[Reliability of the diagnosis of acute otitis media by general practitioners]

OBJECTIVES

To assess reliability of the diagnosis of Acute Otitis Media (AOM) given by General Practitioners (GPs) compared with the diagnosis of Otorhinolaryngologists (ORLs) considered as the reference diagnosis.

METHODOLOGY

Every GP had to include 6 children aged 1 to 4 years for whom he suspected or diagnosed AOM. Parents had to accept to consult the ORL participating in the survey within 48 h.

RESULTS

24 GPs took part in the survey and included at least 1 child, which amounts to a final 57% acceptability rate. Two hundred and eight eardrums were included in the survey. 21.9% of assumptions or diagnosis of AOM (30/137) were declared null by the ORL. GPs diagnose AOM with certainty only in 54% of all cases. The diagnosis and the assumption of AOM were respectively confirmed in 83.8% of all cases and 71.4% by the ORL. The combination of redness and bulge and isolated redness accounted for respectively 44.3% and 26.2% of the main otoscopical factors reminiscent of the AOM according to GPs. In the case of redness plus bulge, the diagnosis was confirmed in 83% of all cases by the ORL as opposed to 75% regarding the isolated redness. AOM was suspected in 57.1% of the eardrums little or not visible with no sign of infection and was not confirmed in 25% of all cases.

CONCLUSION

The global overdiagnosis was 21.9% and 25% when the otoscopy is hindered by the presence of cerumen or when the eardrums show inflammation alone. Even though the overdiagnosis was lower than the reported one in literature, post-graduate teaching on the various cerumen removal techniques and the use of pneumatic otoscopy should contribute to improve the quality of diagnosing AOM.

Treatment of epistaxis in rendu-osler-weber disease by in situ ethibloc® injections

After a brief review of Rendu-Osler-Weber disease, we present the results from a series of 13 patients treated by Ethibloc injections for epistaxis. Based on a review of the literature, typical treatments are presented along with discussion of their efficacy and side effects. In our series, 90% of patients improved after only one injection. All patients reported a decrease in hemorrhage, especially patients with recurrent epistaxis. Five of nine patients reported a decrease in the length of the bleeding episodes. Improvement was reported by 85% of patients within one month following Ethibloc injection. Fifty percent of these patients have persistent good results at 4 Year follow-up. Our results indicate that Ethibloc injections are safe and effective as an alternative treatment for patients that have failed standard treatment options.

[Acute cervical necrotizing fasciitis of pharyngeal origin: possible role of steroidal and non-steroidal anti-inflammatory agents. Apropos of 5 cases]

Within 20 cases of cervical acute necrotizing fasciitis treated in the intensive care unit and hyperbaric oxygen therapy department between 1986 and 1995, the authors report five cases of pharyngeal origin. 4 have been initially treated with anti-inflammatory drugs: non steroidal (1 case), steroidal (2 cases), non steroidal and steroidal (1 case). The five patients have been operated. They needed at least 30 days of endotracheal intubation and hyperbaric oxygen therapy. No death outcome but a important morbidity is reported. The immunosuppressive features of the two type of anti inflammatory drugs are exposed. Different publications suggesting the possible association between non steroidal anti inflammatory drugs and non cervical necrotizing fasciitis are reported. It is not possible to prove a direct link because of the number of our cases, because of the wide number of pharyngitis treated in the area, and because the absence of precise data about the use of anti inflammatory drugs in the initial treatment of this pharyngitis. Existence of other type of antalgic and non immunosuppressive drugs make the use of anti inflammatory drugs not justify.

Complementation analysis of pseudorabies virus gE and gI mutants in retinal ganglion cell neurotropism

Pseudorabies virus glycoproteins gE and gI are required to infect some, but not all, regions of the rodent central nervous system after peripheral injection. After infection of the retina, pseudorabies virus mutants lacking either gE or gI can subsequently infect neural centers involved in the control of circadian function but cannot infect visual circuits mediating visual perception or the reflex movement of the eyes. In this study, we used genetic complementation to test the hypothesis that gE and gI are required for entry into the specific retinal ganglion cells that project to visual centers. These data strongly suggest that gE and gI must function after the viruses enter primary neurons in the retina.

Comparative accuracy of Doppler echocardiographic methods for clinical stroke volume determination

Numerous Doppler echocardiographic methods to measure stroke volume have been proposed in experimental or clinical studies, but their relative accuracy in patients compared with an invasive reference standard remains uncertain. Accordingly, we compared Doppler with thermodilution stroke volume measurement in 18 hospitalized patients, 16 with an acute manifestation of coronary artery disease and two with chronic cardiomyopathies. Doppler time-velocity integrals were measured by darkest line (modal velocity) and the leading edge (maximal velocity) techniques at the aortic annular plane, the mitral orifice, and the mitral annular plane. Two-dimensional echocardiography was used to measure cross-sectional areas (M-mode-corrected at the mitral orifice). The combination of aortic annular cross-sectional area and the leading edge technique of measuring the time-velocity integral of blood flow at this site provided the most accurate measure of stroke volume (r = 0.87, p less than 0.0001, standard error of estimate = 11 cm3; mean difference from thermodilution = 2.8 ml +/- 8.9 ml, p = NS). It also resulted in the most accurate measurement of cardiac output (r = 0.88, p less than 0.0003; mean difference from thermodilution = 0.11 L/min +/- 0.69 L/min, p = NS). Other methods yielded values that correlated less closely and deviated systematically from thermodilution measurements. We therefore conclude that of the six common methods evaluated, the aortic annular leading edge method measures stroke volume with the best accuracy and is most suitable for clinical application.

Transposed ciliary microtubules in Kartagener's syndrome. A case report with electron microscopy of bronchial and nasal brushings

Report is made of the case of a 44-year-old white woman with Kartagener's syndrome marked by respiratory disorders and repeated serous otitis since infancy. The technique of cell sampling through bronchial and nasal brushings facilitated observation of ciliary structures in electron microscopy. The results revealed a specific anomaly in the organization of the ciliary microtubules. The doublet transposition observed may be associated with ciliary dyskinesia.

[By-pass from sub-clavian to carotid artery. A rescue procedure in the treatment of common carotid artery hemorrhage (author's transl)]

Rupture of a carotid artery in an infected or irradiated environment is a tragic event that frequently causes immediate death. Plain ligature, when possible, for these patients in a state of shock, leads to cerebral ischemia in 65% of cases. This can be prevented, if one operates soon enough by an extra-anatomic by-pass, avoiding the infected or irradiated area, between the subclavian artery and the homolateral carotid artery. (Study of 2 cases). Such a procedure could be used preventively when the risk for the carotid is highest (particularly septic surgery followed by irradiation).

[Long term results of dilatation using the tube-bougie method in stenosis following caustic oesophagitis (author's transl)]

The tube-bougie methode suggested by the authors ten years ago for dilatation of oesophageal stenosis is based upon the fact that the instrument dilates only in the oesophagus itself and that it consists, on the one hand at the level of the stomach and secondly at the level of the nose and pharynx of a tube a small calibre which makes it possible to leave the dilating instrument in place for far longer periods (24 to 48 hours) than conventional bougies, increasing the interval between dilatation sessions. This technique has been used several hundred times for various indications, but only 6 cases of caustic oesophagitis (with a total of 440 dilatations) each patient being followed up for more than three and a half years, have been studied in order to determine the effectiveness of the method. Amongst the causes of recurrent stenosis or of an imperfect long term result, the authors stress the role of the reflux of gastric fluid and above all of progressive fibroinflammatory mediastinitis.