[First French-speaking days of users of decision support system in clinical pharmacy: Feedback and perspectives]. / Premières journées francophones des utilisateurs de système d'aide à la décision en pharmacie clinique : retour d'expériences et perspectives.

Clinical decision support systems (CDSS) are tools that have been used for several years by clinical pharmacy teams to support pharmaceutical analysis, with a perspective of contributing to the quality of care in collaboration with the other health care team members. These tools require both technical, logistical and human resources. The growing use of these systems in different establishments in France and in Europe gave birth to the idea of meeting to share our experiences. The days organized in Lille in September 2021 aimed at proposing a time of exchange and reflection on the use of these CDSS in clinical pharmacy. A first session was devoted to feedback from each establishment. These tools are essentially used to optimize pharmaceutical analysis and to secure patient medication management. This session outlined the clear advantages and common limitations of these CDSS. Two research projects were also presented to put the use of these tools into perspective. The second session of these days, in the form of workshops, addressed 4 themes that surround the implementation of CDSS: their usability, the legal aspect, the creation of rules and their possible valorization. Common problems were raised, the resolution of which requires close collaboration. This is a first step proposing a beginning of harmonization and sharing that should be deepened in order not to lose the dynamics created between the different centers. This event ended with the proposal to set up two working groups around these systems: the creation and structuring of rules for the detection of risk situations and the common valorization of the work.

Impact of the 2nd, 3rd and 4th waves of the COVID-19 pandemic on wait times in head and neck cancer: A retrospective study in a French expert center.

BACKGROUND: Treatment delay in head and neck cancer is a major problem, with impact on survival. The COVID-19 (coronavirus disease 2019) pandemic, evolving in waves around the world, caused diagnostic and therapeutic delays in certain cancers. The main objective of the present study was to analyze whether there was a change in wait times during three successive waves in our center. METHOD: This was a single-center retrospective study of patients with a first diagnosis of head and neck cancer. Three groups, corresponding to waves 2, 3 and 4, were compared to a control group corresponding to a pre-pandemic period. Study data comprised median times between first consultation and tumor board meeting (C1-TB) and between tumor board meeting and treatment (TB-T). The significance threshold was set at P<0.005. RESULTS: Ninety-six patients were included in the control group, and 154 in the "waves 2-3-4" group. There was no increase in C1-TB interval (respectively 35 and 26days, P=0.046) or TB-T interval (respectively 27 and 28days, P=0.723). CONCLUSION: Intervals between first consultation and tumor board meeting and between tumor board meeting and treatment did not increase during the 2nd, 3rd and 4th waves of COVID-19 in our center.

Cutaneous manifestations in Hymenoptera and Diptera anaphylaxis: relationship with basal serum tryptase.

OBJECTIVES: To compare the clinical presentation of systemic anaphylaxis to Hymenoptera and Diptera with regard to basal serum tryptase (BT) and to evaluate mastocytosis in patients with elevated tryptase. PATIENTS AND METHODS: The medical records of 140 patients with a history of a systemic reaction to venom were retrospectively reviewed. Symptoms and severity of anaphylaxis and BT were recorded. Most patients with elevated tryptase were screened for mastocytosis: a dermatological examination with a skin biopsy was performed in 19 cases and a bone marrow biopsy in 14 cases. RESULTS: Tryptase was elevated in 23 patients. These patients reported fewer usual skin reactions (urticaria in 26.1% of cases with raised tryptase vs. 76.1% of cases with normal tryptase), more flushing (52.2% vs. 4.3%) and frequently did not present skin reaction (26.1% vs. 9.4%). They presented a more severe reaction (mean grade of severity: 3.48 vs. 2.69). Mastocytosis was diagnosed in seven patients with elevated tryptase: indolent systemic mastocytosis in six cases and cutaneous mastocytosis without systemic involvement in one case. In five cases, mastocytosis was previously undiagnosed. Lesions of cutaneous mastocytosis, diagnosed in five patients, consisted of urticaria pigmentosa in all cases and were often inconspicuous. CONCLUSION: These results demonstrate particular clinical features of the allergic reaction in patients with elevated BT and the higher frequency of mastocytosis in this population. In patients with a severe anaphylactic reaction without urticaria, but with flushing, tryptase should be assayed and an underlying mastocytosis should be considered.

