Long-term results of monthly inhaled pentamidine as primary prophylaxis of Pneumocystis carinii pneumonia in HIV-infected patients.

PURPOSE: To evaluate the long-term efficacy and safety of inhaled pentamidine as primary prophylaxis against Pneumocystis carinii pneumonia (PCP) in patients infected with human immunodeficiency virus (HIV). PATIENTS: Two hundred thirty-two HIV-infected patients with a CD4 cell count below 20% of the total lymphocyte count were given aerosolized pentamidine once every 4 weeks for more than 3 months. Pentamidine aerosols were administered at the hospital under medical supervision. Prevention of bronchospasm was carried out using inhaled salbutamol. RESULTS: Mean duration of prophylaxis was 15.9 months. Eleven patients (4.7%; [95% confidence interval 2% to 7.4%]) developed PCP. Probability to remain free of PCP is 95.6% at 12 months, 94% at 18 months, and 88% at 24 months. Mean delay between the onset of the prophylaxis and the occurrence of PCP for the 11 patients was 12.9 months (range: 4 to 26 months). No major side effect was observed, and minor side effects (cough, acute dyspnea) were infrequent. CONCLUSION: The efficacy and tolerance of aerosolized pentamidine as shown in our study support its use as primary prophylaxis against P. carinii in HIV-infected patients.

HIV prevalence and risk behaviour among intravenous drug users attending HIV counselling and testing centres in Paris.

This study was designed to analyse sexual and drug use behaviour, to determine whether increased awareness can lead to behaviour change, and to evaluate the association between HIV seropositivity and potential risk factors. A 4-month survey was carried out on 147 IVDUs attending three HIV counselling and testing centres, 98% of whom had been using heroin for an average of 7 years, 85% in association with other drugs. Two-thirds of injectors reported having used "safer" injecting practices in the previous year. Most of the IVDUs were heterosexual, and had had an average of three sexual partners in the previous year. More than half of them had had high risk partners. Condoms were used by only 25% of IVDUs, and were more likely to be used with seropositive partners (38% versus 12.7%, p = 0.02). Patients considering themselves to be well informed about HIV transmission shared syringes significantly less often, but had the same sexual behaviour patterns as other subjects. The HIV prevalence rate (8.2%) in our sample was not statistically related to any risk factor apart from drug use duration, the latter possibly reflecting a cumulative exposure to HIV risks. Since sexual risk appears to be a potential long-term hazard for IVDUs, it is important that more attention be paid to providing counselling to specifically address this issue.

[Bronchoceles. Apropos of a case]. / Les bronchocèles. A propos d'un cas.

Bronchoceles form bronchial cul-de-sacs in normal or destroyed walls, post-stenotic or secondary to congenital bronchial atresia or infections in infancy. Because of their rarity they frequently go unrecognised. A precise history may sometimes reveal the cause as post-infectious. The differential diagnosis includes mucoid impaction and bronchial tumors. The most common radiological appearance of a bronchocele is a pulmonary opacity, posing problems of differential diagnosis with cancer; such a case is presented in this article.

[Critical study of the indications for long-term oxygen therapy. Chronic obstructive bronchopneumopathies]. / Etude critique des indications de l'oxygénothérapie à long terme. Bronchopneumopathies chroniques obstructives.

Numerous studies have shown that longterm oxygen therapy in hypoxaemic patients with chronic airflow obstruction (BPCO) is capable of improving the prognosis and decreasing the risk of cardio-respiratory decompensation; in addition sometimes physical capacity and intellectual capacity is improved. Another result often noted is a reduction in the mean hospital stay which corresponds to an improvement in the quality of life. A PaO2 constantly below 55 mmHg (7.3 kPa) is defined by the majority of authors as a precarious state. At this level even a small change in alveolar ventilation or disturbance of distribution would lead to an important fall in the oxygen content of the arterial blood. The stability of the PaO2 during the weeks of respiratory reeducation with specially controlled medical treatment, as well as the willing consent of the patient and his family, are indispensable conditions for the prescription of OLT. When hypoxaemia is of moderate severity (PaO2 between 50 and 60 mmHg (6.6-8 kPa), prolonged medical treatment (with abstention from tobacco) for at least two months is advised and a study of complementary criteria to further validate the indications for oxygen. Such features would include a worsening of the hypoxaemia during exercise of 30 to 40 watts (PaO2 less than 50 mmHg, 6.6 kPa), an elevated haematocrit (greater than 55%), a rise of the P (A-a)O2 (greater than 30 mmHg or 4 kPa), a nocturnal desaturation even in the absence of apnoea (oxyhaemoglobin saturation (SaO2) of less than 80% for more than 50% of the time asleep). Added to these criteria are the radiological, echographic and clinical signs of the effect of hypoxaemia on the pulmonary circulation. Frank pulmonary arterial hypertension observed in hypoxaemia of moderate severity when the PaO2 is in the region of 55 mmHg and is an argument for the prescription of OLT. Amongst the developing criteria, exacerbations of respiratory encephalopathy, intellectual deterioration, progressive wasting, permanent ventilatory embarrassment with tachypnoea, should be borne in mind as the occasion arises. A schedule of 18 hours per day (without stopping for more than 3 hours) is necessary to obtain an improved survival and places a great demand on patient co-operation and on their environment. A prolonged educational programme is required. To achieve such a schedule the use of portable oxygen may be justified so that patients can lead a normal social life.(ABSTRACT TRUNCATED AT 400 WORDS)

