[The clinical pharmacist, an essential element in the new gradation of care for ambulatory patients]. / Le pharmacien clinicien, un maillon indispensable dans la nouvelle gradation de prise en charge des patients ambulatoires.

OBJECTIVE: Pharmaceutical presence in oncology allows the clinical pharmacist to integrate tripartite consultations for primary prescription of oral anticancer drugs. The aim of the study is to describe the deployment of the clinical pharmacy activity in 2 oncology departments since its implementation in 2019, to assess the financial gain of the pharmaceutical interventions through the new gradation of outpatient management published on September 10, 2020, and finally to assess their satisfaction following the deployment of this pathway. METHOD: A retrospective study was conducted to collect pricing data for oral therapy interviews in patients between January 2019 and December 2022. To complement this, a satisfaction survey was conducted by the oral therapy pharmaceutical team between 01/01/2022 and 12/31/2022 among patients undergoing treatment. RESULTS: 579 patients received a targeted pharmaceutical interview as part of the oral therapy patient pathway. The average invoiced amount of a pharmaceutical consultation carried out as part of a tripartite first prescription was 355.44 euros. The 579 patients who benefited from a targeted pharmaceutical interview generated a revenue of 87,545 euros for the hospital. In terms of evaluating patient satisfaction, 163 usable responses were received out of 267 patients questioned, representing a response rate of 61%, with an overall score of 9.1/10. CONCLUSION: Pending the introduction of a specific remuneration for clinical pharmacy activities, the valuation of tripartite consultations is a lever for financing clinical pharmacy activities in hospitals.

Outcomes of targeted treatment in immunocompromised patients with asymptomatic or mild COVID-19: a retrospective study.

The aim of this study was to describe the outcomes of targeted COVID-19 treatments in immunocompromised patients with asymptomatic or mild COVID-19 during the period of expansion of the different Omicron subvariants in France. A retrospective monocentric observational study was performed. All immunocompromised patients aged 18 or more, with asymptomatic SARS-CoV-2 infection or mild COVID-19, and who had received a targeted treatment with sotrovimab, tixagevimab/cilgavimab, nirmatrelvir/ritonavir or remdesivir at the Bordeaux University Hospital from 1st January 2022 to 31st December 2022 were eligible. The primary outcomes of interest was defined as a composite of either (i) progression to moderate (WHO-Clinical Progression Scale at 4 or 5) or severe COVID-19 (WHO-CPS ≥ 6), or (ii) the occurrence of COVID-19-related death. The secondary outcomes of interest were the components of the primary outcome. Outcomes were collected until day 30 after targeted treatment administration or at discharge for patients still hospitalised in relation with COVID-19 at day 30. 223 immunocompromised patients received targeted treatment for asymptomatic SARS-CoV-2 infection or mild COVID-19: 114 received sotrovimab, 50 tixagevimab/cilgavimab, 49 nirmatrelvir/ritonavir, and 10 remdesivir. Among 223 treated patients, 10 (4.5%) progressed to moderate or severe disease: three patients (1.3%) progressed to moderate COVID-19 and 7 (3.1%) patients progressed to severe disease. Among them, 4 (1.8%) died of COVID-19. More than 95% of immunocompromised patients with asymptomatic SARS-CoV-2 infection or mild COVID-19 treated by targeted therapies during the Omicron subvariants era did not progress to moderate or severe disease.

Retinal vessels as a window on amyotrophic lateral sclerosis pathophysiology: A systematic review.

Amyotrophic lateral sclerosis (ALS) is a rare fatal motor neuron disease. Although many potential mechanisms have been proposed, the pathophysiology of the disease remains unknown. Currently available treatments can only delay the progression of the disease and prolong life expectancy by a few months. There is still no definitive cure for ALS, and the development of new treatments is limited by a lack of understanding of the underlying biological processes that trigger and promote neurodegeneration. Several scientific results suggest a neurovascular impairment in ALS providing perspectives for the development of new biomarkers and treatments. In this article, we performed a systematic review using PRISMA guidelines including PubMed, EmBase, GoogleScholar, and Web of Science Core Collection to analyze the scientific literature published between 2000 and 2021 discussing the neurocardiovascular involvement and ophthalmologic abnormalities in ALS. In total, 122 articles were included to establish this systematic review. Indeed, microvascular pathology seems to be involved in ALS, affecting all the neurovascular unit components. Retinal changes have also been recently highlighted without significant alteration of the visual pathways. Despite the peripheral location of the retina, it is considered as an extension of the central nervous system (CNS) as it displays similarities to the brain, the inner blood-retinal barrier, and the blood-brain barrier. This suggests that the eye could be considered as a 'window' into the brain in many CNS disorders. Thus, studying ocular manifestations of brain pathologies seems very promising in understanding neurodegenerative disorders, mainly ALS. Optical coherence tomography angiography (OCT-A) could therefore be a powerful approach for exploration of retinal microvascularization allowing to obtain new diagnostic and prognostic biomarkers of ALS.

