Tracheobronchopathia osteochondroplastica: clinical, bronchoscopic, and comorbid features in a case series.

BACKGROUND: Tracheobronchopathia osteochondroplastica (TO) is a rare condition of unknown etiology. TO is characterized by submucosal nodules, with or without calcifications, protruding in the anterolateral walls of the trachea and proximal bronchi. The objective of this study was to describe TO features and associated comorbidities in a series of patients. METHODS: Patients suffering from TO were retrospectively included by investigators from the Groupe d'Endoscopie Thoracique et Interventionnelle Francophone (GETIF). Demographic, clinical, comorbidities, bronchoscopic, functional, and radiological characteristics, and outcomes were recorded and analyzed. RESULTS: Thirty-six patients were included (69% male with a mean of 65 ± 12 years). Chronic symptoms were described by 81% of patients including cough (74%) and dyspnea on exertion (74%). TO was associated with COPD in 19% of the cases and gastroesophageal reflux disease in 6%. A mild to severe airflow obstruction was present in 55% of the cases. CT scan showed tracheal submucosal nodules in 93% of patients and tracheal stenosis in 17%. Bronchoscopy identified TO lesions in the trachea in 65% of the cases, and 66% of them were scattered. A bronchoscopic reevaluation was performed in 7 cases, 9 ± 14 months [1-56] after initial diagnosis, and showed the stability of lesions in all cases. Three patients underwent interventional bronchoscopic treatment. CONCLUSION: The diagnosis of TO relies on typical bronchoscopic findings and can be evoked on a CT scan. Histologic diagnosis can be useful in atypical cases for differential diagnosis. Given its low consequences in terms of symptoms, lung functions, and evolution, no treatment is usually required.

Evaluation of an interactive teaching method in the teaching of Pulmonology.

INTRODUCTION: For several years, interactive teaching has proved its effectiveness in learning. At the Faculty of Medicine of Tunis (FMT), the interactive sessions are sessions of clarification, illustration, application, and participation (CIAP). AIM: To evaluate pneumology CIAP session in the acquisition of learning by first-year students of the second cycle of medical studies (SCMS1). METHODS: It was a cross-sectional study carried out at the FMT during the academic year 2016-2017 and included students from SCMS1. CIAP session subject was "The chronic respiratory failure". A pre-test and a post-test, with the same subject, were distributed during the session. Knowledge acquisition was evaluated by comparing the scores assigned to the tests. An evaluation of the students' satisfaction with the session progress was made. RESULTS: Ten students attended the CIAP session. The mean score of the pre-test was 2.1 ± 0.7 over 10 points. A statistically significant (p = 0.003) increase in the score was observed for the post-test, which increased to 4.8 ± 0.2. For the evaluation of the session by the students, the best scores were assigned for the items evaluating the achievement of objectives and the facilitation of the session by the teacher (1.9 points).The lowest score was given for the item evaluating the time required for the session (1 point). CONCLUSION: The interactive teaching method "CIAP" was beneficial in terms of learning, as demonstrated by the statistically significant improvement of the post-test score compared to the pre-test and the satisfaction of the students at the end of the session. Moreover, the involvement of all the stakeholders (students, teachers, and institutions) is necessary for the success of this teaching.

Sleep-Related Painful Erections in a Patient With Obstructive Sleep Apnea Syndrome.

Sleep-related painful erection (SRPE) is a rare sleep disorder characterized by recurrent, painful penile erections occurring when awakening from rapid eye movement sleep, while erections are painless during wakefulness. Almost 35 cases have been reported worldwide, and only two of them had an associated obstructive sleep apnea syndrome (OSAS). We report a new case of a 61-year-old man suffering from SRPE associated with OSAS. The adequate treatment of respiratory events with continuous positive airway pressure did not alleviate the SRPE symptoms and excessive daytime sleepiness. The SRPE diagnosis was made by polysomnography coupled with video surveillance when the patient was referred to the sleep laboratory for residual excessive daytime sleepiness. The patient had 2-4 episodes of SRPE/night. Beta-blocker did not alleviate the SRPE, but a transient improvement was noted when the patient was treated with paroxetine. In contrast with the two previously published cases of SRPE plus OSAS, continuous positive airway treatment did not improve SRPE symptoms in our patient.

Acute acoustic trauma: how to manage and how to prevent?

