Diagnostic and prognostic value of Cyfra 21-1 compared with other tumour markers in patients with non-small cell lung cancer: a prospective study of 116 patients.

The diagnostic value of Cyfra 21-1 in non-small lung cancer (NSCLC) has been established, but few studies have focused on its prognostic value. The aim of this study was to compare that of carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 19-9, CA 125, neuron-specific enolase and squamous cell carcinoma antigen. 116 patients with unresectable (n = 88) or resectable (n = 28) NSCLC were prospectively monitored from diagnosis, for a median of 14.4 months. All patients underwent tumour-marker determinations before treatment, then every 3 months. Their diagnostic value was studied using ROC (receiver operating characteristic) curves, based on control measure in 23 patients with benign lung diseases. The prognostic analysis was based on overall survival as the main endpoint. The diagnostic value of Cyfra 21-1 was confirmed, with a sensitivity of 54% and a specificity of 96% at a cut-off value of 3.3 ng/ml. At diagnosis, in the 88 non-surgical NSCLC, besides the presence of metastases (P = 0.017), Cyfra 21-1 (P = 0.017) and CA 125 (P = 0.03) were related to outcome. Elevated levels of Cyfra 21-1 at any time during the disease course was selected by multivariate analysis as additional predictors of poor survival.

Cardiac arrhythmias during the combined use of intravenous aminophylline and terbutaline in status asthmaticus.

The purpose of this study was to evaluate prospectively the occurrence of cardiac arrhythmias during the combined therapy with intravenous aminophylline and terbutaline in 29 consecutive patients with status asthmaticus. The 24-hour Holter recordings were performed during continuous intravenous infusions of aminophylline (0.56 +/- 0.20 mg/kg/h) and terbutaline (0.034 +/- 0.014 microgram/kg/min). Serum theophylline concentration was 12.1 +/- 3.8 micrograms/ml and never reached the toxic level (greater than 20 micrograms/ml). Premature ventricular contractions (PVCs) were absent in 35 percent of patients and 48 percent had rare unifocal PVCs (less than 10/h). Only 17 percent of patients (five of 29) exhibited severe ventricular arrhythmias: PVCs greater than 10/h (n = 3), multifocal PVCs (n = 1); and a short run of ventricular tachycardia (n = 1). Serious supraventricular arrhythmias occurred in only 7 percent of patients (two of 29) who developed sustained runs of atrial tachycardia. These arrhythmias were always clinically well tolerated and spontaneously resolved without any antiarrhythmic treatment. We conclude that severe arrhythmias are rarely observed during combined therapy with aminophylline and terbutaline in status asthmaticus.

Noninvasive estimation of systolic pulmonary artery pressure using Doppler echocardiography in patients with chronic obstructive pulmonary disease.

In patients with acquired or congenital heart diseases, the systolic pulmonary artery pressure (PAPs) can be predicted using continuous-wave Doppler ultrasound (CWD) measurement of the peak velocity of a tricuspid regurgitation (TR) jet. The aim of this study was to determine whether CWD could be used to accurately estimate PAP in patients with chronic obstructive pulmonary disease (COPD). In 41 patients with stable COPD, we prospectively performed CWD and right heart catheterization. The mean value of PAPs for the entire group was 38.5 +/- 14.9 mm Hg. Pulmonary arterial hypertension (PAPs greater than or equal to 35 mm Hg) occurred in 51 percent (21/41) of patients. Doppler estimation of PAP was impossible in 34 percent (14/41) because of poor signal quality (n = 3), absence of Doppler-detected TR (n = 8), and inadequate TR Doppler signal (n = 3). The PAP could be estimated in 66 percent (27/41) of patients. A statistically significant correlation was found between the Doppler-estimated PAP and the catheter-measured PAPs (r = 0.65; p less than 0.001; SEE = 9 mm Hg). Therefore, CWD appears to be useful for the noninvasive estimation of PAP in patients with COPD. However, this method is associated with two limitations: (1) the high percentage of patients in whom the PAP cannot be estimated by CWD, mainly because of the absence of Doppler-detected TR, and (2) the high value of the standard error of the estimate. The combination of CWD with other Doppler methods should increase the feasibility and accuracy of Doppler echography for the prediction of PAP in patients with COPD.

Nutritional status of patients with chronic obstructive pulmonary disease and acute respiratory failure.

