[Implementation of computerized phisician order entry in a hospital setting: what are the keys to success?]. / Implémentation de la prescription informatisée en milieu hospitalier: quelles sont les clés d'un déploiement réussi ?

INTRODUCTION: A software of computerized physician order entry [CPOE] was developed by a data-processing company in collaboration with the Mont-Godinne University Hospital By 2006, parallel to the evolution of the software, the progressive implementation of CPOE was carried out, and currently covers 16 wards, the emergency room, the recovery rooms and the center of medical care [day hospital] as well as the day surgical center OBJECTIVES: Complete computerization of the drug supply chain, including the regulation by the physician, the pharmaceutical validation, the delivery and the follow-up of stocks by pharmacy, the validation of the administration by the nurse and the tariffing of the drugs. METHOD AND RESULTS: In 2006, a working group was created in order to validate specifications allowing the development of a software of CPOE, Linked to the computerized medical record. A data-processing company was selected in order to develop this software. Two beds were computerized in the pneumology ward, in order to test and validate the software. From 2007 to 2009, 3 additional wards were computerized [geriatrics, neurosurgery, revalidation]. A steering committee of CPOE, composed of various members (direction, doctors, pharmacists, nurses, data processing specialistsl is created. This committee allows the installation of the means necessary to the deployment of CPOE in the Institution. Structured teams for the deployment are created: medical and nurse coaches. From 2009 to 2012, the deployment of the software is carried out, covering 16 wards, the emergency room, the recovery room and the day-hospitals. CONCLUSION: The computerization of the drug supply chain is a challenge which concerns the institutional level. The assets of our hospital and our project were: - a strong management committee, making of this project a priority entering the strategical planning of the institution; - a steering committee allowing each type of actor to express his needs, and of prioriser requests; - a closer medical coaching; - teams of nurses coaches, accompanying each ward, during and after the deployment; - a dynamic IT team allowing a relay between the Institution and the data-processing company. These points appeared essential and are as many keys for a successful deployment.

Clinical and pharmacokinetic study of praziquantel in Egyptian schistosomiasis patients with and without liver cell failure.

The pharmacokinetics and therapeutic efficacy of praziquantel (Distocide; Epico, El-Asher-Men-Ramadan City, Egypt) were studied in 40 patients with schistosomiasis mansoni and various degrees of hepatic dysfunction. The patients were allocated into four groups: the first included 10 patients with simple active schistosomiasis while the other three were made up of patients with schistosomiasis associated with liver cirrhosis and splenomegaly according to Child's classification of hepatocellular function. Every patient was treated with 40 mg/kg of praziquantel as a single oral dose. The efficacy of the drug was evaluated after two months by rectal snip examination. The pharmacokinetic parameters did not differ significantly between patients with simple active schistosomiasis (group 1) and those with hepatosplenomegaly with liver involvement but without ascites and jaundice (group 2). However, as liver cell dysfunction became more evident (groups 3 and 4), pharmacokinetic parameters of praziquantel such as the half-life of elimination, the half-life of absorption, the maximum concentration, the time to maximum concentration, and the area under the concentration-time curve increased proportional to the degree of hepatic insufficiency. Linear correlations were found between each of the these parameters on the one hand and hepatic function test results (total bilirubin, direct bilirubin, and serum albumin) on the other. In spite of these pharmacokinetic differences, the cure rates were 70%, 80%, 90%, and 90% in the four groups, respectively. Although the incidence of side effects was high (53%), such effects were transient and mild.

Single-dose pharmacokinetics of aztreonam in healthy volunteers and renal failure patients.

The pharmacokinetics of aztreonam were studied in 6 healthy male volunteers and 12 male patients with various degrees of chronic renal failure after intravenous bolus injection of 1g of the drug. Serum pharmacokinetics of aztreonam were described by an open, two-compartment kinetic model. The serum levels of aztreonam exceeded the reported minimum inhibitory concentration (MIC)90 for Enterobacteriaceae for 8 hours and up to 24 hours, in healthy volunteers and renal failure patients, respectively. However, the serum levels of the drug exceeded the MIC50 for Pseudomonas aeruginosa for only 4 hours and 12 hours in healthy volunteers and patients, respectively. The half-life of elimination (t 1/2/beta) increased significantly (P less than 0.001) from 1.8 +/- 0.14 h in healthy volunteers and to 4.9 +/- 1.1 h in patients with renal failure. The total serum clearance of aztreonam decreased significantly (P less than 0.001) from 84.2 +/- 7.8 ml/h/kg in healthy volunteers to 30.2 + 9.2 ml/h/kg in patients with renal failure. A linear correlation (r = 0.971, P less than 0.001) was found between creatinine clearance and the total serum clearance of aztreonam. The AUC0-infinity increased significantly (P less than 0.001) from 137.5 +/- 12.2 micrograms/h/ml in healthy volunteers to 464 +/- 114.5 micrograms/h/ml in patients with renal failure.

[AZT in community practice]. / L'AZT en pratique de ville.