INTRODUCTION: The consequence of an exposure to intense sounds can be a temporary or permanent hearing loss and even with a rapid therapeutic management, severe sensorineural sequelae may persist. METHODS: the authors report a retrospective study about 64 patients followed for an acute acoustic trauma during a period of 8 years (2006 to 2013). For all the cases, a clinical examination associated to a pure-tone audiometry was conducted. Hearing levels were measured at the frequencies 500, 1000, 2000 and 3000 Hertz. Auditory evoked potentials were performed in 17 cases. The therapeutic and evolutive data were detailed and discussed. RESULTS: All our patients were male with a mean age of 34 years. The cause of acoustic trauma was a firing of a gun near the ear in 48 cases, an explosion near the ear in 5 cases and a sudden exposure to loud noises near military planes in 11 cases. Clinical complaints were acute hearing loss with tinnitus. Audiometric exams found a sensorineural hearing loss with a hearing level average of 38 decibels (dB) +/- 14 SD. The therapy consisted of systemic cortisteroids associated in all the cases to peripheral vasodilators.  It was given intravenously during 10 days and then orally with vasodilators during one to 3 months. Hyperbaric oxygenotherapy have been administrated for 25 patients. The follow-up consisted of questioning about symptoms, clinical examination and pure-tone audiometry. A good evolution was noted in 52 cases (81%) and the mean of hearing level after therapy was: 24 dB +/- 12 dB. Despite a prolonged therapy with vaso-active drugs, tinnitus persisted in 36 cases. CONCLUSION: Controlling noise and its harmful effects through technical devices and safety professionals programs are the best way to reduce the frequency and the sensorineural sequelae due to acute acoustic trauma.

Orbital metastasis revealing an undifferenciated Carcinoma of nasopharyngeal type: a case report.

The evolution of the undifferentiated carcinoma of the nasopharynx (NPC) is marked by the occurrence of regional or distant metastasis. We report a rare observation of bilateral orbital metastasis of NPC. Clinical symptoms were ocular proptosis, blurred vision and eye redness. Imaging permitted to precise the extensions of the tumor which was classified T4N1M1 after clinical and paraclinical exams. The treatment consisted of concomitant radiochemotherapy. The evolution didn't revealed recurrence of the disease after 18 months.

A spiritual sleepiness scale: the Friday prayer.

BACKGROUND: Excessive daytime sleepiness (EDS) affects 5% to 20% of the population and is involved in a large number of traffic accidents. EDS is a major symptom in sleep disorders, especially obstructive sleep apnea syndrome (OSA). The daytime sleepiness is evaluated subjectively using scales and questionnaires based on perception. This study is aimed to build a new questionnaire more suited to our lifestyle and then to compare it to the Epworth sleepiness scales (ESS). METHODS: We administered to 91 adult's patients (76 men and 15 women) consulting for sleep disturbance the ESS and a single subjective question tendency to drowsiness during the Friday prayer. Patients were listed in four groups according to their response to the question «During the past month, have you ever doze or fall asleep during the sermon of the Friday prayer? ¼ By G1 never dozes, G2 low chance of falling asleep, G3 average chance of dozing, G4 high chance of falling asleep. RESULTS: Only 63 patients (58 men and 5 women) responded to both questionnaires. Group 1 included 14 patients with a ESS of 5.5 +/- 1.8, Group 2 included 18 patients with a ESS of 7.3 +/- 1.9, Group 3 included 18 patients with a ESS of 11.05 +/- 2 and Group 4 included 13 patients with a ESS of 14.69 +/- 2.3. The Rho correlation coefficient was high (0.86) and shows a strong correlation between the Results of the two questionnaires. CONCLUSION: the answer to the question " During the past month, have you ever doze or fall asleep during the sermon of the Friday prayer? ¼ seems to be an appropriate Sleepiness Scale among Muslim patients.

Management of combat-related facial injuries.