[Topical anesthesia without the use of an anesthesiologist in adult outpatient cataract surgery: Assessment of selection criteria on consultation, report of 248 cases]. / L'anesthésie topique sans recours à un médecin anesthésiste dans la chirurgie de la cataracte ambulatoire de l'adulte : évaluation des critères de sélection en consultation, à propos de 248 cas.

INTRODUCTION: This work aims to evaluate selection criteria used during the cataract surgery scheduling visit, to choose whether or not there will be an anesthesiologist available during the surgery, depending upon the patient's comorbidities. MATERIALS AND METHODS: Retrospective study performed in 2016 in Angers university medical center. Two groups were established on the cataract surgery scheduling visit, based on patients' comorbidities and vital signs (blood pressure, heart rate). One group of patients were operated with topical anesthesia, with the anesthesia team, the other one only with blood pressure and heart rate monitoring, with, if needed, a written protocol of sedation or blood pressure control, which could be administrated by a circulating nurse. Those two groups were compared in terms of postoperative complications, intraoperative pain and postoperative visual acuity. RESULTS: 248 surgeries were performed on 185 individual patients, with 108 under stand-alone topical anesthesia, and 135 under anesthetist-monitored topical anesthesia. No significant difference was demonstrated between the two groups, in terms of complications, intraoperative pain or visual acuity outcomes. DISCUSSION: This study allows us to assess selection criteria used in our hospital to determine which patients can undergo cataract surgery under topical anesthesia without the anesthesia team. This procedure lowers organizational constraints while still insuring patient safety. Some patients still probably need an anesthesiologist present, such as those with an unstable disease or risk of agitation, in order to optimize the medications administered during surgery.

Bacterial keratitis treated by strengthened antibiotic eye drops: An 18 months review of clinical cases and antibiotic susceptibilities.

PURPOSE: To describe, in patients treated for infectious keratitis, the microorganisms identified and their antibiotic susceptibility over a period of 18 months. METHOD: Retrospective, descriptive, non-comparative study. Medical and biological data were extracted from the patients' file treated with strengthened antibiotic eye drops at Angers University Hospital between January 2015 and June 2016. The main elements noted were the bacteria involved and their susceptibility to antibiotics. Patients' visual acuity at the start and end of treatment was compared. RESULTS: Forty-eight patients were included. Almost one bacterium was identified in 31 patients, totalling 43 pathogens of 24 different species. The most frequently found microorganisms were Gram-positive cocci (55.8%), including Staphylococcus Aureus (14.0%) and Epidermidis (14.0%). All Gram-negative bacilli amounted to 30.2% of the identified bacteria, including 9.3% of Pseudomonas aeruginosa. None of the Gram-positive cocci were resistant to vancomycin and all Gram-negative bacilli were susceptible to ceftazidime and amikacin. Following treatment with at least one of the three antibiotic eye drops produced by our pharmacy (amikacin at 50mg/mL, ceftazidime at 50mg/mL and vancomycin at 25mg/mL), patients' visual acuity was significantly improved (P=0.043). CONCLUSION: The study helped identify the bacterial ecology of patients admitted for infectious keratitis. Among the bacteria identified, none were found to be resistant to any of the three strengthened antibiotic eye drops produced by the hospital pharmacy. These eye drops allowed for a rapid and effective treatment of patients and the improvement of their visual acuity before even identifying the bacteria.

Corneal graft rejection in a patient treated with nivolumab for primary lung cancer.

We report the case of a 58-year-old woman treated with nivolumab for an unresectable squamous non-small cell lung cancer, after first-line cisplatin and gemcitabine combination chemotherapy. This woman had a history of left corneal graft. After 9 cycles of nivolumab, the patient described decreased visual acuity in the left eye with watering and conjunctival erythema. Ophthalmological examination revealed chronic corneal graft rejection. The patient was then treated with an intravenous bolus of corticosteroids (500mg of methylprednisolone) for 3 days, followed by oral prednisone for 4 weeks and subconjunctival corticosteroid injections every 48h, while treatment with nivolumab was discontinued. No clinical benefit was observed 4 weeks later and the corneal graft became totally unfunctional despite of the therapy. We hypothesise that the treatment was started too late. To our knowledge, this is the first reported case of corneal graft rejection related to nivolumab.

[Orbital myositis associated with ipilimumab]. / Myosite orbitaire associée à un traitement par ipilimumab.

