Correlation between lung function tests and peak oxygen consumption in post-TB lung disease.

BACKGROUND: After TB treatment, many patients have post-TB lung disease (PTLD), associated with increased mortality and morbidity. Nevertheless, relationships between lung function testing and exercise capacity in people with PTLD are poorly understood.METHODS: This single-centre study investigated the association between lung function testing and peak oxygen consumption (VO2peak) and percentage-predicted VO2peak (VO2peak (%pred)) in adults with PTLD investigated for surgery.RESULTS: Eighty-two patients (52 males, 30 females) with a mean age of 43.2 years (SD 11.3) were included. Spirometric values of forced vital capacity (FVC) percentage predicted (%pred) and forced expiratory volume in 1 sec (FEV1) %pred suggested significant correlations with VO2peak (%pred) (P < 0.001 and P < 0.001), whereas FEV1/FVC did not. Diffusing capacity for carbon monoxide (DLCO) %pred also correlated significantly with VO2peak (%pred) (P = 0.002). However, the magnitude of all significant correlation coefficients were weak. No significant correlations for any plethysmographic values with VO2peak (%pred) could be robustly concluded. Correlations with VO2peak (ml/kg/min) for most physiological variables were less robust than for VO2peak (%pred).CONCLUSIONS: Although statistically significant, the correlations between any measure of lung function and VO2peak or VO2peak (%pred) were weak, with only FVC correlation coefficient surpassing 0.50.

Position statement for adult and paediatric spirometry in South Africa: 2022 update.

Spirometry is required as part of the comprehensive evaluation of both adult and paediatric individuals with suspected or confirmed respiratory diseases and occupational assessments. It is used in the categorisation of impairment, grading of severity, assessment of potential progression and response to interventions. Guidelines for spirometry in South Africa are required to improve the quality, standardisation and usefulness in local respiratory practice. The broad principles of spirometry have remained largely unchanged from previous versions of the South African Spirometry Guidelines; however, minor adjustments have been incorporated from more comprehensive international guidelines, including adoption of the Global Lung Function Initiative 2012 (GLI 2012) spirometry reference equations for the South African population. All equipment should have proof of validation regarding resolution and consistency of the system. Daily calibration must be performed, and equipment quality control processes adhered to. It is important to have standard operating procedures to ensure consistency and quality and, additionally, strict infection control as highlighted during the COVID-19 pandemic. Adequate spirometry relies on a competent, trained operator, accurate equipment, standardised operating procedures, quality control and patient co-operation. All manoeuvres must be performed strictly according to guidelines, and strict quality assurance methods should be in place, including acceptability criteria (for any given effort) and repeatability (between efforts). Results must be categorised and graded according to current guidelines, taking into consideration the indication for the test.

Living with food allergy: What this means for children.

Health-related knowledge, skills and attitudes that translate to behaviours are important foundations for healthy living. However, deficiencies in any one of these factors have the potential to impact quality of life. This study investigates how Australian children perceive and manage their food allergy as they transition through childhood onto adolescence. To measure this, children aged 12 years and under completed an online survey [under 8 years and 8-12 years] on knowledge, skills and attitudes. Although recruitment involved advertisements to over 700 Australian pre-schools, 44 allergy specialists and multiple representations to the patient support group, Allergy & Anaphylaxis Australia, completion relied on parental notification and/or guidance. Of the 139 participants recruited, 114 commenced the survey with 65 participants under 8 years (58%) and 49 between 8 and 12 years. Results showed participants recognised different ways to keep safe with children under 8 years (N = 65) 100% cognisant of the need to check with 'Mum/Dad' or teachers if they could safely eat food as well as the importance of not swapping lunches, while there was a slight change in compliance for those aged 8-12 years as three (6.1%, n = 3/49) children did not see the necessity of asking an adult/teacher if a food item was safe to eat. Older children were also less likely to tell friends about their food allergy even if they thought they were having an allergic reaction, despite children under 8 years more likely to feel different to friends (38%, n = 24/64) compared to those aged 8-12 years (31%, n = 14/45). Although both groups disliked parents' fussing, for children under 8 years, there was a strong association between this and 'feeling different to friends'. Results from this study highlight the importance of normalising food allergy at home and in the community, so children are confident in telling others about their food allergy.

Persistent chronic respiratory symptoms despite TB cure is poorly correlated with lung function.

