[Clinical pharmacy: Evaluation of physician's satisfactions and expectations in a French regional hospital]. / La pharmacie clinique en milieu hospitalier : une enquête de satisfaction auprès des prescripteurs.

INTRODUCTION: The purpose of the study was to evaluate physician's satisfaction with the clinical pharmacy activities in a French regional hospital. METHODS: Data were collected by face-to-face interviews carried out by a public health intern with physicians from 14 different departments of medicine and surgery. A specifically designed questionnaire was used for this study. This contained 18 closed-ended questions, 3 open-ended questions and 6 questions relating to the multidisciplinary analysis of prescriptions of elderly patients. RESULTS: The questionnaire was proposed to 78 physicians, of which 62 replied (participation rate of 79%). Thirty-seven percent were interns (23/62), 19% were assistants (12/62) and 44% were senior physicians (27/62). Clinical pharmacy satisfaction levels were generally very high. In regard to clinical skills, 87% of the physicians were satisfied with pharmacists' competencies and 91% by the pertinence of transmitted information. Ninety-five percent of the physicians were also satisfied by the logistical aspect and the relationship with pharmacists (reactivity, availability and communication). Analysis of the open-ended questions showed that physicians were in favour of the increased presence of clinical pharmacists on the wards. CONCLUSIONS: This study shows a high level of physician satisfaction in relation to the clinical pharmacy activities in our hospital, and should be viewed as a strong endorsement of the work of the clinical pharmacy. This study highlights some areas of improvement such as increase presence of the clinical pharmacists on the wards. In order to assess periodically our activity, this study must be repeated in the future.

Is a sequencing batch biofilter granular reactor suitable for textile wastewater treatment?

The textile industry releases highly polluted and complex wastewaters, which are difficult to treat and require numerous treatment steps. Innovative technologies for on-site treatment at each factory would permit cost reduction. For this reason, we ran a laboratory-scale study to assess the suitability of a sequencing batch biofilter granular reactor (SBBGR) for textile wastewater treatment, testing four different types of wastewater. Results demonstrate that wastewater characteristics greatly affect the reactor efficiency. Hence, a pre-study is advisable to define the best operational conditions and the maximum treatment capability for the wastewater under analysis. Nevertheless, SBBGR is a valuable biological treatment, effective in the reduction of pollutant load with stable performances despite the variability in wastewater composition. Tests with ozone integration have demonstrated that it is possible to dose small quantities of ozone to obtain an effluent suitable for direct discharge. However, a dynamic ozone dosage should be used to optimize the process as the correct ozone dose strongly depends on the wastewater composition.

Invasive aspergillosis: a severe infection in juvenile systemic lupus erythematosus patients.

Infections are an important cause of morbidity and mortality in juvenile systemic lupus erythematosus (JSLE). Among them, invasive aspergillosis (IA), which is usually related to immunosuppressed patients, has been rarely reported in JSLE. From 1983 to 2011, 5604 patients were followed at our institution and 283 (5%) met the American College of Rheumatology (ACR) classification criteria for SLE. Six (2.1%) of our JSLE patients had IA. One of them was previously reported and five will be described herein. Four of them were female. The median age at JSLE diagnosis was 12 years (8-16) and the median interval between diagnosis of JSLE and IA was 6 months (1-38). All had pulmonary involvement and three of them had systemic involvement. The median Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) was 19 (7-22). Diagnosis of IA was performed by isolation of Aspergillus spp., two in bronchoalveolar lavage culture and by way of autopsy in the others. All of them were treated with corticosteroids and/or immunosuppressive drugs at IA diagnosis (azathioprine and/or intravenous cyclophosphamide). They all required treatment in the pediatric intensive care unit with mechanical ventilation and antifungal therapy (fluconazole, amphotericin B, itraconazole and/or voriconazole); nonetheless, none of them survived. In conclusion, this was the first report that evaluated the prevalence of IA in a large population of JSLE patients from a tertiary pediatric hospital, and clearly showed the severity of the outcome, especially in patients with active disease and treated with immunosuppressive agents. This study reinforces the importance of early diagnosis and treatment with certain antifungals, especially in critically ill patients.

Chronic polyarthritis as the first manifestation of juvenile systemic lupus erythematosus patients.