BACKGROUND: Ipilimumab is a monoclonal antibody targeting cytotoxic T-lymphocyte antigen 4 (CTLA-4) that allows increased survival and, occasionally, complete remission, in the treatment of metastatic melanoma. The most frequent adverse effects are attributed to dysimmunity. We report the case of a female patient who developed orbital myositis during treatment with ipilimumab. PATIENTS AND METHODS: A woman on ipilimumab for a heel melanoma with mediastinal metastases was referred for evaluation of painful diplopia and proptosis that began three days after the fourth infusion of ipilimumab. The clinical examination disclosed a left abductiondeficit associated with conjunctival hyperaemia and palpebral oedema. Orbital MRI disclosed enlargement of the left lateral rectus, enhancing after contrast. An extensive work-up did not find any evidence for thyroid-related eye disease, as well as other orbital inflammatory processes, orbital cellulitis or orbital metastases. Treatment with high-dose oral steroids resulted in complete clinical recovery within a few days. DISCUSSION: To our knowledge, this is the first clinical report of orbital myositis as an adverse event related to anti-CTLA-4 antibody treatment. Both timing and usual profile of adverse events support the hypothesis that orbital myositis has to be attributed there to ipilimumab. Several dysimmune toxicities were observed with ipilimumab. Ophtalmic toxicity has unusually been described. Most cases were uveitis. Whether immune-related adverse events correlate with clinical response to ipilimumab treatment remains to be determined.

[Optic nerve schwannoma]. / Schwannome du nerf optique.

OBJECTIVE: To report the occurrence of an orbital schwannoma probably arising from the optic nerve sheath. PATIENT AND METHOD: Clinical case report. RESULTS: A 65-year-old patient presented with a painless, progressive right proptosis over five years. Magnetic resonance imaging revealed an intraconal mass, radiographically consistent with a cavernous hemangioma. Surgical resection was performed and pathology disclosed a schwannoma affecting the optic nerve. The optic nerve, which does not contain Schwann cells, is exceptionally rarely affected by Schwannomas, which may arise from a few sympathetic nerve fibers or from a few ectopic cells, not normally present within the optic nerve. CONCLUSION: The radiologic appearance of the very rare optic nerve Schwannoma may be confused with a cavernous hemangioma, a more common tumor in this location.

[Acute optic neuritis in children: clinical features and treatment. A study of 28 eyes in 20 children]. / Les neuropathies optiques aiguës de l'enfant: particularités cliniques et thérapeutiques. A propos de 28 yeux chez 20 enfants.

PURPOSE: Analyzing a personal series of children with acute optic neuritis (AON), we studied MATERIAL AND METHODS: A retrospective study of 28 eyes in 20 patients (mean age: 10;7 years), examined between 1982 and 1997, with a follow-up ranging from 6 months to 15 years (mean: 5;5 years). We recorded etiologic factors, clinical features (ocular and extra ocular), biological results, and neuroimaging findings. RESULTS: Initial involvement was uni- or bilateral with poor visual acuity (under 20/200 in 22 eyes of 28). Intracerebral inflammation was present in 9 of 13 cases where MRI was performed. We found a cause in only 7 cases (5 viral diseases and 2 recent vaccinations against hepatitis B). Visual recovery was good (over 20/25 in 20 eyes of 28) whatever the treatment, but AON recurred in 5 children. Four children later developed multiple sclerosis. CONCLUSIONS: The cause of AON is rarely found. After eliminating an infection, we retained viral disease, complication of a recent vaccination against hepatitis B, and neurological diseases. MRI was the imaging study of choice. Development of multiple sclerosis occurred in 4 cases of 20, the same frequency as in the literature. The risk of later development of multiple sclerosis was 20%. Progression of AON was often excellent. Nevertheless, corticotherapy was added, in form of intravenous boluses followed by decreasing oral therapy for one month.

["Idiopathic" acute optic neuropathies in children]. / Les neuropathies optiques aiguës "idiopathiques" de l'enfant.

We reported a retrospective study of 27 children (mean age = 10 years), who presented a loss of vision due to an acute optic neuritis, between 1982 and 1997. The symptoms ar more likely bilateral in children, and frequently associated with systemic viral infection or hepatitis B vaccination. Multiple sclerosis occurs approximately in 20 p. cent of the cases, i.e. less frequently than by adults. Magnetic resonance imaging is now systematic: in 20 children hyperintense nodular abnormalities in a various distribution was demonstrated by 9 children. During the follow-up, 23 eyes of 27 have an excellent recovery of vision, but 4 patients have developed multiple sclerosis. Corticotherapy was uses in 23 cases, in the form of methylprednisolone intravenous flashes in 14 cases.

[Cystoid macular edema and cytomegalovirus retinitis in AIDS patients treated with antiretroviral triple therapy]. / Oedème maculaire cystoïde et rétinite à cytomégalovirus chez des patients HIV traités par trithérapie antirétrovirale.

AIM OF THE STUDY: This study evaluated cystoid macular edema (CME) occurring during inactive cytomegalovirus (CMV) retinitis, in AIDS patients treated with highly active antiretroviral therapy (HAART) and without anti CMV treatment for 10 patients. PATIENTS AND METHODS: 12 patients were followed over 24 months. Assessment was carried out on visual acuity, biomicroscopy, fundus photographs every month, angiography for each patient, CD4 cell count and plasmatic viral load. RESULTS: 7 patients presented CME in association with chronic uveitis, large CMV retinitis scars and posterior pole involvement. CONCLUSION: CME is a new complication of CMV retinitis occurring in patients treated with HAART.