BACKGROUND: Persistent respiratory symptoms and lung function deficits are common after patients with TB. We aimed to define the burden of post-TB lung disease (PTLD) and assess associations between symptoms and impairment in two high TB incidence communities.METHODS: This was a cross-sectional survey of adults in Cape Town, South Africa who completed TB treatment 1-5 years previously. Questionnaires, spirometry and 6-minute walking distance (6MWD) were used to assess relationships between outcome measures and associated factors.RESULTS: Of the 145 participants recruited (mean age: 42 years, range: 18-75; 55 [38%] women), 55 (38%) had airflow obstruction and 84 (58%) had low forced vital capacity (FVC); the mean 6MWD was 463 m (range: 240-723). Respiratory symptoms were common: chronic cough (n = 27, 19%), wheeze (n = 61, 42%) and dyspnoea (modified MRC dyspnoea score 3 or 4: n = 36, 25%). There was poor correlation between FVC or obstruction and 6MWD. Only low body mass index showed consistent association with outcomes on multivariable analyses. Only 19 (13%) participants had a diagnosis of respiratory disease, and 16 (11%) currently received inhalers.CONCLUSION: There was substantial burden of symptoms and physiological impairment in this "cured" population, but poor correlation between objective outcome measures, highlighting deficits in our understanding of PTLD.

The utility of hand-held mobile spirometer technology in a resource-constrained setting.

BACKGROUND: Mobile phone-linked spirometry technology has been designed specifically for evaluating lung function at primary care level. The Air-Smart Spirometer is the first mobile spirometer accepted in Europe for the screening of patients with chronic respiratory diseases. OBJECTIVES: To prospectively assess the accuracy of the device in measuring forced expiratory volume in the first second (FEV1) and forced vital capacity (FVC) in a South African population, and to investigate the ability of the device to detect obstructive ventilatory impairment. METHODS: A total of 200 participants were randomly assigned to perform spirometry with either the mobile spirometer connected to a smartphone or the desktop spirometer first, followed by the other. The FEV1/FVC ratio as well as the absolute FEV1 and FVC measurements were compared, using each participant as their own control. A Pearson correlation and Bland-Altman analysis were performed to measure the agreement between the two devices. We defined obstructive ventilatory impairment as FEV1/FVC <0.7 measured by desktop spirometry in order to calculate the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the Air-Smart Spirometer. RESULTS: There was a strong correlation between the absolute FEV1 and FVC values and FEV1/FVC ratio measured with the mobile Air-Smart Spirometer and more conventional pulmonary function testing, with r=0.951, r=0.955 and r=0.898, respectively. The Air-Smart Spirometer had a sensitivity of 97.6%, specificity of 74.4%, PPV of 73.0% and NPV of 97.8% for obstructive ventilatory impairment. CONCLUSIONS: The mobile Air-Smart Spirometer compared well with conventional spirometry, making it an attractive and potentially affordable tool for screening purposes in a primary care setting. Moreover, it had a high sensitivity and NPV for obstructive ventilatory impairment.

Chronic Tophaceous Gout in a patient with Cyanotic Congenital Heart Disease

Introduction@#Gout is a clinical syndrome resulting from deposition of urate crystals in joints causing inflammation, intense pain and even disability. In 2003 National Nutrition and Health Survey (NNHeS), the overall prevalence of gout was 1.6% and the prevalence of hyperuricemia was 28.4% of the 4498 adults >20 years old. Gout complicating cyanotic congenital heart disease (CCHD) was infrequently recognized in early reports with Somerville referring only nine patients over a period of five years in the registry of two hospitals. Recent studies have shown increased recognition, with Yamamura identifying 16% of the 92 patients with CCHD to have gouty arthritis. There is no local data on the frequency of gout among patients with CCHD @*Case Presentation@#26-year-old male previously diagnosed with Transposition of Great Arteries presented with a mass on the 5th digit of left hand with pathologic bone destruction on radiograph underwent disarticulation of the same finger. Intraoperative findings revealed chalky substances that led to the referral to rheumatology section. A diagnosis of chronic tophaceous gout was considered after review of history. He had a three year history of intermittent polyarticular arthritis involving the elbows, knees and ankle joints and later developed tophi in the helices of the ears and the DIP joint of the fifth digit of the left hand. There is increasing level of hyperuricemia as the severity of arthritis progressed. He had a polyarticular gout flare post operatively. The gout attack resolved after treatment with colchicine. Allopurinol was initiated after control of gout flare with resulting decrease in uric acid level.@*Discussion@#This case described a young male patient with transposition of great vessels with acute intermittent polyarthritis and tophi formation. The occurrence of gout and the complexity of the congenital heart disease have caused a considerable financial, functional and emotional instability on the patient, his parents and extended family. In patients with cyanotic congenital heart disease, the prevalence of hyperuricemia ranges from 16 to 43%. Several factors identified to be associated with hyperuricemia in CCHD in our case which include hypoxemia, polycythemia and impaired renal function. Nonetheless, management of gout in patient with CCHD is similar to the primary and secondary gout.@*Conclusion@#Gouty arthritis should be a differential in a patient with a cyanotic congenital heart disease complaining of joint swelling and tenderness. Early and prompt diagnosis will relieve symptoms and prevent complications that may lead to physical inactivity of patients.

