A decision tree to help determine the best timing and antiretroviral strategy in HIV-infected patients.

Optimal antiretroviral strategies for HIV-infected patients still need to be established. To this end a decision tree including different antiretroviral strategies that could be adopted for HIV-infected patients was built. A 10-year follow-up was simulated by using transitional probabilities estimated from a large cohort using a time-homogeneous Markov model. The desired outcome was for patients to maintain a CD4 cell count of >500 cells/mm3 without experiencing AIDS or death. For patients with a baseline HIV viral load ≥5 log10 copies/ml, boosted protease inhibitor-based immediate highly active antiretroviral therapy (HAART) allowed them to spend 12% more time with CD4 ≥500/mm3 than did delayed HAART (6·40 vs. 5·69 and 5·57 vs. 4·90 years for baseline CD4 ≥500 and 350-499/mm3, respectively). In patients with a baseline HIV viral load ≤3·5 log10 copies/ml, delayed HAART performed better than immediate HAART (6·43 vs. 6·26 and 5·95 vs. 5·18 for baseline CD4 ≥500 and 350-499/mm3, respectively). Immediate HAART is beneficial in patients with a baseline HIV viral load 5 log10 copies/ml, whereas deferred HAART appears to be the best option for patients with CD4 ≥350/mm3 and baseline HIV viral load <3·5 log10 copies/ml.

[Regional audit on fluoroquinolones usage in the hospital and the community: are these antibiotics over-used?]. / Audit régional de l'usage des fluoroquinolones à l'hôpital et en ville : y a-t-il une surconsommation de ces antibiotiques ?

AIM OF THE STUDY: The ecological impact of an over-use or a mis-use of fluoroquinolones (FQs) appears of great importance according to published data. With the objective to set up a regional antibiotic stewardship program, we conducted a regional audit on FQs usage. MATERIAL AND METHODS: [corrected] Ninety general practionners and 15 health care facilities participated to this prospective study. Overall, 511 prescriptions were evaluated (276 from hospital physicians and 235 [46%] from general practionners). The compliance of FQs prescription with national recommendations and with a regional referential was assessed. This regional referential was established in order to preserve FQs. RESULTS: Only 14,3% of the prescriptions complied with the regional referential, even if the choice of FQs were in accordance with national recommendations in 56,8% of the prescriptions. Urinary tract infections (mostly non-complicated) were the most common indication for FQs prescription. CONCLUSION: Analysis of FQs prescriptions shows that there is a significant potential for FQs preservation in Franche-Comté.

Respiratory changes in aortic blood velocity as an indicator of fluid responsiveness in ventilated patients with septic shock.

STUDY OBJECTIVE: To investigate whether the respiratory changes in peak velocity (Vpeak) of aortic blood flow could be related to the effects of volume expansion on cardiac index. DESIGN: Prospective clinical study. SETTING: Medical ICUs of a university hospital (20 beds) and of a nonuniversity hospital (15 beds). PATIENTS: Nineteen sedated septic shock patients who were receiving mechanical ventilation and who had preserved left ventricular (LV) systolic function. INTERVENTION: Volume expansion. MEASUREMENTS AND RESULTS: Analysis of aortic blood flow by transesophageal echocardiography allowed beat-to-beat measurement of Vpeak before and after volume expansion. Maximum values of Vpeak (Vpeakmax) and minimum values of Vpeak (Vpeakmin) were determined over one respiratory cycle. The respiratory changes in Vpeak (Delta Vpeak) were calculated as the difference between Vpeakmax and Vpeakmin divided by the mean of the two values and were expressed as a percentage. The indexed LV end-diastolic area (EDAI) and cardiac index were obtained at the end of the expiratory period. The volume expansion-induced increase in cardiac index was > or = 15% in 10 patients (responders) and < 15% in 9 patients (nonresponders). Before volume expansion, Delta Vpeak was higher in responders than in nonresponders (20 +/- 6% vs 10 +/- 3%; p < 0.01), while EDAI was not significantly different between the two groups (9.7 +/- 3.7 vs 9.7 +/- 2.4 cm(2)/m(2)). Before volume expansion, a Delta Vpeak threshold value of 12% allowed discrimination between responders and nonresponders with a sensitivity of 100% and a specificity of 89%. Volume expansion-induced changes in cardiac index closely correlated with the Delta Vpeak before volume expansion (r(2) = 0.83; p < 0.001). CONCLUSION: Analysis of respiratory changes in aortic blood velocity is an accurate method for predicting the hemodynamic effects of volume expansion in septic shock patients receiving mechanical ventilation who have preserved LV systolic function.