[Aerosol therapy in asthma]. / Aérosolthérapie dans l'asthme.

Today there is a general use of aerosols in the treatment of asthma. To understand their importance it is necessary to know the make-up of an aerosol, physical and chemical factors as well as anatomical factors that influence its deposition and clearance in the tracheo-bronchial tree. In the therapy of asthma, small, easy-to-handle and reliable inhalers are prescribed. Other methods of administering these drugs by inhalation are available: these include nebulisation of the active substance in a liquid form and inhalation of the drug in a powder form. Their efficacy and the rareness of side effects (owing to the fact of minimal systemic absorption) makes them the preferred form of treatment of crises as well as for basic treatment. Nevertheless, to obtain the best therapeutic results the inhalation technique of the aerosol should be correct and some practical improvements are envisaged to alleviate any disadvantages: mixing chambers, mouth pieces, etc. Several drugs are commercially available in aerosol form (beta-agonists, atropine-like drugs, corticosteroids and chromones) which have a place both in the treatment of crises and in the basic treatment of asthma.

[Evaluation of the medical costs of asthma in adults during a l-year follow-up in a hospital environment]. / Evaluation du coût médical de l'asthme de l'adulte au cours d'une année de surveillance en milieu hospitalier.

The medical cost of asthma is difficult to measure because this syndrome is generally studied in amongst a large group of patients with chronic respiratory disease. The aim of this study was to assess the theoretical cost of the medical treatment of asthma in a group of young adults who are free from any other disease; the study lasted for one year of follow up and the treatment was given in the public hospital service. Four particular situations are identified corresponding to four stages of severity of the disease and each of these stages was given a treatment selected as the usual therapeutic regime given in a respiratory service in a public hospital. The first stage was to suit patients suffering from quarterly paroxysmal crises which tended to resolve quickly after a few days of treatment. The second stage was more severe involving patients suffering from monthly paroxysmal attacks and for whom maintenance treatment was necessary. The third stage was for those with unstable asthma with twice monthly asthmatic crises, frequent hospitalisation and continuous treatment between the attacks. In the fourth stage the patients were suffering from continuous dyspnoea which required inpatient hospital care and also intensive care. In all these cases the asthmatic disorder is burdensome both for the patient and for society, a fact which should be appreciated both by doctors and by decision makers in public health. In the average or mild cases the essential annual costs are made up of the cost of diagnosis and follow up.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cough and bronchial obstruction induced by citric acid in smokers, occasional smokers and non-smokers]. / La toux et l'obstruction bronchique induites par l'acide citrique chez les fumeurs, les fumeurs occasionnels et les non-fumeurs.

We have studied cough and bronchial constriction induced by inhaling citric acid in 15 smokers with baseline airflow obstruction, in 13 occasional smokers and 13 non smokers. The threshold for cough was significantly higher in occasional smokers in relation to smokers and non smokers. Citric acid produced the same degree of bronchial constriction at the same time in smokers and occasional smokers: the maximum fall in forced expired volume (FEV1-VEMS) was recorded five seconds after inhalation of the citric acid (dose threshold) and there was no significant difference between the two groups. In the non smokers, the maximum fall in VEMS was recorded twenty seconds after inhalation of the citric acid and was significantly less in relation to that of the smokers and occasional smokers. In the smokers the degree of smoking could influence the fall of VEMS (% predicted). Cough and bronchial constriction after the inhalation of citric acid are probably related to different physiological mechanisms and are linked to the history of smoking.