INTRODUCTION: Combat-related facial injuries involve various lesions of the mouth, the eye sockets and the facial bones. The goal of this study is to precise the particularities of these affections and their therapeutic management. METHODS: A retrospective study was performed about 56 cases of combat-related facial injuries over a period of 5 years (2010 - 2014). RESULTS: Our study included 56 male patients with an average age of 29 years (20-37). The trauma occurred during a real security intervention in all the cases. It was isolated in 18 cases and associated to other lesions in 38 cases. Clinical examination revealed facial edema (57%), facial cuts and lacerations (74%), broken teeth (14%), nasal deformation (26%), skin defect (16%) and periorbital ecchymosis (32%). The diagnosis retained after clinical examination and imaging exams were:  fractures of the mandible (34 cases), of the eye sockets (18 cases), of the nasal bones (15 cases), parotid gland injury (5 cases) and facial arterial injuries in (24 cases). The treatment was surgical in all the cases: stabilization of fractured segments (43 cases), suture of facial and vascular lacerations (51 cases), reduction of nasal fractures (15 cases), and reposition of teeth dislocations (35 cases). The evolution was good in 34 cases. The functional sequelae noted were ophthalmic (7 cases), dental abnormal occlusions (11 cases), residual trismus (4 cases) and facial palsy in 2 cases. CONCLUSION: Combat related facial injuries must be diagnosed and treated early to prevent the functional and, sometimes, life-threatening damages dues to those lesions.

Impact of obstructive sleep apnea on the right ventricle.

BACKGROUND: Right ventricular (RV) involvement in obstructive sleep apnea syndrome (OAS) is controversial. The aim of this study was to determine a correlation between echocardiographic parameters of RV function and severity of OSA assessed by the apnea- hypopnea index (AHI). METHODS: Sixty patients with suspected OSA were enrolled. All patients had overnight polygraphy and an echocardiographic assessment of RV structure and function. Patients were divided into three groups: a control group (n=20) with an AHI<5/h, a group of mild to moderate OSA (n=18) with an AHI=5-30/h and a group of severe OSA (n=22) with AHI≥30/h. RESULTS: There were no differences of age, body mass index and sex among the three groups. There was no difference in systolic pulmonary pressure. RV free wall thickness, end-diastolic surface and right atrium surface were statistically higher in OSA patients compared with controls. The peak systolic myocardial velocity at tricuspid lateral annulus S' were significantly lower in patients compared with controls (14.5±3 vs 12.2±2 cm / s, p<0.001; respectively). This decrease was greater in patients with severe OSA compared with mild to moderate OSA (11.4±3 vs 13.0±1 cm/s, p=0.05, respectively). Right ventricular myocardial performance index (MPI) was significantly higher in OSA compared with controls (0.55±0.12 vs 0.46±0.14, p=0.024, respectively) but it was not correlated with the severity of IAH. CONCLUSIONS: In OSA patients, there was a significant RV dysfunction independently of pulmonary pressure, although the correlation with the severity of IAH was moderate.

Impact of obstructive sleep apnea on the right ventricle.

BACKGROUND: Right ventricular (RV) involvement in obstructive sleep apnea syndrome (OAS) is controversial. The aim of this study was to determine a correlation between echocardiographic parameters of RV function and severity of OSA assessed by the apnea- hypopnea index (AHI). METHODS: Sixty patients with suspected OSA were enrolled. All patients had overnight polygraphy and an echocardiographic assessment of RV structure and function. Patients were divided into three groups: a control group (n=20) with an AHI<5/h, a group of mild to moderate OSA (n=18) with an AHI=5-30/h and a group of severe OSA (n=22) with AHI≥30/h. RESULTS: There were no differences of age, body mass index and sex among the three groups. There was no difference in systolic pulmonary pressure. RV free wall thickness, end-diastolic surface and right atrium surface were statistically higher in OSA patients compared with controls. The peak systolic myocardial velocity at tricuspid lateral annulus S' were significantly lower in patients compared with controls (14.5±3 vs 12.2±2 cm / s, p<0.001; respectively). This decrease was greater in patients with severe OSA compared with mild to moderate OSA (11.4±3 vs 13.0±1 cm/s, p=0.05, respectively). Right ventricular myocardial performance index (MPI) was significantly higher in OSA compared with controls (0.55±0.12 vs 0.46±0.14, p=0.024, respectively) but it was not correlated with the severity of IAH. CONCLUSIONS: In OSA patients, there was a significant RV dysfunction independently of pulmonary pressure, although the correlation with the severity of IAH was moderate.

Researchers' And Medical Student' Experience in Reference Management Software in a Low-Income Country.

