Effects of HIV protease inhibitors on cardiac conduction velocity in unselected HIV-infected patients.

We examined the prevalence and the extent of prolongation of the PR and QRS intervals and their relation to anti-HIV treatments and other clinical characteristics in 970 HIV-infected patients, 749 treated with antiretroviral therapy and 221 untreated. Age, body mass index, heart rate, and treatment with ß-blockers and HIV protease inhibitors (PIs) were independent predictors of increase in the duration of the PR interval. Male gender, Caucasian ethnicity, heart rate, duration of antiretroviral therapy, and use of PIs were independent predictors of an increase in the duration of the QRS interval. Users of HIV PIs had an adjusted QRS-interval duration that was 2.6 ms (95% confidence interval (CI) 1.4-3.9) longer than the interval in nonusers (P = 0.0004). The adjusted odds ratios of first-degree atrioventricular block (n = 54) and complete bundle branch block (n = 23) were 1.62 (95% CI 0.90-2.89; P = 0.10) and 2.71 (95% CI 1.10-7.13; P = 0.03), respectively, in patients taking PIs. These findings may have important clinical implications, particularly with respect to QRS prolongation in patients with myocardial ischemia or heart failure.

Comparison of long term outcome in patients with or without aortic ring abscess treated surgically for aortic valve infective endocarditis.

OBJECTIVE: To assess the long term prognostic significance of aortic valve ring abscess in patients with aortic endocarditis. PATIENTS: A consecutive series of 75 patients who had surgery for aortic infective endocarditis between 1981 and 1989; 35 had aortic ring abscesses (group 1) and 40 did not (group 2). Mean age did not differ between the two groups. Prosthetic valve endocarditis was present in 17% of group 1 and 5% of group 2. Pneumococcal or beta haemolytic streptococcal endocarditis was more common in patients with native valve endocarditis who had aortic ring abscesses (20% v 5%). DESIGN: Cohort analysis. RESULTS: In-hospital mortality (11.4% v 7.5%) and 10 year survival (56% v 66%) were not significantly different between groups 1 and 2. In patients with native valve endocarditis, 10 year survival was 62% and 66%, respectively for patients with or without ring abscess, and 10 year reintervention-free survival was 38% v 58% (p = 0.11). In these patients, the presence of an intercurrent illness, severe congestive heart failure before surgery, and use of valved conduits for surgical treatment were predictors of poorer long term survival. At follow up residual aortic regurgitation was documented in 72% of patients in group 1 and 26% in group 2 (p < 0.01). CONCLUSIONS: Aortic valve ring abscess is not an independent marker of poor long term outcome in patients with infective endocarditis. However, as residual aortic regurgitation appears frequent at follow up, specific surgical techniques should be considered in patients with paravalvar abscesses.

[Endocarditis caused by heart valve prosthesis. Apropos of 35 cases]. / Endocardites sur prothèse valvulaire. A propos de 35 observations.

35 cases of prosthetic valve endocarditis are reported. The diagnostic is based on clinical, echocardiographic, bacteriological and anatomical aspects. Heart failure, neurologic complications, positive culture of prosthesis, Staphylococcus aureus infection and perivalvular abscess are factors of a bad prognosis. The current therapeutic trends associate antibiotic treatment and infected prosthetic valve replacement rather for hemodynamic indications than bacteriological factors. General prognosis has a mortality of 40 p. cent. Prophylaxis of infection, although simple is necessary.

[Screening for a frequent cardiac disorder: mitral valve prolapse]. / Dépistage d'une anomalie cardiaque fréquente: le prolapsus valvulaire mitral.

Mitral valve prolapse (MVP) screening using bidimensional echocardiography was performed on 171 healthy subjects from Lorraine of both sexes, aged 20 to 60 years. Six men and seven women presented this valvular disease. In the Lorraine population, the estimated prevalence of MVP was 7.6% (95% confidence interval: 3.6-11.6%). In this study, only seven cases of MVP had a cardiac auscultation suggestive of MVP. As compared with echocardiography, clinical screening of MVP had a low validity (sensibility 54%, specificity 69%) and a poor positive predictive value (12.5%). Because MVP has severe complications, and because clinical screening has a low performance, a strategy of screening with bidimensional echocardiography could be interesting.

[Palmaz's vascular intraluminal stent. Preliminary results]. / Endoprothèses vasculaires de Palmaz. Résultats préliminaires.