OBJECTIVE: To evaluate the prevalence of chronic polyarthritis in juvenile systemic lupus erythematosus (JSLE) and to describe the manifestations, treatments, and outcomes in these patients. METHODS: From January 1983 to July 2010, 5419 patients were followed up at the Pediatric Rheumatology Unit of the University Hospital and 271 (5%) of them had JSLE (American College of Rheumatology [ACR] criteria). 'Rhupus' was classified as the overlap of juvenile idiopathic arthritis (International League of Associations for Rheumatology [ILAR] criteria) and JSLE. We evaluated demographic data, polyarthritis and other clinical manifestations, disease activity and damage, laboratory exams, radiographic findings, treatments, and outcomes. RESULTS: The prevalence of chronic polyarthritis in this JSLE population was 2.6% (7/271). This articular involvement was the initial manifestation in all seven JSLE patients. The median duration of chronic polyarthritis was 11 months (range 2-15 months). Interestingly, rhupus with chronic polyarthritis and limitation of movement, presence of rheumatoid factor, autoantibodies, and/or radiographic abnormalities (juxtaarticular osteopenia, joint-space narrowing, or erosions) was evidenced in three patients. No patient had deformities of hands and feet associated with Jaccoud's arthropathy or osteonecrosis. All patients were treated with nonsteroidal anti-inflammatory drugs (NSAIDs, naproxen 10-15 mg/kg/day) when polyarthritis diagnosis was established. Prednisone and antimalarials were administered at JSLE diagnosis. The three non-responsive rhupus patients were treated in conjunction with immunosuppressive drugs (methotrexate, azathioprine, and/or cyclosporine). CONCLUSIONS: Chronic polyarthritis was a rare lupus manifestation in active pediatric patients. The interesting overlap between chronic arthritis and lupus, called rhupus suggests a new entity with a different clinical profile and a poor response to treatment with NSAIDs alone. In addition, the occurrence of this association in JSLE patients could be classified as a clinical sub-group of JSLE with possible specific genetic determinants.

Acute pancreatitis in juvenile systemic lupus erythematosus: a manifestation of macrophage activation syndrome?

Acute pancreatitis (AP) is a rare and life-threatening manifestation of juvenile systemic lupus erythematosus (JSLE). The objective of this study was to evaluate the prevalence and clinical features of AP in our JSLE population. AP was defined according to the presence of abdominal pain or vomiting associated to an increase of pancreatic enzymes and/or pancreatic radiological abnormalities. Of note, in the last 26 years, 5367 patients were followed up at our Pediatric Rheumatology Unit and 263 (4.9%) of them had JSLE diagnosis (ACR criteria). AP was observed in 4.2% (11/263) of JSLE patients. The median of age of the JSLE patients at AP diagnosis was 12.4 years (8.8-17.9). All of them had lupus disease activity at AP onset. Three patients were receiving corticosteroids before AP diagnosis. Interestingly, 10/11 JSLE patients fulfilled preliminary guidelines for macrophage activation syndrome, three of them with macrophage hemophagocytosis in bone marrow aspirate and hyperferritinemia. The hallmark of this syndrome is excessive activation and proliferation of T lymphocytes and macrophages with massive hypersecretion of proinflammatory cytokines and clinically it is characterized by the occurrence of unexplained fever, cytopenia and hyperferritinemia. AP treatment was mainly based on intravenous methylprednisolone. Four JSLE patients with AP died and two developed diabetes mellitus. In conclusion, AP was a rare and severe manifestation in active pediatric lupus. The association between AP and macrophage activation syndrome suggests that the pancreas could be a target organ of this syndrome and that pancreatic enzyme evaluation should also be carried out in all patients.

[Invasive pneumococcal pneumonia in children 0-24 months old: does bacterial resistance affect outcome]. / Neumonía neumocócica invasiva en niños de 0 a 24 meses: influye la resistencia bacteriana en la evolución?

