[Diagnosis of a metastatic valvular tumor in a living patient]. / Tumeur métastatique valvulaire diagnostiquée du vivant du malade.

INTRODUCTION: The discovery of an endocardial mass always raises the question of its nature. Infectious endocarditis is the most frequent cause, but others diagnoses must be considered. EXEGESIS: We report a case of endocardial metastasis originating from an upper respiratory tract epidermoid carcinoma in a 48-years-old man. The diagnosis was established while the patient was alive, and survival at the time of writing is 8 months. This case report provides an opportunity for discussion of the differential diagnosis when confronted with an endocardial tumor, i.e. bacterial endocarditis, non-bacterial thrombotic endocarditis, primary cardiac tumors, metastatic osteogenic sarcoma and Libman-Sachs endocarditis. CONCLUSION: Non bacterial thrombotic endocarditis and valvular metastasis should be considered upon discovery of a valvular tumor, in the context of neoplastic disease. The prognosis of endocardial metastasis is poor, but early diagnosis and appropriate management should eventually prolong survival.

Factors related to the prescription of antibiotics for young children with viral pharyngitis by general practitioners and paediatricians in southeastern France.

This study evaluates the antibiotic-prescribing practices of physicians as well as other related issues in the context of viral pharyngitis. In a telephone interview, 535 physicians practising in southeastern France were submitted a clinical case description of an episode of acute pharyngitis in a 2-year-old child. Questions concerned antibiotic treatment and physicians' reasons for their treatment decision. The viral origin of the pharyngitis was more likely to be suspected by paediatricians than by general practitioners (92% vs. 78%, P<0.01); 57% of allopaths (compared with 26% of homeopaths/acupuncturists and 14% of paediatricians, P<0.001) declared they would prescribe an antibiotic in this situation (amoxicillin only in 42% of cases). This difference between allopaths and other physicians was still significant after controlling for knowledge regarding antibiotic therapy. In order to limit the risk of emerging resistant bacteria, it is urgent that training be upgraded for physicians, especially for allopaths.

Efficacy and safety of Buxus sempervirens L. preparations (SPV(30)) in HIV-infected asymptomatic patients: a multicentre, randomized, double-blind, placebo-controlled trial.

The objective of the present study was to compare the efficacy and safety of two doses of SPV(30) in HIV asymptomatic patients. The study was designed as a randomized double-blind multicentre trial of two doses of SPV(30) (990 mg/d and 1980 mg/d) versus placebo. 145 previously untreated subjects with asymptomatic HIV infection (CDC group IV) and CD4 cell counts between 250 and 500 × 10(6)/1 were recruited. There was a statistically significant difference in therapeutic failures between groups in favor of SPV(30) 990 mg including decreases of CD4 cell count < 200 × 10(6)/1 and/or number of clinical aggravations (progression to AIDS or AIDS related complex). The treatment groups differed statistically in the rate of disease progression also in favor of SPV(30) 990 mg/d. Fewer patients receiving SPV(30) 990 mg/d had at the end an increase of viral load greater than 0.5 log (P = 0.029). No severe side-effects were reported in the 3 groups. From these results we conclude that SPV(30) 990 mg/d has beneficial effects in HIV asymptomatic patients and appears to delay the progression of HIV disease.

A non-comparative, multicentre study of cefepime in the treatment of serious bacterial infections.

