[Cushing's syndrome with inhaled corticosteroid: Drug interactions to avoid]. / Syndrome de Cushing sous fluticasone inhalée : interactions médicamenteuses à éviter.

Cushing's syndrome is an iatrogenic event occurring during co-administration of inhaled corticosteroids and potent inhibitors of P450 cytochromes. We report the clinical case of a 29-year-old woman with a past history of asthma treated with inhaled fluticasone propionate (FP), chronic pulmonary aspergillosis and allergic bronchopulmonary aspergillosis (ABPA) treated with itraconazole (ITZ), and Mycobacterium xenopi infection treated with moxifloxacin (MXF), ethambutol (EMB) and clarithromycin (CLR). Four months after initiation of antibiotic and antifungal medication, the patient contracted Cushing's syndrome. Its etiology consisted in interaction between FP, ITZ and CLR, which led to pronouncedly increased corticosteroid concentrations in circulating plasma cells. Following on the one hand cessation of FP and ITZ and on the other hand hydrocortisone supplementation, evolution was favorable. Several cases of iatrogenic Cushing's syndrome induced by co-administration of FP and potent CYP3A4 inhibitors have been reported in the literature. If possible, FP should be avoided in patients being treated with CYP3A4 inhibitors. Due to its differing physicochemical properties, beclometasone may be considered as the safest therapeutic alternative.

Use of immediate release melatonin in psychiatry: BMI impacts the daily-dose.

OBJECTIVE: There is a growing interest in psychiatry regarding melatonin use both for its soporific and chronobiotic effects. This study aimed to evaluate factors impacting the daily-dose. METHODS: In a university department of psychiatry in Paris (France), we conducted a posteriori naturalistic observational study from April 03, 2017 to January 31, 2018. We assessed links between sociodemographic and clinical characteristics and daily dose of melatonin (the daily-dose of melatonin initiation and the daily-dose at Hospital discharge). A survey of drug interactions was performed regarding metabolic inducers and inhibitors of the cytochrome P450 1A2. RESULTS: Forty patients were included and treated with immediate-release melatonin. For patients with no history of melatonin use, the initiation dose of was 2 or 4mg, with no effects of age, weight, BMI, melatonin indication, cause of hospitalization. We found that higher discharge dose was associated with higher BMI (P=0.036) and more reevaluations of melatonin dose (P=0.00019). All patients with a moderate inducer (n=3, here lansoprazole) were significantly more associated with the discontinuation melatonin group (P=0.002). CONCLUSION: The BMI and the number of reevaluations impact the daily dose of melatonin. Two mechanisms may explain that BMI may need higher doses: (i) melatonin diffuses into the fat mass, (ii) the variant 24E on melatonin receptor MT2, more frequent in obese patients, leads to a decrease of the receptor signal.

[Design and assessment of a outpatient living with PICC-line support program: A pilot study]. / Étude pilote d'évaluation d'un programme d'accompagnement pour les patients quittant l'hôpital avec un PICC-line.

The peripheral insertion central catheter (PICC-Line) is indicated for long term intravenous medication administration. Some adverse events (AE) might occur, especially for patients after hospital discharge. Therefore, patient empowerment about the side effects and precaution for use is essential to prevent potential patient harm. A multidisciplinary working group met and designed support program for outpatient living with PICC-line. Pharmacy consultations (PC) were proposed to patient before and after PICC-line insertion. A strip cartoon and card game were created to facilitate patient education. The aim of the study was to assess the comprehension of patient then secondarily to follow up AE awareness. During 10 months, 30 patients of mean age 65.9±14 years were included. Thirty-sixPICC-Line were installed and followed on 1659days of catheterization. 4, 9 and 13patients received respectively no, at least one and two PCs before discharge from the hospital. Although the differences were not statistically significant, comprehension tends to improve when patients benefit from both PCs especially when it concerns complications. Twenty-fiveambulatory AEs were recorded including 9infections or suspicion of infection, 2 thrombosis and 2 displacements of PICC-line. Among the patients who had no PC, four experienced delayed care. In comparison, it occurred in only one patient in the group who received at least one PC after PICC-line insertion. Further studies are warranted to confirm this trend.

[Securing the therapy management during the leave permissions for the elderly patients]. / Sécurisation de la prise en charge médicamenteuse des patients âgés pendant les permissions de sortie.

