[Acute pulmonary edema caused by tocolytic therapy with salbutamol]. / Oedème pulmonaire aigu induit par le salbutamol à visée tocolytique.

BACKGROUND: Acute pulmonary edema may be induced by beta 2-mimetics used for tocolysis. CASE REPORT: A 41-year-old patient, admitted for preterm labor, presented acute pulmonary edema after parenteral tocolysis using salbutamol in combination with corticosteroid therapy to improve fetal pulmonary maturation. DISCUSSION: The pathogenic mechanism is essentially non-cardiologic. Fluid retention is probably the main cause, potentially worsened by corticosteroid administration. If detected early, pulmonary edema is usually and adequately treated by cessation of beta 2-sympathomimetic therapy, oxygen administration and diuretics. Mechanical ventilation can be required. Cardiac function must be assessed after this complication. In preterm labor, the duration of tocolysis with beta 2-sympatomimetics should be reduced.

[Community-acquired Acinetobacter baumannii pneumonia]. / Pneumopathie communautaire à Acinetobacter Baumannii.

We report two cases of community-acquired Acinetobacter baumannii pneumonia. Although most infections occur in hospitalized patients, a few cases of community-acquired pneumonia have been described. This disease occurs predominantly in men, and is often associated with underlying conditions such as cigarette smoking, alcohol abuse, diabetes mellitus, and chronic pulmonary diseases. Community-acquired Acinetobacter baumannii pneumonia cases are generally reported from tropical areas, especially during wet season. Microbiological identification in blood or sputum can be difficult because of frequent misinterpretation and possible confusion with Staphylococcus or Haemophilus infuenzae or neisseriae. Early antibiotherapy is required because of the fulminant clinical course, with approximatively 50% fatality rate.

[Massive paraquat poisoning. Favorable course after treatment with n-acetylcysteine and early hemodialysis]. / Intoxication grave par le paraquat. Evolution favorable après traitement par acétylcystéine et hémodialyse précoce.

Case report of a 30-year-old patient, admitted one hour after an intentional ingestion of paraquat (60 g). The initial treatment included gastric washing, parenteral n-acetylcysteine and forced diuresis. Considering the severity of the intoxication, conventional haemodialysis was started four hours after the ingestion. Plasma concentrations of paraquat, in the lethal range at admission, decreased rapidly and significantly after haemodialysis. This case raises the question of the part played by n-acetylcysteine and haemodialysis respectively in a favourable outcome. As the determination of paraquat blood concentrations requires some delay, these data are of no help for therapeutic decisions. Therefore, in cases of massive poisoning or uncertainty of the ingested dose, a technique of blood purification in indicated. Charcoal haemoperfusion is the most efficient, however conventional haemodialysis, which is more widespread, should be considered if the former is not available.

Early dermabrasion of deep dermal burns with sandpaper. Case reports.

Deep dermal burns are initially difficult to evaluate, and they sometimes heal spontaneously. We present our experience of dermabrasion with sandpaper in four patients. It is a useful alternative to early excision of the scar. Skin grafts are not always required and the aesthetic results are excellent. Dermabrasion should be considered routinely for all deep dermal burns and particularly for facial burns and those caused by scalds.

[Acute renal insufficiency and cerebral infarction during high-dose intravenous immunoglobulin therapy]. / Insuffisance rénale aiguë et infarctus cérébral au décours d'un traitement par immunoglobulines intraveineuses à fortes doses.

INTRODUCTION: Side-effects of immunoglobulins administered via the intravenous route are usually minor. However, acute renal failure and more rarely thrombotic events, including ischemic stroke, have been reported in association with immunoglobulin infusion. To our knowledge, no case of both acute failure and stroke following immunoglobulin has been described until now. EXEGESIS: Two days after immunoglobulin infusion (2 g/kg), a patient who presented with autoimmune thrombocytopenia suffered severe acute renal failure associated with an ischemic stroke in the right anterior choroid artery territory. Moreover, the stroke worsened immediately following a second infusion (1 g/kg). Clinical and neuroradiological examinations were conducted. CONCLUSION: Results indicate the need for both close monitoring of serum creatinine and diuresis before starting immunoglobulin therapy, and limiting the total dose to prevent thrombotic events such as stroke.

