Efficiency of a phone coaching program on adherence to continuous positive airway pressure in sleep apnea hypopnea syndrome: a randomized trial.

BACKGROUND: Continuous Positive Airway Pressure (CPAP) remains the reference treatment for moderate to severe forms of the Sleep Apnea/Hypopnea Syndrome (SAHS). Compliance to the treatment appears to be a key factor to improving health status of these patients. METHODS: We conducted a multicenter, prospective, randomized, controlled, parallel group trial of standard support completed or not within 3 months of coaching sessions for newly diagnosed SAHS patients starting CPAP therapy. This study has been recorded by AFSSAPS with the RCB number: 2009-A01127-50 and received favourably by the Human Studies Committee in France. The coaching session consisted of 5 sessions of telephone-based counselling by competent staff. The primary outcome was the proportion of patients using CPAP more than 3 h per night for 4 months; the secondary outcome was mean hours of CPAP usage in the 2 groups. RESULTS: Three hundred and seventy-nine patients fulfilled the inclusion criteria and were randomized. The percentage of patients using CPAP more than 3 h per night for 4 months was 65 % for the standard support group and 75 % for the coached group. This difference reached a statistical significance (χ2 = 3.97). The mean CPAP usage was increased in the coached group versus standard group. A difference of 26 min was observed (4 h34+/-2 h17 and 4 h08+/-2 h25 respectively, p = 0.04). CONCLUSION: This study shows that SAHS patients who benefit from phone coaching are statistically more compliant to CPAP than a standard support group is. A simple phone coaching procedure based on knowledge of the disease and reinforcement messages about treatment benefits helps to improve CPAP adherence in SAHS patients. TRIAL REGISTRATION: NCT02435355.

[Antivirals for influenza]. / Traitements anti-viraux au cours de la grippe.

This paper describes antivirals active against Myxovirus influenzae (influenza vaccine excluded), together with their indications in inter-pandemic and pandemic situations. Three kinds of antiviral drug, with different mechanisms of action, are active against Myxovirus influenzae: the adamantanes (amantadine and rimantadine); ribavirin; and neuraminidase inhibitors (zanamivir and oseltamivir). Amantadine is available in France but its indications are limited by its inactivity against influenza B virus, its adverse effects, and rapid onset of resistance. Ribavirin is administered by nebulization, exclusively in hospital, for severe cases. Neuraminidase inhibitors are effective on benign influenza; they are also well tolerated, active against subtypes A and B, and rarely elicit resistant mutants in vivo (exclusively seen with oseltamivir, mainly among children). According to their licensing terms, antivirals may be prescribed during epidemics, within 24-48 hours of typical symptom onset. They must not be used prophylactically in place of influenza vaccine, but may be useful when there is a familial or institutional index case, or during pandemics. Use in this latter situation would raise supply problems and, thus, the question of who should be treated first.

[Sleep apnea syndromes and cardiovascular disease]. / Syndromes d'apnées du sommeil et pathologie cardiovasculaire.