[Para valvular leak closure in TAVI]. / Fermeture des fuites para-prothétiques des TAVI.

Literature concerning transcutaneous symptomatic para valvular cardiac leaks closure (PVLC) after trans aortic valve implantation (TAVI) is relatively scarce. Hereby we present 2 clinical cases, one on an Edwards® Sapien 3 valve and the other one on a Medtronic® Evolut R valve. We present also the preliminary results of the 7 PVLC on TAVI included in our prospective FFPP registry during the 2 first years of enrolment (2017-2018), for a total of 158 inclusions for all valves. Seven procedures were performed on 8 leaks, using a majority of vascular plugs (3 Abbott® Amplatzer Vascular Plugs 2 (AVP2), 3 AVP3, 1 AVP4, and 1 muscular Ventricular Septal Defect (VSD) occluder). All procedures were successful without complication. At 1-month follow-up, all patients became asymptomatic. One-year follow-up was already available for 4 patients: 3 of them were symptoms free, and one-who had a second leak not suitable for PVLC-, underwent a « TAVI in TAVI ¼ procedure 2 months after PVLC. This short experience demonstrates the feasibility, the efficacy and the safety of PVLC on TAVI. We expect to be able to offer more in depth information at the end of our prospective ongoing study.

[Fetal lung imaging]. / Evaluation du poumon foetal en imagerie.

Exponential improvements in imaging techniques over the last ten years, through patients' and physicians' wishes for less invasive fetal work-up, now allow us to better explore and understand fetal lung physiology during pregnancy. Diagnostic and prognostic consequences at stake are huge, especially for fetuses at risk of pulmonary hypoplasia. We will decline in three parts (normal lung, malformative lung and pulmonary hypoplasia), through a review of the literature and at the light of our experience, the potentialities and limitations of all imaging modalities (Ultrasound, Doppler, 3D, MRI). Then, we will dwell on future leads and the need for large-scale collaborative studies.

[Prenatal diagnosis of upper limb reduction deficiencies]. / Diagnostic prénatal des anomalies réductionnelles des membres supérieurs.

Ultrasonography has become an indispensable tool in prenatal care providing a throughout screening of the morphological abnormalities of the foetus. The examination of the upper limbs is now part of a routine screening checklist available in France since 2005. Recent progress in past years has focused on the early detection of reductional anomalies. As early as the first trimester scan, the three segments of the upper limb are apparent and transversal anomalies can be easily detected. Early diagnosis of malformations may lead to ethical considerations since women may request for medical termination of pregnancy. Apart from transversal anomalies of the limb which remain most of the time accidental, genetic syndromes may also lead to longitudinal reductions of the upper limb. In such cases, ultrasound may be helpful in genetic counselling by detecting other associate malformations. The search for associate malformations in favour of a genetic syndrome is therefore mandatory before referral to a prenatal consultation with the surgeon. Three-dimensional ultrasound and multi detector computed tomography (MDCT) are being increasingly used as additional procedures to improve diagnosis and long-term prognosis.

[Necrotic livedo after injection of buprenorphine (Subutex)]. / Livédo nécrotique après injections de buprénorphine (Subutex): rôle de l'amidon de maïs contenu dans l'excipient.

INTRODUCTION: Use of buprenorphine (Subutex) is widely used as substitution treatment in opiate addiction although its side-effects are little known. We report a case of localised necrotic livedo subsequent to injection of Subutex. OBSERVATION: A 34 year-old male drug addict on Subutex substitution treatment presented a necrotic livedo and an ulcer with clearly demarcated edges on the skin of the inner elbow. Histological analysis revealed PAS-positive particles in a hypodermic inflammatory lymphohistiocytic infiltrate that were reflective and formed a Maltese cross under polarised light and were identified as maize starch. DISCUSSION: This clinical case describes necrotic livedo lesions induced by injection of Subutex. The underlying mechanisms are associated with maize starch, an excipient used in Subutex. Unauthorised subcutaneous injection of buprenorphine (Subutex) is common among drug addicts but there is little description of the associated complications. In our patient, the presence in cutaneous biopsy samples of maize starch, an excipient of buprenorphine, provides evidence of intravenous administration of this drug.

