Causes and consequences of anti-infective drug stock-outs.

Anti-infective drugs stock-outs are increasingly frequent, and this is unlikely to change. There are numerous causes for this, mostly related to parameters difficult to control: i) 60 to 80% of raw material or components are produced outside of Europe (compared to 20% 30 years ago), with subsequent loss of independence for their procurement; ii) the economic crisis drives the pharmaceutical companies to stop producing drugs of limited profitability (even among important drugs); iii) the enforcement of regulatory requirements and quality control procedures result in an increasing number of drugs being blocked during production. The therapeutic class most affected by drug stock-outs is that of anti-infective drugs, especially injectable ones, and many therapeutic dead ends have recently occurred. We provide an update on this issue, and suggest 2 major actions for improvement: i) to implement a group dedicated to anticipating drug stock-outs within the anti-infective committee in each health care center, with the objectives of organizing and coordinating the response whenever a drug stock-out is deemed at risk (i.e., contingency plans, substitution, communication to prescribers); ii) a national reflection lead by scientific societies, in collaboration with government agencies, upstream of the most problematic drug stock-outs, to elaborate and disseminate consensus guidelines for the management of these stock-outs.

Hysteroscopic management of menstrual disorders: a review of 395 patients.

OBJECTIVE: To evaluate the long-term effectiveness of transcervical resections in menstrual disorders. DESIGN: Retrospective consecutive patient follow-up. PATIENTS: From 1987 to 1993, 395 patients with menstrual disorders (menorrhagia and/or metrorrhagia) were treated with operative hysteroscopy in our department. Resection of endometrial polyps was performed in 65 cases, resection of submucous fibroids in 196, and endometrial ablation in 134. Fourty-one patients had a repeat procedure. RESULTS: Our mean follow-up period was 2.7 years. Thirteen complications were noted (3%), two of which were serious (one hemoperitoneum after uterine perforation, one severe symptomatic hyponatremia). Twenty-eight patients did not remain in contact after hospitalization (7.1%). Menstrual disorders were controlled in 297 patients (75.2%). Failure was noted in 70 patients (17.7%), including hysterectomy in 50 patients and persistent bleeding in 20. CONCLUSION: Hysteroscopic surgery is a satisfying technique for women with abnormal uterine bleeding who want a conservation of the uterus. Better results are noted with resections of polyps and fibroids than with endometrial ablations.

Hysteroscopic management of uterine synechiae: a series of 102 observations.

This retrospective study concerns 102 cases of intra-uterine adhesions treated by exclusive hysteroscopic approach. Fifty-two patients (51%) presented with reproductive problems, 44 patients (43%) with menstrual problems and 6 were asymptomatic. Seventy-eight patients (76.5%) had an antecedent endometrial trauma on a gravid uterus. One hundred and forty-eight operative hysteroscopies were performed to treat 102 patients; 70 patients were treated in one endoscopic session (68.6%), 23 in two sessions (22.6%), 4 in three sessions (3.9%) and 5 in four sessions (4.9%). We report no infectious, hemorragic or metabolic complication but 6 perforations (5.8%). The mean follow-up is 24.4 months (from 6 to 46 months). Ten patients did not keep contact during follow-up. A good anatomical result was obtained in 88 patients (86.2%) after one or two hysteroscopic sessions. A good result on menstrual problems was obtained in 75% of the cases, especially in amenorrhea (90.5% success rate). The reproductive outcome is more disappointing. We obtained 34 pregnancies in 28 patients (10 abortions, 24 live born children). Twenty-two patients achieved no pregnancy (44%), but 13 of these patients presented with additional infertility factors.

[Results and indications of laparoscopic distal tuboplasty]. / Resultats et indications de la coeliochirurgie tubaire distale.

We present a retrospective study of a series of 46 patients who have benefited from a laparoscopic treatment for a distal tubal disease. The results have been expressed in terms of tubulars and adherentiels scores, of the type of plastic effected and of the sterility (pure tubular sterility or associated). The global pregnancy rate is 39, 1% of which 34,8% is IUP and 4,3% EP. We have observed: an average delay of 10,8 months to obtain a pregnancy; the superiority of the fimbrioplasties (rate of pregnancy 75%); the predicted value of tubular score (the cases scored I and II obtain pregnancy rates of 57,7%). The association of endometriosis or of light oligoasthenoteratospermia do not constitute a counter indication of the tuboplasty (in those cases, cumulative rate of pregnancy is 50% and 40% respectively). If no pregnancy is observed during the 18 months following the intervention we recommend that the couple be treated by IVF.

[Hysteroscopic treatment of uterine synechias. A report of 102 cases]. / Traitement hystéroscopique des synéchies utérines. A propos de 102 observations.

