CD-ROM continuous medical education model for the management of urinary tract infections in family practice

OBJECTIVES

This study had for aim to assess the acceptability of a model for continuing medical education, to improve the implementation of best practice recommendations for family practice. The training focused on the management of community acquired urinary tract infections in adults. The secondary objective was to identify barriers in the implementation of these best practice recommendations.

METHODS

We conducted a prospective qualitative study. The intervention included an initial knowledge test, an audio-visual CD-ROM presentation, and a second knowledge test. After the session, family practitioners (FP) were asked to answer a face-to-face questionnaire in order to give their opinion on the training session. Ten FP, working in the Savoie and Isère sub-divisions in France, were included.

RESULTS

All FP were satisfied with the e-learning training session. The element of the session, they best appreciated, was the audio-visual presentation. The comparison between initial and second test results showed a non-significant improvement of knowledge (P=0.07). The barriers, most frequently mentioned for knowledge and use of best practice recommendations, were: lack of time, content unfit for family practice, habits, and the very broad field of expertise required.

CONCLUSION

FP accepted this model of continuing medical education. E-learning seems relevant to improve the implementation of best practice recommendations in family practice.

[Development of a screening scale for children at risk of baby bottle tooth decay]

OBJECTIVE

Baby bottle tooth decay is a severe form of early childhood caries. This study aims to elaborate a screening tool for at risk children in order to facilitate primary prevention.

METHODS

A case-control study was conducted among children suffering from baby bottle tooth decay and children with no dental caries. Cases were children aged 5 years or less at diagnosis who experienced at least four caries with one or more affecting maxillary incisors. Controls were children matched for age and sex. Parents were interviewed by phone about their child's exposure to potential risk factors.

RESULTS

We included 88 children suffering from baby bottle tooth decay and 88 children with no dental caries. In multivariate analysis, low social class (OR 6.39 [95% CI, 1.45-28.11]), prolonged bottle feeding or bedtime feeding (OR 153.2 [95% CI, 11.77-1994.96]), and snacking (OR 5.94 [95% CI, 1.35-26.2]) were significantly associated with baby bottle tooth decay. Regular dental visits were a significant protecting factor (OR 0.13 [95% CI, 0.02-0.77]). A score was developed using these significant risk factors and tested on the survey population. The mean score was 13/20 for cases and 4/20 for controls.

DISCUSSION

These results are in accordance with the literature, except for brushing teeth, which was not significantly associated with baby bottle tooth decay in our study.

CONCLUSION

A screening scale with a score of 20 points was proposed. Future validation is required. Pediatricians and general practitioners should encourage parents to change their habits.

Compliance with recommendations and clinical outcomes for formal and informal infectious disease specialist consultations

The purpose of this study was to compare compliance with recommendations and clinical outcomes between formal and informal infectious disease specialist consultations. Six hundred twenty-seven consecutive adult inpatients who received an infectious disease consultation in a university-affiliated hospital were included. After adjusting for quintile of propensity score, we compared compliance with the consultant's recommendations and clinical outcomes for 443 (70.7%) and 184 (29.3%) formal and informal consultations. Informal and formal consultations were associated with comparable levels of compliance with recommendations for antimicrobial treatment (86.5% vs 88.9%; adjusted odds ratio [aOR], 0.63; 95% confidence interval, 0.34-1.14; P = 0.13) and diagnostic or monitoring tests (72.6% vs 72.0%; aOR, 0.91 [0.53-1.57]; P = 0.73). The rates of early clinical improvement (58.2% vs 58.6%; aOR, 1.11 [0.70-1.74]; P = 0.66), subsequent consultation (34.2% vs 36.3%; aOR, 0.80 [0.53-1.21]; P = 0.29), in-hospital mortality (4.9% vs 8.4%; aOR, 0.55 [0.24-1.24]; P = 0.15), and the median length of stay (23 vs 20 days; aOR of discharge, 0.90 [0.74-1.10]; P = 0.30) did not differ depending on the type of consultation. This study provides observational evidence that informal consultations result in levels of compliance with recommendations comparable to formal consultations, without compromising patient safety. Further study is needed to refine the criteria for requesting or providing informal rather than formal consultations.

