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The acquired immune deficiency syndrome (AIDS) is characterized by the occurrence, in a subject under 60, of Kaposi's sarcoma and/or severe opportunistic infection due to deficiency of the normal cell-mediated immune defence mechanism against the causative agents. In a number of patients, AIDS is preceded by fever, weight loss, profuse sweating, polyadenopathy or diarrhoea. In an epidemiological study conducted by a French multidisciplinary group from March to December, 1982, 25 cases were collected, including 11 cases of isolated Kaposi's sarcoma, 3 cases of Kaposi's sarcoma plus opportunistic infection, and 15 cases of single or multiple opportunistic infection. From this study and international studies, several points of interest have emerged, viz: (1) AIDS is present in France under multiple clinical aspects; (2) a focus of endemic AIDS has been discovered first in Haiti, then in Equatorial Africa; (3) the cause of AIDS is unknown, though presumed to be a virus (retrovirus?); (4) the disease is characterized by selective deficiency of T4 ("helper") lymphocytes; (5) the subjects at risk are male homosexuals, especially those with several partners, but not as much in France as in the USA; (6) none of the French patients was a drug-addict or a haemophiliac.
Since 1960, laparoscopy under local anaesthesia has been gradually abandoned in France and until now oocytes for in vitro fertilization were collected under general anaesthesia, thus increasing the risk of allergic reactions to anaesthesia in these patients who usually undergo several operations. From February to May, 1983, at the Antoine Béclère Maternity, Paris, 50 laparoscopies were performed under local anaesthesia with lidocaine combined with neuroleptanalgesia with diazepam and fentanyl. The procedure was uneventful in 94% of the cases and only 3 women required general anaesthesia. At least one mature oocyte was collected in 46 of these 50 women and 4 pregnancies have already been recorded. Local anaesthesia enables the woman to participate fully in this first stage of in vitro fertilization, increases the out-patient activities of the hospital unit and reduces the cost of in vitro fertilization.
Between 1968 and 1991, 36 pregnancies were reported in 28 patients who had undergone kidney transplantation at the Necker hospital, Paris. Pregnancies with favourable graft outcome were compared with those accompanied by significant deterioration of graft function and requiring haemolysis. The risk factors for renal function deterioration during pregnancy in kidney-transplanted women were found to be an initial nephropathy induced or aggravated by a previous pregnancy, an alteration, even mild, of graft function, hypertension, even controlled by treatment, an HLA mismatch and several episodes of acute graft rejection soon after kidney transplantation.
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The haemolytic uraemic syndrome, first described in 1955 by Gasser, is the number one cause of acute renal failure in infants. There are three types of the haemolytic uraemic syndrome: the seasonal epidemic form with prodromic diarrhoea and generally favourable outcome which usually occurs in infants, a less typical form without signs of digestive tract involvement and no seasonal prevalence which occurs more readily in older children and sometimes in families has a less favourable prognosis, and finally drug- or disease-related forms. Currently, overall mortality due to haemolytic uraemic syndrome has been reduced to about 4%, usually as a result of damage to the central nervous system. Several microorganism, including Shigella dysenteriae, Salmonella typhi, Campylobacter jejuni, Streptococcus pneumoniae, Rickittsiae and certain viruses (Coksackiae, Influenzae, Epstein-Barr) have been identified as causative agents. In 1983, digestive tract infection due to an Escherichia coli strain producing verotoxin was identified as capable of producing haemolytic uraemic syndrome and more rarely thrombopenic thrombotic purpura. The germ produces two exotoxins (whose effect is accentuated by the E. coli lipopolysaccharide endotoxin) which lead to the glomerular microangiopathy causing haemolytic uraemic syndrome. Diagnosis is based on identification (monoclonal antibodies, ELISA, PCR) of the verotoxins themselves or the two encoding genes in stool samples. Symptomatic treatment is essential but the effectiveness of antibiotics is still debated. Theoretically, antibiotics could worsen the syndrome by increasing endotoxin release from lysed bacteria, but inversely they could also prevent the syndrome if given early enough. Further research is required to acquire precise epidemiological data and identify animal reservoirs of verotoxin producing E. coli.