This retrospective study of 102 patients with uterine synechias treated exclusively hysteroscopically included 52 (51%) low fertility patients, 44 (43%) with menstrual disorders and 6 (6%) with no other symptoms. More than three-fourth of the patients (76.5%) had a past history of trauma on a gravid uterus. Operative hysteroscopy was performed 148 times, including sections with scissors in 63 cases (42.4%), section with laser in 4 (3%), uterine collapse in 19 (13%) and electrosection in 62 (41.6%). A single endoscopic procedure was sufficient in 70 patients (68.6%) and 2, 3, 4 procedures were required in 22.6%, 3.9% and 4.9% of the patients respectively. No complications due to infection, bleeding or metabolic disorders occurred, but perforations were seen in 6 patients (5.8%) including 4 cases with complexe synechias. Mean follow-up was 24.4 months (range: 6-49 months); 10 patients were lost to follow-up. Good anatomic results were achieved in 88 patients after 1 or 2 hysteroscopic procedures (86.2%). Clinical results were less satisfactory, particularly in cases with low fertility in which another pathology was often associated (59%). We obtained good results in 75% of the patients with dysmenorrhoea. However, one or more pregnancies was achieved in 28 of the 50 patients contacted later (a total of 34 pregnancies including 10 abortions and 24 normal deliveries). A hysteroscopic procedure should be proposed as first intention treatment in all cases with synechia. In addition to diagnosis, hysteroscopy allows selective, reproducible treatment with little morbidity and conservation of the surrounding endometrium. After several unsuccessful procedures, surgery using Musset's technique can be proposed.

[Ovarian hyperstimulation syndrome in medically assisted reproduction]. / Syndrome d'hyperstimulation ovarienne en procréation médicalement assistée.

Ovarian hyperstimulation syndrome (OHS) is the most serious complication of ovulation induction, particularly in in vitro fertilization. It is a potentially life-threatening situation. Its pathophysiology is poorly understood. This syndrome is explained by a sudden increase in capillary permeability which results in a rapid fluid shift from the intravascular space into a third space leading to haemodynamic changes. In its most severe forms. OHS is characterized by multicystic ovarian enlargement, hemoconcentration, hypovolemia, oliguria, third space accumulation of fluid in the form of ascites and pleural effusion, renal failure, thrombotic disorders. Mild and the most of moderate forms of OHS usually do not require any active form of therapy. Severe OHS requires hospitalization, correction of fluid and electrolyte imbalance, prevention of thromboembolism, aspiration of the ascites and pleural effusion causing respiratory discomfort and dyspnea. Surgical interventions are exceptionally indicated and reserved for ovarian or rupture of ovarian cyst. Although severe OHS may not be completely avoided, early recognition of high-risk factors, judicious monitoring of ovulation induction (plasma estradiol levels and ultrasonography), and, perhaps in future, substitution of hCG for triggering ovulation should reduce the incidence of this iatrogenic syndrome.

[Radiologic aspects of noncalculous inflammation of the biliary tract in AIDS]. / Aspects radiologiques des inflammations non calculeuses des voies biliaires au cours du SIDA.

Six cases of non-lithiasic cholecystitis and 7 cases of inflammatory cholangitis caused by cryptosporidium and/or cytomegalovirus infections have been studied in HIV-1 + patients. All patients were examined with ultrasound and 5 with computed tomography (CT). The appearance is the same as that described for non-lithiasic cholecystitis (pain when the ultrasound probe is applied, thickened gallbladder wall) and sclerosing cholangitis (dilatation and/or stenosis of the bile duct, thickened gallbladder wall). The ultrasound or CT examination of HIV + patients with gallbladder involvement is sufficient to guide treatment when a thickened gallbladder wall is demonstrated. On the other hand, bile duct opacification is the only method allowing the accurate assessment of the extent of lesions in cholangitis, on which the indication for eventual sphincterotomy is based.

[Leiomyoma of the urinary excretory tract]. / Les léiomyomes de la voie excrétrice urinaire.

Four cases of leiomyoma of the urinary tract are presented: 3 locations in the bladder and one location in the ureter. Leiomyomas of the urinary tract are rare. These benign mesothelial tumors require conservative resection. Small lesions can be managed with endoscopic techniques.

[Echographic and x-ray computed tomographic aspects of intramural hematoma of the duodenum. Apropos of a case]. / Aspects échographiques et tomodensitométriques de l'hématome intramural du duodénum. A propos d'un cas.

Radiologic imaging in a case of intramural hematoma of duodenum demonstrated typical appearances of the lesion. Ultrasound imaging of the duodenal hematoma was sufficiently characteristic to be used as a basis for a semeiologic discussion and to orientate diagnosis. The relevant literature is reviewed, and value and indications of different imaging techniques for diagnosis and follow up of the hematoma discussed.