[Extensive cerebral venous thrombosis resistant to heparin: local fibrinolysis with urokinase]. / Thrombose veineuse cérébrale étendue résistante à l'héparine: fibrinolyse locale par urokinase.

A 37 year-old man had headaches for 10 days, then a single tonic-clonic seizure and coma due to an extensive cerebral venous thrombosis. In spite of full-dose heparin treatment for 7 days, the clinical picture worsened along with increasing edema on CT-Scan. Direct thrombolytic treatment was then performed using transvenous catheterization and instillation of Urokinase (2.6 MU over 4 days). A near complete repermeabilization of the sinuses was obtained and the patient improved dramatically in a few days. The only adverse effect of Urokinase was hematuria. Based on our experience and review of the literature which includes 26 previous cases, direct thrombolytic therapy appears to be a relatively safe procedure. This treatment should be considered in a patient with extensive dural sinus thrombosis which fails to respond to heparin treatment.

Nosocomial infections in a thirteen-bed critical care unit in Matinique: epidemiology and cost analysis - abstract

The aim of our study was to analyse the problems caused by nosocomial infections (NI) in our intensive care unit (ICU). 239 patients admitted between January and June 1995 were included in the study. 33 episodes of nosocomial infection were diagnosed in 19 patients (7.9 percent). The overall incidence of NI was 13.9 percent. Lower respiratory tract infections were the most common (6.3 percent). Patients infected on admission to the ICU had more NI than other patients (odds ratio = 3.42, 95 percent confidence interval 3.28 - 4.52, p< 0.05). Gram negative bacteria were involved in 73.2 percent of NI. Acinetobacter baumanii and Peudomonas aeruginosa were responsible, respectively, for 22.4 percent and 25.4 percent of NI. The additional cost due to NI was 33 percent for laboratory investigations and 34 percent for antibiotics. After analysis of our results, our recommendations are a cautious use of antibiotics, more efficient diagnostic tools and particular care in preventing cross contamination of our mostly severely ill or infected patients. (AU)

[Retinal vein occlusion and deep-sea diving]. / Occlusion veineuse rétinienne et plongée sous-marine.

We report a case of retinal vein occlusion after breath-holding diving. After one hour of diving at a maximal depth of eight meters, each apnea no longer than one minute, the patient complained of a diminution of the visual acuity in the left eye. Ophthalmological examination revealed an occlusion of the superior branch of the central vein of the retina in the left eye. This could be considered as a decompression sickness even if the occlusion could happen fortuitously in water. Secondary to the multiple descents, a bubble would have appeared in the vein leading to an obstruction. The purpose of this paper is to discuss a possible link between the breath-holding diving and this kind of accident. We also report the different ophthalmological features that may occur while diving.

Early dermabrasion for deep dermal burns by means of sandpaper

Deep dermal burns are initially difficult to evaluate. They sometimes even undergo spontaneous healing. We present our own experience concerning the use of dermabrasion with sandpaper, a veritable alternative to early scar excision. Skin grafts are not always called for. The aesthetic results are excellent. Dermabrasion should be systematically considered for all deep dermal burns and particularly for scalding burn mechanisms or facial burns (AU)

[Inhaled nitric oxide test for patients with stable chronic obstructive pulmonary disease: value and feasibility]. / Test au monoxyde d'azote chez l'insuffisant respiratoire chronique à l'état stable: intérêt et faisabilité.

