Kinetics and mechanism of the tropospheric reaction of 3-hydroxy-3-methyl-2-butanone with Cl atoms.

The relative rate coefficient for the gas-phase reaction of 3-hydroxy-3-methyl-2-butanone (3H3M2B) with Cl atoms was determined under atmospheric conditions (298 ± 2 K, 720 ± 2 Torr). The products of the reaction were identified and quantified. This work provides the first kinetic and mechanistic determinations of the gas-phase reaction of Cl atoms with 3H3M2B. The rate measurements and the products studies were performed in two simulation chambers coupled to the gas chromatography-mass spectrometer (GC-MS) and the Fourier transform infrared (FTIR) techniques, respectively. The obtained average rate coefficient was (1.13 ± 0.17) × 10(-10) cm(3) molecule(-1) s(-1) using propene and 1,3-butadiene as reference compounds. The major primary reaction products observed in this study were (with % molar yields): acetic acid (42.6 ± 4.8) and 2,3-butanedione (17.2 ± 2.3). Results and mechanism are discussed in terms of the structure-reactivity relationship and compared with the reported reactivity with the other atmospheric oxidants. The atmospheric implications derived from this study are discussed as well.

Lung volume reduction in patients with severe diffuse emphysema. A retrospective study.

BACKGROUND: For most authors, surgery of emphysema is restricted to resection of large bullae, whereas resection of small bullae or lung volume reduction is generally considered to have poor results. STUDY OBJECTIVE: To report our experience of lung volume reduction in patients with severe emphysema without large bullae. PATIENTS: Thirteen patients were operated on from 1982 to 1992. Before surgery, they all had severe diffuse emphysema with a dyspnea grade 4 or 5 and mean FEV1 values of 18 +/- 5% of predicted. Seven patients had a PaCO2 greater than 42 mm Hg. On radiologic evaluation, they had either small bullae or, most often, areas of destroyed lung. INTERVENTION: The surgical procedure was unilateral in 11 patients and bilateral in 2. MEASUREMENTS AND RESULTS: Postoperative assessment included dyspnea grading, FEV1 measurements, and blood gas analysis followed at 6- to 12-month intervals. There was no perioperative mortality and the morbidity was limited. At 6, 12, 18, 24, and 36 months postoperatively, a symptomatic improvement was observed in 92%, 85%, 54%, 31%, and 31% of the patients, respectively, with FEV1 increasing by at least 20% in 92%, 46%, 46%, 31%, and 24% of the patients, respectively. CONCLUSION: Our data show that lung volume reduction may result in symptomatic and spirometric improvement in patients with severe emphysema without large bullae.

Flow limitation and dynamic hyperinflation during exercise in COPD patients after single lung transplantation.

STUDY OBJECTIVE: Using the negative expiratory pressure (NEP) method, we have previously shown that patients receiving single lung transplantation (SLT) for COPD do not exhibit expiratory flow limitation and have little dyspnea at rest. In the present study, we assessed whether SLT patients exhibit flow limitation, overall hyperinflation, and dyspnea during exercise. METHODS: Expiratory flow limitation assessed by the NEP method and inspiratory capacity maneuvers used to determine end-expiratory lung volume (EELV) and end-inspiratory lung volume (EILV) were performed at rest and during symptom-limited incremental cycle exercise in eight SLT patients. RESULTS: At the time of the study, the mean (+/- SD) FEV(1), FVC, functional residual capacity, and total lung capacity (TLC) amounted to 55 +/- 14%, 67 +/- 12%, 137 +/- 16%, and 110 +/- 11% of predicted, respectively. At rest, all patients did not experience expiratory flow limitation and were without dyspnea. At peak exercise, the maximal mechanical power output and maximal oxygen consumption amounted to 72 +/- 20% and 65 +/- 8% of predicted, respectively, with a maximal dyspnea Borg score of 6 +/- 3. All but one patient exhibited flow limitation and dynamic hyperinflation; the EELV and EILV amounted to 74 +/- 5% and 95 +/- 9% TLC, respectively. The patient who did not exhibit flow limitation during exercise had the lowest dyspnea score. CONCLUSION: Most SLT patients for COPD exhibit expiratory flow limitation and dynamic hyperinflation during exercise, whereas maximal dyspnea is variable.