Palmaz's stent is a fenestrated, expansible metallic stent with an apparently small tendency to thrombogenesis, so that anticoagulants are necessary only during the preintimalization period. This stent has recently been introduced in human pathology and has been used in this study for percutaneous or surgical correction of residual or recurrent post-angioplasty lesions. The development, theoretical indications and preliminary results obtained with the insertion of 25 Palmaz's stents into peripheral arteries are presented.

[The combination of penicillin G and ofloxacin: a response to the empirical treatment of community acquired pneumonia]. / L'association pénicilline G-ofloxacine: une réponse au traitement empirique des pneumopathies communautaires.

The aim of this study was to assess the clinical efficacy of a combination of penicillin G and ofloxacin in the treatment of community acquired pneumonia. Thirty eight patients (23 males, 15 females, mean age 62.8 years +/- 19.6) were included. They presented a CAP with the following criteria: fever, abnormal chest X-ray pattern. They received the combination of IV penicillin 12 x 10(6) U daily and IV ofloxacin 200 mg bid. After 48 hours of apyrexia, this treatment was followed by oral ofloxacin alone 200 mg bid. In six cases, the etiologic agent was identified: 2 S. pneumoniae, 1 Chlamydiae psittaci, 2 Staphylococcus aureus, 1 Mycoplasma. In 32 cases, the bacteriological investigation was negative. Five patients were excluded: 2 deaths due to heart failure, 3 alterations of treatment. Twenty eight patients recovered: apyrexia was obtained in 3.5 days. Penicillin G was prescribed for 7.5 days +/- 2.65, followed by ofloxacin alone for 11.43 +/- 3 days. Five patients were considered as clinical failures: 2 deaths due to extensive pneumonia, 3 recoveries after alteration of treatment. Side effects were rare: 1 confusion, 2 skin rashes. As a conclusion: penicillin G and ofloxacin in combination for the initial therapy of CAP, rapidly relayed by ofloxacin alone, permitted 84.3% of recovery in our patients.

Penetration of ciprofloxacin into heart valves, myocardium, mediastinal fat, and sternal bone marrow in humans.

The penetration of ciprofloxacin into heart tissue (valve and myocardium), mediastinal fat, and sternal bone marrow was the object of a prospective nonrandomized study involving 36 patients undergoing mitral and/or aortic valve replacement. Patients were divided into two groups of 18. Group 1 patients were administered a single 400-mg intravenous dose of ciprofloxacin over a 1-h period. Group 2 patients received a 750-mg dose of ciprofloxacin orally every 12 h over the 48-h period preceding surgery. In this group, the last dose of ciprofloxacin consisted of an intravenous infusion of 400 mg. Concentrations of ciprofloxacin in plasma and tissue were assayed by high-performance liquid chromatography. Peak and trough levels in plasma were, respectively, 6.19 +/- 1.73 and 0.54 +/- 0.25 micrograms/ml in group 1 patients and 11.59 +/- 3.95 and 0.89 +/- 0.57 micrograms/ml in group 2 patients. Levels of ciprofloxacin in plasma remained significantly higher in group 2 than in group 1 until 12 h postinfusion (P less than 0.05). Concentrations of ciprofloxacin in heart valves and myocardia rose rapidly by 1 h postinfusion and remained greater than the MICs for usually susceptible pathogens for at least 5 h. Peak concentrations in myocardia were achieved by hour 1 and were 31.6 +/- 25.0 micrograms/g for group 1 and 21.8 +/- 13.0 micrograms/g for group 2. Peak concentrations in heart valves, achieved between hours 1 and 3, were 5.8 +/- 3.2 and 8.3 +/- 3.1 micrograms/g for groups 1 and 2, respectively. In both groups, peak concentrations in mediastinal fat were lower and achieved later. These were 3.1 +/- 3.8 micrograms/g in group 1 and 2.0 +/- 1.8 micrograms/gram in group 2 and were achieved between hours 3 and 5 and hours 1 and 3, respectively. In conclusion, the good diffusion of ciprofloxacin into heart tissue warrants its use for the treatment of bacterial endocarditis. On the other hand, low and delayed concentrations in mediastinal fat could limit its value as an antibiotic prophylactic agent in a cardiovascular surgical setting when administered immediately (less than 3 h) before surgery.

[Role of laser angioplasty in the management of peripheral arteriopathies. Report of 79 cases]. / Place de l'angioplastie-laser dans la prise en charge des artériopathies périphériques. A propos de 79 cas.

