[Diagnostic and therapeutic management of operable bronchopulmonary carcinoid tumours]. / Prise en charge diagnostique et thérapeutique des tumeurs carcinoïdes broncho-pulmonaires opérables.

INTRODUCTION: Bronchial carcinoid tumours (CT), divided into typical carcinoid (TC) or atypical carcinoid (AC), are rare tumours whose therapeutic management remains unspecified. METHODS: Retrospective study collecting cases of bronchial CT operated at the thoracic surgery department of Abderrahmane-Mami hospital of Ariana and recruited from the pneumology departments of Northern Tunisia, during a 12-year period. RESULTS: Ninety patients were collected (74 cases of TC and 16 cases of AC). The mean age was 45 years and the sex ratio H/F=0.5. The chest X-ray was normal in 11 cases, as well as flexible bronchoscopy in seven cases. The tumour was classified: stage IA (10 cases), IIA (28 cases), IIB (31 cases), IIIA (15 cases) and IIIB (six cases). Surgery resulted in a complete resection in 78 patients, an extensive resection in six patients, and a conservative resection in six patients. Adjuvant chemotherapy was given in 10 patients. The survival was 84% at five years and 42% at 10 years. CONCLUSION: The prognosis of CT depends directly on the histological subtype. It is excellent for TC after complete resection, unlike ACs that are similar to well-differentiated bronchial carcinomas.

[Evaluation of inhaler techniques in patients with asthma and chronic obstructive disease]. / Évaluation des techniques d'inhalation dans l'asthme et la bronchopneumopathie chronique obstructive.

INTRODUCTION: The correct method for using inhalation devices (DI) is essential to optimize treatment efficacy. OBJECTIVE: To evaluate the method of inhalation technique, study the correlations with patient characteristics, disease, treatment and measure the impact of direct and individual educational method, centered on the use of technical DI, on improving this technique and control of the disease. METHOD: Prospective study of 54 patients. The therapeutic education program included 3 levels of action: identifying errors in the inhalation technique, demonstrating the inhalation technique and evaluation of therapeutic education. RESULT: The most used DI was metered-dose inhalers (AD) (66.67%). The average error was 4.63 errors/patient for AD and 5.11 for dry powder inhalers. The main factors related to the misuse of DI were lower advanced level of education and age. The therapeutic education has significantly improved the number of errors/patient with improved asthma control (P<0.05) and COPD assessment test (CAT) in the case of COPD. CONCLUSION: Our study confirms the important role of therapeutic education focused on inhalation techniques in improving the use of DI technology and the evolution of asthma and COPD.

[Pulmonary actinomycosis. Diagnostic and therapeutic features]. / Actinomycose pulmonaire. Particularités diagnostiques et thérapeutiques.

INTRODUCTION: Actinomycosis is a rare suppurative infection, subacute or chronic caused by bacteria of the genus Actinomyces. OBSERVATIONS: A case study of 4 patients with prolonged respiratory symptoms. The clinical examination was poor in all cases. The CT-scan showed, in all cases, a suspicious tissue mass. The bronchoscopy diagnosis showed, in 2 cases, a tumor budding and was normal for the 2 other cases. Bronchial biopsies were negative in all cases. Before the prolonged symptomatology, the poor general condition, the endoscopic and the CT aspects; there was a suspect around a pulmonary neoplasia diagnosis, thus raising the need of a surgical treatment for diagnostic and therapeutic purposes. The anatomopathological examination of the resected specimen was in favour of the actinomycosis. The aim of these observations is to draw the attention to the radio-clinical, histological, therapeutic and evolutive aspects as well as the diagnostic difficulties of this condition. CONCLUSION: The radio-clinical presentation of the actinomycosis is often misleading, thus a diagnostic confirmation is required before any useless surgical resection.

[Adherence to treatment with continuous positive airways pressure]. / L'observance du traitement par pression positive continue : étude prospective de 103 patients suivis au service de pneumologie de Nabeul-Tunisie.

INTRODUCTION: Continuous positive airways pressure (CPAP) is the standard treatment for obstructive sleep apnea syndrome (OSAS). It produces substantial benefits if used for the appropriate indication and if patients adhere to treatment. METHODS: We conducted a prospective study of 103 patients treated with CPAP over four years follow-up. RESULTS: Our population had a mean age of 52 years with a sex ratio of 0.63. Face to face, individual education was provided in all cases. CPAP titration was performed by an unattended domiciliary autoadjusted CPAP device in 83.5% of patients for 15 days to one month. Twenty patients refused CPAP treatment after the period of titration. Eighty two patients (98.8%) were treated by constant CPAP. Seventy five percent of the patients complained of at least one side effect. The more common were nasal (56.6%) and mask related problems (40%). Seventy six percent of patients used CPAP for more than 4hours per day. Eleven patients stopped CPAP therapy because of intolerance (10 cases) and reluctance to instrumental therapy (one case). Adherence to CPAP therapy was associated with the severity of OSAS, the level of daytime sleepiness, higher pressures, repeated education during the course of follow up, clinical efficacy and the presence of fewer side-effects. CONCLUSIONS: We obtained satisfactory rates of adherence and tolerance of CPAP assisted by regular medical and technical follow-up of patients.