Effect of HMG-CoA Reductase Inhibitor Drugs (Statins) on Systemic Lupus Erythematosus Disease Activity: A systematic review and meta-analysis

Introduction@#Statins have been shown to have antiinflammatory and immunomodulatory effects. In vitro studies show that these drugs inhibit inflammatory cells, decrease the expression of major histocompatibility complex (MHC), decrease adhesion molecules and inflammatory cytokines (IL6 and IL10), that are also implicated in SLE pathogenesis. In terms of immunomodulary effects, animal studies demonstrate that statins exacerbate/trigger cellular apoptosis and induce a shift in the Th1/Th2 balance leading to B-cell reactivity and production of pathogenic autoantibodies. Whether statins have clinical effects in SLE have not been widely studied. In terms of disease activity, studies show contradicting results. The researchers aim to determine the effect of statins on the disease activity of SLE based on the best available evidence@*Methods@#A systematic literature search of PubMed, Scopus, and Cochrane databases was done with no date and language restrictions. Included studies were on adult SLE patients and randomized controlled trials that used statins as intervention and reported SLE disease activity as an outcome measure. Two reviewers did quality appraisal, risk bias assessment, and data extraction.@*Results@#Three studies met the eligibility criteria and were included in this review. Quantitative synthesis was done. The pooled analysis of these studies suggests that atorvastatin has no significant effect on disease activity using random effects model with an overall effect of 0.12 (P=0.90, 95% CI -1.65, 1.88).@*Conclusion@#Atorvastatin neither increased nor decreased SLE disease activity. Therefore possibly it can be safely given to SLE patients without the risk of triggering or exacerbating a flare.

Complementary and alternative medicine and the search for knowledge by conventional health care practitioners.

The use of complementary and alternative medicines (CAM) is growing rapidly within the western world and the nexus with conventional health care services is expanding. Many nurses and other conventional health care providers are not only using CAM themselves but see many of their clients using these medicines and therapies. The attitudes to CAM can influence client satisfaction and client use of different therapies and many practitioners of conventional health care are seeking education and information to enhance their knowledge and use of CAM. This paper reflects on the attitudes to CAM and the education needs and services in the field of CAM as identified by western health care providers, in particular nurses.

6-Hydroxymelatonin protects against quinolinic-acid-induced oxidative neurotoxicity in the rat hippocampus.

Melatonin, a naturally occurring chemical mediator, although assigned a diverse range of functions, has attracted interest because of its ability to function as a free radical scavenger. Its major hepatic metabolite and photoproduct, 6-hydroxymelatonin (6-OHM), also shares this property. Since singlet oxygen and quinolinic acid (QUIN) are critically involved in the pathology of neurotoxicity, the objective of this study was to investigate the ability of 6-OHM to scavenge singlet oxygen and evaluate its ability to scavenge superoxide anions and reduce QUIN-induced neurotoxicity in the hippocampus in-vivo. The results show that 6-OHM is an efficient inhibitor of singlet oxygen formation as indicated by the rate constants and quantum yields reported for 6-OHM and zinc phthalocyanine (ZnPc), respectively. 6-OHM, appears to reduce QUIN-induced superoxide anion generation in the hippocampus, which provides some evidence of the neuroprotective effects of 6-OHM.

Attitudes of Australian pharmacists toward complementary and alternative medicines.

