ANTIFON-CLIC®, a new clinical decision support system for the treatment of invasive aspergillosis: is it clinically relevant?

BACKGROUND: Invasive aspergillosis (IA) is increasing especially in new groups of patients. Despite advances in management, morbidity and mortality related to IA remain high. Thus, Clinical Decision Support System (CDSS) dedicated to IA are needed to promote the optimal antifungal for each group of patients. PATIENTS AND METHODS: This was a retrospective multicenter cohort study involving intensive care units and medical units. Adult patients who received caspofungin, isavuconazole, itraconazole, liposomal amphotericin B, posaconazole, or voriconazole, for the treatment of IA were eligible for enrollment. The primary objective was the concordance between the clinician's prescription and the prescription recommended by the CDSS. The secondary objective was the concordance according to different hospitals, departments, and indications. RESULTS: Eighty-eight patients (n=88) from three medical hospitals were included. The overall concordance was 97% (85/88) including 100% (41/41) for center A, 92% (23/25) for center B, and 95% (21/22) for center C. There was no significant difference in concordance among the hospitals (P=0.973), the departments (P=1.000), and the indications (P=0.799). The concordance was 70% (7/10) for isavuconazole due to its use as an empirical treatment and 100% (78/78) for the other antifungals. DISCUSSION: The concordance rate was high whatever the hospital, the department, and the indication. The only discrepancy was attributed to the use of isavuconazole as an empirical treatment which is a therapeutic option not included in the CDSS. CONCLUSIONS: This new CDSS dedicated to IA is meeting the clinical practice. Its implementation in routine will help to support antifungal stewardship.

[Oral anticoagulants: a literature review of herb-drug interactions or food-drug interactions]. / Interactions des anticoagulants oraux avec les plantes médicinales ou aliments: une revue de littérature.

OBJECTIVE: To identify herbal medicines and food products which can interact with anticoagulant therapy. MATERIAL AND METHOD: Literature review using key words: "anticoagulants", "herb-drug interaction", "food-drug interaction", "drug chinese herbal", "medicine herbal", "plant preparation", "dietary supplements". DATA SOURCES: Medline (january 1966 to june 2006) and Pascal (1987 to 2006). Case reports, systematic reviews, in vitro studies, clinical studies published in french or in english (or with an english extract) have been undertaken. RESULTS: Eighty articles were selected (two both including a case report and a study): 14 systemic review, 43 case reports, 25 studies (17 studies in humans: nine randomized and controlled, three controlled), six controlled studies in animals and two in vitro studies. DISCUSSION: A wide range of herbal medicines and food products can interact with anticoagulants. Clinical relevance of these effects is difficult to characterise (nature of existing reports, contradiction between studies, difficult extrapolation to human). CONCLUSION: It is difficult to predict the incidence or severity of such interactions. However, awareness of these potential interactions is necessary to achieve optimal anticoagulation therapy: pharmacist can play a crucial role identifying such interactions in case of disturbed INR; clinicians should be informed to monitor closely the therapy, particularly when such products are started or discontinued.

[Physicians' expectations towards pharmacy services on ward]. / Service pharmaceutique en service de soins: quelle adéquation avec les attentes des prescripteurs?

Clinical pharmacy practice reveals an effective strategy to reduce medication errors and related costs. The present study aimed at confronting hospital perscribers' expectations towards pharmacy services and their jugement on the usefulness of routine pharmacist interventions. A questionnaire was sent to 562 prescribers of the Grenoble Teaching Hospital. They were asked to rank 1. key-points of prescribing process and specify those that could be shared with the pharmacist, 2. usefulness of a series of pharmacist interventions extracted from daily routine, 3. opportunity to perpetuate pharmacy service on ward. Questionnaire response rate was 18%. Concerning the key-points of the prescription process, (compliance to indications and guidelines, drug choice, dosage), responses express the physician's monopoly. Pharmacist's input in terms of drug choice or monitoring seems reduced. Experience in working with a clinical pharmacist or "junior prescriber" status have a positive effect on precribers' perception towards clinical pharmacy. 25% of the respondents cite the pharmacist as an active player in managing different key-points of the prescription. After being confronted with clinical examples, 73% of the prescribers consider pharmacists' interventions as useful.

[Osteofluorosis caused by excess use of toothpaste]. / Ostéose fluorée due à une consommation excessive de dentifrice fluoré.

BACKGROUND: Osteofluorosis is caused by chronic fluoride intoxication. Fluoride is used in toothpaste for the prevention of dental caries, and dental fluorosis has often been reported among children and attributed to ingestion of fluoride toothpaste. We report a case of chronic fluoride intoxication caused by excess use of toothpaste in an adult. CASE: A 45-year-old woman consulted a rheumatologist for painful swelling of the fingers, phalangeal rather than articular. She also had brown staining on her teeth. Radiography of the hands showed periosteal apposition on the phalanges. Further work-up ruled out tumoral or thyroid causes. Laboratory tests showed elevated fluoride levels in the blood (50.9 micromol/L, normal<1.5 micromol/L) and in the urine (721 micromol/L, normal<46 micromol/L). On questioning, we found only one cause for chronic fluoride intoxication: excess and unusual use of toothpaste. The patient brushed her teeth 18 times a day and swallowed the toothpaste, because she liked the taste. She consumed a tube of toothpaste every 2 days, thereby swallowing 68.5 mg of fluoride every day. Suspecting fluorosis from toothpaste, we asked the patient to use a toothpaste without fluoride. Sixteen weeks later, the pain had ceased, and laboratory tests showed massively reduced but still elevated fluoride levels in the blood (6.9 micromol/L) and urine (92.7 micromol/L). CONCLUSION: In this rare case of fluoride intoxication, misuse of a normally innocuous product caused osteofluorosis.