[Obtain best usage of meropenem dose in severe infections. Results of an observational multicenter study]. / Optimización de la dosis de meropenem en infecciones graves. Resultados de un estudio multicéntrico observacional.

OBJECTIVE: To describe the effectiveness and tolerability of the dose adjustment of meropenem in empirical treatment of nosocomial infections in critically-ill patients admitted to intensive care medicine services. METHODS: Prospective, observational and multicenter study in patients admitted to 17 intensive care medicine services with nosocomial infection, who were initially treated with meropenem, 1 g every 8 h, were eligible. The initial dose was adjusted to 0.5 g every 8 h if there were: a) a favorable clinical course, and b) microbiological isolation of meropenem-susceptible pathogens or absence of pathogens in cultures. RESULTS: Ninety-two patients in whom meropenem doses were adjusted to 0.5 g every 8 h were included. Ventilator-associated pneumonia followed by bacteremia was the most frequently treated infections. Microbiological studies were positive in 53 patients, with a predominance of gram-positive bacteria (53.7%), especially methicillin-susceptible Staphylococcus aureus, followed by gram-negative bacteria (42.7 %). A total of 18 patients were not evaluable at the end of treatment. Sixty-seven (90.5 %) of the 74 evaluable patients had a favorable clinical course (54 patients cured and 13 improved). In 50 out of 53 microbiologically evaluable cases, eradication or apparent eradication of initial microorganisms was achieved. In 3 cases, the initial pathogen persisted: Acinetobacter baumannii (2 cases) and Pseudomonas aeruginosa (1 case). On three occasions, new pathogens developed during treatment: A. baumannii (2 cases) and methicillin-resistant S. aureus (1 case). Adverse events occurred in 3 patients (4%), none of which was considered severe, and withdrawal of meropenem was not necessary. A total of 25 (27.2 %) patients died, three of them in relation to the infectious process. CONCLUSIONS: Dose adjustment of meropenem to 0.5 g every 8 h is a useful tool in the treatment of severe nosocomial infections in patients admitted to services of intensive care medicine except in cases in which causative pathogens are non-fermenting Gram-negative bacteria.

Candida endophthalmitis in non-neutropenic critically ill patients.

Six non-neutropenic critically ill patients who developed hematogenous endophthalmitis due to Candida spp. were studied prospectively. In all cases the yeast was isolated in blood cultures. The incidence of endophthalmitis in patients with candidemia was 13%, the predominant species being Candida albicans. Four patients were treated with fluconazole, but its efficacy could not be evaluated because three of the patients died. In patients at risk of candidemia, regular ophthalmoscopic examinations are recommended in order to enable early initiation of systemic antifungal therapy in those who develop endophthalmitis.

[Intensified insulin therapy in the management of gestational diabetes]. / Insulinoterapia intensificada en el manejo de la diabetes pregestacional.