BACKGROUND: The increase in the use of complementary and alternative medicine (CAM) by the general public has led to increasing interest in how health professionals view these therapies. OBJECTIVE: To determine the knowledge and attitudes of pharmacists toward CAM. METHODS: An anonymous, self-administered questionnaire was designed and mailed to 1500 randomly selected pharmacists in New South Wales, Australia. RESULTS: Four hundred eighty-four responses were received, with 77% of respondents indicating that they had personally used CAM and 60% correctly identifying that CAM was comprised of more than just botanicals and nutritional agents. The most commonly used CAMs were herbal and vitamin supplements (74%), which was significantly above use of the next most frequent CAM, massage therapy (6%). Most pharmacists (71%) reported offering CAM products for sale; however, 27% of these practices did not have access to CAM information for pharmacy staff or patients. Pharmacists generally viewed CAM positively and believed that they enhanced the customers' image of pharmacy (57%), increased customer numbers (87%), and could increase annual sales (72%). Ninety-one percent of respondents believed that it is necessary for pharmacists to have knowledge of both CAM and conventional medicine to be able to inform patients about their treatment options. Books and journal articles were their primary information sources, with the main reasons for recommending CAM evidence of efficacy and to maintain general health. CONCLUSIONS: CAM use is prevalent among Australian pharmacists. While pharmacists are aware of their role as educators about both CAM and conventional medicines, there is a need for greater access to CAM resources and education on these therapies.

Melatonin generates singlet oxygen on laser irradiation but acts as a quencher when irradiated by lamp photolysis.

Melatonin, a naturally occurring chemical mediator, although assigned a diverse range of functions, has attracted interest in recent years because of its ability to function as a free radical scavenger. Because of the implications of singlet oxygen in neurotoxicity, the objective of the study was to investigate the ability of melatonin to quench singlet oxygen generated using laser irradiation or lamp photolysis. The results show that melatonin produces radicals upon laser irradiation while the lamp photolysis studies show that melatonin is able to scavenge singlet oxygen produced by naphthalene. While melatonin is a free radical scavenger under biological conditions, it acts as a generator of singlet oxygen and or radicals (as PhiDelta is 1.41) when irradiated with laser light, implying that it has the potential to be used in photodynamic therapy in the destruction of tumors.

Patient medication knowledge and adherence to asthma pharmacotherapy: a pilot study in rural Australia.

Asthma is a chronic disease with both inflammatory and bronchoconstrictive elements and often requires multiple medications. Most asthma regimens include medications with different therapeutic modes of action and a number of different medication delivery devices. To effectively participate in their asthma management, patients need to recognize each of their medication types, understand their purpose, adhere to their treatment regimen, and be proficient in using the required delivery devices. This study evaluated patient knowledge of asthma pharmacotherapy and adherence. An interview study was undertaken in two rural locations, in Australia, to elicit participants' knowledge, use, and inhalation device technique. Of participants, 75.9% used preventer medication and the remaining 24.1% used reliever medication only. Of those using preventer medication, 82.5% could distinguish their preventer from a range of asthma medicines. Metered dose inhalers (MDIs) were used by 80% of participants; 23% used a Turbuhaler(R); 24% used an Accuhaler(R); and 5% used an MDI with a spacer device. The study established poor medication knowledge, suboptimal device technique, and disturbing levels of adherence with management recommendations. Asthma education strategies need to be modified to engage patients with low asthma knowledge to achieve improved patient outcomes. Further, strategies need to motivate patients to use preventer medication during times when they feel well.

Respiratory function testing: the impact of respiratory scientists on the training and support of primary health care providers.

OBJECTIVE: In rural Australia access to doctors is limited, access to respiratory physicians even more so and these are the traditional sources of lung function testing. The aim of this study was to assess the feasibility of training and supporting existing rural primary healthcare providers in lung function testing as a screening and monitoring mechanism due to the shortage of healthcare professionals capable of providing such a service. METHODOLOGY: As pharmacists are readily accessible healthcare professionals, they were trained in spirometry measurement and supported with ongoing quality assurance by respiratory scientists. Spirometers were provided to the pharmacists. People purchasing respiratory medications or responding to advertising about the service were tested after giving informed consent. Spirometic assessments were assessed for accuracy and reproducibility. Participants' spirometry results were reviewed and those with abnormal test results were referred to their doctor. RESULTS: Pharmacists were able to competently develop the skills necessary for providing spirometry measurement as a screening and monitoring technique. The level of competence exceeded that reported in previously published studies. Pharmacists were able to successfully identify spirometry results within the normal range. CONCLUSIONS: Training and supporting accessible healthcare professionals to provide lung function testing increases access in areas of need and has implications for respiratory morbidity and mortality in such settings.

Is nCPAP of value in extreme preterms with no access to neonatal intensive care?