Early release of proinflammatory cytokines after lung transplantation.

BACKGROUND: Systemic hypotension may complicate the early postoperative period after lung transplantation. A release of proinflammatory cytokines secondary to lung ischemia/reperfusion injury could be involved in the pathogenesis of this early hemodynamic failure (EHF). STUDY OBJECTIVE: To assess prospectively whether the occurrence of EHF is associated with a release of cytokines in the systemic circulation. DESIGN: Blood samples were taken daily during the first postoperative week in 26 patients who underwent a double or a single-lung transplantation. These patients were divided into three groups: 7 patients who experienced EHF and subsequently died (EHF group); 15 patients without EHF (control group); and 4 patients without EHF but with an identified sepsis (sepsis group). The serum levels of interleukin (IL)-1beta, tumor necrosis factor-alpha (TNF-alpha), IL-6, and IL-8 were compared among the three groups. RESULTS: In the EHF group, the levels of each cytokine peaked at day 1 postoperatively. Cytokine levels at day 1 were significantly higher in the EHF group than in the control group (p<0.0006) or in the sepsis group (p<0.003 except for TNF-alpha). CONCLUSION: We conclude that EHF is associated with a massive release of proinflammatory cytokines that could play a determinant role in the pathogenesis of this complication.

Immediate and long-term results of bronchial artery embolization for life-threatening hemoptysis.

STUDY OBJECTIVES: Bronchial artery embolization (BAE) has been established as an effective technique in the emergency treatment of life-threatening hemoptysis, but few data concerning long-term results and complications of the procedure are available. The aim of this study was to analyze retrospectively the experience of BAE in our center with particular emphasis on medium-term and long-term results and on morbidity. SETTING: University hospital. PATIENTS: Fifty-six patients underwent bronchial arteriography from 1986 to 1996 in our center for the management of life-threatening hemoptysis. Of them, BAE was performed in 46 patients. Their mean age was 51 years (range, 19 to 89 years). The most frequent etiologies of hemoptysis were active or inactive tuberculosis, bronchiectasis, or idiopathic hemoptysis. RESULTS: BAE resulted in an immediate cessation of hemoptysis in 43 of the initial 56 patients (77%). During the first month after BAE, four patients who died from causes other than hemoptysis or who were referred to surgery were excluded from follow-up and in the 39 remaining patients, a complete cessation of hemoptysis was observed in 32 patients. A remission was noted in 28 of the 29 patients followed up between 30 and 90 days after BAE. Long-term control of bleeding was achieved in 25 of the initial 56 patients (45%) followed up beyond 3 months after BAE (median follow-up of 13 months; range, 3 to 76 months). Overall, complications of BAE consisted of two episodes of mediastinal hematoma and three episodes of neurologic damage, two of which improved without permanent sequelae. CONCLUSION: We conclude that BAE may result in long-term as well as immediate control of life-threatening hemoptysis but that complications are not unusual.

Morbidity and mortality related to the native lung in single lung transplantation for emphysema.

It has been advocated that a major drawback of single lung transplantation (SLT) is the risk of serious complications arising from the native lung. The morbidity and mortality related to the native lung in 46 patients who underwent SLT for pulmonary emphysema in Clichy from 1988 to 1997 were reviewed retrospectively. In particular, infectious complications and native lung hyperinflation were searched. Complications arising from the native lung are not unusual after SLT for subjects with emphysema, and it was concluded they are not responsible for a substantial mortality.

[Imaging features of retained surgical foreign bodies]. / Aspects radiologiques des textilomes.

PURPOSE: To study the clinical and radiological manifestations in patients with retained surgical foreign bodies. PATIENTS AND METHODS: Over the last five years, seven patients were found to have retained surgical foreign bodies after abdominal surgery. An analysis of the clinical signs, laboratory findings and imaging features was performed. RESULTS: The clinical and laboratory data were non-specific. The diagnosis of textiloma was suggested based on imaging findings and surgical history before surgical exploration. The characteristic imaging findings at ultrasound and computed tomography consisted of a fluid collection with internal wavy structures. The differential diagnosis includes pyogenic abscesses, hematomas and ruptured hydatid cysts. CONCLUSION: Ultrasonography and computed tomography are essential for the diagnosis and management of retained surgical foreign bodies after abdominal surgery.

