Reply to 'Response to "The opinion of French pulmonologists and palliative care physicians on non-invasive ventilation during palliative sedation at end of life: a nationwide survey'' '.

We read with interest the letter by Twycross and al on our article recently published in BMC Palliative Care. The authors suggest that the term palliative sedation has been used inappropriately and they consider that in the situation described the sedation was a procedural one rather than a continuous deep sedation. We strongly disagree with this point of view. In an end-of-life situation, the priorities are the patient's comfort, pain and anxiety. This type of sedation does not have the characteristics of procedural sedation described in anaesthesia. The French Clayes Leonetti law makes it possible to clarify the intention of the sedation in end-of-life situations.

The opinion of French pulmonologists and palliative care physicians on non-invasive ventilation during palliative sedation at end of life: a nationwide survey.

BACKGROUND: Deciding to withdraw non-invasive ventilation (NIV) at end-of-life (EOL) in patients with chronic respiratory failure is a challenge. The European Association for Palliative Care recommends not maintaining artificial therapies that could prolong life during palliative sedation (PS) at EOL. The aim of this survey was to assess palliative care physicians' and pulmonologists' opinion on withdrawing or maintaining NIV in patients with chronic respiratory failure during PS at EOL. METHODS: From April to May 2019, we performed a prospective survey among pulmonologists (n = 1545) and palliative care physicians (n = 631) in France to determine the prevalence of opinion in favour of maintaining NIV and identify the factors associated with opinion in favour of withdrawing or maintaining NIV with multiple logistic regression. RESULTS: A total of 457 participants were enrolled comprising 202 pulmonologists and 255 palliative care physicians. An opinion in favour of maintaining NIV was found in 88 (19.3 95%CI [15.7; 23.2]) physicians comprising 57 (28.2%) pulmonologists and 31 (12.2%) palliative care physicians (p < 0.001). The factors associated with an opinion in favour of maintaining NIV were spending time looking for advanced directives (AD) in the patient's file (odds ratio (OR): 6.54, 95%CI [2.00; 21.32], p = 0.002) and personal ethics of physicians (OR: 17.97, 95%CI [9.52; 33.89], p < 0.001). The factor associated with an opinion in favour of withdrawing NIV was palliative care training (OR: 0.31, 95%CI [0.16; 0.60], p < 0.001). The three main reasons in favour of maintaining NIV among the nine identified were emotional comfort for close relatives, reducing discomfort of dyspneoa and anticipation of suffocation. CONCLUSION: In France, around 20% of pulmonologists and palliative care physicians declared an opinion in favour of maintaining NIV during PS at EOL because of their personal ethics and spending time looking for AD, if any, in the patient's file. Palliative care training can stimulate reflection help foster a change of opinion about practices, especially in the case of patients with NIV during PS at EOL.

[Obesity hypoventilation syndrome and initial compliance with non-invasive ventilation]. / Syndrome obésité hypoventilation et observance initiale de la ventilation non invasive.

INTRODUCTION: The obesity hypoventilation syndrome (OHS) has an increasing prevalence. Compliance with first-line non-invasive ventilation has not been evaluated, taking into account patients' initial comorbidities. This study consisted of identification of the factors associated with compliance with non-invasive ventilation during the first six months of use. METHODS: A monocentric retrospective study, gathering patients from the pneumology department of Gabriel-Montpied hospital in Clermont-Ferrand, from April 2010 to October 2019. The analysis was carried-out through the collection of computerised medical records (age, mode of entry, patient comorbidities) and compliance reports (average daily hours of use) provided by the regional service provider for the Auvergne area (AIRRA). RESULTS: Being hospitalized for an acute exacerbation and being older than seventy-five years were factors associated with an improved compliance to non-invasive ventilation, with an increase of 1.47h/d and 2.73h/d (P value: 0.018 and 0.02, respectively). Moreover, patients with obstructive sleep apnea hypopnea syndrome and recipients of therapeutic education may prove more compliant over time. CONCLUSION: Age greater than seventy-five years and being hospitalized for an acute exacerbation are predictors of better use of non-invasive ventilation in OHS.

Prevalence of sarcopenia and malnutrition during acute exacerbation of COPD and after 6 months recovery.