[Smoking among nursing students]. / Le tabagisme chez les élèves infirmières.

The aim of this work is to study smoking habits in young adults in a particularly sensitive environment. The data were collected in 28 nursing schools of the Public Hospital System in Paris by means of anonymous self-administered questionnaire. The questions focused on smoking habits, knowledge of risks and student attitudes. The 5,598 respondents (mean age of 22.6 years) were 89 per cent female. The results showed a high prevalence of current smoking (44%) especially amongst the younger students. Students preferred brands with a medium range tar level. Most of the students knew the smoking risk, agreed with the policy of prohibiting smoking in the hospital and thought that it is the role of nurses to counsel patients to stop smoking, but only one third hold a positive view of this role.

[Asthma, urban atmospheric pollution and the weather]. / Asthme, pollution atmosphérique urbaine et météorologie.

The aim of this study, which was carried out in an urban environment, was to research in to a possible relationship between temporal variations in the level of atmospheric pollution in the centre of Paris, compared to the frequency of acute dyspnoeic crises in which asthmatic patients had requested the emergency service (SOS Médecins). This study began in the first half of 1989; during this period there were 701 cases of acute asthma recorded within the Paris city boundary by "SOS Médecins". The pollutants recorded were sulphur dioxide (SO2), an index of black smoke (FN), oxides of nitrogen (NOx), ozone (O3) and soluble sulphate particles (SO4). In addition, the weather patterns were examined and pollen counts were recorded. In spite of a sub-acute episode of pollution in January and February, there was no definite increase noted in the number of emergency calls made for acute asthma. In the first three months, the number of crises were, on average, higher in association with high levels of the principal pollutants (SO2 FN, NOx, SO4) as well as with the periods of high atmospheric pressure; however, only the sulphate content and atmospheric pressure remained correlated with the daily number of asthmatic crises. In the second three months, there were some co-variations uniquely associated with sulphate particles, the atmospheric pressure, and above all the ozone level (allowing for a gap of one day). The influence of the daily variations in total pollen content or of grass pollens did not show up in this study.

[Urban asthma and habitat]. / Asthme urbain et habitat.

This study examines in urban area the housing conditions in asthma patients who called a first-aid association of doctors (SOS Médecins) and their relationships to symptoms. The patient population is compared with the non asthmatic population who called SOS Medecins during the same period. During the first six months of 1989, among 102,791 calls, 701 were related to acute asthma symptoms, and 100 non asthma patients were sorted at random as a control group. A telephonic questionnary has been carried out to asthmatic patients and to control group. A particular aspect of asthma in Paris is given in this study: the homogeneous distribution of asthma attacks in the different districts of Paris, (with a light prevalence in three districts of the city). Sex, age, occupation were non discriminant and no significant difference was established in housing conditions and indoor air pollution sources, between the two groups of asthma and non-asthma patients.

[Hepato-pulmonary Nocardia infections (report of one case) (author's transl)]. / Nocardiose hépato-pulmonaire. A propos d'un cas.

Actinomycosis due to Nocardia asteroides is a mainly pulmonary disease; the metastases are due to migration of the germ in the blood from the primary lung focus. The case reported here concerned a patient whose initial symptoms were mainly hepatic, suggesting an amoebic abscess of the liver. The pulmonary lesions appeared only secondarily with presence in the sputum of the nocardia which was responsible. Prolonged treatment with trimethoprime sulfamethazole led to complete and lasting cure of the lesions, confirmed radiographically and by a liver scan.

[Symptomatology of tuberculosis]. / La séméiologie de la tuberculose.

First described long before the beginning of our era, the clinical presentation of tuberculosis has not really changed much over the course of ages. Although early diagnosis and the introduction of bacteriocidal antibiotics have led to a decline in the most severe forms, at least in developed countries, the general and functional symptomatology, characteristic of chronic tuberculosis, remains unchanged in non-immunodeficient patients. Inversely, in patients with and immunodeficiency syndrome, the distribution and clinical course of the fundamental signs and symptoms have undergone a considerable modification as a result of intercurrent clinical signs of other opportunistic diseases involving both the lung and extrapulmonary organs.