The prevalence and features of malnutrition in COPD patients have been studied extensively in stable conditions but are poorly defined in the presence of acute respiratory failure (ARF). Nutritional status was prospectively assessed, on hospital admission, in 50 consecutive COPD patients presenting with ARF, 27 of them requiring mechanical ventilation (MV). Malnutrition, defined on a multiparameter nutritional index, was observed in 60 percent (30/50) of all patients, and in 39 percent (13/33) of those whose body weight was equal to or above 90 percent ideal body weight (IBW). Malnutrition was more frequent in those patients who required MV than in those who did not (74 percent vs 43 percent, p < 0.05). Subcutaneous fat stores were decreased (triceps skinfold thickness [TSF] < 80 percent pred) in 68 percent of patients, and markedly depleted (TSF < 60 percent pred) in 52 percent of them. The indices of lean body mass, ie, mid-arm muscle circumference (MAMC) and creatinine height index (CHI) were decreased in, respectively, 42 percent and 71 percent of patients, but MAMC was severely depressed (< 60 percent pred) in only 6 percent of them. A severe decrease of prealbumin (< 100 mg/L), retinol-binding-protein (< 20 mg/L), and albumin (< 20 g/L) serum concentrations was observed in, respectively, 22 percent, 28 percent, and 4 percent of patients. These results suggest that an assessment of nutritional status using a multiparameter approach should be systematically performed in COPD patients with ARF, especially in those requiring MV, as malnutrition may have deleterious effects on weaning off MV.

Hyperlactatemia during acute severe asthma.

OBJECTIVE: To evaluate arterial lactate levels during treatment of acute severe asthma (ASA) and the prognostic value of arterial hyperlactatemia in ASA. DESIGN: Prospective study. SETTING: A respiratory intensive care unit (ICU) of a university hospital. PATIENTS: 29 consecutive patients admitted to the ICU for ASA not intubated on admission and with a peak expiratory flow (PEF) < 150 l/min or an arterial carbondioxide tension (PaCO2) > 40 mm Hg. All patients received standardized treatment during the first 24 h including i.v. and nebulized salbutamol, i.v. theophylline, and dexamethasone. MEASUREMENTS AND RESULTS: Arterial lactate levels were serially measured by an enzymatic method during the first 24 h following admission. On admission, the mean arterial lactate level was 3.1 +/- 0.38 mmol/l (range 1.1-10.4); 17 patients (59%) had arterial hyperlactatemia with a lactate level > 2 mmol/l. No difference was found in lactate levels between patients with progressively worsening asthma and those with an acute onset of severe asthma. No correlation was found between arterial lactate levels on admission, on the one hand, and respiratory rate (RR), heart rate, PEF, pH, PaCO2, arterial oxygen tension, potassium, phosphorus, creatine kinase, or transaminase values on admission, on the other hand. All patients developed an important but transient increase in arterial lactate levels during treatment, with a peak at 7.72 +/- 0.46 mmol/l and a mean elevation of 4.62 +/- 0.45 mmol/l (range 0.4-12.1), from the initial admission value contrasting with a significant clinical improvement assessed by RR, PEF, and arterial blood gas parameters. CONCLUSION: This study suggests that, in ASA, arterial hyperlactatemia is frequently present on admission to the ICU. Delayed hyperlactatemia is a constant finding during treatment of ASA. Initial or delayed hyperlactatemia seems of no prognostic value because none of the patients required mechanical ventilation. The effects of therapy for acute asthma on lactate metabolism still need to be studied.

Seizures related to severe hypophosphataemia induced by mechanical ventilation.

A patient with chronic obstructive pulmonary disease and acute respiratory failure developed grand mal seizures in the hours following onset of mechanical ventilation. These seizures were associated with an acute increase in arterial pH and were related to the occurrence of acute severe hypophosphataemia associated with recovery from respiratory acidosis.

Bronchial hyperresponsiveness following acute severe asthma.

OBJECTIVE: To evaluate bronchial hyperresponsiveness (BHR) early after recovery from acute severe asthma (ASA). DESIGN: Prospective study including all patients admitted to the intensive care unit (ICU) for ASA over a 12-month period. SETTING: University teaching ICU and pneumonology department. PATIENTS: 41 consecutive patients admitted to the ICU for ASA. Results were compared with those of a control group with stable asthma and no history of ASA or steroid therapy, matched for sex and age. MEASUREMENT AND RESULTS: Of the 41 patients, 40 completed respiratory function tests 10 days after ICU admission, and the minimal dose of acetylcholine inducing a fall in forced expiratory volume in 1 s (FEV1) of 20% or more (PD AC) could be determined safely by a novel method in 26 patients with an FEV1 above 60% predicted. PD AC (micrograms) was found to be significantly lower in ASA than in control patients. Very severe BHR (PD AC < or = 100 micrograms) was found in 18 ASA patients, but not in the control patients; 5 ASA versus 12 control patients had marked BHR (100 > PD AC < or = 500 micrograms); and 3 ASA versus 14 control patients had moderate BHR (> 500 micrograms). A similar level of BHR was found in ASA patients with progressive or acute worsening. No correlation was found between PD AC and admission PaCO2 value, admission peak expiratory flow (PEF) value, delay in improvement of PEF, delay in PD AC determination, or prechallenge FEV1 value. CONCLUSION: BHR measurement is safe soon after an episode of ASA if done with caution. At this time, patients who are free of clinical symptoms and have no significant objective bronchial obstruction appear to have severe bronchial hyper-responsiveness.

