Asthma-COPD overlap syndrome (ACOS) vs 'pure' COPD: a distinct phenotype?

BACKGROUND: Some studies suggest that asthma-COPD overlap syndrome (ACOS) is associated with worse outcomes than chronic obstructive pulmonary disease (COPD). The goal of this study was to further explore the clinical characteristics and survival of patients with ACOS identified in a real-life cohort of patients with COPD. METHODS: Data from the French COPD cohort 'INITIATIVES BronchoPneumopathie Chronique Obstructive' (n = 998 patients) were analyzed to assess the frequency of ACOS defined as a physician diagnosis of asthma before the age of 40 years and to analyze its impact. Univariate analyses were performed to assess the relationship between ACOS and sociodemographic characteristics, risk factors (smoking, occupational exposure, atopic diseases), symptoms (chronic bronchitis, dyspnea-modified Medical Research Council scale and baseline dyspnea index), quality of life (QoL), mood disorders, exacerbations, comorbidities, lung function, prescribed treatment, and survival. RESULTS: ACOS was diagnosed in 129 patients (13%). In multivariate analyses, ACOS was associated negatively with cumulative smoking (odds ratio [OR]: 0.992; 95% CI 0.984-1.000 per pack-year) and positively with obesity: OR: 1.97 [1.22-3.16], history of atopic disease (hay fever: OR: 5.50 [3.42-9.00] and atopic dermatitis: OR 3.76 [2.14-6.61]), and drug use (LABA + ICS: 1.86 [1.27-2.74], antileukotrienes 4.83 [1.63-14.34], theophylline: 2.46 [1.23-4.91], and oral corticosteroids: [2.99;.1.26-7.08]). No independent association was found with dyspnea, QoL, exacerbations, and mortality. CONCLUSIONS: Compared to 'pure' COPD patients, patients with ACOS exhibit lower cumulative smoking, suffer more from obesity and atopic diseases, and use more asthma treatments. Disease severity (dyspnea, QoL, exacerbations, comorbidities) and prognosis (mortality) are not different from 'pure' COPD patients.

T-cell activation during exacerbations: a longitudinal study in refractory asthma.

BACKGROUND: Asthma exacerbations represent the main source of costs and morbidity in asthma care, and drugs specifically designed to prevent exacerbations are needed. A prerequisite is to dispose of a precise knowledge of inflammatory events leading to exacerbations. OBJECTIVE: To study T-cell activation during exacerbations from severe refractory asthmatics. METHODS: Proportions of blood T-cell interleukin (IL)-13, interferon-gamma, IL-4, IL-5, IL-10 production and of CD4+CD25+(high)CD62L+CD45RO+ [T regulatory (Treg)] cells were determined by flow cytometry. Blood cytokine mRNA was studied by reverse transcription-polymerase chain reaction and the respective protein levels were determined by cytokine beads array. Depletion of Treg cells was performed to study their activation. T-cell cytokines were detected in parallel in induced sputum. RESULTS: At baseline, T helper 2 (Th2) cells were increased in asthmatics, whereas T helper 1 (Th1) and Treg T cells were decreased. T helper 2 cells increased before exacerbations, followed by Th1 cells, in blood and induced sputum, albeit Treg cells decreased in parallel with IL-10-producing T cells. Concordant results were found at the mRNA level. The suppressive activity of Treg cells was impaired during exacerbations compared to baseline. CONCLUSIONS: New insights are given into pathophysiology of asthma exacerbations: Although at baseline T-cell activation is Th2-biased, a mixed Th1/Th2 activation occurs during exacerbations. The Treg cell deficiency found at baseline in SRA increases during exacerbations.

[Changing patterns of medication prescription for COPD patients in France. Impact of long-acting muscarinic antagonists' availability]. / Évolution des traitements de fond entre 2001 et 2012 chez les patients atteints de BPCO en France. Impact de la mise à disposition des anticholinergiques de longue durée d'action.

INTRODUCTION: We studied the pattern changes over time of medication prescriptions for COPD and their conformity with French and international recommendations using data from patients in the prospective French cohort "Initiatives BPCO". METHOD: Eight hundred and forty-six patients have been included during a first period from August, 2001 till May 2006 (n=425) and a second period from June, 2006 till June, 2012 (n=421). The pivotal date was based on the tiotropium availability in France. RESULTS: During period 1, we recruited older patients (average 65 vs 64 years), less often women (19 vs 26 %) and having less severe airflow obstruction (mean FEV1 48 vs 54 %). The ICS prescriptions decreased in mild COPD, but there was no change for inhaled long-acting beta-2 agonist (LABA) (68 %). The use of LABA+LAMA association without ICS increased from 0.9 to 7 %, but remained lower than the fixed LABA+ICS association (26 %), less often prescribed than the triple association LABA+ICS+LAMA (32.5 % in period 2). The use of long-acting bronchodilators increased from 68 to 80 % between both periods. Vaccinations and rehabilitation remained insufficiently prescribed. LAMA had been added but did not appear to replace other drugs.