Impact of the unfolded protein response on the pathogenicity of the necrotrophic fungus Alternaria brassicicola

The unfolded protein response (UPR) is an important stress signalling pathway involved in the cellular development and environmental adaptation of fungi. We investigated the importance of the UPR pathway in the pathogenicity of the plant necrotrophic fungus Alternaria brassicicola, which causes black spot disease on a wide range of Brassicaceae. We identified the AbHacA gene encoding the major UPR transcription regulator in A. brassicicola. Deletion of AbHacA prevented induction of the UPR in response to endoplasmic reticulum stress. Loss of UPR in mutants resulted in a complete loss of virulence and was also associated with a cell wall defect and a reduced capacity for secretion. In addition, our results showed that the UPR was triggered by treatment of mycelia with camalexin, i.e. the major Arabidopsis thaliana phytoalexin, and that strains lacking functional AbHacA exhibited increased in vitro susceptibility to antimicrobial plant metabolites. We hypothesize that the UPR plays a major role in fungal virulence by altering cell protection against host metabolites and by reducing the ability of the fungus to assimilate nutrients required for growth in the host environment. This study suggests that targeting the UPR pathway would be an effective plant disease control strategy.

Smart control of monodisperse Stöber silica particles: effect of reactant addition rate on growth process

Control over the synthesis of monodisperse silica particles up to mesoscopic scale is generally made difficult due to intrinsic limitation to submicrometric dimensions and secondary nucleation in seeded experiments. To investigate this issue and overcome these difficulties, we have implemented single step processing by quantifying the effects of the progressive addition of a diluted tetraethyl orthosilicate solution in ethanol on the size and monodispersity of silica particles. Contrary to particles grown in seeded polymerization, monodisperse particles with size up to 2 microm were synthesized. Moreover, the particles exhibit a final diameter (d(f)), which varies with V(-1/3) over more than 2 orders of magnitude in rate of addition (V). On the basis of a kinetic study in the presence of addition showing that particle growth is limited by the diffusion of monomer species, we developed a diffusion-limited growth model to theoretically explain the observed d(f)(V) behavior and quantitatively retrieve the measured amplitude and exponent. Using a single parameter procedure, we can therefore predict and generate in the room temperature range, monodisperse particles of a targeted size by simply adjusting the rate of addition.

Postoperative analgesia by epidural methylprednisolone after posterolateral thoracotomy

The aim of this study was to evaluate the potential analgesic effect of epidural methylprednisolone (MP) after posterolateral thoracotomy (PLT). Adult male patients undergoing PLT for lung surgery were included in a prospective, randomized, double blind study. Peroperative analgesia (bupivacaine plus sufentanil) was given by a thoracic epidural catheter associated with general anaesthesia. After surgery, patients received either MP 1 mg kg(-1) followed by a continuous epidural infusion of MP 1.5 mg kg(-1) during 48 h (MP group) or 0.9% saline as a bolus injection and continuous epidural infusion (P group). Additional morphine analgesia was administered by i.v. patient-controlled analgesia. Pain was assessed at rest and with mobilization every 4 h after operation during 48 h with a visual analogue scale (VAS). The primary end-point was the total morphine requirements during the 48 first postoperative hour. Twenty-four patients were allocated to MP (n=12) and P (n=12) groups. Characteristics of the two groups were similar. There were no differences between groups for morphine requirements (median and interquartile range) during the 48 h: 59 mg (40-78) in MP group vs 65 mg (59-93) in P group. There were no differences between groups for morphine requirements every 4 h during the 48 h and VAS for pain at rest and evoked pain. No side effects were reported. It was concluded in this small study that these results did not support the use of epidural steroids for postoperative analgesia after PLT.