This prospective study was undertaken to investigate the efficacy of nasal continuous positive airway pressure (nCPAP) in a group of extremely small infants denied access to a neonatal intensive care unit (NICU) in South Africa. Consecutive infants weighing less than 1200 g and/or of a gestational age below 28 weeks admitted to the neonatal ward with respiratory distress syndrome (RDS), and who were refused admission to the NICU, received either nCPAP (Infant Flow System E.M.E., UK) of headbox oxygen. Of 22 infants, 11 infants were included in the treatment group (nCPAP) and 10 in the control group. Within the first 24 h, two infants (18 per cent) in the nCPAP group and eight infants (80 per cent) in the control group died (p = 0.007) (survival OR = 18; RR = 4.09). A statistically significant improvement in the arterial-alveolar (a/A) oxygen ratio occurred in the nCPAP group between postnatal day 1 and day 3 of life (0.17 vs. 0.36; p < 0.005). Neonatal complications occurred in six (55 per cent) infants who survived the first 24 h of life. Eighty per cent of the infants with intraventricular haemorrhage (IVH) died, as well as all the infants who were born before arrival at the hospital. At the time of discharge from hospital, 45 per cent (five infants) in the nCPAP group survived vs. 20 per cent (two infants) in the control group. The neurodevelopmental outcome of six of the surviving seven infants were evaluated at 1 year of corrected age. The neurodevelopmental outcome as assessed by the Griffith Score was within normal limits in all infants. One infant has sensorineural deafness and one is deaf and has a possible mild spastic diplegia (both in the treatment group). We conclude that nCPAP significantly improves the short-term survival of very low birth-weight (VLBW) infants with moderate to severe respiratory distress syndrome who could not be admitted to intensive care. nCPAP significantly improves the a/A oxygen ratio between day 1 and day 3 of life.

Polyaspartamides as water-soluble drug carriers. Part 1: Antineoplastic activity of ferrocene-containing polyaspartamide conjugates.

BACKGROUND: Numerous detrimental side effects and/or lack of water-solubility of anticancer drugs often prove dose-limiting in chemotherapy. Water-soluble polymeric drug carriers may overcome/minimise many of these limitations. MATERIALS AND METHODS: Aspartic acid polymers to which ferrocene-containing antineoplastic agents are covalently bound, were tested for cytotoxicity against murine EMT-6 cancer cells. Cell survival was measured by means of the colorometric 3-(4,5-dimethylthiazol-2-yl)-diphenyltertrazolium bromide assay. RESULTS: The 90% lethal dosage of pure 3-ferrocenylbutanoic acid is 452 microg/mL LD90 for the polymeric derivative, expressed in terms of 3-ferrocenylbutanoic acid content, is only 65 microg/ml. A polymer structural effect in drug activity was evident: longer side chains linking drugs to polymer backbones enhanced drug activity. Drug activity is also enhanced if drug modifications (to enable drug anchoring) resulted in a lower ferrocenyl reduction potential. CONCLUSIONS: The effectivity of antineoplastic drugs may be enhanced by covalently anchoring them on suitable biodegradable water-soluble polymeric drug carriers.

Comparison of a new desktop spirometer (Diagnosa) with a laboratory spirometer.

BACKGROUND: The Diagnosa is a fully integrated system, able to determine spirometry, ECG, blood pressure and body composition. Real time data can be transferred via Internet to a remote receiving center. OBJECTIVES: The aim of this study was to perform biological testing of the spirometry component in subjects with normal and pathological pulmonary function. METHODS: A group of 45 patients (mean age 43.3 years, 30 males) was tested on both the Diagnosa and the standard Jaeger Masterlab spirometer according to the guidelines of the American Thoracic Society. Three subgroups of 15 subjects each (normal spirometry, obstructive and restrictive airflow limitation) were selected. RESULTS: All measurements performed with the Diagnosa (FVC, FIVC, FEV(1), PEF, FEF(25), FEF(50), FEF(75)) correlated closely (r = 0.92-0.99) with those performed with the Jaeger spirometer and showed good limits of agreement (the largest difference between the two devices being 0.2 liter for FEV(1)). Analysis of the 3 subgroups showed no difference for any parameters compared to the overall group. Electronic transfer of all data was successful. CONCLUSIONS: The Diagnosa spirometer is comparable to a standard laboratory spirometer and can be used reliably for telemedicine purposes.

Compliance of the respiratory system as a predictor for successful extubation in very-low-birth-weight infants recovering from respiratory distress syndrome.