[Evaluation of ventilatory functions in amyotrophic lateral sclerosis]. / Evaluation des fonctions ventilatoires.

As the clinical signs of amyotrophic of lateral sclerosis (ALS) are late and not specific, spirometric measurements, study of respiratory strength muscles and analysis of night respiratory parameters are used to evaluate ventilatory functions. The prognostic value of vital capacity is well established, but with a poor sensitivity to detect the initial form of ALS. Gazometric parameters remain normal for a long time. Hypercapnia is late and due to a major reduction in the force of the inspiratory muscles. Level of diurnal venous bicarbonate could detect nighttime hypoventilation. Noninvasive techniques (Pimax, Pemax, snifftest) are available to explore the strength of respiratory muscles. Sleep is characterized by a long period of hypoventilation, essentially during REM-sleep. There are no guidelines concerning the appropriate mode, type and rhythm of explorations of diurnal and nocturnal respiratory functions.

[What is the role of life support systems in amyotrophic lateral sclerosis?]. / Quelle est la place de la suppléance des fonctions vitales? Quelle est la problématique liée à la trachéotomie et à l'intubation en urgence?

There is very little information in the medical literature concerning the problems of tracheotomy and emergency intubation in amyotrophic lateral sclerosis. Nevertheless, we can assumed that: explicative information for the patient is important, emergency ventilation is not very frequent, emergency ventilation was not systematic, prognosis of emergency ventilation is very poor.

[Pyogenic granuloma revealing fistula and deep infection: five cases]. / Botriomycomes révélant une fistule et un foyer infectieux profond: cinq cas.

BACKGROUND: Pyogenic granuloma, or botryomycosis, occurring after minor injury or scratching with a septic implement, is a rapidly growing benign inflammatory vascular tumour, often involving the skin or mucous membrane. We report 5 unusual cases of pyogenic granuloma revealing fistula tracking to foreign bodies such as a pace-maker or orthopaedic material, and deep infectious sites with fistula. METHODS: This retrospective study included 5 men of average age 72.2 years over a period of 22 years (between 1981 and 2003). Clinical images were recorded and a diagnosis of botryomycosis was confirmed in all patients by histological analysis. Four patients presented suppuration. The time from initial clinical signs to diagnosis, presence of traumatic events, screening for microscopic organisms, response to systemic antibiotic therapy, recurrence and clinical features of botriomycosis were analysed. RESULTS: All patients presented botryomycosis with fistula and suppuration revealing deep bone infection and in one patient, pace maker infection. Complete resolution of the lesions occurred after excision of foreign material and prolonged systemic antibiotic therapy. CONCLUSION: We report the first series of botryomycosis revealed by fistula and showing deep infectious disease. Pyogenic granuloma is a well-known but rarely reported dermatologic condition.

Association of oral almitrine and medroxyprogesterone acetate: effect on arterial blood gases in chronic obstructive pulmonary disease.

Almitrine (A) and medroxyprogesterone acetate (MA) given separately improve arterial blood gases in some patients with chronic obstructive pulmonary disease (COPD); the aim of this study was to assess the effect of the two drugs given together. Forty-eight patients with irreversible COPD and hypoxaemia were prospectively enrolled into a 14-day run-in period and received single-blind oral treatment with double placebo. Patients whose PaO2 remained stable (less than 10% change; n = 29, 25 males, mean age 65.6 years) were included in a 14-day active treatment period and randomly assigned to three groups. They received double-blind oral treatment with: A (50 mg bid, group A, n = 10); MA (20 mg tid, group MA, n = 9); A (50 mg bid) and MA (20 mg tid, group A+MA, n = 10). Anthropometric and spirometric measurements were similar in the three groups and so were the arterial blood gas values at the beginning and the end of the run-in period. At the end of the active treatment period, blood gas changes (mean+/-SE) were significantly different between groups (P<0.05, Kruskal-Wallis test), with improvement in both hypoxaemia and hypercapnia in group A+MA only: delta PaO2 = 7.4+/-1.9 mmHg, delta PaCO2 = -5.1+/-1.7 m mHg (P<0.05, Wilcoxon test). In short-term treatment, the association of A and MA is more efficient than either drug alone at improving arterial blood gases in COPD patients.