BACKGROUND/OBJECTIVES: Sarcopenia defined by the association of skeletal muscle mass depletion and a decreased physical performance is underdiagnosed in chronic obstructive pulmonary disease (COPD) patients. The objective was to assess prevalence of sarcopenia and malnutrition in hospitalized COPD patients during an acute exacerbation, after 6 months follow-up and the 1-year survival. SUBJECTS/METHODS: Hospitalized COPD patients were recruited for the assessment of body composition, handgrip strength, respiratory function, and maximal inspiratory and expiratory pressures (MIP and MEP), during hospitalization and 6 months later. Sarcopenia was defined according to the criteria of the European Working Group on Sarcopenia in Older Adults, malnutrition was defined according to French criteria 2007. Survival data were collected 12 months after hospitalization. RESULTS: We analyzed data from 54 patients, aged 68 ± 9 years and BMI 26.9 ± 7.8 kg/m2, with an average FEV1 of 1.13 ± 0.49 l (45 ± 16% predicted value). Sarcopenia and malnutrition prevalence were, respectively, 48% and 52% during hospitalization, 30% and 30% after 6 months. MIP and MEP were lower in sarcopenic patients (p = 0.01 and 0.009, respectively). In multivariate analysis, skeletal muscle mass index and MIP were positively correlated at 6 months' follow-up (r = 0.40, p = 0.04). The 1-year survival rate was lower in sarcopenic patients (65 vs 86%, p = 0.03), particularly when malnutrition was associated (p = 0.02). CONCLUSIONS: Sarcopenia in COPD patients is highly prevalent during and after recovery of an acute exacerbation, exposing to lower survival. A multimodal management is required to treat sarcopenia and improve prognosis.

Medically Defined Infertility Versus Self-Perceived Fertility Problem: Implications of Survey Wording for Assessing Associations with Depressive Symptoms.

Objective: To examine how measures of infertility based on medical criteria and based on self-perception relate to depressive symptoms among women with infertility. Background: Survey-based studies of depressive symptoms have used either measures of self-reported infertility based on meeting medical criteria or measures of self-perceived fertility problems, but seldom both. It is, therefore, not known which type of measure is more closely associated with depressive symptoms. Materials and Methods: Using ordinary least-squares multiple regression, this study compares associations between a measure of meeting medical criteria for infertility and a measure of self-perceived fertility problems with a common measure of depressive symptoms. Data come from the National Survey of Fertility Barriers, a population-based survey of 4,711 U.S. women. Results: Both meeting medical criteria for infertility and self-perception were associated with depressive symptoms after controlling for a number of relevant variables, but the coefficient for the self-perception measure was slightly higher than the coefficient for medical criteria. Conclusion: If possible, both medical criteria and self-perception measures should be used in studies of the consequences of infertility for psychosocial outcomes. If only one measure can be used, self-perception of a fertility problem is an acceptable measure.

[An unusual cause of chylothorax: primary amyloidosis]. / Une cause exceptionnelle de chylothorax: l'amylose primitive.

BACKGROUND: Amyloidosis is a large family of diseases defined by the presence of extra cellular protein deposits which can remain localised but are generally diffuse. Pleural involvement with effusion is rare (6% only), and difficult to diagnose because the clinical signs are non-specific. OBSERVATION: We report the case of a 77 year old man, hospitalized for anasarca, with recurring pleural effusions despite two drainages and talcage. Pleural aspiration revealed a chylothorax. ProBNP was high: 24000 ng/l. Echocardiography revealed a restrictive cardiomyopathy and suggested the diagnosis of a systemic disease. Negative peripheral biopsies led us to perform an endomyocardial biopsy, which confirmed the diagnosis of amyloidosis AL. CONCLUSION: We report an original case of primary amyloidosis presenting as a chylothorax and confirmed by an endomyocardial biopsy. We highlight the multi factorial character of pleural effusions associated with amyloidosis. This explains the delay in treatment and the disease's critical nature (median survival 2 months). The prognostic value of proBNP is also emphasised.

Infertility and psychological distress: a critical review of the literature.