[From first symptom to diagnosis and from diagnosis to treatment of tuberculosis: still a long delay]. / Du premier symptôme au diagnostic et du diagnostic au traitement de la tuberculose: un délai qui reste long.

OBJECTIVE: The aim of this investigation was to determine the delay between the first symptom and diagnosis of pulmonary tuberculosis and onset of treatment. STUDY DESIGN: Fifty-two consecutive patients presenting with confirmed pulmonary tuberculosis over an 18 month period (June 1, 1991 to December 31, 1992) at the Cochin Hospital in Paris. RESULTS: The mean delay between first symptom and diagnosis was 2 weeks in 14 patients (27%), 3 to 4 weeks in 10 patients (19%) and over 4 weeks in 28 patients (54%). The delay between diagnosis and onset of treatment was less than 8 days in 39 patients. CONCLUSION: Delay was not shorter when symptoms were present. This situation could have an effect on tuberculosis morbidity.

[Opinions and behavior of asthmatic patients towards treatment using aerosols]. / Avis et comportement des malades asthmatiques vis- à-vis des traitements par aérosols.

An ever increasing number of drugs prescribed in the treatment of asthma are presented as aerosols, so that patients may be requested to inhale many puffs every day. In this study, the opinion of asthmatic patients was sought and their behaviour towards aerosols during attacks and in long-term treatment was recorded by means of a questionnaire. The answers confirmed that asthmatics liked aerosols and found them usually effective, but 60% of these patients exceeded the stated dose, and if the drug failed to bring the expected relief, 30% waited 24 hours before calling for a doctor. In long-term treatments, 80% of the patients studied said that 10 puffs a day were a nuisance, and 12% were switched to another treatment for that reason. These results are very important. Doctors should reinforce the patients' education and limit the number of daily puffs they prescribe to obtain better compliance of asthmatics with their treatment.

[Health effects of chronic exposure to tobacco smoke on a non-smoker population]. / Effets sanitaires d'une exposition chronique à la fumée de tabac sur une population de non fumeurs.

A study devised to evaluate the effects of chronic exposure to tobacco smoke on the health of a population of non-smokers was conducted in a prison. Fourteen volunteers among male, non-smoking prisoners in good health and without history of lung disease were put for thirty days in a cell that was already occupied by three smokers. These subjects were examined on arrival and on the 30th day of their imprisonment. The examination included filling a questionnaire concerning daily habits and food, respiratory function tests, measurement of CO in the expired air, measurement of nicotine, cotinine, thiocyanates and cadmium concentrations in blood and in urine, and measurement of mutagenic substances excreted. The purpose of the study was to detect possible changes in the variables tested between the first and last days of confinement. No significant difference could be demonstrated within this lapse of time. These results are in agreement with the data available in the literature. In the present state of our knowledge, it is difficult to find evidence of a biological impact, notably on the concentrations of the specific indicators nicotine and cotinine, in subjects passively exposed to tobacco smoke.

[Can weight gain during weaning from smoking be limited using nicotine gum?]. / Peut-on limiter la prise de poids chez les fumeurs lors du sevrage tabagique en utilisant la gomme à la nicotine?

One hundred subjects smoking more than 20 cigarettes per day were divided into two groups allocated at random to either nicotine gum or a placebo gum. Forty-eight subjects stopped smoking, irrespective of the treatment received. The magnitude of weight gain after given up smoking and the benefits of nicotine gum were evaluated. Weight gain was found to increase in ex-smokers compared with persistent smokers, but the increase was less pronounced in subjects who chewed nicotine than in those who chewed the placebo, although the difference was not statistically significant. However, enough gum must be chewed for the appetite and feeling of hunger to be reduced.

[Short-term chemotherapy of tuberculosis. Cooperative French trial]. / Chimiothérapie de courte durée de la tuberculose. Essai coopératif français.

A cooperative french trial in the treatment of pulmonary tuberculosis has compared the efficacy and the tolerance of daily antituberculous regimes, one of short duration of 18 weeks (HRSZ/HRZ), the other of standard duration of 9 months (HRE). Of 204 patients included in the trial 180 were analysed. No significant difference was found between the two regimes regarding either biological tolerance or clinical outcome. Four relapses were seen within 24 months of the onset of treatment, two in each regime, which shows that 18 weeks treatment is ethically acceptable. Such short course therapy is useful in those patients who would sometimes find prolonged therapy difficult or would be likely to abandon treatment prematurely.