A total of 35 pregnancies in 28 Pregestational Diabetic Patients (PDP) were followed with the goal of achieving and maintaining near normoglycemia (as many pre-postprandial glycemias as possible between 60-140 mg/dl); 13 patients (16 pregnancies) were assigned to Subcutaneous Continuous Preprogrammed Insulin Infusion (SCII) because of high risk pregnancies (HRP) (at least one of the following: former history of spontaneous abortions, stillbirths, premature deliveries and/or sterility). The remaining 12 PDP's (15 pregnancies with no past history of the above nature) were treated with Multiple Conventional Insulin Injections (MCII). Both groups were comparable regarding the following clinical parameters: age, time of onset and class of diabetes. All patients were instructed in performing 3 to 7 daily Self Capillary Blood Glucose controls (SCBG). Mean follow-up observation period was (mean +/- SEM) 28.5 +/- 2.5 weeks for SCII and 3.2 MCII and 28.8 +/- 3.2 weeks for MCII. All the 3 PDP drop out's (4 pregnancies) belonged to the CMII group. No drop out's were recorded in the SCII group. Both insulin therapy approaches were similarly effective in improving metabolic control in that comparable levels of mean blood glucose (MBG) and HbA1 were attained by SCII and MCII (Fig. 1). Compliance, as evidenced by average of daily SCBG was also similar in both groups (Fig. 2). Such satisfactory metabolic control was achieved mostly because of an increase in the percentage (65%) of "fair" glycemias (60-139 mg/dl) and not because of an increase in hypoglycemias (< 60 mg/dl) which could have canceled out an undesirable degree of hyperglycemias thus rendering "false satisfactory" MBG's and HbA1 (Fig. 1). With the above degree of metabolic control obtained there occurred no severe hypoglycemic episodes requiring medical intervention. All newborns to the PDP's who remained under treatment showed an adequate APGAR (X +/- SEM, 9.5 +/- 0.2) regardless of the modality (SCII or MCII) of insulin delivery used (Tables 1, 2). The single malformed baby found in this series was born to a patient on SCII who happened to start on the intensified insulin treatment rather late in her pregnancy (21st week) and, in addition, the patient self medicated with high doses of chlorpromazine because of recurrent vomiting episodes. Incidence of neonatal hypoglycemia (HY) or macrosomy (MS) was comparable in both groups (Tables 1, 2). It is to be pointed out, however, that PDP's who bore the babies with no HY or MS had presented a larger number of low glycemic values than mothers who bore the babies with HY and/or MS.(ABSTRACT TRUNCATED AT 400 WORDS)

Insulinoterapia intensificada en el manejo de la diabetes pregestacional. / [Intensified insulin therapy in the management of gestational diabetes]

A total of 35 pregnancies in 28 Pregestational Diabetic Patients (PDP) were followed with the goal of achieving and maintaining near normoglycemia (as many pre-postprandial glycemias as possible between 60-140 mg/dl); 13 patients (16 pregnancies) were assigned to Subcutaneous Continuous Preprogrammed Insulin Infusion (SCII) because of high risk pregnancies (HRP) (at least one of the following: former history of spontaneous abortions, stillbirths, premature deliveries and/or sterility). The remaining 12 PDPs (15 pregnancies with no past history of the above nature) were treated with Multiple Conventional Insulin Injections (MCII). Both groups were comparable regarding the following clinical parameters: age, time of onset and class of diabetes. All patients were instructed in performing 3 to 7 daily Self Capillary Blood Glucose controls (SCBG). Mean follow-up observation period was (mean +/- SEM) 28.5 +/- 2.5 weeks for SCII and 3.2 MCII and 28.8 +/- 3.2 weeks for MCII. All the 3 PDP drop outs (4 pregnancies) belonged to the CMII group. No drop outs were recorded in the SCII group. Both insulin therapy approaches were similarly effective in improving metabolic control in that comparable levels of mean blood glucose (MBG) and HbA1 were attained by SCII and MCII (Fig. 1). Compliance, as evidenced by average of daily SCBG was also similar in both groups (Fig. 2). Such satisfactory metabolic control was achieved mostly because of an increase in the percentage (65

) of [quot ]fair[quot ] glycemias (60-139 mg/dl) and not because of an increase in hypoglycemias (< 60 mg/dl) which could have canceled out an undesirable degree of hyperglycemias thus rendering [quot ]false satisfactory[quot ] MBGs and HbA1 (Fig. 1). With the above degree of metabolic control obtained there occurred no severe hypoglycemic episodes requiring medical intervention. All newborns to the PDPs who remained under treatment showed an adequate APGAR (X +/- SEM, 9.5 +/- 0.2) regardless of the modality (SCII or MCII) of insulin delivery used (Tables 1, 2). The single malformed baby found in this series was born to a patient on SCII who happened to start on the intensified insulin treatment rather late in her pregnancy (21st week) and, in addition, the patient self medicated with high doses of chlorpromazine because of recurrent vomiting episodes. Incidence of neonatal hypoglycemia (HY) or macrosomy (MS) was comparable in both groups (Tables 1, 2). It is to be pointed out, however, that PDPs who bore the babies with no HY or MS had presented a larger number of low glycemic values than mothers who bore the babies with HY and/or MS.(ABSTRACT TRUNCATED AT 400 WORDS)