Primary pneumococcal pericarditis complicated by acute constriction.

We report a case of a 31-year-old male with primary pneumococcal pericarditis. Severe acute constrictive pericarditis developed within a month of the onset of the illness in spite of adequate antibiotic therapy and pericardial drainage.

Pulmonary polymorphic centroblastic type malignant lymphoma in a patient with lymphomatoid granulomatosis, Sjögren syndrome and other manifestations of a dysimmune state.

A case of lymphomatoid granulomatosis arising in a patient with a long history of dysimmunity is reported. The autopsy reviewed the final evolution into a high grade malignant lymphoma with IgM K immunoglobulin production and discovered in deep lymph nodes modifications similar to angio-immunoblastic lymphadenopathy.

[Second primary cancers after small-cell lung cancer]. / Seconds cancers primitifs après cancer bronchopulmonaire à petites cellules.

The records of 1,371 patients with small cell carcinoma of the lung (SCLC) treated between 1983 and 1994, were reviewed for the occurrence of second primary malignancies (SPM). One was excluded for analysis because of insufficient data. Eight synchronous SPM (SSPM) and 8 metachronous SPM (MSPM) were identified, SSPM included non-small cell lung cancer in 6 patients, 1 head and neck cancer and 1 oesophageal cancer. Median survival after the diagnosis of SSPM was 6 months. The MSPM were detected between 1 and 6 years after the diagnosis of SCLC. MSPM included lung cancer (3 patients), gastrointestinal malignancies (2 patients), 1 hematologic malignancy, 1 prostatic cancer and 1 head and neck cancer. The median survival time after the diagnosis of MSPM was 4 months. Occurrence of SPM is a singular pattern of patients with SCLC. Tobacco consumption, genetic factors and carcinogenic effects of multimodality treatment are supposed mechanisms to explain SPM.

[Coronary thrombosis and long term anticoagulant treatment. Results of 173 autopsies after myocardial infarction]. / Thromboses coronaires et traitement anticoagulant au long cours Résultats de 173 autopsies après infarctus du myocarde

Report of an anatomical-clinical study concerning 173 patients with an average follow-up period of 5 and 1/2 years after the onset of myocardial infarction. They were subdivided into four comparable groups differing only in the quality of the long-term antivitamin K treatment which was administered. A survey of the coronary artery and myocardial lesions was performed for every heart. Acute occlusive coronary artery thromboses were four times less frequent in the correctly treated group then in the other three groups (p less than 0.001). There was no significant difference between the insufficiently treated groups and the untreated group. Recurrent myocardial infarctions were accompanied in 90 per cent of cases by acute occlusive coronary artery thromboses and were four times less frequent when treatment was efficient (p less than 0.001). These results confirm the part played by coronary artery thrombosis in the aggravation of coronary atherosclerosis and justify the attempts at long-term prophylaxis. The provide the proof that antivitamin K administration, at efficient dosage, maintained for a long time, has a significant influence on the cause of death in these patients, by decreasing the number of coronary artery thrombosis. Long-term anticoagulant treatment, in spite of its haemorrhagic complications and limits, should not be given up until a new efficient treatment is available.

[Tobacco detoxication by acupuncture and group psychotherapy]. / La désintoxication tabagique par acupuncture et psychothérapie de groupe.