Patients suffering from chronic lung disease (CLDP) often develop secondary pulmonary hypertension (HP), which contributes to right ventricular dysfunction and worsens their prognosis. In order to evaluate the severity of this HP, pharmacodynamics tests are periodically proposed to these patients. Therefore, the administration of vasodilators is limited by systemic and pulmonary side-effects. Inhaling nitric oxide gas (NO) has been reported to induce a selective pulmonary vasodilation. The purpose of this study was to evaluate the safety and efficacy of an inhaled NO test perfected in our service. Sixteen CLDP were investigated in the absence of acute pulmonary failure. All had severe pre-capillary HP, confirmed after placement of a thermodilution pulmonary-artery catheter (mean pulmonary artery pressure >20 mmHg, pulmonary capillary wedge pressure >12 mmHg). Each subject breathed spontaneously NO in a concentration of 10 ppm for 15 minutes. They were connected through a facial mask and a one-way valve put on the inspiratory connection of a ventilator (Drager-Evita), to a tank of nitrogen with a NO concentration of 900 ppm. Hemodynamic variables and gas exchange were measured before, during and after gas inhalation. The inspired fractions of NO and NO2 were determined using a Polytron analyser (Drager). The methemoglobin levels were measured with spectrophotometry (OSM3). Inhaled NO acts as a selective pulmonary arterial vasodilator, without systemic effect. The action on the shunt is variable. Methemoglobin levels are remained <0.01%. All the patients were satisfied with the way of NO administration. In view of the lack of systemic effects, its seems that the NO inhaled test proposed in this study may be used accurately to evaluate the HP of chronic lung disease patients.

[Nursing care evaluation, how to measure it and why?]. / La charge en soins infirmiers, comment la mesurer et pourquoi?

Quality of care assessment is based on three main prerequisites: to describe precisely patients or case-mix, to measure the level of care, to evaluate the outcomes and finally to consider the relationships between these parameters. Indicators to measure the level of nurses' workload have been developed from different concepts and methodologies: The range of nurses' activities is very wide, such as cares achieved in the presence of patient, cares achieved after medical prescription or specific nurse cares, administrative tasks, research activities, etc. Indicators may take into account a more or less important part of this field, but most of them are usually focused on patient's care. The value of each parameter may be a calculated coefficient or a time unit. If one considers the time as the best unit to measure the intensity of work, it is also an underlying concept to differentiate the actual time, obtained by timing, from the required time, necessary to achieve correctly the action. In the same way, required cares are also the best to consider. Indeed measuring required time for required cares is necessary to reach quality aim. The nurses' workload may be directly calculated with a specific indicator or indirectly estimated from a severity or disability scoring system. The selection of the indicator depends of the purpose of the evaluation process. If the question is to improve and develop quality of care and professional practices, the indicator has to take into account the required cares. The PRN system (Project de Recherche en Nursing) developed in Canada is probably the reference indicator. However this score is complex and cannot be daily used.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnostic value of direct examination of the protected specimen brush in ventilator-associated pneumonia.

Interpretation of the protected specimen brush (PSB) technique is based on quantitative bacterial cultures (QC), which unfortunately requires at least 24 h. We prospectively compared the diagnostic value of direct examination (DE) and QC of PSB specimens in 75 patients with suspected pneumonia. We also determined the optimal technique for DE. QC was performed using the serial dilution technique. From the original suspension, two cytospin slides were obtained and stained by the May-Grünwald Giemsa (MGG) and the Gram method for DE. If the prescreening on the MGG-stained slide was positive, the morphology and the Gram staining of the organisms were assessed on the Gram-stained slide. Using the 10(3) colony forming units (cfu.ml-1) threshold for defining PSB as positive or negative, DE had a sensitivity of 85% and a specificity of 94%. In a parallel in vitro study, 18 pairs of PSB specimens were collected from respiratory secretions inoculated with S. aureus. From each pair, one brush was processed as described above and the other was smeared on a glass slide prior to performance of QC. Using direct smear instead of cytocentrifuged preparation, slightly but significantly affected QC. Direct examination of cytospin slides is highly predictive of quantitative bacterial culture results, and provides rapid information regarding the Gram-stain morphology of the causative organisms. It may therefore guide initial therapy.