Breathing pattern during sequential swallowing in healthy adult humans.

Sequential liquid swallowing is a common daily occurrence during which coordination of deglutition and breathing are highly regulated to avoid pulmonary aspiration and to maintain hematosis. We studied the effects of sequential water swallowing (SWS) at fixed swallowing rates and with regular succession of swallows on respiration in healthy subjects. Thirty-one normal adults (19 men, 12 women) with a mean age of 27.96 ± 3.68 yr were explored at rest and during SWS (at 12 and 24 swallows/min). Respiration was recorded by intranasal air pressure changes and timing of deglutition by an acoustic method. Oxygen saturation [arterial O2 saturation from pulse oximetry ( SpO2 )] was monitored with a finger probe. During SWS, we determined the respiratory phase (inspiration or expiration) before and after each ingestion cycle (IC; period of sustained apnea including 1 or more swallows). We also measured inspiratory time (TI), expiratory time (TE), respiratory cycle duration (TT), respiratory rate (RR) and SpO2 at rest and during SWS. We showed that respiration was interrupted by sequential swallows determining a succession of ICs that were often preceded and followed by expiration. During SWS, TI decreased and TE increased compared with rest ( P < 0.01). However, TT, RR, and SpO2 did not change. It seems that the preferential coupling of swallowing with expiration during SWS is favored by an increase in TE to ensure airway protection, although the repetitive swallows, RR, and SpO2 were not altered during SWS. These data may be useful to study the effects of aging and pathological conditions on swallowing and breathing coordination during SWS. NEW & NOTEWORTHY Sequential water swallowing induces ingestion cycles that are often preceded and followed by expiration. Moreover, inspiratory time decreases and expiratory time increases during sequential swallowing compared with rest without changes in ventilatory cycle duration, respiratory rate, and oxygen saturation.

The diagnosis of tuberculosis in dialysis patients.

The incidence of tuberculosis (TB) is high in patients undergoing chronic dialysis than it is in the general population. The diagnosis of TB is often difficult and extrapulmonary involvement is predominant. This study investigates the spectrum of clinical presentations and outcome in dialysis patients during a nine-year period. TB was diagnosed in 41 patients. Anti-TB drugs, adverse effects of therapy, and outcome were noted. Thirty-eight patients (92.6%) were on hemodialysis and three were on peritoneal dialysis (7.3%). The mean age at diagnosis was 50.8 years and the male/female ratio was 1.16. Four patients had a history of pulmonary TB. Extrapulmonary involvement was observed in 32 (78 %) patients. The bacteriological confirmation was made in 41.46% and histological confirmation was made in 26.83%, and in the rest, the diagnosis was retained on the criterion presumption. Nineteen patients (46.34%) developed adverse effects of antitubercular drugs. Eight patients (19.51%) died during the study from TB or adverse effects of treatment. Low urea reduction ratio and female sex were associated with poor prognosis in our study. The clinical manifestations of TB in patients on dialysis are quite nonspecific, making timely diagnosis difficult, and delaying the initiation of curative treatment, which is a major determinant of the outcome.

Acute Respiratory Failure as the First Manifestation of Antisynthetase Syndrome.

We report the case of a 40-year-old man with acute respiratory failure syndrome that later proved to be an initial manifestation of antisynthetase syndrome. The diagnosis of this rare combination of a connective tissue disease and an acute respiratory failure is difficult in a previously asymptomatic patient. Early diagnosis and immunosuppressive therapy started precociously prevented the disease progression and resulted in a good outcome.

Vitamin D deficiency and interleukin-17 relationship in severe obstructive sleep apnea-hypopnea syndrome.

PURPOSE: We aimed to assess Vitamin D (VD) abnormalities in patients with severe obstructive sleep apnea-hypopnea syndrome (OSAHS), to study its association with clinical and polygraphic data, and to correlate VD levels with interleukin-17 (IL-17). METHODS: Ninety-two patients with severe OSAHS were consecutively enrolled between September 2014 and February 2016 and compared to age-, sex-, and body mass index (BMI)-matched controls. Anthropometric parameters and medical history were collected. The serum levels of VD and IL-17 were determined by radioimmunoassay and enzyme-linked immunosorbent assay, respectively. RESULTS: Ninety-two severe OSAHS patients and thirty controls were enrolled in the study. All OSAHS patients had VD deficiency. The mean level of VD was at 7.9 ng/ml among OSAHS group versus 16.8 ng/ml among control group. IL-17A levels were elevated (20.3 pg/ml) in OSAHS group compared to healthy group (10.05 pg/ml). VD levels were negatively correlated with nocturia severity (r = -0.26; P = 0.01) and positively correlated with mean O2 saturation (r = 0.59; P = 0.02) and lowest O2 saturation (r = 0.3; P = 0.03). IL-17 levels were positively correlated with nocturia severity (r = 0.24; P = 0.03) and negatively correlated with mean O2 saturation (r = -0.42; P = 0.03). A significant negative association was observed between IL-7 and VD levels (r = -0.64, P = 0.2 10-4). The magnitude of this correlation was higher for important nocturia, lower MSaO2, or higher BMI. CONCLUSIONS: VD deficiency in patients with severe OSAHS is common with a negative association between IL-17 and VD serum levels. Hypoxia could play an important role in this association. Further studies are needed to clarify this relationship.