In the out-patient tobacco detoxication unit created, in 1977, within the pneumology department of the Hôtel-Dieu hospital, Paris, the method used is a combination of acupuncture and group psychotherapy. Its effectiveness has been evaluated, over a 2-year period, by means of a questionnaire mailed to each patient and followed, if necessary, by up to 3 reminders. A computer-assisted assessment of the data thus collected provided a follow-up of varying duration of the 555 patients concerned; 488 patients were treated, then contacted, and 371 (76 p. 100) answered the questionnaire. Weaning--defined here as complete detoxication with a 2 to 28 months follow-up when the questionnaire was filled--was obtained in 24 p. 100 of the patients who answered. Other evaluation criteria would have given figures ranging from 18 p. 100 to 58.6 p. 100. The main reason for failure mentioned by the patients was lack of will. An exhaustive study of 84 publications concerning more than 10,000 candidates to weaning showed that similar results are obtained with several types of psychotherapy, acupuncture and auriculotherapy: a success rate of about 60 p. 100 at the end of treatment, 40 p. 100 at 3 months and 30 p. 100 at 6 months and one year. The results obtained with drugs are not as good, perhaps because their use betrays a lesser desire to give up smoking.

[Fatal hemoptysis during bronchial aspergillosis with multiple pulmonary artery aneurysms]. / Hémoptysie fatale au cours d'une aspergillose bronchique par anévrysmes artériels pulmonaires multiples.

Aspergillosis with fatal outcome are usually pulmonary invasive aspergillosis with or without dissemination, developed in patients with severe immunosuppression. We report a fatal case of bronchial necrotizing aspergillosis in a young woman with diabetes mellitus, who developed similar lesions to "Semi-invasive Aspergillosis", so-called "Chronic Necrotizing Pulmonary Aspergillosis". This aspergillosis was complicated by large pulmonary artery aneurysms requiring an hemostatic lobectomy. These aneurysms, secondary to the bronchial lesions, contrast with infectious aneurysms (so-called mycotic) secondary to septic embols. They differ from Rasmussen's aneurysms, due to tuberculosis, by their size, fusiform shape and extent. Lesions of vessels' walls and parietal fungal invasion in the vicinity of an endo-bronchial aspergilloma explain the vascular rupture. The multiplicity of these aneurysms, showed on C T Scan, is responsible for death by post-surgical recurrence of hemoptysis.

[Value of alveolar lavage and transbronchial biopsy in the diagnosis of isolated sarcoid uveitis]. / Intérêt du lavage alvéolaire et des biopsies transbronchiques dans le diagnostic des uvéites sarcoïdosiques isolées.

The diagnosis of sarcoidosis is established by biopsy of sarcoid tissues demonstrating non-caseating granuloma, but difficulties arise when extra pulmonary organs are involved separately. Positive histologic signs can however be found in the lung even when there are no radiologic features. Bronchoalveolar lavage and biopsies were performed in 19 patients presenting severe, strictly isolated uveitis (5 cases of anterior uveitis, 3 cases of posterior uveitis and 11 cases of panuveitis). Criteria of positivity were non-caseating granuloma and lymphocytosis. Positive signs were obtained in 6 cases (31,5%); 1 case of posterior uveitis and 5 of panuveitis. There was no case of false positive results but one false negative result. There was a lack of correlation between results of these investigations and angiotensin converting enzyme blood levels. These investigations are non-invasive in experienced hands.

[Inhalation pneumonia presenting as a pneumocystis infection]. / Pneumopathie d'inhalation révélée par une pneumocystose.

A case of Pneumocystis carinii pneumonia is presented. Following presentation a chronic alveolitis was uncovered, which was due to ultimately repeated and prolonged inhalation of sweets containing gum arabic. The diagnosis was confirmed by a trans-bronchial biopsy and by chemical analysis of centrifugation of the alveolar lavage deposit. After cessation of the inhalation the progress was satisfactory both in terms of clinical status and lung function measurement.

[Effect of a single dose of nifedipine on the CO transfer capacity in patients with scleroderma]. / Effet d'une prise unique de nifédipine sur la capacité de transfert du CO de patients sclérodermiques.

The calcium antagonists are currently used in the treatment of Raynaud's syndrome for patients with scleroderma. The effect on the pulmonary vasculature in these patients is little understood. The study reported here is based on 15 patients with scleroderma. In each patient lung volumes, expiratory flow and transfer factor (DLCO) were carried out in a basal state and one hour after the administration of sub lingual nifedipine. Nine patients showed a diminution in the DLCO before taking the product but the mean variation after nifedipine was not significant. Different mechanisms may explain the absence of any effect: irreversible vascular disease or the absence of pulmonary arterial hypertension or hypoxic constriction, the latter conditions were previously associated with the efficacy of nifedipine. Thus it does not seem that nifedipine, in acute tests, has an effect on the pulmonary localisation of scleroderma, at least in the absence of pulmonary arterial hypertension.

[Tuberculosis in a Parisian pneumology department: 151 cases]. / La tuberculose dans un service de pneumologie parisien: 151 cas.