[Obstructive sleep apnea syndrome. Is it a risk factor for diabetic retinopathy?]. / Le syndrome d'apnée de sommeil. Est-il un facteur de risque de rétinopathie diabétique ?

PURPOSE: The goal of our study was to evaluate the prevalence of diabetic retinopathy in type 2 diabetic patients with obstructive sleep apnea syndrome. PATIENTS AND METHODS: We performed a comparative study including 60 type 2 diabetics separated into 2 groups: a 1st group composed of 20 patients with obstructive sleep apnea syndrome and a 2nd group composed of 40 patients without this syndrome. The two groups were matched for age and length of diabetes. All patients underwent a complete ophthalmic examination. RESULTS: In both groups, the mean patient age was 59 years, the diabetes had been present for an average of 10 years, and the HbA1c was 10%. Diabetic retinopathy was diagnosed in 11 patients from the 1st group (55%) and 6 cases from the 2nd group (15%) (P=0.03). Non-proliferative and proliferative retinopathy were found in 7 cases (35%) and 4 cases (20%), respectively, in the 1st group and in 3 cases (7.5%) in the 2nd group for both types (P=0.03 and P=0.042, respectively). Diabetic macular edema was observed in 4 patients (20%) in the 1st group and 2 patients (5%) in the 2nd group (P=0.04). CONCLUSION: Obstructive sleep apnea syndrome is an independent risk factor for the appearance and aggravation of diabetic retinopathy. This underscores the importance of systematic screening for, and timely management of, sleep apnea.

[Endobronchial hamartochondroma]. / Hamartochondrome endobronchique.

INTRODUCTION: Endobronchial hamartochondroma is a form of rare benign tumour. Compared to those that occur in the lung parenchyma, the endobronchial form can potentially be managed by relatively conservative treatment involving per-endoscopic resection. COMMENT: A 61-year-old patient had a dry cough and chest pain for 3 months. Their clinical examination was normal, but thoracic CT scan showed lingular collapse. Bronchoscopy revealed the presence of a multilobar tumour occluding the orifice of the lingula bronchus. Bronchial biopsies were consistent with the diagnosis of a hamartochondroma. Before the destruction of any of the left upper lobe parenchyma, the tumor was resected surgically and the patient had an uneventful postoperative course. CONCLUSION: Endobronchial hamartochondroma support must be rapid to avoid irreversible parenchymal consequences downstream obstruction involving an often mutilating surgery. Essentially endoscopic treatment should be the most conservative possible.

[Evaluation of the deficiency and the submaximal exercise capacity in obstructive sleep apnoea patients]. / Exploration de la déficience et de l'incapacité des patients atteints d'un syndrome d'apnées hypopnées obstructives du sommeil.

BACKGROUND: In addition to excessive daytime somnolence, exercise limitation is a likely consequence of the cardiorespiratory problems that occur in patients who have obstructive sleep apnoea (OSA). However, few studies have evaluated the aerobic capacity of this patient group. AIMS: To evaluate submaximal exercise capacity over the 6-minute walking test (6-MWT). To determine the factors that influence 6-minutes walking distance (6-MWD). INCLUSION CRITERIA: 120 consecutive patients with severe OSA treated by continuous positive airway pressure who were medically stable will be included. EXCLUSION CRITERIA: 6-MWT contraindications, orthopaedic or rheumatologic diseases likely to influence walking capacity and corticosteroid therapy. INVESTIGATIONS: polysomnography, electrocardiogram, plethysmography, and two 6-MWT's. Indicators of impaired exercise capacity: stops during the walk, 6-MWD less than or equal to predicted lower limit of normal, end walking dyspnoea greater than or equal to 5/10, oxygen saturation fall greater than or equal to five points, end walking heart rate less than or equal to 60 % maximal predicted. Data from our obese patients aged 40-60 years old will be compared with data from 45 age-matched obese subjects free from OSA. EXPECTED RESULTS: OSA will significantly affect the submaximal exercise capacity and will accelerate the ageing of the cardiorespiratory-muscle chain. Submaximal exercise capacity of obese subjects having OSA, compared to subjects free from OSA, will be significantly deteriorated. 6-MWD of OSA patients will be significantly influenced by: resting plethysmographic data, apnoea hypopnoea index, arterial hypertension, obesity or smoking histories.