[Graft dysfunction, acute rejection and bronchiolitis obliterans in lung and heart-lung transplantation]. / Dysfonction du greffon, rejet aigu et bronchiolite oblitérante dans la transplantation pulmonaire et cardiopulmonaire.

Three complications which influence both survival and quality of life in transplanted patients will be the object of this chapter. Graft dysfunction: this is a severe re-implantation oedema leading to inefficiency of the graft as regards haemostasis whether or not associated with haemodynamic complications. The liberation of free radicals and/or cytokines induced by ischemia-reperfusion of the graft plays an important role in the pathogenesis of this syndrome. Acute rejection: the mechanism is complex leading to the intervention of an immune response stimulated by the detection of allo-antigens. The clinical picture is often non-specific. Treatment requires boluses of methyl prednisolone completed by decreasing dose of corticosteroid therapy orally. The syndrome of bronchiolitis obliterans: this is a progressive failure of the airways. This syndrome occurs in the long term in 50% of patients and presents with progressive dyspnoea associated with persistent or recurrent cough. The pathogenesis is brought about principally by a chronic rejection with a specific cytotoxic reaction of T lymphocytes against the airway epithelium which expresses Class II major histocompatibility antigens. Attempts at curative treatment can be extremely deceptive and leads to, at best, a slowing in decline of respiratory function.

[Asthma and its treatment during pregnancy]. / L'asthme et son traitement au cours de la grossesse.

Asthma occurs in 0.4 to 4.0% of pregnant women and is considered to be the most frequent respiratory disease during pregnancy. Physiological modifications during pregnancy, including hyperventilation due to increased progesterone levels and lower residual volume and functional capacity resulting from increased uterine volume can interfere with the asthmatic disease and require adapted management. Results of studies evaluating the interaction between asthma and pregnancy provide a wide variety of results. For some authors, manifestations of asthma may worsen during pregnancy requiring reinforced medical treatment in as many as 42% of the patients. For others bronchial hyperreactivity is significantly diminished during pregnancy. These findings should be examined in light of several individual factors including the spontaneous clinical course of asthma itself and more rigorous control during pregnancy. It is thus very difficult to predict the effect of pregnancy on clinical manifestations of asthma in any given patient or from one pregnancy to another. Certain authors have observed a correlation between IgE levels and the gravity of asthma in pregnant women: normally IgE levels tend to decline during pregnancy but may remain unchanged or increase if asthma manifestations worsen. Therapeutic options remain unchanged during pregnancy although only drugs proven safe for the fetus may be used. If carefully managed, pregnancy in the asthmatic patient usually reaches term with no major problem.

[Isolation of three species of Nocardia in a patient receiving long-term corticosteroid therapy]. / Isolement de trois espèces différentes de Nocardia chez un patient recevant une corticothérapie au long cours.

INTRODUCTION: Nocardia are saprophyte bacteria of the environment responsible for systemic infections in immunodepressed patients, due essentially to long-term corticosteroids. OBSERVATION: A patient having received corticosteroids for sarcoidoses for a year was hospitalised because of disseminated granulomatosis (neurological, respiratory, abdominal and cutaneous). Culture of various bacteriological samples isolated three species of Nocardia: N. otitidiscaviarum in uretheral pus and pus from the right gland, N. nova and N. asteroides in respiratory samples (protected distal sampling and broncho-alveolar washing). COMMENTS: Other than the mixed Nocardia infections described habitually, infections with two different species of Nocardia have recently been reported. Our case report is the first to have isolated three concomitant species of Nocardia.

[Selection criteria of candidates for lung transplantation]. / Critères de sélection des candidats à la transplantation pulmonaire.