OBJECTIVE: To develop additional criteria to predict for successful extubation of very-low-birth-weight infants recovering from respiratory distress syndrome. DESIGN: Prospective study. SETTING: Neonatal intensive care unit at a university teaching hospital. INTERVENTIONS: Infants ready for extubation according to clinical, ventilatory and blood gas criteria were studied. Before extubation, tidal volume (Vt), minute ventilation, respiratory rate/Vt and mean inspiratory flow were measured during two different ventilatory settings: (i) during intermittent mandatory ventilation (IMV); and (ii) while breathing spontaneously with endotracheal continuous positive airway pressure (CPAP). Tidal volume was obtained through electronically integrated flow measured by a hot-wire anemometer. Total respiratory compliance (Crs) was determined during IMV and was derived from the formula Vt/PIP-PEEP, where the difference between peak inspiratory pressure (PIP) and positive end-expiratory pressure (PEEP) represented the ventilator inflation pressure. MEASUREMENTS AND MAIN RESULTS: Each of 49 infants was studied once before extubation. 33 infants (67%) were successfully extubated and 16 (32.6%) required reintubation. Infants in the success and failure groups were matched for gestation, post-conceptional age, study weight and methylxanthine therapy at the time of study. Successful extubation was associated with a higher mean absolute Crs value (ml/cm H2O) specific Crs value (standardised for body length; ml/cm H2O/cm) compared with infants in whom extubation failed (0.67 v. 0.46; P = 0.01 and 0.018 v. 0.014; P = 0.03, respectively). Analysis of ROC curves detected thresholds for Crs (0.5 ml/cm H2O) and Vt (7 ml) for predicting successful extubation. An absolute Crs value 0.5 ml/cm H2O or more improved the likelihood of successful extubation when compared with clinical/ventilator and blood gas criteria. The likelihood of successful extubation was 81% if the Crs value was > or = 0.5 ml/cm H2O. A tidal volume of 7 ml or more was less sensitive in contributing to successful extubation (sensitivity 69%). The major causes for extubation failure included atelectasis (diffuse and/or localised) and the presence of a patent ductus arteriosus. CONCLUSIONS: In addition to following very precise ventilatory criteria for extubation, we found that bedside measurement of total respiratory system compliance added to the likelihood of extubation success in infants recovering from respiratory distress syndrome. Prospective studies are needed to validate the findings of this study.

[Evaluation of a clinical course in an oncology department during the second cycle of medical education. A 12-year study by questionnaire among 321 students]. / Evaluation d'un stage hospitalier en cancérologie au cours du deuxième cycle des études médcales. Enquête par questionnaire chez 321 étudiants en 12 ans.

The comprehensive cancer center in the Southwest of France, Bergonié Institute hosts medical students in 4th-6th year of their studies, for 4-month courses. This course was evaluated at its end by a questionnaire, during two periods of 6 years: 1983-88. 161 students; 1990-95, 160 students. Due to the policy of the Bordeaux University, these students were significantly younger during the second period: 48.4% in 4th year vs 25.8% in the first period (P = 0.00024). The main reasons for choosing this hospital were to meet cancer patients (54.8%), to improve knowledge in oncology (49.7%) or to see a variety of diseases, unlike in other specialty services (20.8%). At the end of the course, the main investigation in oncology appeared to be pathology (40.8%), radiology (38.2%) or blood cell counts (14.5%). Their training was highly (2+) or very highly (3+) rated by 67.9% of the students in theoretical matters, by 66% in clinical practice and by 92.5% in behavior. The best-learned fields were relations with patients (67.4%), treatments (24.5%) and clinical examination (23.5%). Students declare to have been negatively impressed by failures and deaths (34.7%), patients in poor condition (24.7%) or treatments poorly tolerated or not efficient enough (12.2%). They declare to have been well impressed by cooperation of caregivers (26.5%), comprehensive care (22.7%), teachers' efforts (22.1%), patient-caregiver relations (21.%) and courageous patients (18.1%). Finally students' presence during consultation is useful to see outpatients in good condition or cured patients. Between the first and the second period, there is a significant decrease of clinical training and a trend in favor of improved treatment and better prognosis. Thus this hospital appears mainly useful for training in patient-doctor relations and in clinical practice in a variety of diseases. Efforts have to be made to further improve clinical training. Such an investigation should be pursued to check the students' training periodically. This will allow the adaptation and improvement of the teaching, in accordance with changes in patients' conditions and treatments.