Asthma exacerbations in Reunion Island: Environmental factors.

INTRODUCTION: Reunion Island is a French overseas department characterized by a tropical climate with 2 distinct seasons. While the prevalence of asthma among adults in Reunion Island is close to that in mainland France, mortality and hospitalization rates are twice as high. To date, however, no epidemiological studies have evaluated the influence of environmental factors in asthma exacerbations in Reunion Island. METHODS: From January 2010 to June 2013, 1157 residents of Saint-Denis visited the emergency rooms of the Centre hospitalier universitaire site Nord de Saint-Denis for asthma. After exclusion of children under the age of 3, 864 visits were analyzed. These were correlated with the following daily factors: pollens and molds, meteorological parameters (temperature, precipitation levels, humidity and relative humidity levels, wind), pollutants (sulfur dioxide (SO2), nitrogen oxide (NOx), and the fine particles PM10 and PM2.5), and the influenza virus. The correlation between these factors was evaluated using the DLNM and GO-GARCH models. RESULTS: Of the 864 analyzed visits, 532 were by pediatric patients (aged 3 to 16 years) and 332 by adult patients (aged over 16 years). In adults, pollens positively correlated with asthma exacerbations were Urticaceae, Oleaceae, Moraceae, and Chenopodiaceae. In children, these were Urticaceae, Oleaceae, Poaceae, and Myrtaceae. Molds positively correlated with asthma exacerbations in adults were ascospores and basidiospores. Only basidiospores were positively correlated with exacerbations in children. Temperature was positively correlated with exacerbations in both adults and children. The pollutants PM10 and NOx were positively correlated with exacerbations in children. Influenza epidemics were strongly correlated with exacerbations in both adults and children. CONCLUSION: Our analysis shows that in Reunion Island, asthma is exacerbated by pollens (Urticaceae, Oleaceae, Moraceae, Chenopodiaceae in adults; Urticaceae, Oleaceae, Poaceae, Myrtaceae in children), molds (ascospores and basidiospores in adults; basidiospores in children), temperature, influenza, and the pollutants PM10 and NOx (in children).

[Self medication with Annona muricata L. (corossol) as an anti-cancer agent in Reunion]. / Automédication par Annona muricata L. (corossol) à visée anticancéreuse à la Réunion.

INTRODUCTION: Annona muricata L. also called soursop, graviola, guanabana and sapoty (French creole) is a fruit tree growing in tropical countries. The fruits, seeds, leaves and roots are used in traditional medicine. Potential anticancer effects encourage patients to consume this product as self medication. The object of the study was to determine the prevalence of use of graviola as an anticancer agent by patients treated for a lung cancer. METHODS: Our survey took place in two thoracic oncology day cares units of the university hospital of Reunion. All the patients treated by chemotherapy and immunotherapy for lung cancer were asked the same questions in a face to face interview over a 6-month period. RESULTS: One hundred questionnaires were collected. Sixty seven patients consumed graviola. In 53.7%, graviola was consumed as an anticancer agent and 25 patients took it regularly. Most often graviola was ingested as an infusion of boiled leaves (69.5%). The supply was exclusively local. CONCLUSIONS: A quarter of patients treated by chemotherapy for a lung cancer in Reunion consume graviola regularly as self medication. The consequences of this intake, drug interactions and side effects are unknown and would be interesting to identify.

[Thoracic endometriosis complicated with pneumopericard and iterative pneumothorax due to bullous dystrophy]. / Endométriose thoracique compliquée de pneumopéricarde et pneumothorax itératifs sur dystrophie bulleuse.