Over a 6-year period 23 patients with massive haemoptysis were treated at the Hôpital Tenon, Paris. Eighteen of these, usually considered "non-surgical" cases, underwent emergency embolization of the bronchial artery (B.A.E.). The immediate outcome was favourable in 14 patients; 4 died of early recurrence. B.A.E. therefore appears to be a valuable treatment of massive haemoptysis in "non-surgical" patients or in patients awaiting transfer to a thoracic surgery unit. However, because of the failure rate, B.A.E. cannot compete with thoracic surgery in its classical indications, and its effectiveness and safety should be compared with those of balloon catheter endobronchial tamponade in "non-surgical" patients.
Between May, 1983 and September, 1987, 8 per cent of the patients hospitalised for an HIV infection (i.e. 30 patients, 20 with an ARC and 10 with AIDS) had tuberculosis. The percentage of patients originating from Central Africa or Haiti was important (23 per cent). Tuberculosis was thoracic (76 per cent) and/or extrathoracic (63 per cent). The main organs involved were the lungs (n = 21), the mediastinal lymph nodes (n = 9), the superficial lymph nodes (n = 9), and the liver (n = 8). The pulmonary infection was often multilobar (n = 14), but without caverns. The tuberculin PPD (purified protein derived) test was positive in 63 per cent of ARC patients and in 30 per cent of AIDS patients. The diagnosis of tuberculosis was confirmed in 27/30 patients by culture of Mycobacterium tuberculosis (n = 23) and/or histology (n = 13), and in the remaining patients by response to a specific treatment. In 3 patients with normal X-ray film of the chest, M. tuberculosis could be recovered by culture of the gastric fluid. Antituberculous treatment was effective, but its optimum duration is to be determined since relapse may occur, even after one year of treatment. The side-effects of the treatment were unusually frequent (54 per cent). The occurrence of tuberculosis seemed to aggravate the prognosis of the HIV disease, since 57 per cent of the ARC patients reached the stage of AIDS within 6 months on average. These results are in agreement with the new recommendations of the Centers for disease control which include extrapulmonary tuberculosis in the AIDS criteria. However, in our study, pulmonary tuberculosis had the same detrimental effect and should therefore be included in the AIDS criteria.
Four years of activity in the one-day hospital (ODH) and the several-day hospital care (SHC) of the Hypertension Clinic at the Hôpital Saint-Joseph, Paris, were evaluated and compared. All data were recorded using the computerized Artemis system. Evaluation was performed by means of two prospective studies: a controlled trial of 121 patients randomized to either ODH or SHC, and a prospective follow-up study of 633 patients. Criteria for admission to the controlled study were: diastolic BP between 95 and 120 mmHg, age between 30 and 65 years, no anti-hypertensive treatment at first visit, no major cardiovascular or renal complication and no suspicion of secondary hypertension. Similar criteria applied to the uncontrolled study. The results, assessed after 2 years, were the same in both studies, with a drop-out rate of about 15%, a mean diastolic BP lower than 95 mmHg in 80% of the patients and a bodyweight reduction of about 1 kg in obese patients. The percentage of smokers who stopped cigarette smoking was higher in the SHC groups than in the ODH groups. It is concluded that the ODH system is effective in the initial management of hypertensive patients but that greater educational efforts are needed to effectively reduce cigarette smoking in OHD patients and bodyweight excess in both OHD and SHC patients.