Multi-resistant strains of Gram-negative bacteria are rapidly emerging as a frequent cause of serious bacterial infection in the hospital environment. Effective treatment must include an antibiotic with activity against these organisms. In an open multicentre study, cefepime was evaluated as empirical therapy in 156 hospitalized patients (mean age 57 years) with serious infection of the urinary tract (n = 43), lower respiratory tract (n = 101) and skin and soft tissue (n = 12). In 18 patients, septicaemia/bacteraemia was also diagnosed. Cefepime, 2 g bd, was administered for a maximum of 16 days (mean 8). Of 98 pathogens isolated, 75 were Gram-negative and 23 were Gram-positive species. Ninety-four of the pathogens were susceptible to cefepime, including multi-resistant isolates such as Pseudomonas aeruginosa and Enterobacter cloacae. The overall clinical cure rate, excluding septicaemia/bacteraemia, was 92% (94/102); the corresponding bacterial eradication rate was 95% (52/55). In patients with septicaemia/bacteraemia, the clinical cure rate was 87% (13/15) despite eradication of 100% (11/11) of the assessable pathogens. Cefepime was well-tolerated, although 14 (9%) patients experienced local intolerance at the infusion site. Other drug-related adverse events were reported in six (4%) patients and included diarrhoea, pruritus, rash and urticaria. Cefepime is safe and effective as empirical treatment for serious infections commonly found in the hospital setting. Clinical cure and bacterial eradication can be achieved with a convenient bd dosing schedule.

Evaluation of pefloxacin, ofloxacin and ciprofloxacin in the treatment of thirty-nine cases of chronic osteomyelitis.

From October 1983 to October 1986, 39 patients with chronic osteomyelitis (of at least two month's duration) were treated with either pefloxacin (n = 15), ofloxacin (n = 17), or ciprofloxacin (n = 7). The length of treatment ranged from 3 to 6 months; follow-up examinations were performed up until July 1988. The infecting bacterial strains (19 Staphylococcus aureus, 2 Staphylococcus epidermidis, 10 Escherichia coli, 8 Pseudomonas aeruginosa) were all sensitive to the quinolone prescribed. Twenty-nine of the 38 evaluable patients had a satisfactory outcome at follow-up examinations 14 to 48 months after the end of treatment. Fourteen of the 21 patients with gram-positive bacterial infections responded satisfactorily, as did 15 of the 17 patients infected by gram-negative bacteria. Nine cases of failure were observed (2 for pefloxacin, 4 for ofloxacin, 3 for ciprofloxacin). The infecting bacteria were Staphylococcus aureus in six cases (3 on ofloxacin, 3 on ciprofloxacin). The infecting bacteria were Staphylococcus aureus in six cases (3 on ofloxacin, 3 on ciprofloxacin), and Staphylococcus epidermidis (ofloxacin), Escherichia coli (pefloxacin), and Pseudomonas aeruginosa (pefloxacin) in one case each. In all these cases, local conditions (presence of a foreign body in 5 cases, sequestra in 3, and post-radiotherapy necrosis in 1) could have been responsible for treatment failure. Tolerance was good; adverse effects observed in the pefloxacin and ofloxacin groups disappeared after treatment was ended. Bone levels varied but were always superior to the MIC for the pathogen. In view of the satisfactory results, the possibility of oral administration, and the good tolerance, these quinolones should be considered as alternative agents for the treatment of chronic osteomyelitis.

The diffusion of pefloxacin into bone and the treatment of osteomyelitis.

Pefloxacin was evaluated in the treatment of bone infections. A clinical trial was performed in 15 patients with chronic osteitis (5 Staphylococcus aureus, 5 Pseudomonas aeruginosa, 3 Serratia sp., 1 Proteus mirabilis, and a mixed infection with a Streptococcus faecalis and Escherichia coli). Patients were given pefloxacin 400 mg 12-hourly iv for 48 h followed by oral treatment. Bone biopsies from the iliac crest were carried out after at least seven days treatment, 2 h after the last dose. Serum levels were estimated at the same time. In 13 patients the pefloxacin levels were between 2 and 10 mg per g of bone and always greater than, or equal to, the MIC for the infecting organism. In 11 patients treated for six months and followed up for up to 14 months after the completion of treatment, the therapy was successful. In another two patients, the results were excellent with closure of fistulae, but there was only limited follow-up. There were two failures: in one (post-radiation osteitis) the infection persisted and in the other there was intolerance of the antimicrobial. In both cases there was no increase in the MIC of pefloxacin against the organisms. Three patients underwent operations for orthopaedic indications, after at least two months of treatment. Bone cultures from the initial focus remained sterile. Side-effects were mild.