[Acute respiratory distress syndrome in the initial phase of myocardial infarction in adults]. / Le syndrome de déstresse respiratoire aiguë de l'adulte à la phase initiale de l'infarctus du myocarde.

Four patients developed an acute respiratory distress syndrome characterised by clinical and radiological signs of pulmonary oedema, a protein-rich oedema, severe hypoxemia refractory to oxygen therapy, contrasting with normal left ventricular filling pressures and indicating increased permeability of the alveolo-capillary membrane, 24 to 72 hours after the onset of acute myocardial infarction. After having excluded the usual causes of the acute respiratory distress syndrome, the authors suggest that acute myocardial infarction, especially when extensive, may cause a lesion of the alveolo-capillary membrane by an unknown mechanism. Treatment consisted in mechanical ventilation with positive expiratory pressures in 3 cases and with continuous positive pressure during spontaneous respiration in the third patient and in relay with controlled ventilation in the other two. These techniques of ventilation improved the hypoxemia and led to complete cure in all cases without evolution to pulmonary fibrosis. In addition to mechanical ventilation, all patients were given systematic antibiotic therapy because of the possibility of an infectious etiology while waiting for the results of microbiological and serological testing and because of the high risk of superinfection which plays an essential part in the outcome of the condition. The immediate response to treatment was favourable in all cases. One patient died suddenly of cardiogenic shock two weeks after this episode. The other patients are still alive 39, 38 and 20 months after infarction. The importance of the diagnosis of the acute respiratory distress syndrome in the acute phase of myocardial infarction resides in its therapeutic implications which are quite different to those of cardiogenic shock.(ABSTRACT TRUNCATED AT 250 WORDS)

[Severe anaphylactic shock with heart arrest caused by coffee and gum arabic, potentiated by beta-blocking eyedrops]. / Choc anaphylactique grave avec arrêt cardiaque au café et à la gomme arabique, potentialisé par un collyre bêta-bloquant.

The case of a male patient who experienced four allergic accidents after drinking coffee is reported. Two serious anaphylactic reactions with cardiac arrest occurred after a continuous treatment with beta-blocking eye drops (timolol) was prescribed. Dual sensitivation to coffee and to the gum arabic coating roasted coffee beans was demonstrated by skin prick tests and by human basophil degranulation tests. Occupational allergy to green coffee has been widely described, but food sensitization to these two allergens has not yet been reported. This case also draws attention to the risk, inherent in beta-blockers, of immuno-allergic reactions. These drugs produce a loss of compensatory cardiovascular mechanisms and make those who take them resistant to the conventional treatment of anaphylactic shocks, which explains the serious accidents that occurred in this patient. The authors stress the usefulness of a thorough investigation for food allergy to a rare allergen in patients with idiopathic anaphylaxis.

[The locked-in syndrome]. / Le syndrome de verrouillage.

The locked-in syndrome is poorly understood, and may be misdiagnosed as coma. The syndrome consists of complete paralysis of all four limbs and the lower cranial nerve pairs, associated with an unaltered consciousness. Vertical eye movements and blinking remain intact, so allowing some form of communication by way of eye codes. Obstruction of the vertebral and basilar vascular system is the major cause, but the six cases reported show the aetiological diversity of this syndrome. If the vascular obstruction is diagnosed within the first few hours, fibrinolytic therapy may be considered. Although the patients usually die within a few days or after several months, some rare cases of recovery after several weeks have been reported. Intensive care is required by these patients (tracheostomy, artificial ventilation, intensive nursing care); the physicians and nursing staff looking after them should always keep in mind that these patients are conscious and able to communicate.

[Hemoptysis of medical origin: endobronchial hemostasis with a Fogarty catheter under endoscopic control]. / Hémoptysies de cause médicale: hémostase endobronchique par sonde de Fogarty sous contrôle fibroscopique.

The authors present a case of haemoptysis which caused tracheo-bronchial inundation and which was treated by the insertion of a Fogarty catheter. They describe the technique and discuss its advantages and disadvantages.

[Spontaneous hepatic rupture during an uncomplicated twin pregnancy]. / Rupture hépatique spontanée au cours d'une grossesse gémellaire non compliquée.

Liver subcapsular haematoma and its consequence, spontaneous hepatic rupture, are very rare complications of pregnancy. They are mainly associated with pre-eclampsia. The diagnosis is difficult and the maternal and fetal mortality rates are high. We report the case of a spontaneous hepatic rupture on a normal liver during an uncomplicated twin pregnancy with a favorable outcome for both the mother and the newborns.