INTRODUCTION: Although the use of Reference Management Software (RMS) is increasing in developed countries, they seem to be unknown and less used in low-income countries. AIM: To discover the major trends in the use of RMS among researchers and Ph.D. students in Tunisia, as a low-income country. METHODS: A hardcopy survey was filled out by researchers and Ph.D. students during an educational seminar at the faculty of medicine of Sfax in 2016 with the aim to collect qualitative data to determine the participants' knowledge and use of RMS. RESULTS: The survey collected 121 participants, among them, 53.7% know RMS. Mendeley proved to be the best-known software (41.5%), followed by Zotero (35.3%) and Endnote (23%). Training sessions in RMS were taken by 5% of participants. Among the 121 participants, 26.5%of them use RMS., Mendeley was the most used (46.9%), followed by EndNote (28.1%) and Zotero (25%). The most commonly popular feature in RMS is inserting citations (66.9%). Therefore, the analysis, of the reasons behind the choice of RMS proves that the software was used because it is convenient (38.4%),  most known (38.4%),  easy (30.7%), or suggested by colleagues (30.7%). The free and open-source software was preferred by 81% of the participants. g. However, 50.4% ignore the fact that Zotero is free. Several types and sources of captured citations were unknown by 53.8% and 59% of the rest of the participants. CONCLUSION: The results clearly show that the lack of awareness about RMS in Tunisia is due to the absence of a formal training. As a result, the need for such training is highly important for researchers to be able to benefit from the different advantages of RMS while conducting their academic medical education.

The relationship between the fraction of exhaled nitric oxide and the level of asthma control.

BACKGROUND: The evaluation of asthma control, based on symptoms and risk factors for exacerbation does not provide information about airway inflammation, reflected by fractional exhaled nitric oxide (FeNO). The impact of FeNO in the evaluation of asthma control has not been well recognized. The purpose of this study was to evaluate the contribution of FeNO measurement in the assessment of asthma control. METHODS: A prospective cross-sectional study was carried out for four months and included 148 adult asthmatics. For each patient, the demographic data, asthma control test (ACT) score, medication adherence, skin prick test positivity, FeNO level, and spirometry results were recorded independently. The correlation between ACT score and FeNO level was analyzed. RESULTS: The mean ACT score was 20.9±3.7 and the mean exhaled FeNO level was 30.4±25.8 ppb. Asthma was controlled in 71.6% of patients. Mean FeNO values were significantly higher in patients with uncontrolled asthma (42.1±30.8 versus 27±19 ppb, p=0.01). A significant negative correlation was observed between FeNO level and ACT score (r=-0.33, 95% confidence interval [CI], -0.51-0.10; p=0.001). FeNO had a high negative predictive value (79.9%) and specificity (63.2%), but a low sensitivity (59.5%) and positive predictive value (39%). The area under the receiver operating characteristic (ROC) curve was of 0.7 (95% confidence interval [CI], 0.53-0.74; p=0.01). CONCLUSIONS: Using just FeNO to evaluate asthma control represents a limited approach because of the low predictive accuracy of FeNO for diagnosing uncontrolled asthma.

Determining the optimal time to assess the reversibility of airway obstruction.

CONTEXT: The optimal time to interpret bronchodilator reversibility remains controversial. This time may affect a positive diagnosis and manage asthma and chronic obstructive pulmonary disease (COPD). AIMS: We sought to document the time when maximum respiratory function is reached after inhalation of salbutamol and to define the optimal time of bronchodilator response to assess the reversibility or non reversibility of airway obstruction. SUBJECTS AND METHODS: This prospective analytical study was spread over 8 months and included 58 patients with asthma or COPD with airway obstruction. Spirometry was performed before and at 5, 10, 15, 20, and 30 min after salbutamol inhalation (200 mcg) administered through pressurized metered-dose inhalers and large volume spacer. RESULTS: After salbutamol inhalation, the mean individual peak bronchodilation occurred at 20 min for the forced vital capacity and at 30 min for the forced expiratory volume in 1 s. The percentage of reversible patients in our sample was guideline dependent. It increased from 53% to 67.2% when using the American Thoracic Society/European Respiratory Society definition compared to using the Global Initiative for Chronic Obstructive Lung Disease. The maximum number of reversible patients was significantly different at 20 min compared to 5 and 10 min. CONCLUSIONS: Interpreting bronchodilator reversibility after 20 min was the ideal time to judge the reversibility or nonreversibility in obstructive ventilatory disorders in adults.