OBJECTIVES: The incidence of tuberculosis has risen since 1992. We studied cases observed in our department to search for factors favouring this increased incidence. METHODS: A retrospective assessment of 151 cases of tuberculosis observed over a 3 year period in a department of pneumology in Paris was performed. RESULTS: Fifty-two percent of the patients were foreigners; 66% lived in a poor socio-economic environment included 18% with no permanent residence; 29% were alcoholics. An association with human immunodeficiency virus infection was seen in 7% of the cases. Another immunodepression factor was found in 15%. Tuberculosis was discovered in a context of respiratory distress in 7% or the patients. Outcome was fatal in 6%. Three months after diagnosis 22% of the patients were lost to follow-up. CONCLUSION: This series emphasizes the major role of socio-economic factors in the rising incidence of tuberculosis and the need for urgent and adapted measures for therapeutic management in an often non-compliant and socially instable population.

[Wegener's granulomatosis. Therapeutic indications and follow-up course. Apropos of 5 cases]. / La granulomatose de Wegener. Indications thérapeutiques et suivi évolutif. A propos de 5 observations.

Five cases of Wegener's granulomatosis treated with cyclophosphamide (CPM) and prednisolone are reported. Four of these patients received intermittent intravenous boluses of cyclophosphamide with the aim of improving the prognosis and renal function and at the same time to attenuate any haematological or vesical toxicity of CPM. The initial response to treatment by boluses of CPM was favourable in all cases but three patients presented with relapses, which were sometimes repeated and boluses of CPM did not enable a remission to be maintained at the time. Recourse to continuous oral therapy in place of bolus therapy proved viable for the maintenance of remission in two cases. The bladder and haematological tolerance to the bolus was satisfactory but an episode of severe neutropenia led to an adaptation of the dose of CPM. The intermittent administration above all the low cumulative dose of CPM obtained with the boluses will explain the better vesical and haematological tolerance observed depending on the capacity to maintain a prolonged remission. The indications for boluses of CPM in the treatment of Wegener's granulomatosis remain uncertain and do not seem to be totally without inconvenience.

[Respiratory function abnormalities and pneumonia in HIV-positive patients. A prospective study of 112 patients]. / Anomalies fonctionnelles respiratoires et pneumopathies des patients VIH+. Etude prospective de 112 patients.

Pulmonary function studies are often limited to the alone measurement of transfer lung factor for CO (TLCO) in screening for pneumonia in patients with Human Immunodeficiency Virus (HIV) infection. We prospectively measured pulmonary function tests (PFT) in 112 HIV seropositive patients. The population consisted of two groups: on one hand, a group free of clinical and radiological abnormalities, on the other hand, one with respiratory symptoms and/or abnormal chest X-Ray, with or without overt pneumonitis. For this latter group, a fiberoptic bronchoscopy with bronchoalveolar lavage was routinely performed in addition to PFT. In case of pneumonitis, PFT showed a restrictive disease and a reduced TLCO. The specificity of this functional pattern was however weaker in the subgroup of drug abusers than in the non-drug addicts. This difference was above all linked to a low TLCO value in the subgroup of drug addicts without pulmonary complications. Multivariate statistical analysis, including discriminant analysis, maintained the same sensibility and improved specificity of PFT in diagnosis of pneumonia, especially if the analysis takes the existence of drug abuse into account. Moreover, initial PFT, performed before any lung disease, improved the sensibility of the screening. The results are discussed in relation to new tests proposed for the screening of pneumonitis in HIV positive patients. At the present time, PFT seems to be useful and enables one to understand natural functional evolution.

[Dosage adjustment of metoclopramide for controlling vomiting induced by cisplatin: pharmacokinetic approach]. / Ajustement posologique du métoclopramide pour le contrôle des vomissements induits par le cisplatine: approche pharmacocinétique.

Ten patients under cisplatin-containing chemotherapeutic regimens received constant rate continuous infusions of metoclopramide in doses adjusted to each individual case for optimal plasma concentration. Dosage adjustment was based on simple pharmacokinetics with determination of metoclopramide distribution and elimination values in each patient. From these values were calculated the individual loading and maintenance dosages required to obtain the sustained plasma concentration of 0.85 mg/l reported in the literature as being correlated with a good antiemetic effectiveness. The mean plasma concentration in the 10 patients studied was 0.84 +/- 0.19 mg/l with doses which varied considerably owing to marked scattering of pharmacokinetic parameters. Treatment was effective in 6 out of 10 patients and well tolerated by all.