From May 1988 to November 1989, 79 of the 341 patients admitted to our center requiring angioplasty for peripheral artery disease were treated by laser angioplasty (LA) associated with secondary dilatation. Laser angioplasty was performed with and Nd-YAG laser coupled by an optical fiber to 1.8, 2.2 and 3 mm sapphires. The population studied included 64 men and 15 women (mean age: 66 years). Functional outcome before LA was class II in 85% of cases (n = 67) and class III and IV respectively in 10 (13%) and 2 patients. Laser angioplasty was the primary indication in 61 patients (77%) with a femoropopliteal (n = 53), iliac (n = 7) or axillary (n = 1) arterial obstruction. Laser angioplasty was the secondary indication in stenoses which could not be negotiated by a guide or balloon (23%; n = 18). Laser angioplasty led to repermeabilization of arterial occlusions in 82% of cases. The best results were obtained for short occlusions of less than 3 cm (n = 5; 100%) and for femoropopliteal lesions (n = 60; 85%). Stenoses were revascularized in all cases. Complementary dilatation was performed at the same time in all revascularized patients. Forty-seven revascularized patients were followed up 3 to 6 months after LA. Results were good in 36 cases (77%); restenosis occurred in 7 cases (15%); and reocclusion in 4 cases (8%). It was possible to treat all restenoses percutaneously (dilatation: n = 5; extruder: n = 1; stent: n = 1).(ABSTRACT TRUNCATED AT 250 WORDS)

[In vivo bactericidal effect of ciprofloxacin, ofloxacin and pefloxacin against Staphylococcus aureus]. / Etude de l'activité bactéricide in vivo de la ciprofloxacine, de l'ofloxacine et de la péfloxacine vis-à-vis de Staphylococcus aureus.

The bactericidal activity of ciprofloxacin, ofloxacin, pefloxacin, against methicillin sensitive S. aureus (2 different strains) was studied on a model of infected fibrin clots inserted subcutaneously in rabbit. The quinolones were delivered intravenously, as a single daily dose of 100 mg/kg/day. The bactericidal activity was evaluated by determining for various time points (1 h, 2 h, 6 h, 12 h, and 24 h after the infusion of the antibiotics), viable organisms in the dissolved clots. This study shows that: 1) No significant difference appears between the quinolones studied. 2) The in vivo early bactericidal activity of quinolones against S. aureus appears to be better than oxacillin but lesser than oxacillin-netilmicin combination.

Mitral valve prolapse as a risk factor for infective endocarditis.

The frequency of mitral valve prolapse was assessed in 48 patients with mitral valve endocarditis and in 96 controls matched for age and sex, attending a routine family screening clinic or having surgery of the limbs. The frequency of mitral valve prolapse in cases with endocarditis (9 of 48 patients) was more than three times that in controls (6 of 96) (odds ratio 3.5; 95% confidence interval [CI] 1.1-10.5). When patients with rheumatic heart disease, an established risk factor for infective endocarditis, were excluded from the study group, patients were nearly six times more likely to have infective endocarditis than were controls (odds radio 5.7; 95% CI 1.8-18.4). However, a higher risk of infective endocarditis was seen only in the subjects with mitral valve prolapse and a previously known systolic murmur (odds ratio 14.5; 95% CI 1.7-125). The results indicate that mitral valve prolapse constitutes a true risk factor for infective endocarditis only when associated with the presence of a precordial systolic murmur.

Significance of spontaneous obstruction of high degree coronary artery stenoses between diagnostic angiography and later percutaneous transluminal coronary angioplasty.

Among 265 patients with severe coronary artery stenoses amenable to percutaneous transluminal coronary angioplasty, 13 (5%) developed new total coronary occlusion of the vessel to be dilated during the period between diagnostic coronary angiography and repeat coronary angiography at the time of the operation. Time from diagnostic to "therapeutic" angiography (76 +/- 74 vs 31 +/- 31 days, p less than 0.0001), degree of coronary stenosis on diagnostic angiography (85 +/- 7 vs 80 +/- 8%, p less than 0.05) and impaired coronary flow distal to the narrowing (Thrombolysis in Myocardial Infarction grade 2: 38 vs 10%, p less than 0.01) were the only variables related to the occurrence of spontaneous coronary occlusion. The clinical course of the patients who developed new total coronary occlusion was remarkably favorable. Twelve of the 13 patients had unchanged or improved anginal symptoms. The electrocardiogram at rest remained unchanged in 11 patients and there was no transmural myocardial infarction. Eight patients had 2 ventriculograms and the mean ejection fraction remained unchanged (only 2 patients had greater than 5% decrease in ejection fraction between the 2 examinations). Spontaneous occlusion of high degree coronary artery stenoses is not unusual and is usually well tolerated, presumably due to the development of collateral circulation.