This essay reviews the literature on the social psychological impact of infertility, paying special attention to the relationship between gender and the infertility experience. It is convenient to divide the literature into articles which explore the possibility that infertility may have psychological causes (Psychogenic Hypothesis) and those which examine the psychological consequences of infertility (Psychological Consequences Hypothesis). The psychogenic hypothesis is now rejected by most researchers, but a related hypothesis, which states that stress may be a causal factor in infertility, is worthy of exploration. The descriptive literature on the psychological consequences of infertility presents infertility as a devastating experience, especially for women. Attempts to test the psychological consequences hypothesis have produced more equivocal results. In general, studies which look for psychopathology have not found significant differences between the infertile and others. Studies which employ measures of stress and self-esteem have found significant differences. The psychological consequences literature is characterized by a number of flaws, including over sampling of women, small sample size, non-representative samples, failure to study those who have not sought treatment, primitive statistical techniques, and an over-reliance on self-reports. Studies on infertility and psychological distress need to take into consideration both the duration of infertility and the duration of treatment. Finding an appropriate set of "controls" is a particularly intractable problem for this area of research. In general, the psychological distress literature shows little regard for the social construction of infertility. By taking what should be understood as a characteristic of a social situation and transforming it into an individual trait, the literature presents what is essentially a medical model of the psycho-social impact of infertility. Most researchers conclude that infertility is a more stressful experience for women than it is for men. Most studies have found that the relationship between gender and infertility distress is not affected by which partner has the reproductive impairment. Future research needs to be better informed by theoretical considerations. Scholars need to pay more attention to the way the experience of infertility is conditioned by social structural realities. New ways need to be developed for better taking into account the processual nature of the infertility experience. Efforts need to be make to include under-studied portions of the infertile population. Finally, more effort needs to be made to better integrate the empirical study of the experience of infertility with important social policy questions.

[Long-term oxygen therapy at home. Compliance with the medical prescription and observance of the daily duration of at least 15 hours]. / Oxygénothérapie au long cours à domicile. Respect de la prescription médicale et observance d'une durée quotidienne d'au moins 15 heures.

Long-term domiciliary oxygen therapy in patients with chronic respiratory failure significantly improves both survival and quality of life. These therapeutic objetives are only achieved by daily oxygen therapy of more than 15 hours. For a period of 3 months, we have prospectively measured the duration of oxygen therapy in 930 patients with chronic airflow obstruction. This is carried out by reading the meters on the oxygen concentrators, or for liquid oxygen by checking the weight of the cylinders at each delivery, making allowances for the flow rate and also for natural loss from evaporation. The instructions for oxygen therapy and the true therapy of the patient were then gathered using a questionnaire. The practitioners were questioned on the prescription for oxygen therapy which had been made for each patient, and more generally on their usual criteria for prescribing long-term oxygen therapy. The patients (82% male) were aged between 67 +/- 8 years, and were on domiciliary oxygen therapy 36 +/- 24 months, with hypoxaemia (PaO2 = 56 +/- 9 mmHg), hypercapnea (PaCO = 47 +/- 8 mmHG) and suffering from airflow obstruction (FEV1/VC = 42 +/- 14%). The duration of prescribed oxygen therapy was on average 16 +/- 3 hours. The mean duration of oxygen therapy achieved was 14.5 +/- 5 hours, but only 45% of the patients (419/930) managed daily oxygen therapy superior of equal to 15 hours and were categorised as compliant.(ABSTRACT TRUNCATED AT 250 WORDS)

[Protected distal aspiration in the identification of pathogenic microorganisms in pneumologic intensive care]. / Apport de l'aspiration protégée distale à l'identification de micro-organismes pathogènes en réanimation pneumologique.

To identify the micro-organisms responsible for bronchopulmonary infections in intensive care patients is an absolute prerequisite to successful treatment. Numerous techniques of specimen collection have been used to facilitate this bacteriological diagnosis. In this study, which involved 27 intensive care patients selected according to various criteria of infection, endotracheal aspiration (a commonly used but not very specific technique) was compared with protected distal brushing under fibroscopy and with protected distal aspiration. The latter method, still seldom used, proved as specific as protected distal brushing (hitherto regarded as the reference method), but it also presents the enormous advantages of being rapid, non-traumatic, devoid of side-effects and easily performed in hospital routine by paramedical staff.

Psychological distress by type of fertility barrier.

BACKGROUND: We examined fertility-specific distress (FSD) and general distress by type of fertility barrier (FB). METHODS: In a random sample telephone survey, 580 US women reported their fertility intentions and histories. Six groups of women were identified: (i) no FBs, (ii) infertile with intent, (iii) infertile without intent, (iv) other fertility problems, (v) miscarriages and (vi) situational barriers. Multiple regression analyses were used to compare groups with FBs. RESULTS: Sixty-one percent reported FBs and 28% reported an inability to conceive for at least 12 months. The infertile with intent group had the highest FSD, which was largely explained by (a) self-identification as infertile and (b) seeking medical help for fertility. The no FB group had a mean Center for Epidemiological Studies Depression scale score above the commonly used cut-off of 16, although 23% of the women with FBs did score above 16. CONCLUSIONS: FBs are common. Self-identification as infertile is the largest source of FSD. More women with FBs had elevated general distress than women without FBs; mean general distress was below 16 for all FB groups. It may be that, for some women (even those with children), FBs can have lasting emotional consequences, but many women do heal from the emotional distress that may accompany fertility difficulties.