[Basal cell carcinoma of the first toenail]. / Carcinome basocellulaire de l'appareil unguéal de l'hallux.

BACKGROUND: Basal cell carcinoma is a very common form of skin cancer but its occurrence on the toenail unit is very rare. We report such a case of basal cell carcinoma localized on the proximal nail fold of the right hallux. CASE REPORT: A 67-year-old woman had a 7-year history of a non-healing ulcer on the proximal nail fold of the right hallux after antibiotics and treatment of her onychomycosis. Bowen's disease and squamous cell carcinoma were suspected. Histopathologic examination of a biopsy specimen revealed infiltrative basal cell carcinoma. The lesion was surgically excised with a 0.5 cm margin and the defect was repaired by full-thickness skin graft with good functional and cosmetic results. DISCUSSION: Basal cell carcinoma is the most common skin cancer but its localization on fingers, toes and nail units is very rare. Only six cases of basal cell carcinoma on the toe nail unit have been reported to date in the literature. Clinical aspects often mimic benign processes, resulting in misdiagnosis. Treatment requires simple excision or Mohs micrographic surgery. Our case emphasizes the value of biopsy for all nail unit lesions of atypical appearance, course or therapeutic response.

[Cutaneous calciphylaxis treated by autologous keratinocytes graft and subtotal parathyroidectomy]. / Nécrose cutanée par calciphylaxie traitée par greffe de kératinocytes autologues et parathyroïdectomie partielle.

BACKGROUND: Cutaneous calciphylaxis, seen most often in dialysis patients, is characterised by skin necrosis, and is a disabling and lifethreatening disease. Despite intensive topical treatment, recourse to parathyroidectomy is often necessary. We report the case of a female patient with skin necrosis due to calciphylaxis: pain and necrotic lesions were controlled by grafting of cultured autologous keratinocytes (Epibase). CASE REPORT: A 75-year-old woman with a 5-year history of dialysis-dependent chronic renal failure secondary to nephroangiosclerosis presented a very painful necrotic ulceration on her left leg. In spite of an autologous patch grafts, the lesions rapidly deteriorated. Laboratory data showed high levels of calcium, phosphate and parathyroid hormone and imaging suggested parathyroidal adenoma. Although cutaneous biopsy was not performed, the diagnosis of cutaneous necrosis due to calciphylaxis with tertiary hyperparathyroidism was established. Treatment consisted of a low-calcium and low-phosphorus diet with autologous keratinocytes grafts (Epibase). After the third application of keratinocytes, the pain disappeared, necrosis ceased and wound healing began. Subtotal parathyroidectomy was performed two months after the start of grafts. At three months, the patient was cured. DISCUSSION: . Calciphylaxis is an obstructive vascular disease secondary to calcification of the arterioles leading to ischemic tissue necrosis. Prompt diagnosis is essential since this disease is disabling and life-threatening due to sepsis and ischemic complications. In our case, autologous keratinocyte grafts allowed pain relief to be achieved within large expanses of cutaneous necrosis after correction of calcium and phosphorus levels, thereby allowing parathyroidectomy to be performed under optimal conditions.

Prenatal diagnosis of fetal cerebral abnormalities by ultrasonography and magnetic resonance imaging.