[In vivo bactericidal activity of an oxacillin-netilmicin combination against Staphylococcus aureus. Influence of the rhythm of netilmicin administration]. / Etude de l'activité bactéricide in vivo de l'association oxacilline-nétilmicine vis-à-vis de Staphylococcus aureus. Influence du rythme d'administration de la nétilmicine.

The bactericidal activity of two regimens of netilmicin (8 mg/kg/day) given intravenously once a day (od) or thrice daily (tid) both alone and in combination with oxacillin (200 mg/kg/day) was compared using a model of fibrin clots infected with a strain of Staphylococcus aureus (10(7) CFU/g) sensitive to methicillin and netilmicin (clinical isolate) and implanted subcutaneously in rabbit. This study shows that: 1) Netilmicin given alone as both single and divided doses results in early bacterial killing but does not exert a bactericidal effect after 24 hours because of a significant late increase of the number of bacterial. 2) The netilmicin-oxacillin combinations are more bactericidal at 1 h, 2 h and 24 h than oxacillin alone (P less than 0.001). 3) The oxacillin-netilmicin combination appears to be better for bacterial killing when netilmicin is given thrice daily (P less than 0.001). It is hard to draw a clinical inference from such an experimental study but it seems that 8-hour divided doses intervals should be better for administration of netilmicin than single daily dose during the acute period of staphylococcal infections.

[Pyoderma gangrenosum: treatment with plasma exchange (4 cases)]. / Pyoderma gangrenosum: traitement par échanges plasmatiques (4 cas).

Four patients with pyoderma gangrenosum were treated by plasma exchange. The series included one woman (cervical localization) and three men (sural localization in 1 case, multiple trunk and facial localizations in the second case and multiple, recurrent localizations on trunk and limbs in the third case). In 2 cases another disease was associated (ulcerative colitis in 1 case and Crohn's disease in the other). Between 6 and 12 plasma exchange sessions were carried out in combination with corticotherapy (1/2 mg/kg/day). Results in 2 cases were rated as very good: progression of the disease interrupted and no further pain after the 1st plasma exchange, rapid healing of lesions (a skin graft was necessary for a lesion of hand exposing tendons). A good result was obtained in the 3rd case with interruption of progression of lesions after the 1st plasma exchange but slower relief of pain. Treatment was considered a failure in the 4th case since there was no obvious regression in lesions or pain. Three of the 4 patients had no recurrences, one patient developing recurrences on 4 occasions responding well to plasma exchange each time. Pyoderma gangrenosum is a good indication for use of plasma exchange, which limits extension of ulcerating lesions, suppresses or reduces pain and decreases esthetic prejudice.

[Bases of antibiotherapy in neuromeningeal infections]. / Bases de l'antibiothérapie des infections neuro-méningées.

An early treatment and an adequate antimicrobial chemotherapy are major prognostic factors for bacterial meningitis, brain abscesses and related infections. The necessity of an early therapy requires to begin an empiric antibiotic treatment prior to obtain microbiological results. The principles that apply to empiric therapy of other types of infections are equally applicable to the treatment of central nervous system (CNS) infections and include: the capacity of achieving adequate levels of antibiotic in the CNS and for the brain (pharmacokinetic criteria), the knowledge of the most likely etiologic agents for central nervous system infections and their antibiotic susceptibility (bacteriological criteria). The main clinical types of CNS infection are reviewed for their usual etiologic agents, with a definition of an optimal "bacteriological deal" for each situation. Most studies emphasize the striking differences in the clinical features, etiologic agents and prognosis of spontaneously occurring (primary) meningitis, as opposed to post-traumatic or post-surgical, frequently Gram negative bacillary (secondary) meningitis and other CNS infections (brain abscesses and related infections). These studies, as our experience, suggest that the selection of an empiric therapy must be adapted for each clinical situation. Ampicillin still appears to be an ideal agent for empiric therapy for primary meningitis in older children and adults, in whom meningitis are usually caused by N. meningitidis and S. pneumoniae. In younger children (before 6 years), H. influenzae is more often implicated and the occurrence of beta lactamase mediated resistance to ampicillin in as high as 15% of isolates led to use a third generation cephalosporin as an empiric therapy. Neonatal meningitis, meningitis following trauma or surgery, brain abscess, subdural empyema, epidural abscess are caused by various etiologic agents including Streptococcus sp, Staphylococcus sp, Enterobacteriaceae, and for brain infections, anaerobic bacteria. Each situation led to specific recommendations by authors. Finally, miscellaneous aspects of therapy as the usefulness of intrathecal or intraventricular therapy, duration of treatment and place of the neuro-surgery during CNS infections are briefly reviewed.