Sleep-disordered breathing is very common and is associated with an increased risk of cardiovascular disease, cardiac arrhythmia and stroke. There are two types of sleep apnea: obstructive and central. The objective of this review is to provide a broad perspective of the pathophysiological and clinical aspects of the two types of apnea and to discuss their cardiovascular adverse effects. The diagnosis of sleep apnea syndrome is based on polysomnography, and severity is measured with an apnea-hypopnea index that counts the total number of apneas per hour of sleep. Recent large epidemiologic studies have shown that sleep apnea affects about 16% of men and 5% of women between 30 and 65 years of age. Obstructive sleep apnea is characterized by abnormal collapse of the pharyngeal airway during sleep, snoring, vigorous inspiratory efforts causing frequent arousal, and excessive daytime drowsiness. Central sleep apnea with Cheyne-Stokes respiration is a form of periodic breathing with frequent periods of hyperventilation, and carries a poor prognosis in patients with heart failure. Obstructive apnea can also have substantial health consequences. Although the exact mechanism linking sleep apnea with cardiovascular disease is unknown, there is evidence that obstructive apnea is associated with a group of proinflammatory and prothrombic factors that are also important in the development of atherosclerosis. Nocturnal and daytime sympathetic activity is elevated after sleep apnea. Autonomic abnormalities include an increased resting heart rate, decreased cardiac rhythm activity, and increased blood pressure variability. Obstructive apnea is associated with endothelial dysfunction, increased C-reactive protein and cytokine expression, elevated fibrinogen levels and decreased fibrinolytic activity. Enhanced platelet activity and aggregation, leukocyte adhesion and accumulation of endothelial cells are common in both obstructive apnea and atherosclerosis. Surges in sympathetic activity, blood pressure, ventricular wall tension and afterload adversely affect ventricular function. Many studies have shown that patients with obstructive apnea have an increased incidence of daytime hypertension, and this syndrome is recognized as an independent risk factor for hypertension. Obstructive apnea is associated with myocardial ischemia (silent or symptomatic), acute coronary events, stroke and transient ischemic attacks, cardiac arrhythmia, pulmonary hypertension and heart failure. Central sleep apnea is frequent in severe heart failure. Most heart failure patients with pulmonary congestion chronically hyperventilate because of stimulation of vagal irritant receptors and central and peripheral chemosensitivity. When PaCO2 falls below the threshold required to stimulate breathing, the central drive to respiratory muscles and air inflow ceases and central apnea ensues. Apnea, hypoxia, CO2 retention and arousals provoke elevated sympathetic activity, increased afterload and elevated left ventricular transmural pressure, and promote the progression of heart failure. Tentative relationships have been identified between central apnea and markers of inflammation, oxidative stress and endothelial dysfunction. Recent mid-terms trials showed that nocturnal use of positive airway pressure in patients with the two types of apnea alleviates symptoms, reduces sympathetic activity, improves ventricular function and quality of life, and reduces daytime drowsiness. More studies are needed to understand the mechanisms underlying the relationship between sleep apnea and cardiovascular disease, but clinicians should be aware of this link and should attempt to identify patients with these syndromes.

La Asociación Médica Franco-Argentina: fundación y visión pionera. Homenaje al Dr. Louis Pasteur Vallery-Radot a cincuenta años de su fallecimiento / The Franco-Argentine Medical Association: foundation and pioneering vision. Tribute to doctor Louis Pasteur Vallery-Radot on the 50th anniversary of his death

Se hace una reseña histórica de la fundación de la Asociación Médica Franco-Argentina. Se mencionan sus propósitos fundacionales, sus protagonistas y su contexto social.

A historical review of the foundation of the Franco-Argentine Medical Association is made. Its foundational purposes, their protagonists and the social context are mentioned.

Limited operation for severe multisegmental bilateral bronchiectasis.

BACKGROUND: Some patients exhibiting severe multisegmental bilateral bronchiectasis are no longer improved with antibiotic treatment and drainage and, most of the time, operation is contraindicated. In our institution, limited operation has been offered to select patients for this indication. We report our data regarding the feasibility and utility of such a procedure. METHODS: We studied 16 patients who underwent surgical removal of nonlocalized disease between 1990 and 1999. We report the mortality and morbidity rates of this surgical procedure and the clinical, bacteriological, and functional data for each patient. RESULTS: There was no mortality and the morbidity was low (18%, all with favorable outcome). Symptoms such as hemoptysis, sputum production, or dyspnea were also improved. The recurring infections decreased in frequency in 8 patients and disappeared completely in 5 others. The bacteriological data assessment revealed disappearance of germs in 4 patients and persistence of chronic colonization in others. Postoperative spirometric data were not worsened and postoperative computed tomographic scans did not show progression of lesions not removed. CONCLUSIONS: These results suggest that, in properly selected patients, lasting symptomatic improvement can be achieved by resection. Limited operation may be indicated in nonlocalized bilateral bronchiectasis, provided that a target can be identified. This procedure is supported by physiopathologic arguments and is particularly relevant to patients with bronchiectasis with cystic and functionless territories.