We found magnetic resonance imaging (MRI) of the fetal brain to be effective in confirming or denying diagnosis of fetal cerebral defects when ultrasonography was inconclusive or incomplete. In this paper we describe 31 cases in which ultrasonographic evidence of fetal brain defects was verified by MRI. MRI was performed after curarization of the fetus. In 21 cases, ultrasonographic evidence was confirmed by histological study of the fetus or postnatal radiological examination. In 10 cases, ultrasonographic diagnosis was denied by MRI and healthy infants were born. In one case of cerebral toxoplasmosis, ultrasonography detected periventricular calcifications but MRI was normal. In 20 cases MRI ascertained or further documented the ultrasonographic findings. However in 4 of these 20 cases autopsy of the fetus was required to determine the exact nature of the lesion.

[MRI and in utero ventriculomegaly]. / IRM et ventriculomégalie in utero.

Ventriculomegaly constitutes the major indication of fetal brain MRI. MRI is therefore of utmost importance to look for a cause through the depiction of criteria of malformations and through the definition of criteria of destructive lesions. Malformations and destructive lesions are the most common causes of ventricular dilatation. Some challenging points are worth mentioning in term of mechanism with the challenge of hydrocephalus (in term of increased in intracranial pressure) and of isolated ventriculomegaly. The image itself is also challenging since a similar image may be of different origin. In term of natural history of fetal brain injury an irregular, nodular aspect of the ventricular wall and/or the germinal matrix is often the only pathologic MRI finding that is known to be of clastic origin. In term of prognosis the challenge is represented by the isolated mild ventriculomegaly, the literature being quite confusing. The purpose of this review paper is to highlight the underlying mechanisms and pathophysiology of ventricular dilatation based on results from the literature as well as from personal experience.

[Surgery in utero on a two-headed monster. The value of echography]. / Intervention in utero sur monstre double. Intérêt de l'échographie.

A binovular triplet pregnancy with a normal fetus and bicephalic monster was diagnosed by ultrasound after 19 weeks of amenorrhoea. After selective amniocentesis and genetic studies the diagnosis led us to kill the double monster in utero by injecting hypertonic saline into its aorta. The healthy twin went on growing normally in the following weeks. Premature vaginal delivery resulted in the expulsion of a macerated double monster and the birth of a baby weighing 1,650 g in blood health. This case history leads us to discuss the value of ultrasound in multiple pregnancies and the ability to carry out intra-uterine procedures in these special cases.

[The prognostic value of raised uric acid in the blood in arterial hypertension in pregnancy. 58 cases (author's transl)]. / Valeur pronostique de l'hyperuricémie dans les hypertensions artérielles de la grossesse. A propos de 58 observations.

The authors have carried out research in 58 cases to see whether the findings of high uric acid levels in the blood are of prognostic value in all cases of arterial hypertension in pregnancy whatever the aetiology. The material studied consisted of 30 true cases of toxaemia of pregnancy, 13 cases of recurrent toxaemia and 15 cases of the vasculo-renal syndrome on top of the pre-existing pathological condition. In 37 cases where the blood uric acid level was lower than 300 micromoles there were only 4 minor complications. Serious complications were found in 6 cases in which the patients had a blood uric acid level highthan 480 micromoles. This study confirms the prognostic value of blood uric acid levels. The estimation of these levels, however, seems to be of less value in making a differential diagnosis between the various kinds of toxaemia and hypertension found in pregnant women due to different aetiologies.

[Ultrasonic size of fetal crump-rump length in first trimester of pregnancy. Accuracy of gestational age assessment (author's transl)]. / La mesure échographique de l'embryon. Une détermination précise de l'âge gestationnel.

The fetal crown rump length was measureed by means of pulsed ultrasound. The normal values between 49 and 94 days from the onset of the last menstrual period were determined in 72 patients. Statistical analysis showed a good correlation between gestationnal age and fetal crown rump length. The usefulness of this measure is so demonstrated: assessment of gestational age, within few days.

[Congenital heart disease and nuchal translucency with normal karyotype. Report of 3 cases]. / Cardiopathie congénitale et clarté nucale avec caryotype normal. A propos de 3 cas.