Thoracic endometriosis is a rare entity characterized by presence of endometrial tissue in pleura, lung parenchyma or airways. Most frequent manifestations are catamenial pneumothorax, hemothorax, hemoptysis and pulmonary nodules. We report here a rare case of a woman with thoracic endometriosis who developed iterative pneumothorax and pneumopericardium on bilateral bullous pulmonary dystrophy. She was a 37-year-old woman without any tobacco exposure and with previous history of pleural tuberculosis treated 5 years earlier. She was first referred to our centre for right pleuro-pneumothorax and hemorrhagic ascites. Pleural fluid examinations did not show any tuberculosis relapse, the evolution was favorable after thoracic drainage and there was no parenchymal lung abnormality on CT scan after surgery. Celioscopic peritoneal examination revealed stage IV peritoneal endometriosis. One year later, she was admitted for left catamenial pneumothorax. Thoracic CT scan showed apparition of large subpleural bulla. She underwent thoracotomy for bulla resection and left partial pleurectomy. Two years later, she was hospitalized for right pneumothorax and compressive pneumopericardium. Surgical lung biopsies confirmed pleuropulmonary endometriosis. Thoracotomy was performed for talcage pleurodesis and diaphragmatic leakages sutures. Lung bulla are rare in thoracic endometriosis, mechanism of their formation remains unknown. Pericardial involvement is rare in endometriosis; we report here a unique case of pneumopericardium.

[Multiple ground-glass opacities nodules]. / Nodules en verre dépoli et adénocarcinome EGFR muté.

INTRODUCTION: Ground-glass opacities nodules are frequently detected with the advances of radiological imaging. These can be preinvasive lesions such as atypical adenomatous hyperplasia but also invasive lesions. It leads to question in patients with lung cancer about treatment strategy and follow up. CASE REPORT: We report the case of a 72 years-old woman followed for a lung adenocarcinoma with an EGFR mutation of the right upper lobe stage IIb. The CT scan shows multiple pure ground-glass opacities in the same lobe of the primitive tumor but also in the other lobe. On the piece of lobectomy, histopathology of two ground-glass opacities showed atypical adenomatous hyperplasia. CONCLUSION: Ground-glass opacities nodules could be found in patients with an operable lung cancer. These can be multiple and match with atypical adenomatous hyperplasia but also carcinomas lesions. The radiological surveillance is still the standard. The strategy for surgical resection has to be defined especially in case of multiple lesions which can require repeated surgical resection.

[Lung transplantation in Reunion Island, current situation from January 2005 till May 2015]. / État des lieux de la transplantation pulmonaire à la Réunion de janvier 2005 à mai 2015.

Lung transplantation (LT) is a therapeutic option for patients with terminal respiratory failure and high risk of mortality in two years. Until now, this activity is not performed in Reunion Island. The candidate potential are thus directed to the metropolitan reference centres causing logistics and financials constraints. This work presents a current situation of the pulmonary transplantation in Reunion Island. This retrospective study includes patients from Reunion Island with respiratory insufficiency who have been transferred to metropolitan centres to apply to LT. The selection was made from January, 2005 till May, 2015. Twenty-nine patients included, aged from 14 to 64 years, were transferred to metropolitan France: 13 patients with cystic fibrosis, 13 patients with pulmonary fibrosis, 1 patients with bronchiectasis, 1 patient with chronic obstructive pulmonary disease (COPD) and 1 patient with pulmonary arterial hypertension. Fifteen patients underwent LT (4 live in Reunion Island, 5 live in metropolitan France and 6 are dead), 1 patient is alive on waiting list, 3 died on the waiting list, 7 patients were refused for transplantation and 3 patients are lost to follow-up. The number of patients transferred for LT increases over 10 years with a maximal incidence in 2013 of 7 repatriated patients including 3 transplanted patients. LT could be performed in half of our patients with possible come back and follow-up on Reunion Island. Indications follow the current trends except an under representation of COPD.

Introduction of a PCT-based algorithm to guide antibiotic prescription in COPD exacerbation.