Amongst the elements which contributed to the success of the early lung transplants at the beginning of the 1980's we feel that the careful selection of candidates probably played a predominant role. If some of the selection criteria initially described remain somewhat intangible, others have either been eased or have been invalidated. The experience acquired over the last 15 years has enabled to precise the optimal moment to include patients on the waiting list and to refine the choice for the type of surgical procedure according to the underlying disease. This article aims to review the different selection criteria for candidates for transplantation and stresses those which have recently undergone change.

[Bronchiolitis obliterans after lung transplantation]. / Bronchiolite oblitérante après transplantation pulmonaire.

Lung transplantation has become a realistic treatment in some patients with severe respiratory impairment or severe pulmonary arterial hypertension. Immunosuppression therapy is about the same in all transplantation units and includes cyclosporin, corticosteroids and azathioprine. The diagnosis of acute rejection episodes has been greatly facilitated by the histological study of transbronchial biopsies obtained by endoscopy. Improvements in the short-term prognosis of these patients have made it possible to individualize an unusual and delayed complication: bronchiolitis obliterans. This progressive and diffuse obstruction followed by destruction of the transplant's bronchioles is interpreted as a consequence of chronic rejection. The diagnosis of bronchiolitis obliterans is difficult and rests essentially on degradation of the respiratory function resisting to increased immunosuppression. Some viral infections perhaps contribute to its development, and it may be so severe as to require another lung transplantation.

[Post-lung transplantation bronchiolitis obliterans]. / Bronchiolite oblitérante post-transplantation pulmonaire.

Bronchiolitis obliterans is an anatomical lesion with multiple aetiologies. In the lung transplant patient the pure forms of bronchiolitis obliterans are probably the consequence of a process of chronic rejection; in fact necropsy tissue or lungs removed which have been transplanted show that the lesions of bronchiolitis obliterans are often associated with parenchymal disorders, vascular and proximal bronchial disease, which are sequelae of phenomena of rejection or infection. The effect of bronchiolitis obliterans on lung function is constant; this may appear progressively or in stages. Increasing immunosuppressive treatment may arrest the progress. This rarely occurs and the development of respiratory failure tends to be the rule. It is exceptional to achieve the diagnosis of bronchiolitis obliterans from the examination of a transbronchial biopsy. It is a combination of features, both clinical and respiratory function, negative bacteriology and virological investigations as well as the absence of any efficacy of conventional treatment for rejection which leads to the diagnosis. In certain cases the question of a pulmonary re-transplantation is raised.

[Lung volume reduction surgery in emphysema]. / Chirurgie de réduction de volume dans l'emphysème.

Lung volume reduction surgery in emphysema has, as an objective, the reduction of dyspnoea and an increase in the exercise tolerance in patients with respiratory insufficiency suffering from diffuse emphysema. In principle the resection of the most diseased areas of emphysema leads to improvement in the mechanical properties of the emphysematous lung and correct pulmonary hyperinflation. The respiratory function benefits both objective and subjective, produced by surgery are real but transitory and inconstant depending in particular on the evolutionary profile of the emphysematous disease. The indications should be further refined and an objective comparison of different surgical techniques has not been achieved. The impact on the quality of life for these patients is unknown.

[Single-lung transplant in chronic obstructive disease]. / Greffes monopulmonaires chez les obstructifs chroniques.

The feasibility and the good immediate acceptability of unilateral lung transplants in the patients with obstructive respiratory problems have recently been demonstrated and since the initial reports, some hundreds of lung transplants have been performed in various parts of the world for this indication. Nevertheless, few results of respiratory function are currently available in the medium term. We report these in a series of 20 patients with severe obstruction who were given single lung transplants. The actual probability of survival for 1 and 2 years was 75 and 70% respectively with 4 peri-operative deaths and 2 later deaths. In the 16 survivors of more than 6 months, in relation to the pre-operative values, a significant improvement was observed 3 months after the graft in the FEV1 which rose from 17 +/- 6 to 53 +/- 13% of the predicted values. The PaO2 rose from 52 +/- 10 to 81 +/- 3 mmHg. The distance covered on the six minute walking test went from 99 +/- 84 m before the graft to 587 +/- 147 m 6 months after the operation. In addition to the improved distance, the lung function was stable in a group of patients as the months went by, although there was a fall in the respiratory function in others with the appearance of the syndrome of bronchiolitis obliterans or in 2 patients with bronchial complications. The four patients with severe deterioration in the graft function were re-transplanted with a good clinical result in three of them, the fourth dying in the immediate post-operative period. We conclude that single lung transplant represents an effective treatment both in the short and medium term in patients with chronic airflow obstruction.