Evaluation of Tuberculin Skin Test Positivity and Early Tuberculin Conversion among Medical Intern Trainees in Tunisia.

BACKGROUND: As healthcare workers (HCWs), medical trainees are at a high-risk for acquisition of tuberculosis (TB) infection and disease. To our knowledge, there are no published data about TB infection among medical trainees in Tunisia.To determine the tuberculin skin test (TST) positivity and tuberculin conversion among a group of medical trainees in different departments at our institution. MATERIALS AND METHODS: We performed a prospective study using the TST. The study was conducted in two steps: 1) an initial TST survey and 2) an evaluation of the TST conversion rates. RESULTS: Among 114 participants, the TST was positive (≥10 mm) in 26.3% and negative (<5 mm) in 57%. The conversion rate of TST was 4%, which was only observed among the trainees assigned to the pulmonary departments. The significant predictor variables of TST positivity were a history of nosocomial TB exposure and training in a high-risk area. CONCLUSION: Despite the small number of participants, the high TB conversion rate among the trainees is alarming. This population represents an important target group for a latent tuberculosis infection screening program in countries with limited resources such as Tunisia.

Role of metalloproteinases MMP-2 in asthma.

Background - Many metalloproteinases (MMPs) play a role in the pathogenesis and modulation of the severity of asthma. MMP-9 is the predominant in asthma but other MMPs are involved such as the MMP-2. Aim - To determine the role of single nucleotide polymorphism of the gene MMP2 in susceptibility to asthma and its severity. Methods - Study case-control with prospectively enrolled patients with asthma and healthy subjects. We determined within two groups genotypes corresponding to the MMP2 polymorphism in -735C / T position, using a polymerase chain amplification technique associated with a polymorphism in the length of restriction fragments. Results - We included 150 patients with asthma and 150 healthy controls. Comparison of allele and genotype frequencies of the studied polymorphisms between patients and controls showed that there was no association between the SNP-735C / T and susceptibility to asthma and its severity. Conclusion - The role of MMP 2 in asthma remains unclear and no study has been conducted till date, to determine the role of MMP-2 -735C/T gene polymorphism in asthma. This study does not disprove such association. Further studies are needed to clarify the exact role the pathogenesis of asthma.

Contribution of fixed-dose combinations in the treatment of tuberculosis.

Background - The introduction of fixed-dose combinations (FDCs) of TB treatment in Tunisia is recent (July 2009). WHO and the National Tuberculosis Programme recommend the use of fixed-dose combination (FDC) tablets for the treatment of tuberculosis (TB). The effectiveness of ADF has been demonstrated, however the risk of relapse and tolerance were controversial. Objective - Through a retrospective study, we evaluate, the contribution of FDCs compared with dissociated treatment (TD) (efficacy, tolerance and the occurrence of relapses). Patients and methods - This is a retrospective study conducted in the Department of Pneumology la Rabta. Are included patients with pulmonary tuberculosis (TB) first attack. Two groups were studied: Group I (TC) treated between July 2009 and June 2011 who received ADF. Group II (TD) treated between July 2008 and June 2009 who received TB dissociated treatment. Results - One hundred and seventy one patients were included: 122 in the TC group with an average age of 39.2 years and 49 patients in the TD group with an average age of 38.2 years. Male predominance was observed in the two groups (82/75.5%). The period of apyrexia was below 7 days at more than 80% of patients in the two groups. Sputum smears conversion were obtained between one and two months (median 52,8 vs 55,8 days) in both groups with no significant difference (p = 0.06). The rate of smears conversion at 2 months was 74% in TC group versus 65.3 % (p = 0.12). Eighty patients (65%) of the TC group and 29 patients (59%) of the TD group had one or more adverse effects to treatment without significant difference (p = 0.270). The most common adverse effects were those related to digestive system (17.2% vs 6.1%), liver toxicity (7.4% vs 4.1 %) and urticaria (9.8% vs 8.1%). The treatment successful rate was: 73.7 % in TC group and 77.5 % in TD group. There was no significant difference in treatment compliance, neither in relapse rate nor in the death rate. Conclusion - This study demonstrated non-inferiority of the effectiveness of ADF with a comparable safety. Its effects in the prevention of relapse and resistance BK remain unproven.