Insulinoterapia intensificada en el manejo de la diabetes pregestacional. / [Intensified insulin therapy in the management of gestational diabetes]

A total of 35 pregnancies in 28 Pregestational Diabetic Patients (PDP) were followed with the goal of achieving and maintaining near normoglycemia (as many pre-postprandial glycemias as possible between 60-140 mg/dl); 13 patients (16 pregnancies) were assigned to Subcutaneous Continuous Preprogrammed Insulin Infusion (SCII) because of high risk pregnancies (HRP) (at least one of the following: former history of spontaneous abortions, stillbirths, premature deliveries and/or sterility). The remaining 12 PDPs (15 pregnancies with no past history of the above nature) were treated with Multiple Conventional Insulin Injections (MCII). Both groups were comparable regarding the following clinical parameters: age, time of onset and class of diabetes. All patients were instructed in performing 3 to 7 daily Self Capillary Blood Glucose controls (SCBG). Mean follow-up observation period was (mean +/- SEM) 28.5 +/- 2.5 weeks for SCII and 3.2 MCII and 28.8 +/- 3.2 weeks for MCII. All the 3 PDP drop outs (4 pregnancies) belonged to the CMII group. No drop outs were recorded in the SCII group. Both insulin therapy approaches were similarly effective in improving metabolic control in that comparable levels of mean blood glucose (MBG) and HbA1 were attained by SCII and MCII (Fig. 1). Compliance, as evidenced by average of daily SCBG was also similar in both groups (Fig. 2). Such satisfactory metabolic control was achieved mostly because of an increase in the percentage (65

) of [quot ]fair[quot ] glycemias (60-139 mg/dl) and not because of an increase in hypoglycemias (< 60 mg/dl) which could have canceled out an undesirable degree of hyperglycemias thus rendering [quot ]false satisfactory[quot ] MBGs and HbA1 (Fig. 1). With the above degree of metabolic control obtained there occurred no severe hypoglycemic episodes requiring medical intervention. All newborns to the PDPs who remained under treatment showed an adequate APGAR (X +/- SEM, 9.5 +/- 0.2) regardless of the modality (SCII or MCII) of insulin delivery used (Tables 1, 2). The single malformed baby found in this series was born to a patient on SCII who happened to start on the intensified insulin treatment rather late in her pregnancy (21st week) and, in addition, the patient self medicated with high doses of chlorpromazine because of recurrent vomiting episodes. Incidence of neonatal hypoglycemia (HY) or macrosomy (MS) was comparable in both groups (Tables 1, 2). It is to be pointed out, however, that PDPs who bore the babies with no HY or MS had presented a larger number of low glycemic values than mothers who bore the babies with HY and/or MS.(ABSTRACT TRUNCATED AT 400 WORDS)

[Treatment of Ewing's sarcoma by radiotherapy and adjuvant chemotherapy : results at 3 and 5 years (author's transl)]. / Traitement du sarcome d'Ewing par radiothérapie et chimiothérapie adjuvante : résultats à 3 et 5 ans.

The local treatment of Ewing's sarcoma by radiotherapy is classically linked to a very poor prognosis : 10 to 15% of 5 years survival, 75 to 95% of distant metastasis in 2 years. The combination of local radiotherapy to a systemic adjuvant chemotherapy have been recently shown to give a real benefit to this prognosis. The therapeutic trial of the EORTC and GETO, presented here allows us to hope a disease free survival at 5 years for 50% of our patients and a complete survival at 5 years for 56% of them.

[Multiple primary malignant melanomas. A report of five cases (author's transl)]. / Mélanomes malins primitifs multiples. A propos de cinq observations.

The authors present 5 cases of primary malignant melanomas occurring simuatlneously or successively, diagnosed at Institut Gustave Roussy over a period of 10 years. This work emphasizes the need for searching possible changes of nevi in melanoma patients.

[The risk of hemorrhage versus the thromboembolic risk in patients with prosthetic valve]. / Le risque hémorragique en face du risque thrombo-embolique chez les porteurs de prothèse valvulaire.