[Pulmonary emphysema: surgical indications]. / Emphysème pulmonaire: indications chirurgicales.

Surgery for pulmonary emphysema, with the exception of lung transplantation, is limited at present to resection of the emphysematous areas. The resection of a unique bulla within an otherwise healthy parenchyma can be indicated in case of complications but rarely in asymptomatic patients. When the bullae are large (i.e. volume greater than one-third of the hemithorax) in a patient suffering from diffuse emphysema, bullectomy is the ideal indication. Mortality varies from 0 to 10%, essentially due to infection or acute respiratory failure. In most patients, the subjective improvement in terms of dyspnea and the objective improvement as measured by spirometry remains significative up to 5 years after surgery. Inversely, surgical resection is classically considered to be contraindicated in patients with small poorly-limited bullae. Recent data would however question this idea since subjective and objective improvement after reduction of the lung volume is still present 1 year after surgery in most patients, even those with severe obstruction. The mechanism is probably related to increased elastic recoil. Even if only temporary improvement can be achieved for a few years, the persisting course of emphysema would suggest that volume reduction should always be entertained as an alternative before lung transplantation.

Intraabdominal panniculitis. Report of three cases and review of the literature.

Intraabdominal panniculitis is a rare, benign idiopathic disorder of the mesentery. Patients usually present with abdominal pain and a palpable mass. The cross-sectional imaging findings are characteristic and consist of a fibrofatty central mesenteric mass lesion encapsulating the mesenteric vessels with displacement of the bowel loops, that can suggest the diagnosis. Imaging is also important to establish a definitive diagnosis by an image-guided percutaneous biopsy, assess extent of the disease for selection of appropriate therapy, exclude associated abnormalities namely malignancies, and for follow-up.

[Treatment of severe acute asthma]. / Traitement de l'asthme aigu grave.

Severe acute asthma remains associated with significant mortality. Medical treatment of acute severe episodes includes oxygentherapy, inhaled or intravenous beta-2-agonists, and high doses of systemic corticosteroids. The benefit of additional treatment with other agents such as nebulized ipratropium bromide, epinephrine and intravenous aminophylline is still not well defined. Mechanical ventilation, which remains necessary in case of life-threatening acute respiratory failure, addresses specific problems: PaCO2 may be allowed to remain elevated and ventilator settings should be chosen that avoid barotrauma under appropriate sedation. The use of inhalation anesthesics, helium or even extracorporeal life support necessitates further study to determine the optimal therapeutic strategy in those particular situations.

[Intrahospital mortality during acute exacerbations of COPD. Study EABPCO-CPHG of the College of the Lung specialists of General hospitals (CPHG)]. / Mortalité intrahospitalière au cours des exacerbations aiguës de BPCO. Etude EABPCO-CPHG du Collège des pneumologues des hôpitaux généraux (CPHG).

INTRODUCTION: The objective of the present study was to determine the in-hospital mortality rate in the EAPCO-CPHG cohort and to identify risk factors. METHODS: All patients with COPD acute exacerbation admitted to the pneumology department of 68 French general hospitals between October 2006 and June 2007 were included in the EABPCO-CPHG cohort. RESULTS: At discharge, vital status was known for 1817 patients. Forty-five patients died during their hospital stay, i.e., an in-hospital mortality rate of 2.5%. Mutivariate analysis identified age (OR=1.07 [1.03-1.11]), grade greater than 2 dyspnea in stable state (OR=3.77 [1.68-8.57]), and number of clinical signs of severity during the acute exacerbation (OR=1.36 [1.11-1.55]) as independent risk factors for in-hospital mortality. CONCLUSIONS: In-hospital mortality in patients admitted to a pneumology department of a general hospital is quite low. Simple clinical criteria allow easy identification of at-risk patients and should enable management to be improved.