Since 1972, 280 patients with severe irreversible myocardial damage have been referred to La Pitié Hospital, Paris, for heart transplantation; 95 were excluded on account of absolute contra-indications. Owing to the limited number of available transplants, only 66 of the 185 remaining patients were transplanted. Transplantation was orthotopic in all but 3 cases: 1 patient had heterotopic transplantation and 2 had heart-lung transplantation. The most common post-operative problems were graft rejection and complications of the immunosuppressive treatment; 82% of the transplanted patients were discharged 2 months on average after surgery; 47% overcame the first year problems and resumed an almost normal social and professional life; 21 are still alive, one of them after 9 years. During the last 2 years, technical refinements and the advent of more potent immunosuppressive agents (anti-lymphocyte serum from rabbits, cyclosporin A) and better diagnostic methods (repeated endomyocardial biopsies and immunological surveillance) have resulted in considerable improvement in the patients' outcome, with an actuarial survival rate of 77% at one year and 70% at two years. Since transplants are now better tolerated after the second year and since they possess remarkably good and durable functional properties, this reduction in early and late mortality, which used to be the main cause of failure, raises hopes of a marked increase in prolonged and satisfactory survival.
Beta-lactamases still play an important part in medical bacteriology, as shown by the emergence, since 1983, of plasmid-mediated beta-lactamases with an enlarged spectrum (SHV-2, CTX-1, etc.). Such enzymes are only produced by enterobacteria and, more specifically, by Klebsiella pneumoniae. This phenomenon, described in Europe and in Africa, is certainly more widespread than it would appear, as some strains are now known to be less sensitive to third generation cephalosporins (MIC 1 to 4 mg/l). Despite differences in behaviour (cefotaximase and ceftazidimase phenotypes), resistance to amino-, carboxy- and ureido-penicillins is associated with reduced sensitivity or resistance to oxyimino beta-lactams (cefotaxime, ceftriaxone, ceftazidime, aztreonam), but cefamycins and imipenem are untouched. Being sensitive to enzyme inhibitors (e.g. clavulanic acid), these beta-lactamases can easily be detected and some infections (notably urinary tract infections) can probably be treated using these inhibitors. These enzymes show modified kinetic constants (better affinity and quicker hydrolysis) against penicillins, third generation aminothiazolimino-cephalosporins and aztreonam. The producing strains are mutants, with aminoacid 1 to 2 substitutions, of those which produce the usual plasmid-borne and transposable beta-lactamases (TEM or SHV). Because these beta-lactamases are plasmid-mediated, enzyme production mechanisms are spreading among enterobacteria species in relation to other resistance markers (tobramycin, netilmicin, amikacin). Strains which produce these new enzymes are mainly isolated from patients treated in intensive care units.
Cultures of specimens from the abdominal cavity (14) or the lower genital tract (11) were positive for Chlamydia trachomatis in 25 (22.7%) of 110 patients with a laparoscopic diagnosis of acute salpingitis. Microimmunofluorescence serodiagnosis showed positive IgG levels (greater than or equal to 1/64) in 35 patients (32%). Of the 34 patients in whom a second serodiagnosis was performed after 6 weeks, 20 (58%) had positive IgG levels (greater than or equal to 1/64) and 12 (35%) had a fourfold or more change in dilution. Thus, culture and serodiagnosis provided evidence of Chlamydia infection in 46% of the patient population. Forty-six patients were followed up for several months to evaluate the response to antibiotic therapy. Among tetracyclines, lymecycline was effective in 19/25 cases, doxycycline in 15/19 cases and minocycline in 2/4 cases. Switching to another tetracycline after failure of the first one usually gave satisfactory results.
The main species of mycobacteria isolated in 62 of the 316 acquired immunodeficiency syndrome patients admitted to the Claude Bernard Hospital, Paris, between January, 1983 and October, 1986 were studied retrospectively according to their site of isolation and their pathogenic role. Mycobacterium tuberculosis was isolated in 19 cases (from pulmonary specimens in 17 cases); this species was present in 59 percent of our African patients as against 20 percent of our European patients. M. avium intracellulare was isolated in 33 cases (17 from blood, 12 from the lung and 11 from the gastrointestinal tract) and was found in 55 p. 100 of our European patients. Other species that were isolated less frequently were M. xenopi (5 cases), M. kansasii (3 cases), M. aurum, M. chelonae, M. fortuitum, M. gordonae, M. simiae and M. terrae (1 case each). Post mortem specimens obtained from 110 acquired immunodeficiency syndrome patients were cultivated during the same period. In 20 patients, at least one specimen was positive for a mycobacterium: M. tuberculosis in 2 cases, M. avium intracellulare in 18 cases. Twenty-nine of the 33 patients in whom M. avium intracellulare was isolated were considered a posteriori as being infected by this organism. The therapeutic approach varies according to the species involved. No treatment seems to be truly effective against M. avium intracellulare. Pending the results of cultures, no direct bacteriological examination can provide information on the mycobacterial species concerned; however, a conventional antituberculosis treatment may be instituted, particularly in patients from Africa or Haiti.
