Expectations in the Development of Computer Technology in Primary Care: A Multidisciplinary Delphi Study Among 23 French Experts.

The goal of this study was to determine a consensual proposition for the development of computer tools in primary care. A Delphi study using colored abaci was conducted among 23 French experts, some of whom were patients. The tools expected by the experts were: a customizable knowledge database integrated into an efficient clinical support system, a follow-up calendar designed as a collaborative patient-focused tool, and an information exchange data system.

[Aspects of pneumocystosis seen in a French pneumonology department in 1987-1988]. / Aspects des pneumocystoses observées dans un service de pneumologie français en 1987-1988.

Over a 2 years' period, 49 AIDS patients and 3 non AIDS patients were treated for pneumocystosis in our chest department. Forty-six were male and 6 were female. Pneumocystosis was the first opportunistic infection in 77 p 100 of patients. Fever above 38.5 degrees C was the major symptom in 92 p 100. Cough was present in 90 p 100 and dyspnoea in 94 p 100. Clinical symptoms had begun 21.7 +/- 15.7 days before diagnosis. Mean PaO2 value was 50.9 +/- 15.7 mmHg. Forty-eight patients were initially treated by daily intravenous administration of trimethoprim 960 mg and sulfamethoxazole 4,800 mg. Three patients received a pentamidine aerosol and one received DFMO. Treatment was effective in 39 patients; 11 patients died between the 5th and the 29th days of treatment; 2 had an early relapse. Fever disappeared after 9.8 +/- 6.6 days, and blood gases returned to normal within 10.8 +/- 7.7 days. All patients whose PaO2 was above 56 mmHg were cured. Thus, the trimethoprim-sulfamethoxazole combination proved active in the treatment of pneumocystosis. Other treatments are useful in case of side-effects or failure of the initial therapy. Failures can be suspected on the fourth day of treatment and in such cases CMV co-infection must be looked for and treated.

[Current aspects of bronchial tuberculosis]. / Les aspects actuels de la tuberculose bronchique.

The authors report a retrospective study of 34 cases of bronchial tuberculosis observed between 1981 and 1985 with precise endoscopic and histological data. Analysis of the population showed a male predominance (71 p. 100) and a high incidence of black Africans (54 p. 100), much higher than that observed in the general population of tuberculosis in our department (20 p. 100 of black Africans). Three groups of patients were identified with respect to age: group I, 23 patients aged 18 to 32 years; 22 of these patients were black Africans (98 p. 100) with primary tuberculosis; group II, 4 patients aged between 44 and 56: all were immunocompromised; group III, 7 patients over 65 years of age with reinfections: 6 of these 7 patients were French nationals. Apart from the specific problem of immunodepression observed in group II, two distinct features were identified: the primary lympho-bronchial infection of the young African and tuberculous bronchial reinfection of European women over of the age of 65.

[Routine use of 6-month antitubercular treatment in 300 patients]. / Application en routine d'un traitement antituberculeux de 6 mois chez 300 malades.

Over a 2-year period, all patients with incipient tuberculosis seen in a hospital unit were given a 6-month treatment consisting of rifampicine, isoniazide, pyrazinamide and ethambutol. A retrospective study of these 300 patients showed that the treatment was effective, with no failure if taken for more than 2 months. Relapses were rare when the drugs were taken regularly, the responsible M. tuberculosis strain was sensitive, and there was no associated malignancy (present in 1.4% of the cases). The drugs were moderately well tolerated, and treatment had to be modified because of side-effects in 4.6% of the patients. It also appeared that 57% of the patients fully complied with the prescription, and 16% were lost sight of by the hospital unit. Treatment was altered in 36% of the cases, but in 16% changes were introduced by private doctors for reasons which retrospectively proved to be without medical grounds. It is concluded that this 6-month chemotherapeutic regimen was effective in more than 98% of the cases, and that the main problem in management of tuberculosis is the patient's compliance with treatment.

A comparison of flunisolide inhaler and beclomethasone dipropionate inhaler in bronchial asthma.

Ninety-nine patients, who had never previously taken inhaled steroids were enrolled in a randomized, single-blind, parallel study, the aim of which was to compare the efficacy and safety of flunisolide inhalation, 500 mcg twice daily, with beclomethasone dipropionate inhaler 100 mcg four times daily for the treatment of chronic asthma. The treatment period was for 6 weeks. The patients were examined clinically at entry, week 3 and week 6 and both treatment groups showed a marked improvement in almost all parameters during the course of the study. Flunisolide was statistically significantly superior to beclomethasone dipropionate for wheezing at week 6, coughing at week 6 and chest tightness at weeks 3 and 6. The number of asthma attacks per day decreased significantly more with flunisolide treatment than with beclomethasone dipropionate. The over-all evaluation of efficacy by both doctors and patients also showed flunisolide to be superior to beclomethasone dipropionate. In several other parameters there was a trend shown favouring flunisolide, and beclomethasone dipropionate did not show a superiority over flunisolide in any efficacy parameter. Both drugs were well-tolerated, with unpleasant taste being the most frequent complaint in the flunisolide group. No patient in either group withdrew from the study because of adverse events. In this study, flunisolide inhaler was more effective than beclomethasone dipropionate inhaler for the treatment of chronic asthma exhibited by patients who had never been treated with inhaled steroids.