Sit-to-stand test and 6-min walking test correlation in patients with chronic obstructive pulmonary disease.

BACKGROUND: The 6-min walking test (6MWT) is one of the most commonly used tests to assess exercise capacity during chronic obstructive pulmonary disease (COPD). However, it is a relatively time-consuming test. Many authors assessed the usefulness of simpler methods, as the sit-to-stand test (STST), to estimate exercise capacity. PURPOSE: To demonstrate the feasibility of STST, in comparison to 6MWT, for the evaluation of functional status in Tunisian COPD patients and evaluate its correlation to the severity of the disease. METHODS: We studied patients with COPD (Global Initiative for Chronic Obstructive Lung Disease A-D). All patients had plethysmography and manual quadriceps femoris muscle strength evaluation. Each patient completed a 6MWT and a STST. During the tests, dyspnea severity (Borg scale), heart rate, pulsed oxygen saturation, and blood pressure were measured. RESULTS: In 49 patients with stable COPD (mean age 67.06 ± 8.4 years, mean forced expiratory volume in the first second 46.25% ± 19.64%), 6MWT and STST were correlated with each other (r = 0.47, P = 0.001). During 6MWT and STST, the rise in heart rate, systolic blood pressure, and severity of dyspnea were statistically significant compared to baseline (P < 0.05). However, cardiorespiratory stress was lower after STST than after 6MWT (P < 0.05). A statistically significant positive correlation was noted between the 6MWT distance and forced vital capacity (r = 0.357, P < 0.05). The 6MWT was negatively correlated with dyspnea severity at baseline (r = -0.289, P < 0.05) and with BODE index (r = -0.672, P < 0.01). STST was correlated only with age (r = 0.377, P < 0.01). No correlation was found between both tests and quadriceps femoris strength. CONCLUSION: As like as 6MWT, STST can determine functional status during COPD. In addition, it is less time consuming and produces less hemodynamical stress compared to 6MWT. STST can be used as an alternative for 6MWT in patients with COPD.

Drug Rash with Eosinophilia and Systemic Symptoms to antituberculosis treatment.

Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) syndrome reflects a serious hypersensitivity reaction to drugs. This syndrome is an uncommon adverse reaction due to antituberculosis drugs and is sometimes difficult to identify the culprit agent. We report a case of a 45-year-old woman who received combined antituberculosis drugs (RHZE) for lymph node tuberculosis. Clinical manifestations included fever, dyspnea, rash, hypereosinophilia and visceral involvement (liver involvment). After symptom resolution and biology normalization, anti-tuberculosis drugs were reintroduced successively one after another. Systemic symptoms reappeared with the four anti-tuberculosis drugs. The clinical outcome was favorable with second line antituberculosis treatment.

[Infuenzae A (H1N1): about 189 cases]. / Grippe A (H1N1): à propos de 189 cas.

BACKGROUND: Influenza A (H1N1) is a contagious acute respiratory infection caused by a subtype influenza virus A (H1N1). The later had caused a pandemic in 2009. Despite its low mortality, the disease was more severe in some subgroups. OBJECTIVES: Describe confirmed cases of influenza A (H1N1) addressed to the pulmonary department of the Rabta hospital and identify risk factors. METHODS: During the pandemic influenza A (H1N1), pulmonary department of Rabta hospital was identified among the centers to receive and detect new cases in addition to hospitalization of severe ones. All subjects had nasal and pharyngeal swabs. The authors distinguished non-severe and severe cases; hospitalization was indicated for severe forms. RESULTS: From September 2009 to March 2010, influenza A (H1N1) has been confirmed in 189 patients. The average age was 27.3 years [2-72 years]. Sex ratio was 1.2. Contagion was found in all patients. Twenty-two patients were hospitalized for the severe form. Mean age was 56 years, sex ratio was 0.47. Among them, 20 patients had at least one co-morbidity. Most frequently found risk factors were diabetes (9 cases), chronic respiratory disease (9 cases) and pregnancy (6 cases). All patients received ozeltamivir. The dose was doubled in severe cases. Nonspecific antibiotic therapy was prescribed in 11 cases. Seven patients were hospitalized in intensive care unit, among whom 4 died. Mortality in severe forms was 18% and overall mortality 2.1%. CONCLUSIONS: Through this Tunisian series, we emphasize the potential severity of influenza A (H1N1). This justifies a systematic vaccination of subjects at risk even away from pandemic period.