[Broncholithiasis: six cases]. / La broncholithiase: six observations.

Broncholithiasis is an exceptional condition characterized by the presence of stony formations in the bronchial lumen. We report six cases. Mean age was 41 years. Revealing signs were hemoptysis (n=5), cough (n=5), fever (n=1) and recurrent lower respiratory tract infections (n=1). Physical examination found sonorous rales in two patients and was normal in four. The chest x-ray showed a parenchymal opacity suggestive of calcification in one patient, atelectasia in two, and alveolar images in three. Bronchial endoscopy demonstrated broncholithiasis in one patient, an endobronchial blood clot in one patient with abundant hemoptysis, an endoluminal bud simulating a tumor in two, an inflammatory aspect in one, and was normal in one. Thoracic computed tomography demonstrated broncholithiasis in three patients. Treatment consisted in lobectomy in five patients. The pathology specimen confirmed broncholithiasis in all five and in one revealed caseofollicular lesions of the hillar nodes. Anti-tuberculosis treatment was prescribed for this patient. Therapeutic abstention with regular surveillance was chosen for one patient with an uncomplicated broncholithiasis. Broncholithiasis is an exceptional condition with potentially serious consequences. Certain diagnosis is based on high-resolution computed tomography and endoscopic findings but can nevertheless be a surgical discovery.

[Prognosis of mucoepidermoid carcinoma of the bronchi]. / Les carcinomes mucoépidermoïdes bronchiques: quel pronostic?

BACKGROUND: Mucoepidermoid cancer is exceptional in the respiratory tract, accounting for only 0.2% of primary lung cancers. CASE REPORTS: We report three cases of mucoepidermoid carcinoma. The inaugural signs were hemoptysia in a 10-year-old child, recurrent lower respiratory tract infections in a 13-year-old child, and dyspnea with chest pain in a 32-year-old adult. Bronchial fibroscopy disclosed a proximal endobronchial tumor in all three patients. Pathology study of the operative specimen identified low-grade malignant mucoepidermoid carcinoma in the two children and high-grade malignant mucoepidermoid carcinoma in the adult. Surgical resection was performed for the pediatric cases. Outcome was favorable with recurrence-free survival at eight years in the first child. The surgical resection was less radical in the second child due to locoregional extension. This child was lost to follow-up. The clinical course was rapidly fatal in the third patient who presented metastatic spread at diagnosis and died one month later. DISCUSSION: The prognosis of mucoepidermoid tumors of the bronchi is closely related to tumor grade and extension at diagnosis. Unlike high-grade mucoepidermoid carcinoma, the progression of low-grade tumors, which predominate in children, is generally slow, enabling good prognosis if diagnosis is established early. Early search for these tumors in patients presenting chronic or recurrent respiratory manifestations would avoid late diagnosis and improve prognosis.

[Abundant hemothorax revealing extralobular pulmonary sequestration]. / Un hémothorax abondant révélateur d'une séquestration pulmonaire extra-lobaire.

Hemothorax is an exceptional, serious and misleading manifestation of extralobular sequestration. We report the case of a 15-year-old patient who consulted for chest pain and sudden onset dyspnea. The chest x-ray revealed fluid pleural effusion. Pleural puncture produced a bloody fluid and the angioscan showed a hyperdense formation without a systemic artery. Thoracotomy was performed. A left intrapleural pyramidal formation vascularized with a pedicle from the thoracic aorta was identified and sequestrectomy performed. At two years, the patient has remained symptom free. Extralobular sequestration is an exceptional cause of hemothorax. The absence of an aberrant systemic vessel on the angioscan should not rule out the diagnosis of sequestration. Precautions must be taken at surgery to avoid vessel damage.

[Hydatid cyst of the mediastinum: 14 case reports]. / Kyste hydatique primitif du médiastin: 14 cas.

PURPOSE: The objective of this study was to describe the different radiological features of the hydatid cyst of the mediastinum. MATERIALS AND METHODS: We conducted a retrospective study on 14 patients (seven women, seven men), diagnosed with mediastinal hydatid cyst, aged 13-67 years (mean, 48 years) over a period of 16 years in our hospital where 71 cases of hydatid disease are annually diagnosed. The patients were explored by chest radiography (n=14), chest ultrasonography (n=10), abdomen ultrasonography (n=14), computed tomography (CT scan) (n=13), and magnetic resonance imaging (MRI) (n=8). RESULTS: The chest x-ray showed an opacity of the anterior (n=11), middle (n=1), and posterior (n=1) mediastinum. The thoracic ultrasound confirmed the liquid nature of the mass with a multivesicular aspect (n=9). CT and thoracic MRI made it possible to precisely locate the mediastinal compartment involved and study the relationship to adjacent structures. A purely mediastinal location was found in only six cases. In the remaining cases, it was associated with hepatic (n=7) and pleural (n=1) locations. CONCLUSION: Hydatid cysts of the mediastinum are very uncommon. Diagnosis can be made by chest sonography. CT scan is the main tool for diagnosis and the study of possible extension. Our study showed a more frequent location to the anterior mediastinum.