[Impact of regional guidelines on the management of urinary tract infections with antibiotics]. / Impact d'un guide régional pour la prise en charge des infections urinaires sur les pratiques d'antibiothérapies.

AIM AND METHOD: We assessed the impact of a committed guideline at the end of the first quarter 2008 on the management of urinary tract infection (UTI) with antibiotic prescription (fluoroquinolone, fosfomycin, and nitrofurantoin), by analysing reimbursement data for ambulatory care provided by the regional health insurance agency. RESULTS: During the survey, we observed a 13.2% decrease of norfloxacin prescriptions between the first quarter 2008 and the first quarter 2009. The (fosfomycin+nitrofurantoin)/norfloxacin ratio increased between the third quarter 2007 and the first quarter 2009 from 0.55 to 0.72 and from 0.82 to 1.13 for general practitioners and hospital physicians respectively. The global number of patients treated with these antibiotics remained stable during the period. The number of fluoroquinolone prescription was stable between the first quarter 2008 and the first quarter 2009 with 28,427 DDD and 28,363 DDD, respectively; while the number of single dose rise in the same time from 151 DDD to 427.5 DDD, respectively. DISCUSSION: The three messages which seem to be essential for an optimal use of fluoroquinolones in UTIs are: no treatment for bacterial colonisation (asymptomatic bacteriuria) except for specific cases, no indication for fluoroquinolones in non-complicated acute cystitis and for elderly women, UTI is complicated only if it occurs in women with co-morbidities regardless of age. CONCLUSION: Our indicators suggest that our guideline had an impact on the prescription of fluoroquinolones for uncomplicated acute cystitis.

Markov modelling of HIV infection evolution in the HAART era.

The aim was to investigate the impact of the main prognostic factors on HIV evolution. A multi-state Markov model was applied in a cohort of 2126 patients to estimate impact of these factors on patients' clinical and immunological evolutions. Clinical progression and immunological deterioration shared most of their prognostic factors: male gender, intravenous drug use, weight loss, low haemoglobin level (<110 g/l), CD8 cell count (<500/mm(3)) and HIV viral load (>5 log(10) copies/ml). Highly active retroviral therapy reduced the risks of clinical progression and immune deterioration whatever patients' CD4 cell count. Risk reductions were 41-60% for protease inhibitor-based and 27-68% for non-nucleoside reverse transcriptase inhibitor-based regimens. Three-year transition probabilities showed that only patients with a CD4 cell count >or=350 CD4/mm(3) could in most cases maintain their immunity. This model provides 'real life' transition probabilities from one immunological stage to another, allowing decision analyses that could help determine the beneficial therapeutic strategies for HIV-infected patients.

[Anuria, cholestatic jaundice, thrombocytopenia, hemolysis. Immunoallergic complication due to ajmaline]. / Anurie, ictère cholestatique, thrombopénie, hémolyse. Accident immunoallergique dû à l'ajmaline.

A 75 year old man, treated with ajmaline, was admitted with malaise, fever, acute renal failure and cholestatic jaundice. Haemolytic anaemia and thrombocytopaenia were also found with a positive indirect Coomb's test in the presence of ajmaline. The immunological and haematological data are discussed in the light of previously published cases.

[Usefulness of micro-organism counts in positive haemocultures (author's transl)]. / Intérêt du comptage de germes pour l'interprétation d'une hémoculture positive.

In patients with positive haemoculture counting the number of micro-organisms per ml of blood can be of interest for both diagnosis and prognosis. Contamination is practically excluded when values exceed 20 organisms/ml, and bacteraemia when they exceed 500 organisms/ml. Generally, the higher the count the greater the likelihood of septicaemia. Values lower than 2 organisms/ml correspond in most cases to Gram-negative infections. Excluding the latter, which carry a high lethal risk, the mortality rate in septicaemia increases with the number of micro-organisms in the blood.

[Inappropriate secretion of anti-diuretic hormone in a case of intermittent acute porphyria (author's transl)]. / Sécrétion inappropriée d'hormone anti-diurétique au cours d'une porphyrie aiguë intermittente.

The authors report the case of a patient who presented, during two exacerbations of intermittent acute porphyria, a grave psychiatric syndrome secondary to severe hyponatraemia. The later was due to inappropriate secretion of anti-diuretic hormone confirmed by laboratory tests and the stimation of anti-diuretic activity in the urine. The course was favourable under the effects of symptomatic treatment including sodium supplements and fluid restriction. The anti-diuretic syndrome disappeared on each occasion without sequelae at the time of regression of the exacerbation of porphyria.