Peritoneal tuberculosis did not disappear from France during the 1990s.
To determine the characteristics of peritoneal tuberculosis in the north-eastern suburbs of Paris.
A retrospective study of ...cases diagnosed with peritoneal tuberculosis between 1990 and 1998 in five suburban hospitals in the north-east region of Paris.
Twenty-seven cases of adult peritoneal tuberculosis were diagnosed. There were nine women and 18 men, with a mean age of 37.5 years, 88.9% of whom were foreign born. General and digestive symptoms--abdominal pain and/or ascites--were present in 96.3% of the cases. The mean delay in treatment was 30 days. Peritoneal involvement was isolated in 25.9% of cases, and associated with pulmonary tuberculosis in 40.7% or hepatic tuberculosis in 25.9%. Co-infection with HIV (human immunodeficiency virus) was present 14.8% of cases. Culture of ascites fluid, laparoscopy and/or laparotomy (n = 17), with directed biopsy, aided in the formal diagnosis of peritoneal tuberculosis in 59.2%. One relapse and one case of multiresistance were observed. The mean duration of treatment was 9 months (range 6-12 months). Three patients received treatment with corticosteroids, and 91.2% of the patients achieved cure without sequelae.
Peritoneal tuberculosis is not rare in the Paris region. The diagnosis should be suspected in case with ascites and fever, and can be confirmed by laparoscopy with sampling for bacteriology and histology. The methods of treatment need to be standardised.
A stochastic control strategy for individualizing teicoplanin dosing schedule in neutropenic patients is proposed and compared to the usual Bayesian approach based on the mode of the posterior ...density of the model parameters. Teicoplanin disposition is described by a bicompartmental model. Age, body weight, serum creatinine, white blood cell count, and sex can be included as covariates. Posterior density of model parameters is obtained by Bayes theorem under a discrete form from which the posterior density of teicoplanin trough concentrations are computed for any dosing schedule. Optimal maintenance dose is determined by minimizing the cost associated, through a logarithmic risk function, to the concentrations being outside the therapeutic range. In Monte Carlo simulation studies on 300 individuals, stochastic control was more accurate than, and equally precise as the usual Bayesian approach. Two-sample based predictions were not better than one-sample based ones. Inclusion of covariates in the model improved dramatically the performances of both strategies. A small retrospective study based on real data (n = 16 patients) shows that reasonable accuracy (bias of 0.7 mg/L) and precision (3 mg/L) in teicoplanin trough concentration prediction is obtained with both strategies provided that covariates are taken into account.
Chez les adultes neutropéniques fébriles, les glycopeptides ne devraient pas être prescrits en première intention sauf en cas de suspicion d'emblée d'une infection sévère à bactérie à Gram positif. ...Le taux résiduel sérique du glycopeptide doit, à notre avis, être mesuré au moins une fois initialement chez l'adulte neutropénique, car les sous-dosages liés à l'augmentation de la clairance ou du volume de distribution peuvent conduire à une inefficacité thérapeutique. La vancomycine et la teicoplanine sont aussi efficaces dans le traitement des infections à bactéries à Gram positif dans cette population avec dans certaines études une meilleure tolérance de la teicoplanine, notamment en association à des médicaments néphrotoxiques. La facilité d'utilisation de la teicoplanine lui permet d'être prescrite chez des patients en hospitalisation à domicile et le coût global des traitements doit être intégré dans la stratégie de prescription. La surveillance périodique de la sensibilité des bactéries à Gram positif aux glycopeptides doit désormais être systématique dans les unités d'onco-hématologie.
Glycopeptides should not be prescribed as a first-line therapy in adults with febrile neutropenia, except in patients with presumed severe infection due to Gram positive bacteria. Trough serum levels should be monitored because of increased clearance and/or distribution volume described with such antibiotics. Both vancomycin and teicoplanin are equally effective in the management of Gram positive bacterial infections in this setting; teicoplanin seems to be better tolerated according to several studies. The easy administration of teicoplanin may facilitate the outpatient management of neutropenic adults with confirmed Gram positive infections. The global cost of such treatments has to be analyzed and the epidemiology of Gram positive bacteria resistance to glycopeptides should be carefully monitored in hematology units.
Only leprosy resource centres undertake surgery for neuritis. Patients' accessibility to this surgical procedure is poor because these centres are often far from their homes. The aim of our work is ...to study the feasibility of neuritis surgery in the field.