[Ovarian tumors and cysts after 50 years of age. Retrospective study from 1979 to 1989 at the Foch hospital]. / Tumeurs et kystes ovariens après 50 ans. Etude rétrospective des années 1979 à 1989 au C.M.C. Foch.

This is a retrospective study carried out between the years 1979 and 1989 to look at the anatomopathology of tumours and ovarian cysts occurring in women over 50 years of age who had operations in our department. We found a raised incidence of malignant tumours (30%) when a late diagnosis is made (70% diagnosed at stages 3 and 4). There was a higher incidence of fibrothecomas (10%) along with the nine tumours. This is an important finding because functional cysts have only been found in non-menopausal women or in women who have recently had their menopause who have been taking hormone replacement therapy. Ovarian cysts in menopausal women are therefore primarily organic. This result makes it possible to outline a therapeutic regime specifically designed for the menopausal women. In effect the proposed treatment would either be laparoscopic surgery or laparotomy because it is very doubtful whether ultrasound puncture should be carried out because one cannot be sure that it is not a malignant cyst. The authors take the occasion of this study to view the complimentary tests that can be carried out for ovarian cysts. These are mainly ultrasounds and estimations of CA125. The therapeutic methods that are available are then transparietal cystectomy or intraperitoneal cystectomy or intraperitoneal cystectomy which means laparotomy with removal of the cyst.

[Acardiac twins]. / Les jumeaux acardiaques.

An acardiac twin in a multiple pregnancy initially develops normally and is a specific complication of monozygous multiple pregnancies. Development results from arterio-arterial and veno-venous anastomoses leading to predominance of one of the twins. The haemodynamic abnormalities in the dominated twin lead to the disappearance of the heart and major morphologic malformations. Outcome is generally unfavourable in 50% of the pregnancies with an acardiac twin. Complications in the healthy twin include heart failure, then hydramnios, and finally premature delivery which is the cause of most of the deaths. Proposed treatment currently relies on treating the heart failure in the healthy twin or interrupting vascularization between the two twins leading to in utero death of the acardiac twin. Antenatal diagnosis is made by echography and is useful for evaluating the prognosis for the pregnancy according to the growth of the acardiac twin.

[Panhypopituitarism secondary to pituitary metastases]. / Panhypopituitarisme secondaire à une métastase hypophysaire.

BACKGROUND: Hypophyseal metastatic localizations are uncommon and rarely the first expression of a primary cancer. We report an exceptional case revealed by panhypopituitarism and diabetes insipidis. CASE REPORT: Brain MRI visualized an intra- and suprasellar tumoral formation found to be a cribiform adenocarcinoma. The primary tumor could not be identified. Despite radiotherapy, surgery and chemotherapy combining carboplatin and etoposide, the tumor progressed with the development of cervical and mediastinal nodes. The patient died one year after onset of the clinical signs. DISCUSSION: Diagnosis of hypophyseal metastasis is mainly based on indirect evidence: rapid course, invasion of neighboring structures. Optimal management of these rare tumors remains to be determined.

[Modes of administration of inhaled corticosteroids in mild to moderate persistent asthma]. / Modalités d'administration des corticoïdes inhalés dans l'asthme persistant léger à modéré.

Inhaled corticosteroids are the treatment of choice for asthma. However, poor compliance by patients is one of the principal difficulties forced by clinicians. Thus, it seems important to propose the minimal daily number of doses. This study has compared the various modes of administration of inhaler corticosteroids and was carried out in patients with mild to moderate persistent asthma. Thus, comparing two to four doses per day shows an identical efficacy if the dose is less than 800 micrograms per day. At higher doses only two studies have been carried out and there are discordant results. The studies compare two doses versus one single dose per day and equally disagree with numerous works in favor of a single daily dose. In the single study carried out for at least twelve months the twice daily dose was the most effective. Thus it seems reasonable to suggest a single dose for mild persistent asthmatics. For moderate persistent asthmatics the choice between a single or twice daily dose would depend on the therapeutic compliance of the patient.

[Mucoepidermoid bronchial tumor with an unusual radiologic presentation]. / Une tumeur bronchique muco-épidermoïde à présentation radiologique originale.