OBJECTIVES: Prescribing antibiotics for COPD exacerbations is not easy. Procalcitonin (PCT) is a useful biomarker that helps reduce the rate of antibiotic therapies. However, its proper cut-off levels are often unknown. We aimed to assess the impact of a PCT-based algorithm to guide antibiotic therapy prescription in COPD exacerbations. METHODS: We conducted an observational, retrospective, and before/after study. We reviewed physician practices regarding PCT test and antibiotic therapy prescription to all patients hospitalized for COPD exacerbation. We then analyzed the rate of antibiotic prescriptions and the number of PCT tests prescribed before and after the introduction of a protocol validated by previous high-power studies. The primary endpoint was the rate of antibiotic prescriptions. RESULTS: A total of 124 patients before protocol and 121 patients after protocol were included. Antibiotic prescriptions decreased by 41% after protocol introduction (59% vs. 35%, P<0.001), with no increase in morbidity and mortality at Day 30. Compliance with protocol was complete in 60% of cases and partial (no PCT guidance to discontinue antibiotics) in 8% of cases. Both antibiotic duration (8.3 days vs. 8.7 days) and length of hospital stay (8.5 days vs. 8.3 days, P=0.78) did not change. CONCLUSION: Hospital physicians are already using PCT-based algorithm to guide antibiotic prescription in COPD exacerbations. Disseminating information on the appropriate PCT cut-off level to use to decide whether or not to initiate antibiotics is effective. Its proper use should be clarified to reduce antibiotic prescriptions to these overexposed patients.

[Pulmonary MALT lymphoma and paraneoplastic syndromes]. / Lymphome du MALT pulmonaire et syndromes paranéoplasiques.

INTRODUCTION: Primary pulmonary lymphoma is a rare disease; diagnosis is often delayed because of atypical clinical presentation and slow progression. OBSERVATION: A 42-year-old woman consulted because of haemoptysis. Chest CT-scan showed multiple nodular calcified masses. A lung biopsy led to the diagnosis of pulmonary amyloidosis with pulmonary MALT lymphoma (mucosa-associated lymphoid tissue). The patient developed two paraneoplastic syndromes: a hypertrophic osteoarthropathy and mucinosis. CONCLUSION: Multiple nodular amyloidosis can be a mode of presentation for pulmonary lymphoma. Paraneoplastic syndromes must be systematically considered and can help in early diagnosis of the disease and its relapse.

[Massive haemoptysis revealing bilateral sequestration in an adult: 3-year follow-up after embolization and surgery]. / Hémoptysie massive révélatrice de séquestration pulmonaire bilatérale chez un adulte : évolution à 3ans après embolisation et chirurgie.

Pulmonary sequestration is a rare vascular malformation which is most of the time unilateral. We report here the case of a 35-year-old male admitted for severe haemoptysis revealing bilateral pulmonary sequestration: one type 1 of Pryce in the right lower lobe and one type 2 of Pryce in the left lower lobe. Bilateral embolization was performed followed by a segmental resection of the left lower lobe sequestration by thoracotomy. After 3-year follow-up, the patient was asymptomatic and had no recurrence of haemoptysis. Enhanced computed tomography scan showed proximal occlusion of the right lower lobe sequestration systemic artery.

[Paucisymptomatic presentation of an allergic bronchopulmonary aspergillosis]. / Une aspergillose broncho-pulmonaire allergique de présentation pauci-symptomatique.

Clinical atypical presentations of rare lung disease can cause a diagnostic issue. In this case report, allergic bronchopulmonary aspergillosis is not like in the traditional form of severe asthma but is revealed by a persistent cough. CT scan and biological examinations should be prescribed when there is doubt in confirming the diagnosis. Diagnostic and therapeutic management should be done early in this disease to avoid complications such as bronchiectasis.

[American histoplasmosis: clinicopathological features in immunocompetent and immunocompromised patients. A report of two cases of infection by Histoplasma capsulatum on Reunion Island]. / Histoplasmose : aspects clinicopathologiques chez l'immunocompétent et l'immunodéprimé. À propos de deux cas d'infection à Histoplasma capsulatum sur l'Île de la Réunion.

