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.

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.

[Chronic respiratory insufficiency. Incidence in the results of surgical valvular replacement]. / Insuffisance respiratoire chronique. Incidence sur les résultats de la chirurgie de remplacement valvulaire

Out of 400 files of patients who underwent valvar correction between 1968 and 1974 under extra corporeal circulation by the thoracic route through median sternotomy 180 were kept for this study. All these 180 patients had a complete functional spirometric examination before operation, analysed in correlation with their valve disease. 39 of them had severe ventilatory insufficiency. Nevertheless the post-operative period was usually simple, and respiratory insufficiency was responsible for one death only of this series. These data were confirmed by the study of 45 autopsied patients who died after operation. At distance from operation, 80 patients were studied, 25 of whom had severe ventilatory insufficiency. In more than half the cases, and particularly in the mitral ones, the ventilatory deficiency was improved. Thus it is concluded that, respiratory insufficiency is rarely a contra-indication to valve replacement surgery in habitual conditions of the median sternotomy as a thoracic route.

[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.

[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.

[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.

[Recent acquisitions concerning mediatinopulmonary sarcoidosis]. / Acquisitions récentes concernant les sarcoïdoses médiastino-pulmonaires.

Sarcoidosis is a disease defined by two criteria: one quantitative involvement if several organs or tissues showing its systemic character) the other qualitative (presence in all affected organs of giant cell and epitheloid cell granulomas without caseation). The first seems to counter balance the absence of specificity of the second. Unfortunately, the quantitative factor may be lacking in the mediastino-pulmonary forms owing to their apparently localised character. The diagnosis is thus based on a critical study of the clinical context (age, general health radiological appearances) and indirect signs of diffusion (biopsies, immune reactions, Kweim test). The therapeutic indications should take into consideration the tendancy to spontaneous recovery which occurs in 98% of cases. Prolonged corticosteroid therapy may be difficult to stop. No treatment should therefore be given unless there are complications or associated lesions exposing the patient to the risk of severe and permanent sequelae.

[Short-term use of beclomethasone dipropionate in the treatment of spasmodic obstructive bronchopneumopathies]. / Utilisation du dipropionate de béclométhasone en cures courtes dans le traitement des bronchopneumopathis obstructives spasmodiques.

Forty-two patients were treated with beclomethasone dipropionate in doses of 400 microgram daily for no longer than three months. There were three main indications : attempt to withdraw corticosteroids or sympathomimetics ; treatment prior to desensitization ; treatment of asthma with severe permanent dyspnea. In 8 patients, systemic steroids of sympathomimetic drugs could be withdrawn. Dosage could be reduced by 50% or more in 21 cases, and by less than 50% in 9 cases. There were 3 failures, and results were unassessable in one case. No major side-effects were observed.

[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.

[Pleural aspergillosis. One case of giant mycetoma (450 g) (author's transl)]. / Aspergillose pleurale. A propos d'un cas d'aspergillome pleural géant (450 g).

Pleural aspergillosis is an uncommon localization; only about 60 observations have been previously reported and two-thirds of them in France. A new case characterized by the presence of a giant mycetoma (450 g) is reported. It should be kept in mind that this lesion develops in the residual cavity, resulting from a therapeutic pneumothorax. Conservative surgery is therefore required and enables (as shown in this case) a satisfactory recovery of the underlying parenchyma.

[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.

[A comparative study of three procedures used for studying bronchopulmonary bacterial flora (author's transl)]. / Etude comparative de trois techniques d'étude de la flore bactérienne broncho-pulmonaire.

Three methods of taking samples of bronchopulmonary secretions; transtracheal aspiration (TT), sputum collection, and fibro-aspiration, were compared in 43 patients with severe pneumopathies. There was no significant difference in the number of times a pure or dominant germ was isolated by using the three procedures in these 43 cases. In contrast, however, there was a significantly lower number of polymorphous flora and more sterile samples observed when using TT than with the other two methods. When antibiotics are given 1 to 7 days before taking the samples, there is a significant reduction in the number of cultures having a germ in the pure state.