[Benign myoepithelioma of the lung]. / Myoépithéliome bénin du poumon.

Benign myoepithelioma of the lung is a benign tumor caused by proliferating myoepithelial cells with no ductal component. These tumors are exceptional: only three cases have been reported in the literature. We report a fourth case in a 37-year-old woman at 8 months gestation. Pathological proof of diagnosis was obtained.

IL-18 mRNA expression and IFN-gamma induction in bronchoalveolar lavage from Behçet's disease.

OBJECTIVE: IL-18 expression and functional activity has been identified in several autoimmune and infectious diseases. To clarify the potential role of IL-18 during pulmonary Behçet's disease (BD), we have explored the capacity of IL-18 to induce the expression of IFN-gamma. METHODS: We studied bronchoalveolar lavage (BAL) from 12 patients with BD, 10 patients with silicosis as the control disease and 10 BAL from healthy subjects. BAL fluid, and BAL fluid cell cultures were investigated for IL-18 estimation by ELISA. Analysis of IL-18 and IFN-gamma gene expression was carried out before and after LPS stimulation. RESULTS: BD patients had significantly elevated levels of IL-18 in BAL fluid compared with control disease and healthy subjects. Induction of IFN-gamma and IL-18 were observed from BD-BAL fluid cells both spontaneously and after LPS stimulation, at higher levels compared to silicosis patients and healthy subjects (HC). Spontaneously only BD BAL cells expressed IL-18 mRNA and IFN-gamma mRNA. Forty-eight hours after LPS stimulation IL-18 mRNA and IFN-gamma mRNA were observed in BD, silicosis and HC cells. Recombinant IL-18 induced IFN-gamma production in BD- BAL fluid cells. CONCLUSION: Administration of IL-18 induced greater IFN-gamma production in BD-BAL fluid cells, than in normal BAL fluid cells. Our data indicate that IL-18 up-regulation is a feature of BD and suggest that IL-18 and IFN-gamma may contribute to the local inflammatory response in BD.

Elevation of serum soluble E-selectin and VCAM-1 in severe asthma.

OBJECTIVE: To investigate the significance of circulating adhesion molecules associated with leucocyte-endothelial cell interactions in asthma, serum levels of soluble E (sE)-selectin, soluble P (sP)-selectin, soluble L (sL)-selectin, and soluble vascular cell adhesion molecule-1 (sVCAM-1) were measured in mild, moderate and severe asthma. METHOD: Serum levels of sE-selectin, sP-selectin, sL-selectin, and sVCAM-1 were measured in 32 women with asthma and 30 healthy donors using an enzyme-linked immunosorbent assay method. Twenty patients were suffering from severe asthma, and 12 from mild/moderate asthma. RESULTS: Serum sE-selectin and sVCAM-1 levels from patients with asthma were significantly higher than those observed in healthy donors (p < 0.01). The levels of sP-selectin were the same as those of controls. The level of sE-selectin exhibited an important increase in the severe asthmatic patients compared with mild/moderate asthma (p < 0.01). The sVCAM-1 level was increased in severe asthma when compared with healthy controls. There was no correlation between the levels of soluble selectins and the age of the patients. A significant correlation was found between sE-selectin and sVCAM-1 levels. CONCLUSION: These data indicate that circulating soluble forms of the selectins may have different kinetics during the clinical course of asthma, suggesting that they may reflect different inflammatory pathways in severe asthma. Both sVCAM-1 and sE-selectin may be useful immunological markers for monitoring disease activity in asthma.

[Multiple hydatid cysts of the thigh: the role of magnetic resonance imaging]. / Hydatidose multiple de la cuisse: place de l'imagerie par résonance magnétique.

Hydatid cysts of the thigh are uncommon in our country despite a high frequency of hydatic disease which is estimated to affect 5.33% of the general population. Diagnosis is usually made late in the clinical course. Ultrasonography, CT scan and magnetic resonance imaging are the most helpful diagnostic tools. We report a case of a 76-year-old female smoker who had undergone surgery for a hydatic cyst of the right lung at the age of 56 years. In June 1997, the patient was admitted for decompensation of chronic obstructive lung disease. Physical examination revealed a 6 cm painless mass in the right thigh which had developed progressively over the last year. Ultrasonography showed multiple hydatic cysts. Magnetic resonance imaging confirmed the diagnosis, showing interconnected multivesicular cystic formations. Medical treatment was given due to respiratory failure and patient refusal of a surgical procedure.