We report a case of low-grade malignant mucoepidermoid bronchial tumor in a 21-year-old woman who presented with hemoptysis. There was a striking radiological presentation with a unilateral clear radiograph. Lung scintigraphy demonstrated perturbed ventilation and perfusion of the left lung. Pulmonary angiography only showed diminished peripheral vascularization. The main vessels were clear. These anomalies fit the radiological category of air trapping accompanied by probably hypoxic pulmonary vasoconstriction. Mucoepidermoid tumors account for only 0.5-1% of all primary lung tumors. They are found in adults as well as in children. There are two clear-cut histological forms with very different prognosis. The tumors of high-grade malignancy are considered as undifferentiated carcinomas and should be treated as such. The prognosis is much better for tumors of low-grade malignancy and current treatment is surgical in the absence of recurrence after isolated endoscopic treatment.

[Acute pleurisy revealing post-myocardial infarction syndrome]. / Pleurésie aiguë révélatrice d'un syndrome postinfarctus du myocarde.

We report a case of Dressler's syndrome in which the diagnosis was made following an investigation of pleurisy which the laboratory data revealed as inflammatory. A myocardial infarction which had occurred two months earlier had passed unnoticed. The principal value of this case was to draw attention to the syndrome which may initially be a pleurisy but also clinically the picture may mimic pneumonia, both alone or together may be associated with classical pericarditis. Pleurisy occurs in Dressler's syndrome but it is rarely the presenting diagnosis as the cardiac picture tends to predominate.

[Treatment of urinary incontinence by vaginal approach]. / Traitement de l'incontinence urinaire par voie vaginale.

The vaginal route is routinely used for surgical cure of exersion-induced urinary incontinence. This technique has the advantage of being rapid and easily performed during a short hospital stay. Long-term results however, have been debated. Certain factors have been identified in the literature which would affect long-term failure. These factors indicate that the "ideal" vaginal route should be based on the Burch operation starting at the upper portion and working downwardly. Finally, sphincter failure or detrusor instability must be eliminated before an operation for exertion-induced incontinence can be indicated since such a combination would modify the procedure.

[Ovarian cysts in women over 50 years of age. A retrospective study from 1979 to 1989 at Foch Medicosurgical Center]. / Les kystes de l'ovaire après 50 ans. Etude rétrospective des années 1979 à 1989 au C.M.C. Foch.

This was a retrospective study for the years 1979 to 1989 involving histological examination of ovarian cysts in women over 50 years who underwent surgery in our Department. A higher incidence of malignant tumours was found (32%), associated with a late diagnosis (70%) diagnosed stage III or IV). There was a higher incidence of fibrothecomas (10%) among benign tumours and functional cysts were only found in non menopausal or recently menopausal women taking hormone replacement therapy. There results allow a more specific therapeutic attitude in menopausal women i.e. laparoscopic surgery or laparotomy. Ultrasound puncture is very debatable, since this is inappropriate for an organic cyst. The authors review the complementary investigations performed for ovarian cyst, these include essentially ultrasound and Ca 125. Possible therapies include transparietal cystectomy, intraperitoneal cystectomy or laparotomy and excision.

[Significance of systematic endoscopic decannulation. Retrospective study on intensive care patients]. / Intérêt de la fibroscopie systématique de décanulation. Etude rétrospective portant sur des malades de réanimation.

We performed a retrospective study in 42 consecutive tracheotomy patients hospitalized in an intensive care unit. Endoscopy was used systematically to assess all patients at decanulation and whenever symptoms suggested possible tracheal granuloma. Nine tracheal granulomas were evidenced. There was no significant association between presence of a granuloma and patient status: age, underlying chronic respiratory failure, or tracheobronchial infection. In initial stages, tracheal granulomas usually have little clinical expression. Difficulty in weaning from ventilatory assistance is generally the main sign. The long-term course after decanulation can progress to major respiratory disorders due to tracheal stenosis. We emphasize the importance of systematic endoscopy at decanulation to recognize existing granulomas early when local treatment remains simple (usually laser vaporization).

[Respiratory variant of constrictive pericarditis. Report of 4 cases]. / Forme respiratoire des péricardites constrictives. A propos de 4 cas.

Constrictive pericarditis was diagnosed in four patients who presented respiratory impairment and pleural effusion, associated with right ventricular failure in two. The cause was probable tuberculosis in two cases, post-irradiation lesions in one and unknown in one. The diagnosis was suspected due to the normal heart volume and pathological electrocardiogram as well as the computed tomographic findings demonstrating pericardial morphology. Right catheterism confirmed the diagnosis: increased right ventricular telediastolic pressure with a dip plateau and equivalent pressures in the right atrium and ventricle. Early diagnosis allowed pericardectomy in two cases. In one case, the subacute epicardopericarditis regressed with corticosteroids and antituberculosis therapy.