A pharmacokinetic study of ceftazidime was conducted in 1983, together with a clinical study, on 7 neonates (3 of them premature), 4 infants and 3 children. The antibiotic was administered by slow intravenous injection in mean doses of 30 mg/kg twice in 24 h in neonates and thrice in 24 h in older children. Blood samples were collected by micropuncture, and assays were performed by the microbiological method on agar plates. Curves of plasma concentrations over time showed two slopes compatible with a two-compartment model. The alpha half-life was the same in neonates and infants; the beta half-life varied from 1.9 to 5 h. The highest values were observed in the 3 youngest and most immature neonates. In infants and older children the mean beta half-life was the same as in adults: 1.4 +/- 0.19 h. The results of several studies performed on neonates differed as regards the influence of term, post-natal age and bodyweight on the pharmacokinetic constants of ceftazidime. A dose of 25 to 50 mg/kg twice a day administered to premature and full-term neonates during the 1st week of life gives therapeutically effective concentrations. Doses of 30 to 50 mg/kg 3 or 4 times a day are necessary in infants and older children. Dosage should be adjusted to renal maturity and renal functions as well as to the infection treated.
A medical audit was conducted in a Paris hospital on patients who, in 1975, underwent cholecystectomy for uncomplicated gallstones. The audit comprised the duration of pre- and post-operative hospitalisation, the Social Security grading of medical acts, biochemical and radiological examinations and the quality of medical care, as assessed by morbidity and mortality rates. The results were brought to the knowledge of all members of the surgical team concerned. Similar studies conducted two and five years later showed that self-restriction on the part of the physicians resulted in improved costs through shorter stays in hospital (especially before surgery) and less extensive and numerous examinations, the incidence of complications remaining the same.
Between january 1, 1983 and december 31, 1986, 360 implantable infusion devices were inserted for systemic chemotherapy. Most of the devices were Port A Cath systems. The main complications observed were thrombosis (18 cases, 5%) and infection (8 cases, 2.2%). Since one year the catheters are being introduced by subcutaneous puncture of the subclavian vein, the chambers being placed in a small lateral subclavicular cavity. Intra-operative radiography is necessary to minimize the risk of malposition and thrombosis. These systems, relayed by external pumps, enable chemotherapeutic regimens to be administered sequentially over a 24-hour period.
Clinical assessment is an essential fundamental element in the evaluation of comatose states, particularly in children. Paediatricians quickly recognized that the early Glasgow Coma Scale, used for over 20 years in adults, is inadapted for children because it lacks brain stem criteria, involves interpretation of motor response (particularly difficult in infants) and uses verbal response which is of little value before language acquisition. The first attempt at standardized coma assessment in children was the Paediatric Coma Scale, developed in Australia in 1982. This scale improved on the Glasgow scale, removing the motor retraction response, modifying the verbal response scale (normal, words, sounds, crying, or none) and quantifying the best possible score as a function of age. In 1983 a fundamental modification was proposed in the Jacob scale. Besides removing the motor retraction response, this scale replaced the verbal scale with one based on ocular behaviour, thus evaluating consciousness of presence or stimulation. The vestibular response and pupil reactions were also included to assess brain stem activity. In 1987, we introduced the Bicêtre scale which uses ocular behaviour instead of verbal response and separates ocular diameter as a specific criteria. Assessment of four reflexes (mimic, photomotor, cornea and cough) provides precise information on the activities of the different levels of the brain stem. Several comparative studies have been conducted to determine the positive predictive value and interpersonal variability of these scales. In a prospective multicentric study of 277 comatose children aged 6 months to 15 years, we found that the Bicêtre scale had a positive predictive value of 94% for good outcome at 24 hours and that interpersonal disagreement occurred in only 10.1% of 65 cases studied (compared with 13.5% for the Glasgow scale which was studied simultaneously). Paediatricians now have reliable clinical scales for assessing the conscious level in children.