Staphylococcus aureus mediastinitis: prognostic usefulness of an early medicosurgical therapy.

Six cases of acute Staphylococcus aureus mediastinitis after median sternotomy were reported. Five resulted from an asymptomatic disseminator of S aureus present in the operating room. Each case was characterized by an acute bacteremic phase, occurring after a mean interval of 8.2 +/- 1.7 days after the surgical procedure; within 24 to 36 hours all patients had a temperature above 39 degrees C, toxic appearance, and marked leukocytosis. Pericicatricial inflammation was moderate, instability of the sternum was present in only two patients, and chest roentgenogram was not helpful in making an early diagnosis. No risk factor for mediasinitis in connection with the perioperative or postoperative periods was noted in cases compared with a control group of 103 patients. All strains of S aureus were susceptible in vitro to the antibiotic regimen used in prophylaxis. All patients underwent early surgical reopening of the mediastinum within 47 +/- 15 hours after the first sign of acute mediastinitis. Mediastinal debridement and continuous irrigation-suction with dilute povidone-iodine solution were associated with intravenous antistaphylococcal therapy for a period of four to six weeks. All patients survived and no recurrence was observed, a finding we think due to early diagnosis and aggressive medicosurgical therapy.

[Treatment of post-traumatic and post-neurosurgical bacterial meningitis with ceftriaxone alone or in combination with fosfomycin]. / Traitement des méningites bactériennes post-traumatiques et post-neurochirurgicales par la ceftriaxone seule ou en association avec la fosfomycine.

From 1984 to 1986, 13 patients (10 adults, 3 children) with bacterial meningitis following neurosurgery or traumatism were given ceftriaxone alone 6 times at a dose of 40 mg/kg one IV injection per day, or in association 7 times with fosfomycin at a dose of 200 mg/kg/day, 3 IV perfusions every 4 h. The bacteriological diagnosis was confirmed in 9 cases (3 Staphylococcus aureus, 4 Streptococcus pneumoniae, 1 Klebsiella, 1 Peptococcus). In vitro neither synergy nor antagonism were observed between the two antimicrobial agents. The acute infections episode resolved in all patients except on who died with a negative CSF culture. One superinfection meningitis with Achromobacter was seen. CSF concentrations of ceftriaxone were assayed and found to be comparable with those reported by most authors. Tolerance was excellent for all our patients.

Localized hypertrophic osteoarthropathy due to arterial graft sepsis from an enteroprosthetic fistula.

The case of a 73-year-old man with localized left-lower-limb hypertrophic osteoarthropathy in association with aortic left-iliac-artery bypass and enteroprosthetic fistula was studied. The patient presented first with massive gastrointestinal bleeding and with pain and swelling of his left leg. He was hospitalized on numerous occasions for recurrent episodes of bacteremia involving enteric flora; hypertrophic osteoarthropathy and aortoduodenal fistula were documented before surgery. Symptoms and signs of hypertrophic osteoarthropathy were markedly alleviated after removal of the infected prosthesis. A review of the literature revealed seven additional patients with a similar presentation. The diagnosis of infected arterial graft with enteroprosthetic fistula may be extremely difficult, and a delay in this diagnosis may be lethal. Awareness of this uncommon association may lead to prompt diagnosis and early surgical therapy.

[Legionnaires' disease in hairy cell leukemia. 2 new cases]. / Maladie des légionnaires au cours d'une leucémie à tricholeucocytes. Deux nouvelles observations.

We report the cases of two patients who developed legionnaires' disease during the course of hairy cell leukaemia. The clinical features are described with special emphasis on the severity of illness in one patient and marked jaundice in both. These cases demonstrate the enhanced susceptibility to Legionella pneumophila infections in patients with hairy cell leukaemia. We therefore suggest a reevaluation of empiric antimicrobial treatment of pneumonia in such patients.