Influence of respiratory disease on perioperative cardiac risk in patients undergoing elective surgery for abdominal aortic aneurysm

We retrospectively reviewed perioperative cardiac complications in a series of 214 patients who underwent surgical treatment for infrarenal aortic aneurysm between 1992 and 1996. There were 192 men and 22 women, with a mean age of 68.3 years. Cardiac risk factors included angina in 28% of patients and previous myocardial infarction in 25%. Resting electrocardiography was normal in 80 patients (37.5%). Depending on clinical findings, thallium-201 scintigraphy was undertaken in 76 patients (35.5%) and led to elective coronary arteriography in 22 patients (10%). Results of coronary arteriography revealed lesions in 14 patients. Aortic reconstruction was performed by the transperitoneal route in all patients. Procedures consisted of aortoaortic bypass (63%), aortobiiliac bypass (27.5%), or aortobifemoral bypass (9.5%). Nine patients (4.2%) died within the first 30 postoperative days. The cause of death was myocardial infarction (MI) in two patients (1%), colonic necrosis in two (1%), acute pancreatitis in one (0.5%), acute renal insufficiency in three (1.4%), and multiple organ failure in one patient (0.5%). Nonfatal cardiac complications were observed in 15 patients (7%). Statistical analysis of risk factors revealed two predictors of perioperative cardiac complications, i.e., history of chronic bronchitis and reoperation. On review of the literature, we cannot propose a routine preoperative work-up. Prospective multicentric studies are needed to determine the predictive value of current preoperative screening methods.

Arterial pressure and neurologic morbidity during carotid surgery under peridural anesthesia

In 163 carotid reconstructions under peridural anesthesia performed from 1988 to 1991, we routinely measured residual systemic and carotid artery pressure during clamping. Seventy-nine patients (48.5%) were asymptomatic and 84 (51.5%) had a history of neurologic manifestations in the form of transient ischemic attacks (28%) or stroke (13.5%). None of the patients died perioperatvely. Eight patients (4.9%) had strokes, with complete recovery in five. A shunt was placed in 22 patients (13.5%) because of neurologic evidence that carotid clamping was poorly tolerated. This study showed a distinct association between residual pressure in the internal carotid artery and systemic arterial pressure and intraoperative neurologic morbidity. Using a cutoff value of 35 mm Hg for residual pressure, the sensitivity was 77% and specificity 81%. Using a cutoff of 80 mm Hg, the sensitivity was 60% and specificity 86%. There was no correlation between mean systemic arterial pressure and residual carotid artery pressure. The use of a shunt was the only factor with predictive value for postoperative neurologic complications. These findings suggest that measurement of systemic arterial pressure and residual carotid artery pressure is useful during carotid surgery, but further study is needed before this information can be extrapolated to carotid surgery under general anesthesia.

[An unusual cause of pericardial effusion during pleural drainage]

A 66-year-old man was admitted for mitral valve replacement required by a mitral regurgitation resulting in a severe heart failure. He also suffered from chronic respiratory failure, related to a left concavity cyphoscoliosis. Postoperatively, hypoxemia occurred. His chest X-ray showed a left pleural effusion indicating a percutaneous pleural drainage. A local anaesthesia with a 21 G needle was performed prior to drain insertion, which was easily introduced into the pleural cavity. A few minutes later, the patient experienced an acute haemorrhagic shock. He was immediately transferred into the operating room, where the cardiac surgeon discovered and treated a coronary artery effraction. The vascular lesion was attributed to the needle used for local anaesthesia. The patient was discharged twelve days later without sequelae. Two factors were responsible for this accident: the patient's cyphoscoliosis and his left ventricle enlargement. This complication is uncommon. However, in case of a particular patient's anatomy, it is suggested to use a score devised to anticipate the risk of a difficult pleural drainage. This score should include general, thoracic, spinal, cardiac, hepatic and splenic morphology.

[Peroperative pneumothorax in thoracotomy: the value of pulse oximetry]

Two cases of pneumothorax occurring during thoracotomy under one-lung ventilation are reported. One case occurred before pneumonectomy was carried out. The decrease in Spo2 shown by pulse oximetry, together with the increase in airway pressures, rapidly led to the diagnosis of pneumothorax. In the other case, the accident occurred after pneumonectomy, with a suddenly impossible ventilation, and a drastic decrease in Spo2 leading to hypoxic circulatory arrest. Hypoxaemia occurring during one-lung ventilation may be due to different causes. Shunting in the upper part of the lung is the main cause, but other diagnoses must be discussed, such as airway obstruction by blood or sputum, displacement of the selective endotracheal tube, bronchospasm, and pneumothorax. Monitoring of Spo2 by pulse oximetry would therefore seem to be mandatory during thoracic surgery, in order to allow an early diagnosis of hypoxaemia and speed up the treatment of its cause.