A surgeon trained in this surgery was recruited by Bom-Pastor hospital in Brazilian Amazonia, which is located 400 km away from the leprosy resource centre. Patients operated from May 1996 to December 1997 were enrolled in this retrospective study.
A total of 45 operations were carried out during 17 procedures on 13 patients, among which 12 were multibacillary cases. The decompression surgery was performed with a median delay of 1 year after leprosy diagnosis and 3.5 months after the neuritis diagnosis. Among 17 operations, 14 were performed for painful neuritis of recent onset unsuccessfully treated with corticoids or recurring during the month after corticoids were withdrawn. The other three operations were performed for long-standing neuritis with paralysis and deformity. Pain was relieved in all the cases of recent neuritis, except for one patient who suffered from a serious steroid-dependant erythema nodosum leprosum. An improvement of motor function was observed in one out of three patients with long-standing neuritis. Adverse effects were few: a scar infection with a rapid recovery and a keloid scar. Two neurites recurred 2 and 10 months after the surgery.
In an endemic leprosy region, field access to surgery for neuritis appears to prove real progress in the management of leprosy neuritis.
Propos. –
La chirurgie de décompression des névrites lépreuses n’est pratiquée que dans des centres de référence de lutte contre la lèpre, souvent éloignés des lieux de résidence des patients qui ne ...peuvent y accéder. L’objectif de ce travail est d’évaluer la faisabilité de cette chirurgie dans des conditions sanitaires précaires.
Méthodes. –
Un chirurgien général formé à cette technique a été recruté par l’hôpital Bom-Pastor situé dans une région isolée d’Amazonie brésilienne, distante de 400 km du centre de référence. Les patients opérés entre mai 1996 et décembre 1997 ont été inclus dans cette étude rétrospective.
Résultats. –
Quarante-cinq décompressions ont été effectuées, au cours de 17 interventions, chez 13 patients dont 12 atteints de lèpres multibacillaires. La chirurgie était réalisée après un délai médian de un an suivant le diagnostic de lèpre et de trois mois et demi suivant le diagnostic de névrite. Elle était pratiquée 14 fois sur 17 pour des névrites hyperalgiques récentes résistantes aux corticoïdes ou récidivantes dans le mois suivant l’arrêt de la corticothérapie et trois fois pour des névrites anciennes avec déficit moteur et déformation. La chirurgie de décompression a permis une disparition des douleurs dans tous les cas de névrites récentes sauf chez un patient présentant une réaction de type 2 sévère, corticodépendante. Une amélioration fonctionnelle a été observée chez un des trois patients présentant des névrites anciennes avec déficit moteur. Les complications chirurgicales ont été une infection de cicatrice d’évolution favorable et une chéloïde. Deux névrites ont récidivé deux et dix mois après la chirurgie.
Conclusions. –
Dans une région isolée où la lèpre est endémique, la possibilité de réaliser une chirurgie de décompression représente un progrès réel dans la prise en charge des névrites lépreuses.
Purpose. –
Only leprosy resource centres undertake surgery for neuritis. Patients’ accessibility to this surgical procedure is poor because these centres are often far from their homes. The aim of our work is to study the feasibility of neuritis surgery in the field.
Methods. –
A surgeon trained in this surgery was recruited by Bom-Pastor hospital in Brazilian Amazonia, which is located 400 km away from the leprosy resource centre. Patients operated from May 1996 to December 1997 were enrolled in this retrospective study.
Results. –
A total of 45 operations were carried out during 17 procedures on 13 patients, among which 12 were multibacillary cases. The decompression surgery was performed with a median delay of 1 year after leprosy diagnosis and 3.5 months after the neuritis diagnosis. Among 17 operations, 14 were performed for painful neuritis of recent onset unsuccessfully treated with corticoids or recurring during the month after corticoids were withdrawn. The other three operations were performed for long-standing neuritis with paralysis and deformity. Pain was relieved in all the cases of recent neuritis, except for one patient who suffered from a serious steroid-dependant erythema nodosum leprosum. An improvement of motor function was observed in one out of three patients with long-standing neuritis. Adverse effects were few: a scar infection with a rapid recovery and a keloid scar. Two neurites recurred 2 and 10 months after the surgery.
Conclusions. –
In an endemic leprosy region, field access to surgery for neuritis appears to prove real progress in the management of leprosy neuritis.