We report three pregnancies where enlarged nuchal translucency was discovered at the first trimester transvaginal ultrasound examination; congenital heart disease developed later. Two cases of hypoplastic left heart were diagnosed prenatally at the mid-trimester sonographic examination. The pregnancies were terminated. In the third case, a supravalvular pulmonary stenosis was discovered on the second day of life. Further investigations demonstrated a mutation on the elastin locus, thus confirming the diagnosis of Williams-Beuren syndrome. The role of nuchal translucency as a risk marker for congenital heart disease is discussed.

[Loco-regional analgesia by electronic stimulation during labor]. / Analgésie loco-régionale au cours du travail par stimulation électronique

This is a preliminary report on an original method of local regional electronic analgesia. From it the first results can be deduced. The threshold for pain which was appreciated at 25 mmHg without electronic stimulation was raised to 48 mm Hg under electronic stimulation. Fetal ill-effects are nil.

[The influence of present therapeutic methods and especially of beta-blockers on fetal and maternal prognosis in hypertensive syndromes in pregnancy. 43 case records (author's transl)]. / Influence des thérapeutiques actuelles et notamment des bêta-bloquants sur le pronostic foetal et maternel des syndromes hypertensifs de la grossesse. A propos de 43 observations.

The authors studied 43 cases of arterial hypertension in pregnancy in an attempt to determine the efficiency and safety of different anti-hypertensive drugs. The patients were divided into two major groups: arterial hypertension which revealed itself during pregnancy (true toxaemias of pregnancy and relapsing toxaemias), and arterial hypertensions which were added on to a pre-existing pathology (arterial hypertension, diabetes, chronic nephritis). The cases in these different classes were then divided into two definite groups according to the need for therapy: the first group was treated by rest and hydrallazine as a single therapeutic agent. In the second group multiple agents were needed because of the arterial hypertension, and one was a beta-blocker. Complications were found particularly in the second group of true toxaemias of pregnancy where unfortunately 5 fetal deaths occurred that were attributable to the severity of the hypertension more than to the beta-blockers, which were administered for longer and in higher doses without major complications in recurrent toxaemias and pre-existing arterial hypertension cases.

[Meadows syndrome. A case history (author's transl)]. / Le syndrome de Meadows. A propos d'une observation.

The authors, having studied a case of Meadows syndrome, confirm that this cardiomyopathy is a specific entity in pregnancy and the puerperium. They point out the difficulties in diagnosis, as Meadows syndrome seems to be diagnosis of elimination. They point out that a paraclinical balance has to be drawn up very fully on the biological and haemodynamic planes to confirm this condition. Finally, after a short discussion about the therapy, they tackle the problem of the prognosis for life and for future childbearing in these patients, which is determined by the persistence or absence of cardiac enlargement.

[Prenatal diagnosis of fetal goiter revealing iodine utilization defect]. / Goitre néonatal découvert in utero, révélateur d'un trouble de l'organification de l'iode.

We report on a case of fetal goitrous diagnosed on ultrasonogram done at 31 weeks of gestation. Thyroid maternal function was normal and no therapeutic was responsible. Hormonal test done on cord blood supported diagnosis of prenatal hypothyroidism. The infant was born prematurely at gestation age of 34 without antenatal treatment. He was eutrophic with clinical and biological signs of hypothyroidism and a large goiter. Therapy with thyroxine was instituted on the third day of life. At 9 months, growth and development are normal. Congenital hypothyroidism has an incidence of approximately 1 in every 4000-5000 live births. Rarely fetal goitrous hypothyroidism have been attributed to thyroid hormone dyshormonogenesis. When fetal goiter is diagnosed on ultrasonography, without maternal hypothyroidism or therapeutic and when hypothyroidism is confirmed on fetal blood, this diagnosis must be suspected.

[Biopsy of the internal mammary lymph node by anterior thoracotomy (author's transl)]. / Biopsie de la chaîne mammaire interne par thoracotomie antérieure (pour bilan pronostique du cancer du sein).

The authors suggest a new technique of biopsy of the internal mammary lymph node by anterior thoracotomy, through the large pectoral respecting entirely the costal presentation. After a presentation of different operating cycles, they report their results.