AZT is the only available antiviral treatment. While using it, several problems appear to a general practitioner. 1) The supervision of the toxic effects, which is simple but does imply an experience. 2) The interaction of several drugs, while considering, among other difficulties, the great number of similar drugs available in pharmacies. 3) The psychological investment of the patient, for whom AZT is all at a time, a threat, a coercitive weapon and a hope. A proper knowledge of these problems allows the G.P. to work in agreement with the hospital practitioner.

[Neurospychiatric symptoms in HIV infected patients and the role of efavirenz]. / Troubles neuropsychiatriques chez les patients infectés par le VIH et rôle de l'efavirenz.

Efavirenz has now become commonly used to treat HIV infection. Neuropsychiatric disorders have been reported in patients treated with efavirenz. Several factors often make it hard to determine the cause of these disorders: HIV infected patients take many different drugs, they may suffer from various organ diseases, and may also be heavily affected by problems in their everyday life. The French experts group working on neuropsychiatric side effects of efavirenz has undertaken a review of these disorders with the aim to identify: (1) semiology, (2) epidemiology in the global population, in HIV infected patients, and in patients treated with efavirenz. The expert group suggests recommendations to manage these disorders.

Pharmacokinetics of cefodizime in normal individuals and in patients with renal failure.

The pharmacokinetics of cefodizime (HR 221) were studied in 6 healthy male individuals and 12 male patients with various degrees of chronic renal failure following intravenous bolus injection of 1 g of the drug. Serum pharmacokinetics were described by an open two-compartment kinetic model. The serum levels of cefodizime exceeded the MIC90 for Enterobacteriaceae, Haemophilus influenzae and Neisseria gonorrhoeae for more than 12 h in healthy individuals and 24 h in renal failure patients. The half-life of elimination was significantly prolonged (p less than 0.001) from 2.7 +/- 0.2 h in healthy volunteers to 7.7 +/- 1.5 h in renal failure patients. The total systemic clearance decreased significantly (p less than 0.001) from 43.3 +/- 5.8 ml/h/kg in healthy volunteers to 23.2 +/- 5.6 ml/h/kg in renal failure patients. A linear correlation (r = 0.9; p less than 0.001) was found between creatinine clearance and the total systemic clearance of cefodizime. The AUC0-infinity in patients with renal failure was more than double the value in healthy volunteers. An equation to calculate the 1-gram dose interval of cefodizime in patients with compromised renal function is provided.

Pharmacokinetics of cefodizime in patients with liver cirrhosis and ascites.

The pharmacokinetics of cefodizime were studied in 6 healthy male volunteers (group A) and 6 patients with liver cirrhosis and ascites (group B) receiving 1 g of the drug as an i.v. bolus. Cefodizime was assayed in serum and ascitic fluid (AF) samples by a microbiological assay. The serum concentration-time curve fitted a two-compartment open model in group A and a three-compartment open model in group B. Initially, the serum level of cefodizime in group A exceeded that in group B for about 10 h; thereafter the reverse occurred until 24 h post-dosing. Cefodizime penetrated rapidly into the AF, reaching a peak at 6 h, and its AF level was still above the MIC90 for Enterobacteriaceae in most patients at 24 h post-dosing. The half-life of distribution did not differ significantly between the two groups, while the elimination half-life was prolonged significantly (p < 0.001) from 2.7 +/- 0.2 h in group A to 5.4 +/- 0.8 h in group B. The central volume of distribution (Vc) did not differ significantly in the two groups, while the terminal volume of distribution (Vp) was significantly smaller (p < 0.01) in group A (0.172 +/- 0.30 l/kg) than in group B (0.55 +/- 0.20 l/kg). The area under the serum concentration-time curve (AUC0-infinity serum) was significantly larger (p < 0.001) in group A [322 +/- 34 (micrograms/ml).h than in group B (180 +/- 34 (micrograms/ml).h]. The area under the AF concentration-time curve (AUC0-infinity ascites) in group B was 141 +/- 37 (micrograms/ml).h.(ABSTRACT TRUNCATED AT 250 WORDS)

Disturbances of impulse formation: an expert system for ECG interpretation.

This paper describes an expert system (ES) that aids in interpretation of some disturbances of impulse formation from electrocardiographic records. The system consists of a user interface, a knowledge base, an inference engine and an explanation facility. It is implemented using Turbo PROLOG and uses the built-in interpreter for goal proving or disproving. The user interface gets information about the case by interrogation through multiple choice or Yes/No questions. The response is processed and stored in a dynamic database. After the interview the processed data are stored in a permanent file for subsequent calls. The knowledge base contains domain rules of the If-Then variety. The inference engine supports the logic-based method of knowledge organization, which is controlled by backward-chaining. The explanation facility is able to give reasons for any fact in the dynamic database. The main diagnosis, the diagnostic criteria and the algorithm used are explained and illustrated with examples. Sample outputs of the system are also given.