INTRODUCTION: Histoplasmosis is a fungal infection caused by Histoplasma capsulatum var. capsulatum. It shows pulmonary or multivisceral involvement. Infective spores are inhaled from soils that contain bat or bird guano. The clinical picture depends on the intensity of the exposure and the immune status of the host. CASE REPORTS: We report two cases of histoplasmosis that reflect its variability in clinical and histopathological expression: a pseudo-tumoral nodular form or histoplasmoma in a pauci-symptomatic immunocompetent patient and a disseminated form with severe respiratory and mucocutaneous involvement in an immunocompromised patient. The histoplasmoma presented as a spiculated, hypermetabolic, solitary pulmonary nodule. Histopathological examination showed well-formed epithelioid granulomas with caseous central necrosis containing numerous histoplasma yeasts. In the patient with disseminated infection, the diagnosis was confirmed by seeing yeast forms in bronchoalveolar lavage fluid and skin biopsy. CONCLUSIONS: These patients are the second and third cases of histoplasmosis reported on Reunion Island. Both had traveled in endemic areas several years previously. The most likely pathophysiological mechanism is the reactivation of an old latent infection. There is, therefore, no argument at present in favor of the presence of contaminated soils on Reunion Island.

[Age and management decisions in patients with primary lung cancer]. / Age et décision de prise en charge des patients atteints d'un cancer pulmonaire primitif.

INTRODUCTION: Therapeutic decisions are difficult in elderly patients because of the heterogeneity of this population. Our objective was to evaluate the role of age in the management of patients suffering from primary lung cancer seen in the department of respiratory diseases of the Limoges regional teaching hospital between 2002 and 2004. METHODS: A cross sectional study analysed the management of 363 patients suffering from primary lung cancer. The patients were divided into two groups according to their age (less than seventy or seventy and over). A comparison was made between the management of the two groups. RESULTS: The comparisons according to age produced evidence of reduced activity, greater dependence, an increased Charlson score, less frequently administered radiotherapy and chemotherapy, and more frequent symptomatic treatment in the elderly group (p<0.001). CONCLUSIONS: The geriatric assessment of patients suffering from primary lung cancer should make allowance for the physiological age of the patient and adapt the management to ensure the best quality of life.

[Molecular strain typing contribution to epidemiology of tuberculosis in Limousin (1998 to 2006)]. / Intérêt du typage moléculaire pour l'épidémiologie de la tuberculose en Limousin (1998-2006).

OBJECTIVES: We conducted a molecular epidemiology of Mycobacterium tuberculosis in Limousin, a French area with a low incidence of tuberculosis (4.8/100,000 inhabitants in 2005) to define the molecular diversity and the pattern of transmission. DESIGN: Two hundred and fifty-nine strains were isolated (each strain corresponds to one patient) from 1998 to 2006. Both spoligotyping and MIRU15 were chosen for our study because of their discriminatory power. RESULTS: Only 165 medical records were available: 99M/66F, mean age 56.4 years (14-94), 32.7% foreign-born patients, 16.9% homeless or living in shelters, 21.8% of immunocompromised patients (three HIV positive), 14.5% of alcohol addicts. Pulmonary manifestations were predominant (81.8%) with 45.1% of positive smears. Two strains among the 259 presented a multidrug resistance. Spoligotyping identified 136/259 spoligotypes (110 unique, 26 clusters composed of two to 36 isolates); within these 26 clusters, ST53 (n=36) and ST50 (n=19) were the most frequent. Three major families were observed as follow: T1 (30%), Haarlem (30%) and LAM (20%). MIRU15 identified 28/36 isolates in the ST53 group and 14/19 in the ST50 group. Eleven clusters (32 strains) with identical ST-MIRU15 were obtained with a proved case of recent transmission. Alcohol dependence, immunosuppression and pulmonary infections seem to be involved in transmission factors. CONCLUSION: M. tuberculosis strains isolated in Limousin are characterized by their high genetic diversity. The rate of recent transmission (8.1%) is low and therefore a reactivation process is predominant in this area.

[Pleural metastases of sclerosing epithelioid fibrosarcoma]. / Métastases pleurales d'un fibrosarcome épithélioïde sclérosant.