Between January 1, 1983 and October 1, 1990, we performed 266 surgical operations in 255 patients with human immunodeficiency virus (HIV) infection. We report the reasons for these operations and compare them with those recorded in all patients operated upon in our department between January 1, 1988 and December 31, 1989 (4,960 operations in 4,498 patients). During the 1988-89 period, 2.4 percent of these patients had HIV infection, which suggests that the proportion of patients operated upon is the same in an HIV-infected population as in the general population. The proportion of HIV-infected patients who underwent surgery for diagnostic purposes or as adjuvant treatment was 42.7 percent as compared with 37.3 percent in the general population. Among laparotomies, 37.3 percent were exploratory in the HIV group versus 7.3 percent in the control group. The emergency surgery rate was the same in both groups. In gastrointestinal surgery, proctological operations were performed in 33.5 percent of the HIV group versus 7.4 percent of the control group. Among other types of surgery, only splenectomies were more frequent in HIV-infected patients than in the general population (6.3 versus 1.7 percent).
From October, 1976 to February, 1982, 48 patients with T1N0 non-small cell bronchopulmonary carcinoma were operated upon at the Laennec Hospital, Paris. Their characteristics were: mean age 57 years (range: 43-80 years); sex ratio 23; type of surgery: 35 lobectomies, 11 pneumonectomies, 2 bilobectomies; histology: 30 epidermoid carcinomas, 15 adenocarcinomas, 3 bronchoalveolar carcinomas. On 1st January, 1983, 10 patients had relapsed after a mean complete remission period of 20 months (range: 2-29 months); 5 only had a local relapse. The actuarial probability of relapse at 5 years is 45%. Twelve patients died after a median survival of 21 months (range: 0-44 months). Of these, 3 died post-operatively, 8 after relapse and 1 of infarction during a first complete remission. Most relapses involved the mediastinum (50%) and the brain (30%). As the preventive role of mediastinal and cerebral irradiation has now been demonstrated in more extensive forms of non-small cell carcinomas, such irradiations would be justified in the T1N0 forms.
From 1975 to 1980, computerized data on the sensitivity of 11 342 strains of S. aureus to the main antibiotics were evaluated in relation to drug consumption and hospital activity. Sensitivity to tetracyclines and chloramphenicol increased by 7.3% and 11.4% respectively, but sensitivity to gentamicin decreased by 12%. There was no change in sensitivity to other antibiotics. In vitro response to methicillin was found to have a considerable influence on changes in sensitivity. Sensitivity to tetracyclines increased among methicillin-sensitive strains, while methicillin-resistant strains became more sensitive to chloramphenicol and less sensitive to gentamicin. During the same period, the consumption of chloramphenicol, tetracyclines and aminoglycosides decreased by 84%, 54% and 15% respectively. Hospital activity remained unchanged. The fact that methicillin-resistant strains failed to become more sensitive to the main antibiotics, with the exception of chloramphenicol, might be due to antibiotic pressure in intensive care units where these strains are usually isolated.
A universal severity index for acutely ill patients was applied to 794 acute patients treated in eight medical and surgical French intensive care units located in teaching or community hospitals either in Paris or in provincial towns. Measured on the first day in hospital from objective numerical data, the index proved reliable and correlated well with hospital mortality and the sustained therapeutic efforts of the first 24 hours. It could be used in multicentre studies to compare outcomes and evaluate new treatments.