The management of thirty immunocompromised patients with tuberculosis.

Between 1978 and 1981, 30 of 870 bacteriologically confirmed cases of tuberculosis occurred in immunocompromised hosts. One year after the diagnosis, 11 patients were dead, only 2 of them of tuberculosis. In the other 19 patients, the course of tuberculosis under standard chemotherapy was the same as in nonimmunocompromised hosts. Among the 24 patients still alive more than 2 months after the diagnosis of tuberculosis, the treatment of the underlying disease was changed in 14 patients to avoid worsening of the course of tuberculosis; 5 patients died and 4 kidney transplant carriers rejected their transplants. The treatment of the underlying disease was not changed in 10 patients: all of these remained alive 1 yr later, and 2 were kidney transplant carriers who did not reject their transplants. We conclude that the clinical response of the immunocompromised tuberculous host was good and that treatment of the underlying disease should not be modified.

[Mycobacterioses]. / Les mycobactérioses.

Mycobacteriosis are opportunistic infections caused by atypical mycobacteria. These have microscopic features resembling those of tubercle bacillus but differ in their cultural and biochemical characteristics and above all, their resistance to antituberculous antibiotics. The lesions chiefly involve the lungs, the lymph nodes or the skin and usually mimick those of tuberculosis. The diagnosis rests on repeated isolation in pathological specimens of the same atypical mycobacterium with a sufficient number of colonies, or on its sole presence in effusion fluids, biopsies or surgical specimens. Treatment with antibiotics is disappointing, except for M. kansasii. Surgical treatment can only be considered in those exceptional cases when the patient is young, has limited lesions and is not immuno-depressed.

[Results of antibiotic sensitivity and "Streptococcus pneumoniae" serotype tests in the Pitié-Salpêtrière hospital, France, 1979-1980 (author's transl)]. / Surveillance de la sensibilité aux antibiotiques et sérotypage de Streptococcus pneumoniae à la Pitié-Salpêtrière (1979-1980).

Among 244 strains of S. pneumoniae, 24% are resistant to tetracycline, 10% to sulfamethoxazole-trimethoprim (SMZ-TMP) and 1.6% to erythromycin. A low grade resistance to penicillin G is observed in two strains (MIC 0,12 and 0,3 mg/l). Clinical correlations indicate that only 48% of the S. pneumoniae isolated are undoubtedlzy responsible for bacterial infection. The serotypes isolated from blood cultures and from other specimens are not statistically different. Only 67% of the strains belonged to serotypes included in the 14-valent vaccine.

[Continuous non-invasive monitoring in respiratory resuscitation]. / Méthode de surveillance continue non sanglante en réanimation respiratoire.

Non-invasive methods of monitoring have two principal objectives: --the detection of vital problems requiring immediate treatment : reflex monitoring or type I; --continuous surveillance, as sophisticated as possible, of a large number of parameters which help to predict the outcome either spontaneously or as a result of treatment. These two objectives are reached in different ways according to whether the patients are or are not artificially ventilated. At present it seems that the best compromise between cost, ease of operation, reproducibility and non-invasiveness are obtained by the following techniques: --type I Monitoring (reflex) in patients artificially ventilated : pressure or spirometric alarm; if spontaneously breathing : electrical impedance or simple E.C.G.; --type II Monitoring (or reflection) in patients on ventilators : study of expired CO2, careful analysis of pressure curves, compliance; for those breathing spontaneously : PO2 and PCO2 picked up transcutaneously and possibly impedance of the lungs separately.

[Acute mercury vapour poisoning (author's transl)]. / Intoxication aiguë par inhalation de vapeurs de mercure.

Two persons, exposed to high concentration of mercury vapour in their home developed a few hours later febrile illness with interstitial pneumonitis and mercurial stomatitis. Symptomatic treatment was associated with dimercaprol (BAL) and steroïds; an alveolar washing was performed to remove non-absorbed mercury in the respiratory three which seems to be responsible for the observed inflammatory reaction and, sometimes, the delayed development of fibrosis. A review of the literature revealed that such intoxications had been previously described in about 20 cases. Prognosis depends on the severity of the pulmonary lesions. Fatalities have been described in 9 cases (10%); in 8 cases the victims were young children or old people. An acute gingivo-stomatitis is generally observed. The onset of mercurial encephalopathy is an uncommon feature. Renal disturbances are exceptionally described and always mild. There is no correlation between the clinical condition of the patient and the levels of mercury in the urine.

[Transcutaneous measurement of pO2.(author's transl)]. / Mesure de la pO2. par voie transcutanée (tcpO2).

An apparatus which allowed the measurement of transcutaneous paO2 (tcpO2) was tested on adults in an intensive care unit. The correlation between tcpO2 and blood paO2 was satisfactory (r = 0.91, n = 111), but the slope of the regression line was variable from one subject to another. On account of the poor transfer of information from the arterial blood to the skin surface, this slope could be very flat (0.43 in one of the subjects in the study). The response time of the apparatus was very short and allowed a study of the effect on the individual of variations in FIO2. The equipment appears useful for continuous non invasive monitoring of the progress of the pO2, but it cannot directly give the true value of the paO2.