376 adults were followed up for between 2 and 153 months after surgery (mean: 3.8 years); all of them, with the exception of 8, received anticoagulant treatment. The results were subjected to statistical analysis using several tests. Thromboembolic complications occurred in 16 per 100 after 5 years, and 8.5. per 100 of them were fatal. Among the factors favoring this complication are the type of valvular disorder (the rate of throembolism being 4 times greater with mitral valve defects), the type of prosthesis, and the efficiency of the anticoagulant therapy (the risk of thromboembolism being four times greater in those patients whose treatment has been inneffective). Against the vitamin antagonists must be set the haemorrhages: the incidence of lethal haemorrhage in this series was 6.4 per 100 patients per treatment year. There was a proven hypoprothrombinaemia to below the desirable level in two thirds of these cases, and in one case out of four an additional predisposing factor could be demonstrated. Haemorrhage and thromboembolism are together responsible for one in four of the late deaths. In order to reduce the mortality, several solutions are considered, one of which is to utilise anti-aggregation treatment. However, the vitamin K antagonists remain an essential part of treatment in the majority of cases; it can only be justifiable to withhold them in those patients in whom the risks of haemorrhage are for various reasons considered to be too high. The introduction of biological valves or of valves with a lessened risk of embolism is highly desirable in such cases.

Results of a randomized clinical trial of preoperative irradiation versus postoperative in treatment of tumors of the hypopharynx.

Preoperative radiotherapy vs postoperative radiotherapy in the management of patients with primary tumors of the hypopharynx was evaluated by a prospective, randomized clinical trial. A statistically significant difference (p less than 1%) existed in favor of postoperative radiotherapy relative to survival rates, complications, and quality of survival. The postoperative radiotherapy group showed a 56% 5-year survival rate compared to 20% in the preoperative radiotherapy group. An analysis of the results is discussed.

Modes of invasion of cancer of the larynx. A statistical, histological, and radioclinical analysis of 120 cases.

A statistical comparison between histologic and radioclinical data was performed on a series of 120 cases of total laryngectomies in order to study the modes of invasion of laryngeal cancer and to quantify the differences of results as evaluated by pathological and by clinical examinations. The first part of this study deals with the spread of cancer depending on its site of origin; the second part examines spread regardless of the primary location of the laryngeal tumor. The comparative results show that it was difficult to determine the deep invasion of structures such as the preepiglottic space and the cartilages from the radioclinical examination, especially in cases of cancer developed on a laryngocele. This study emphasizes the importance of the histological examination of laryngeal specimens as described here in order to codify the modes of invasion and, as a result, to help the otorhinolarynglologist in the choice of the best treatment.

[Results of a hemodynamic study of valve diseases surgically treated with prosthesis]. / Résultats de l'étude hémodynamique des valvulopathies opérées par prothèse

The haemodynamic status after valve replacement surgery and the preoperative haemodynamic parameters have been studied for their predictive value in a series of 217 patients who have had aortic, mitral or mitro-aortic valve replacements; all cases had a preoperative catheterisation, and 132 had a postoperative catheterisation at an average of 15 months postoperative. The following conclusions have been drawn from the study: 1. The operation (which consisted of replacement with a Starr valve with Silastein ball-valve in 8 cases out of 10) resulted in a substantial, and statistically significant, improvement in the minor circulation pressures and in the cardiac index. The ejection fraction also increases in most cases. 2. The increase in the cardiac index is significantly greater in aortic stenosis than in aortic incompetence, and in the aortic group than in the mitral group. 3. Improvement is early, and occurs within the first few weeks, in the aortic group; it occurs more gradually in the mitral group, in whom serial catheterisations show a gradual decrease in the pulmonary arterial and capillary pressure and an increase in the cardiac index which may be progressive until the second postoperative year. 4. Analysis of the mean values of the various parameters as a function of the clinical findings, and of the incidence of failures and early or late deaths from haemodynamic changes, has failed to show that the preoperative haemodynamic picture has a statistically significant predictive value.