Sclerosing epithelioid fibrosarcoma is a rare tumor recently described. The histological presentation can be confused with certain soft tissue benign tumors and certain sarcomas. Metastatic spread is usually late in the natural course of the disease. We report a case of recurrent sclerosing epithelioid fibrosarcoma with pleural metastases which developed ten years after surgical resection of the primary tumor. The tumor was formed by small uniform round epithelioid cells with a clear cytoplasm. The tumor cells were strongly positive for vimentin. This clinical case is discussed in light of other cases reported in the literature.

[Smoking cessation in the pregnant woman: descriptive study in Limousin]. / Sevrage tabagique chez la femme enceinte : étude descriptive en Limousin.

OBJECTIVE: Among obstetricians and midwives, estimate the percentage of smokers, appraise the proportion of medical professionals who mention the subject of nicotine addiction to their pregnant patients, and assess the quality of the information delivered to patients as well as their own experience in the field of tobacology. PATIENTS AND METHODS: Between February and March 2002, 188 postal questionnaires were sent to obstetricians and gynecologists, midwives and midwife students of public hospitals in Limousin and private clinics in Limoges. RESULTS: The response rate was 75,5% (142 answers) and the median age was 37 years old (20-59). 43,6% of the respondents were current smokers. Patients' smoking habits would be asked for and the risks of tobacco smoking would be explained by the majority of praticians and midwives. Minimal counsel to be given was known and given by 34,4% of gynecologists an 26,5% of midwives. Smoking cessation counselling was never proposed by 62% of gynecologists and 79% of midwives. Seventy per cent of them did not have any specific training in the field of tobacology during their studies. DISCUSSION AND CONCLUSION: There seems to be a deficiency in smoking cessation help for pregnant women in Limousin. Specifics programs and trainings for obstetricians, gynecologists, as well as midwives should be organized.

[Diagnosis of lung cancer. Role of PET/CT fusion scan in lung cancer]. / Diagnostic des CBP. L'apport de la fusion TEP-TDM dans le diagnostic des cancers bronchiques.

Whole-body positron emission tomography (PET) with radiolabeled [18F]-fluoro-2-deoxy-D-glucose (18FDG) plays an important role in the diagnosis, staging, and management of lung cancer. The preferential accumulation of FDG in malignant cells assists in the differentiation of benign and malignant tissue. However, PET alone does not allow an accurate anatomic localisation of FDG uptake. The combination of PET with CT images improves the spatial resolution, sensitivity and specificity of the test. PET/CT, as with PET alone, is indicated for the diagnosis of pulmonary nodules as well as the locoregional and extrathoracic staging of non-small-cell lung cancer (NSCLC). In many published studies, PET/CT has been shown to be superior to CT alone, to PET alone, or to both imaging techniques used separately to evaluate pulmonary nodules or for staging NSCLC. Now, PET/CT imaging is being investigated in the staging and management of small-cell lung cancer, in radiation treatment planning, in response prediction following treatment and in the detection of lung cancer recurrence in NSCLC. PET/CT is likely to have an important role in the management of lung cancer. New machines are in development and new radiopharmaceutical agents must be assessed.

[Contribution of DNA chips in lung cancer: an update]. / Où en est l'apport des puces à ADN en cancérologie pulmonaire? Le point en juin 2002.

Progress in techniques and computer processing over the last few years have led to the development of new methods of molecular biology. These new methods allow rapid data processing, often allowing data to be shared via networks. An example of this new technology is the transcriptome analysis via a microarray chip. This chip allows analysis of a very large number of RNA messenger transcripts that can be used for diagnostic or prognostic purposes. The first applications in lung cancer have been aimed to distinguish pulmonary adenocarcinoma from other adenocarcinomas. Another approach is to use these chips as a diagnostic tool to identify genes with expressions specific for non-small-cell lung cancer. The early results have been promising and encouraging for future developments, particularly in the domain of applied therapeutics.