[Infections in chronic obstructive pulmonery disease]. / Les infections au cours des bronchopneumopathies obstructives.

Infection plays an important role in COPD, particularly during exacerbations. The principal pathogens involved in exacerbations are viruses (influenza and parainfluenza virus, picornavirus, and respiratory syncytial virus). Bacteria (mainly Haemophilus influenzae, Streptococcus pneumoniae, Branhamella catarrhalis) are isolated from sputum in approximately 50% of exacerbations and 25% of patients with stable state. Recent data favor of a proinflammatory role of these bacteria in the natural history of the disease. The role of atypical pathogens like Chlamydia pneumoniae may be underestimated. Trials of antibiotic treatment have shown a slight but significant benefit, particularly in patients with recent-onset purulent sputum. The benefit is more significant in patients with stable severe obstructive disease. Guidelines have been published in industrialized countries on the use of antibiotics in this indication. The role of infections in the pathogenesis of obstructive lesions is controversial. Some authors have forwarded a "vicious circle" hypothesis, in which impairment of mucociliary clearance by tobacco smoke contributes to bronchial colonization by bacteria, and this further impairs mucociliary clearance and promotes airway epithelial injury. COPD is a major risk factor for community-acquired pneumonia.

[Respiratory pathology associated with pneumococcus]. / Pathologie respiratoire liée au pneumocoque.

Pneumococcal pneumonia is the leading cause of death due to infectious diseases in industrialized countries. Risk factors are mainly elderly and comorbidities. Increasing prevalence of multiresistant strains to antibiotics is a major problem for public health. Lobor consolidation remains the most frequent pattern, nevertheless less frequent than in the pre-antibiotic era; it's not significantly predictive of pneumococcal etiology. Extra-respiratory complications are more frequent in bacteremic pneumonia. Signs and symptoms are not different in HIV positive patients. There are no clinical predictive signs of penicillin-resistant pneumococcal pneumonia; nevertheless some risk factors have been identified: young age(particularly children in day-care centers), elderly patients, previous eéta-lactam treatment, nosocomial acquisition, prior hospitalization. Biologic diagnosis tools (blood cultures, sputum culture) are now completed by antigen-detection tests, particularly urinary antigen test. Most active béta-lactams on in vitro resistant strains (penicillin, amoxicillin, céfotaxime, ceftriaxone) remain the first line treatment. Mortality is near 12-15% cases among hospitalized patients, 95% of deaths concerning more than 60 years patients. Outcome is not significantly affected by drug resistance. Pneumococcal vaccination is a very important prevention among elderly and patients with underlying chronic medical conditions. Pneumococcal vaccine in France is largely ignored by general practitioners.

[Treatment and prevention of pneumococcal pneumonia]. / Pneumonies à pneumocoque: traitement et prévention.

Streptococcus pneumoniae is the most commonly identified pathogen in patients with community-acquired pneumonia. 40% of isolated strains in France are of decreased sensibility to penicillin, two third being multiresistant to antibiotics. However, high doses of some beta-lactams are effective in vivo against the majority of circulating strains (MIC > 2 mg/L). For this reason according to French guidelines amoxicillin (3 g/day) is the first line recommended treatment. Telithromycin is an alternative, or ceftriaxone (1 g/day) in more severe cases. If the level of resistance increases (MIC > 4 mg/L) guidelines would be revisited. Effectiveness of pneumococcal vaccination has been confirmed in cases of bacteriemic pneumococcal pneumonia (elderly patients included). Vaccine is recommended among persons with comorbiditie(s) and 65 years old population.