First isolation of Mimivirus in a patient with pneumonia.

BACKGROUND: Mimiviridae Mimivirus, including the largest known viruses, multiply in amoebae. Mimiviruses have been linked to pneumonia, but they have never been isolated from patients. To further understand the pathogenic role of these viruses, we aimed to isolate them from a patient presenting with pneumonia. METHODS: We cultured, on Acanthamoeba polyphaga amoebae, pulmonary samples from 196 Tunisian patients with community-acquired pneumonia during the period 2009-2010. An improved technique was used for Mimivirus isolation, which used agar plates where the growth of giant viruses is revealed by the formation of lysis plaques. Mimivirus serology was tested by microimmunofluorescence and by bidimensional immunoproteomic analysis using Mimivirus strains, to identify specific immunoreactive proteins. The new Mimivirus strain genome sequencing was performed on Roche 454 GS FLX Titanium, then AB SOLiD instruments. RESULTS: We successfully isolated a Mimivirus (LBA111), the largest virus ever isolated in a human sample, from a 72-year-old woman presenting with pneumonia. Electron microscopy revealed a Mimivirus-like virion with a size of 554 ± 10 nm. The LBA111 genome is 1.23 megabases, and it is closely related to that of Megavirus chilensis. Furthermore, the serum from the patient reacted specifically to the virus compared to controls. CONCLUSIONS: This is the first Mimivirus isolated from a human specimen. The findings presented above together with previous works establish that mimiviruses can be associated with pneumonia. The common occurrence of these viruses in water and soil makes them probable global agents that are worthy of investigation.

Distribution of COPD-related symptoms in the Middle East and North Africa: results of the BREATHE study.

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. However, its epidemiology in many developing countries is poorly characterised. The objective of this analysis was to evaluate respiratory symptoms which could be COPD-related in a large sample of individuals aged ≥ 40 years in ten countries in the Middle East and North Africa (Algeria, Egypt, Jordan, Lebanon, Morocco, Saudi Arabia, Syria, Tunisia, Turkey and United Arab Emirates), together with Pakistan, using a standardised methodology. A random sample of 457,258 telephone numbers was contacted. A screening questionnaire was administered to each eligible participant, which included six questions relating to respiratory symptoms. Of 65,154 eligible subjects, 62,086 agreed to participate and 61,551 provided usable data. The age- and gender-adjusted prevalence of symptoms (persistent productive cough or breathlessness or both) was 14.3% [95% CI: 14.0-14.6%], ranging from 7.2% in UAE to 19.1% in Algeria. Symptoms were more frequent (p < 0.0001) in women (16.7%) than in men (12.2%). The adjusted prevalence of COPD according to the "epidemiological" definition (symptoms or diagnosis and cigarette use ≥ 10 pack · years) was 3.6% [95% CI: 3.5-3.7%] (range: 1.9% in UAE to 6.1% in Syria). COPD was more frequent (p < 0.0001) in men (5.2%) than in women (1.8%). The frequency of symptoms was significantly higher in cigarette smokers (p< 0.001), as well as in waterpipe users (p < 0.026). In conclusion, the prevalence of COPD in this region seems to be lower than that reported in industrialised countries. Under-reporting and risk factors other than smoking may contribute to this difference.

The burden of chronic obstructive pulmonary disease in the Middle East and North Africa: results of the BREATHE study.

COPD is a progressive pulmonary disease which may have a profound impact on general health status and quality of life. This article presents data on the burden of COPD obtained from the BREATHE study in the Middle East, North Africa and Pakistan. This study was a large general population survey of COPD conducted in eleven countries of the region using a standardised methodology. A total of 62,086 subjects were screened, of whom 2,187 fulfilled the "epidemiological" definition of COPD. Data on symptoms, perceived disease severity, impact on work, limitations in activities and psychological distress were collected. 1,392 subjects were analysable of whom 661 (47.5%) reported experiencing an exacerbation of their respiratory condition, 49.4% reported comorbidities and 5.5% reported severe breathlessness as measured with the MRC breathlessness questionnaire. The degree of breathlessness, as well as the perceived severity, was correlated with the overall disease impact as measured with the COPD Assessment Test (p < 0.001). 374 subjects (28.4%) reported that their respiratory condition prevented them from working and this proportion rose to 47.8% in subjects who perceived their respiratory condition as severe. 47.9% of subjects reported difficulties in normal physical exertion, 37.5% in social activities and 31.7% in family activities. Psychological distress was reported by between 42.3% and 53.2% of subjects, depending on the item. In conclusion, the burden of COPD is important, and covers central aspects of daily life. For this reason, physicians should take time to discuss it with their patients, and ensure that the management strategy proposed addresses all their needs.