted, including (1) a synthesis of international guidelines on non-pharmacological interventions in the treatment of fatigue among adults in oncology, (2) a systematic review of recent data in the literature, (3) a comparison between the synthesis of guidelines and the systematic review with the aim of updating the levels of evidence.

RESULTS

Five guidelines were synthesized; 111 systematic reviews were analyzed. Their comparison mainly showed: (1) a convergence in favor of the use of physical activity, educational interventions and cognitive-behavioral therapies, with levels of evidence ranging from moderate to high; (2) a consolidation of short-term efficacy evidence to support the use of mindfulness-based approaches and yoga; 3) the persistence of a lack of sufficiently reliable data to establish the efficacy of other types of intervention.

DISCUSSION

Supported by international guidelines and recent data, the use of non-pharmacological interventions in the treatment of fatigue is critical and has to become better known.

[Trends in the use of midurethral slings after the new legislation: A nationwide survey]

INTRODUCTION

The French Department of Health published on October 23, 2020 a decree governing acts associated with mid-urethral sling (MUS) operations. The aim of this study was to evaluate the changes in practice following this new legislation.

METHODS

A cross-sectional study was carried out among French urologists and gynecologists using an online survey to collect changes in practices since the publication of the decree.

RESULTS

From January to February 2021, 436 surgeons participated in the survey. Among these surgeons, 87% were aware of the new legislation and 56% of them considered the decree as useless. The order resulted in an increase in working time in 81% of cases. Among these surgeons, 66% of the surgeons worked in tertiary referral centers for the management of incontinence, of which 55% had a multidisciplinary meeting in urogynecology. Among the surgeons, 31% considered this meeting to be useful but 80% considered that it did not lead to any change in surgical indications, even though 33% of complications of BSU were discussed there. In conclusion, 61% of surgeons felt more reluctant to schedule a BSU placement with this new legislation.

CONCLUSION

The majority of questioned surgeons considered the decree as useless. It generated few changes in practices which already respected the law on information, consultation, consent, experience and training. Most urologists and gynecologists are more reluctant to offer MUS after this new legislation.

LEVEL OF EVIDENCE

4.

Treatment of aseptic osteonecrosis of the femoral head: Historical aspects

The treatment of aseptic osteonecrosis (ON) of the femoral head has been the subject of numerous therapeutic and surgical proposals due to the absence of medical treatment with proven efficacy. For many years, the goal of surgical treatment was to avoid total hip replacement (THR) with uncertain survival in patients considered too young (30-50 years) for this procedure. Numerous conservative treatments were thus proposed: core decompression with numerous variants, non-vascularized and vascularized bone grafts, intertrochanteric and rotational transtrochanteric osteotomies, cementing. The lack of a common classification and a lack of knowledge of natural history complicated the interpretation of the results for a long time. Nevertheless, it appeared that these treatments were effective only in the very early stages and among these in the limited ONs, medial rather than central and especially lateral, with discrepancies according to etiologies apart from sickle cell disease recognized by all as being pejorative. For the same reason, partial arthroplasties have been attempted and abandoned in turn: femoral head total and partial resurfacing and femoral prosthesis. The most recent advances are stem-cell-enhanced core decompression and progress in total arthroplasty, whose reliability has made it possible to extend the indications to increasingly younger patients seeking treatment with guaranteed or near-guaranteed efficacy. Most of the other interventions have disappeared or almost disappeared because of their lack of effectiveness especially in extensive and post-fracture ONs, sometimes because of their complexity and the length of their post-operative management, and also because they complicate and penalize a future total arthroplasty. This argues for early detection of ON at an early stage where the "head can be saved" by stem cell augmented core decompression, a minimally invasive treatment that leaves the chances of success of a THR intact.

[Management of patients with a suspicion of giant cell arteritis: Survey among general practitioners and specialists]

INTRODUCTION

Headache, visual disturbances and shoulder and hip girdle pain are frequent symptoms of consultation and the diagnosis of giant cell arteritis (GCA) can be evoked in these situations. However, GCA is a rare disease, and the management modalities of a clinical suspicion of GCA are poorly described, which warranted this study.

METHODS

This is a survey evaluating the management of a suspected case of GCA. The questionnaires were sent to general practitioners (GPs), members of the French Rheumatology Society (SFR) and the French National Society of Internal Medicine (SNFMI) RESULTS: One thousand four hundred and fifty two physicians responded to the survey, including 967 GPs (66.6 %) and 485 other specialists (33.4 %). GPs immediately referred the patient to the emergency room in 42 % of cases, and to a specialist colleague in 72 % of cases in the presence of visual symptoms. GPs and other specialists reported performing temporal artery biopsy (TAB) respectively in 46.7 % and 69.7 % of cases (P<0.05). GPs and other specialists reported using diagnostic imaging in 7.4 % and 16.2 % of cases, respectively (P<0.05). Temporal artery ultrasound was the most used diagnostic imaging. The average prednisone equivalent dose prescribed as initial treatment was 1mg/kg/day for GPs and 0.7mg/kg/day for other specialists (P<0.05).

CONCLUSION

Some suspected GCA patients would be managed by their GPs. Imaging was little used for the diagnosis of GCA and TAB remained the preferred diagnostic examination. The initial prednisone equivalent dose varied between GP and other specialists.