INTRODUCTION: In Uruguay community acquired bacterial pneumonia is a significant cause of morbidity and mortality. S. pneumoniae is the most frequent agent. The disease is more severe in children less than two years old. The relationship between pneumococcal penicillin resistance and outcome is still an unresolved problem. OBJECTIVES: To compare the outcome of children 0 to 24 months old hospitalized in the Hospital Pediátrico-Centro Hospitalario Pereira Rossell, with invasive pneumococcal pneumonia caused by S. pneumoniae susceptible and resistant to penicillin. PATIENTS AND METHODS: Children 0 to 24 months old with invasive pneumococcal pneumonia, admitted between January 1st 1998 and December 31st 2005 were included. Susceptibility to penicillin was defined as a MIC < 0.06 microg/ml, reduced susceptibility was defined as a MIC of 0.1 to 1 microg/ml (intermediate) and as a MIC >or= 2 microg/ml (resistant). Outcome was evaluated with the following criteria: empyema, sepsis, septic shock, mechanical ventilation, and death. Length of hospital stay and outcome were compared in both groups. RESULTS: Inclusion criteria were met by 168 children. S. pneumoniae was susceptible to penicillin in 90 children and with reduced susceptibility in 78. Both groups were similar in age, comorbidity, nutritional status and initial antibiotic treatment. There were no significant differences in outcome and length of hospital stay. CONCLUSIONS: S. pneumoniae resistance to penicillin did not affect the outcome of pneumonia in this group of children.

Neumonía neumocócica invasiva en niños de 0 a 24 meses: ¿influye la resistencia bacteriana en la evolución? / Invasive pneumococcal pneumonia in children 0-24 months old: does bacterial resistance affect outcome?

Introducción. En Uruguay, la neumonía bacteriana adquirida en la comunidad causa una importante morbimortalidad. Streptococcus pneumoniae es el agente etiológico más frecuente. La enfermedad es más grave en niños menores de 2 años. Un interrogante aún no totalmente aclarado es la relación que existe entre la susceptibilidad disminuida del neumococo a la penicilina y su evolución. Objetivos. Comparar la evolución de niños de 0 a 24 meses de edad hospitalizados en el Hospital Pediátrico del Centro Hospitalario Pereira Rossell con neumonía invasiva por cepas de S. pneumoniae sensibles y con susceptibilidad disminuida a la penicilina. Pacientes y métodos. Se incluyó a los niños de 0 a 24 meses, hospitalizados entre el 1 de enero de 1998 y el 31 de diciembre de 2005, con neumonía neumocócica invasiva, en los que se determinó la concentración inhibitoria mínima (CIM) para la penicilina. Se consideraron sensibles las cepas con CIM <0,06 g/ml y con una susceptibilidad disminuida las cepas con CIM entre 0,1 y 1 g/ml (susceptibilidad intermedia) y las cepas con CIM 3 2 g/ml (resistentes). Se comparó la duración de la estancia hospitalaria y la evolución de ambos grupos a través de la presencia de los siguientes criterios de gravedad: empiema, sepsis, shock séptico, necesidad de asistencia ventilatoria mecánica y muerte. Resultados. Cumplieron los criterios de inclusión 168 niños. Las cepas de S. pneumoniae fueron sensibles a penicilina en 90 niños y con susceptibilidad disminuida en 78. Ambos grupos fueron comparables en relación con la edad, la comorbilidad, el estado nutricional y el tratamiento antibiótico al ingreso. La evolución medida por los criterios de gravedad mencionados no mostró diferencias significativas. El promedio de estancia hospitalaria fue similar en ambos grupos. Conclusiones. La resistencia de S. pneumoniae a la penicilina no influyó en la evolución de la neumonía en este grupo de niños

Introduction. In Uruguay community acquired bacterial pneumonia is a significant cause of morbidity and mortality. S. pneumoniae is the most frequent agent. The disease is more severe in children less than two years old. The relationship between pneumococcal penicillin resistance and outcome is still an unresolved problem. Objectives. To compare the outcome of children 0 to 24 months old hospitalized in the Hospital Pediátrico-Centro Hospitalario Pereira Rossell, with invasive pneumococcal pneumonia caused by S. pneumoniae susceptible and resistant to penicillin. Patients and methods. Children 0 to 24 months old with invasive pneumococcal pneumonia, admitted between January 1st 1998 and December 31st 2005 were included. Susceptibility to penicillin was defined as a MIC < 0.06 g/ml, reduced susceptibility was defined as a MIC of 0.1 to 1 g/ml (intermediate) and as a MIC 3 2 g/ml (resistant). Outcome was evaluated with the following criteria: empyema, sepsis, septic shock, mechanical ventilation, and death. Length of hospital stay and outcome were compared in both groups. Results. Inclusion criteria were met by 168 children. S. pneumoniae was susceptible to penicillin in 90 children and with reduced susceptibility in 78. Both groups were similar in age, comorbidity, nutritional status and initial antibiotic treatment. There were no significant differences in outcome and length of hospital stay. Conclusions. S. pneumoniae resistance to penicillin did not affect the outcome of pneumonia in this group of children

Interleukin-18 in chronic joint diseases.