Passive immunotherapy in AIDS: a double-blind randomized study based on transfusions of plasma rich in anti-human immunodeficiency virus 1 antibodies vs. transfusions of seronegative plasma.

A randomized double-blind controlled trial was conducted to determine the efficacy of passive immunotherapy in the treatment of symptomatic human immunodeficiency virus (HIV) infection. This trial included 86 symptomatic patients randomized to receive plasma rich in anti-HIV-1 antibody or standard seronegative plasma. Each patient in both groups received a 300-ml infusion every 14 days over a 1-year period, and every 28 days thereafter, in addition to zidovudine and other conventional prophylactic treatments. Plasma donors were selected among symptomless seropositive individuals with a CD4 lymphocyte count > or = 400 x 10(6) cells per liter, a negative p24 antigen assay, and a high concentration of anti-p24 antibody. The plasmas were heat-inactivated before infusion. During the study period (day 28-day 365) scheduled by the protocol, clinical benefit from passive immunotherapy was observed in delaying the appearance of the first AIDS-defining event (P < 0.009) and reducing the cumulative incidence of such events, which was estimated 3-fold higher in the control group compared to the treatment group. Seven deaths occurred in the treatment group vs. 11 in the control group (P = 0.27). A total of 47 patients died or exhibited new AIDS-defining events, 18 in the treatment group and 29 in the control group (P = 0.009). No clinical benefit was observed after the 1-year period with infusions performed every 4 weeks. These results indicate a favorable effect of passive immunotherapy on the evolution of advanced AIDS.

[Passive immunotherapy in AIDS: transfusion of plasma rich in anti-p25 antibody (phase I trial)]. / Immunothérapie passive dans le SIDA: utilisation transfusionnelle de plasma riche en anticorps anti-p25 (essai de phase I).

The present study is a therapeutic trial of phase I, based on the principle of passive immunotherapy in acquired immunodeficiency syndrome (AIDS). Eighteen patients with full blown AIDS (stage IV C2 of CDC) were subdivided into two groups: nine receiving every two weeks 300 ml of plasma collected from HIV-1 seropositive symptomless (stage II or III of CDC) individuals, and nine (control group) receiving 300 ml of seronegative plasma at the same rythm and for the same period. Each patient received seven transfusions. Clinical and biological results during the transfusional and post-transfusional periods are reported.

Passive immunotherapy in AIDS: a randomized trial of serial human immunodeficiency virus-positive transfusions of plasma rich in p24 antibodies versus transfusions of seronegative plasma.

To assess the place of passive immunotherapy in the treatment of AIDS, a randomized study was conducted that evaluated the safety and short-term efficacy of serial transfusions of human immunodeficiency virus type 1 (HIV-1) seropositive plasma in 18 patients. Heat-inactivated anti-HIV antibody-rich plasma was compared with seronegative fresh-frozen seronegative plasma given in addition to zidovudine and other conventional prophylactic treatments. Seven transfusions every 2 weeks of immune plasma significantly reduced (2 vs. 8, P = .016) the number of opportunistic infections. Antigenemia became undetectable. When transfusions were stopped, positive p24 antigenemia returned at a level higher than before treatment and was correlated with a severe clinical deterioration, suggesting a rebound effect. This trial suggests that passive immunotherapy is promising in AIDS treatment. It confirms also that plasma donation does not affect donors' CD4 cell count over a 1-year period. In patients with severe immunodeficiency, special attention should be paid to withdrawal of an effective therapy as virologic relapse may be explosive and poorly tolerated.

Longitudinal study of plasma HIV-1 RNA concentrations during the asymptomatic stage of HIV infection measured using AMPLICOR HIV monitor and NASBA HIV-1 RNA QT tests. ACCTES Association.

The predictive value of two methods for measuring HIV RNA concentration in plasma was assessed in relation to CD4 lymphocyte counts during the asymptomatic period of infection. The design was a retrospective longitudinal case-control study for a mean period of 60 months involving 20 asymptomatic patients included in the French National prospective survey. The CD4 counts in these patients during the last 36 months of the study were stable (non-progressors) or declined (progressors). Plasma RNA concentrations were determined in each subject annually using the AMPLICOR and NASBA techniques. Only AMPLICOR gave RNA titers above the cut-off value for all the patients. The techniques agreed satisfactorily, although there was a difference, median 0.4 log10, between the AMPLICOR and NASBA values. The non-progressors had low and stable RNA concentrations. The concentration was higher in the progressors, according to the AMPLICOR technique, from their inclusion in the study, and according to the NASBA technique, from 1 year after inclusion. However, only four of ten individual progressors had stable plasma HIV RNA concentrations significantly above those of the non-progressors before the decline in their CD4 counts. These were all and only the patients with a decline in lymphocyte counts more than 100 CD4/mm3/year. In each of the other progressors, the RNA concentration was not significantly different from those of the non-progressors. Thus, when making decisions about therapy, plasma HIV RNA determinations cannot be used in place of CD4 counts and may provide valuable additional information.