Leave permission can be granted over a limited period of hospitalisation during which the patient can return home under the responsibility of the hospital. Despite its frequency, this practice is not evaluated in terms of maintaining the security of medication. This complex process involves several actors, processes and locations. In that case, the drug iatrogenic risk is not at all negligible, especially for the elderly. Patient comprehension of medication is not always easy and must be evaluated before leaving the hospital. Therefore, a risk analysis has been initiated to ensure the medical practice's security of our geriatric hospital. Multidisciplinary working group meetings were dedicated to analyse and overcome 21 unacceptable failure modes. The establishment of traceability nurse/patient for the medication intake, information and evaluation of drug monitoring allowed the patient's medication compliance. In the meanwhile, the role of the working group on the security of the internal drug circuit in the hospital has integrated the harmonization of practices, a unique source of information and a variety of comprehensible, readable and informative materials to propose to the patients. These preventive actions have been formulated to secure, optimize and to individualize drug management during the leave permission. In the context of optimization during transit period home/hospital, this process reorganized by the working group can be integrated in a public health approach to reduce the number of preventable readmissions.

[Kawasaki disease and cranial nerve involvement: two cases]. / Maladie de Kawasaki et atteinte des nerfs crâniens. À propos de 2 observations.

CNS involvement, except classical lymphocytic meningitis, is exceptionally rare in Kawasaki disease. Herein, we report on two atypical cases of KD with cranial nerve inflammation. The first case presented supranuclear vertical palsy and the second case Bell palsy. Outcome was promptly favorable with IV immunoglobulins, with no long-term complications. No specific KD biomarkers are available and diagnosis of atypical forms is difficult. KD can mimic a systemic illness and appropriate therapy may be delayed.

[Arterial hypertension with renal disease revealed by heart failure in infants: two case reports]. / Hypertension artérielle d'origine rénale révélée par une défaillance cardiaque chez le nourrisson : à propos de 2 cas.

While blood pressure measurement methods in infants are well established, hypertension, a rare disease in this population, may still be revealed by heart failure. Kidney diseases are the most common causes of hypertension, prompting the search for a renovascular cause to start appropriate treatment. We report on 2 cases of late diagnosis of hypertension in infants, with hypertensive cardiomyopathy, one in the context of autosomal recessive polycystic kidney disease and the other in the context of renal artery stenosis with hemodynamic disorder, hypertensive encephalopathy and neurological sequelae. In both cases, the equilibrium of blood pressure was difficult to achieve in the acute phase. Renal ultrasound is fundamental for diagnosis. The potential complications related to hypertension require early diagnosis, emphasizing the importance of measuring blood pressure during a routine consultation in infants.

[Infectious complete atrioventricular block in children: 2 case reports]. / Blocs auriculoventriculaires complets d'origine infectieuse chez l'enfant: à propos de 2 observations.

We report 2 cases of children who developed a complete atrioventricular block following an infection, varicella without complication initially in the first case and Mycoplasma pneumoniae pneumopathy in the second case, in which a first-degree congenital heart block was diagnosed on this occasion. In case 1, the treatment consisted in oral corticosteroids leading to the recovery of sinus rhythm; the course was unfavorable in the second case and required a permanent pacemaker. This cardiac complication of bacterial or viral infection is rare in children but evolves to permanent conduction disturbance in 1/3 of the cases. It is important to detect this disorder, which is feasible simply by a clinical examination and an electrocardiogram.

[Primary cutaneous aspergillosis complicated with invasive aspergillosis in an extremely preterm infant: case report and literature review]. / Aspergillose cutanée secondairement invasive chez un nouveau-né prématurissime : cas clinique et revue de la littérature.

Aspergillus is a ubiquitous fungus that can cause primary cutaneous aspergillosis in extremely low-birth-weight (ELBW) neonates, then be invasive and lead to death. ELBW neonates are particularly at risk because of decreased qualitative immune defenses and defects in the skin barrier. Broad-spectrum antimicrobial therapy and corticosteroids, often used in these patients, contribute to increased risk. We present a fatal case of primary cutaneous aspergillosis complicated with invasive aspergillosis, confirmed by autopsy, in an ELBW infant. The source of contamination was probably non-sterile disposable latex gloves used for neonatal care. The early recognition of this source led to its eviction for other hospitalized ELBW infants and no outbreak was observed.