Interleukin-18 is a cytokine member of the IL-1 super family that seems to exert powerful Th1-promoting activities in synergy with IL-12. Here we describe the participation of IL-18 in inflammatory joint diseases, in particular rheumatoid arthritis, adult onset Still's disease and juvenile idiopathic arthritis. The emphasis of this study was to summarize in vivo and in vitro studies that focused the action of this pro-inflammatory cytokine on the arthritic process as well as its role in the complex network of chemical mediators involved.

Correlation between osteochondral changes depicted by magnetic resonance imaging and disease progression.

PURPOSE: To determine the consequences of the chronic use of systemic corticosteroids in children with juvenile rheumatoid arthritis by means of evaluating osteochondral effects depicted by magnetic resonance imaging. PATIENTS AND METHODS: We reviewed clinical and magnetic resonance imaging findings in 69 children (72 knees) with juvenile rheumatoid arthritis. Two groups were studied. Group I: 34 (49.3%) children had previous or current use of systemic corticotherapy (22 girls; 12 boys; mean age: 11.3 years; mean disease duration: 5.9 years; mean corticotherapy duration: 2.9 years; mean cumulative dose of previous corticosteroids: 5000 mg); Group II: 35 (50.7%) children had no previous use of corticosteroids (27 girls; 8 boys; mean age: 11.7 years; mean disease duration: 5.3 years). The groups were compared statistically. RESULTS: In the group that had received corticotherapy (Group I), osteochondral abnormalities were significantly correlated to long-standing disease (>3.5 years; p<0.001). This correlation was not found in the group that had no previous history of corticotherapy (Group II). No correlations were established between median dose of corticosteroids and magnetic resonance imaging findings. CONCLUSION: It is important to further investigate the long-term intra-articular effects of systemic corticotherapy to ensure that the side effects of the aggressive therapy will not be more harmful for the joints than the symptoms suffered over the natural course of the disease.

Juvenile rheumatoid arthritis of the knee: evaluation with contrast-enhanced color Doppler ultrasound.

BACKGROUND: Contrast-enhanced color Doppler ultrasonography is a non-radiation-bearing tool that can be of value for assessment of inflammatory and vascular synovial changes in juvenile rheumatoid arthritis (JRA). OBJECTIVES: To evaluate the effect of contrast-enhanced color Doppler ultrasound (US) in the evaluation of synovial changes in the knees of children with JRA. MATERIALS AND METHODS: Sagittal color Doppler sonograms of 31 knees in 22 patients with JRA and of 10 knees in 5 control subjects were obtained before (at baseline) and after (at peak contrast phase) intravenous injection of SHU 508. Images were assessed for overall mean pixel intensity within the synovial tissue and for peak enhancement ratios [[(mean pixel intensity values at maximum contrast enhancement-unenhanced mean pixel intensity values)/unenhanced mean pixel intensity values] x 100]. The joints were classified into three groups by clinical/laboratory criteria: group A (active disease in the knee), n = 9; group B (quiescent disease with serum chemistry levels of active disease), n = 12 and group C (remission disease), n = 10. RESULTS: Mean color pixel intensity values were markedly increased by the use of US contrast agents in groups A (P = 0.004) and B (P = 0.0001), did not reach statistical significance in group C (P = 0.06) and remained essentially unchanged in the control group (P = 0.25). Enhancement ratios for the three groups of JRA patients were not different (P = 0.38) (mean +/- SD, 720% +/- 402 for group A, 731% +/- 703 for group B and 314% +/- 263 for group C). CONCLUSION: Contrast-enhanced color Doppler imaging holds promise for the detection of active synovial inflammatory disease in subclinical cases of JRA, thereby allowing earlier treatment and improved clinical outcome.