The ETHICA study (part I): elderly's thoughts about intensive care unit admission for life-sustaining treatments.

PURPOSE: To assess preferences among individuals aged ≥80 years for a future hypothetical critical illness requiring life-sustaining treatments. METHODS: Observational cohort study of consecutive community-dwelling elderly individuals previously hospitalised in medical or surgical wards and of volunteers residing in nursing homes or assisted-living facilities. The participants were interviewed at their place of residence after viewing films of scenarios involving the use of non-invasive mechanical ventilation (NIV), invasive mechanical ventilation (IMV), and renal replacement therapy after a period of invasive mechanical ventilation (RRT after IMV). Demographic, clinical, and quality-of-life data were collected. Participants chose among four responses regarding life-sustaining treatments: consent, refusal, no opinion, and letting the physicians decide. RESULTS: The sample size was 115 and the response rate 87 %. Mean participant age was 84.8 ± 3.5 years, 68 % were female, and 81 % and 71 % were independent for instrumental activities and activities of daily living, respectively. Refusal rates among the elderly were 27 % for NIV, 43 % for IMV, and 63 % for RRT (after IMV). Demographic characteristics associated with refusal were married status for NIV [relative risk (RR), 2.9; 95 % confidence interval (95 %CI), 1.5-5.8; p = 0.002] and female gender for IMV (RR, 2.4; 95 %CI, 1.2-4.5; p = 0.01) and RRT (after IMV) (RR, 2.7; 95 %CI, 1.4-5.2; p = 0.004). Quality of life was associated with choices regarding all three life-sustaining treatments. CONCLUSIONS: Independent elderly individuals were rather reluctant to accept life-sustaining treatments, especially IMV and RRT (after IMV). Their quality of life was among the determinants of their choices.

[Targeted agents in the treatment of lung cancer]. / Place des traitements ciblés dans la prise en charge des cancers broncho-pulmonaires.

Lung cancer is in France, the leading cause of cancer death. Despite the dramatic advances that have allowed in a few years to go, for metastatic cancer, from a median survival without specific treatment of 4.5 months and now almost always more than one year, survival remains disappointing and further improvements are needed. Progress in the accumulated knowledge of the inner workings of normal and tumoral cells have paved the way for the development of targeted therapeutics called biological or simply targeted therapies. Two biological processes are already the target of marketed drugs, this is the way the receptor of epidermal growth factor (EGFR) and the path of neo-angiogenesis. It is almost assumed that, in the very near future, the inhibition of EML4-ALK will also be the subject of new drugs. In the medium term, it is conceivable that the molecular dissection of the tumors actually lead to the prescription of treatments tailored to mutations and other abnormalities that direct the growth of cancers.

[Epidemiology and delays in the management of 355 patients with lung cancer]. / Epidémiologie et délais de prise en charge de 355 patients atteints de cancer bronchique.

BACKGROUND: The epidemiology of patients with lung cancer in a Seine-Saint-Denis hospital are reported, as well as causes of diagnostic and therapeutic delays in their management. MATERIAL AND METHODS: Retrospective analysis of cases diagnosed from January 1, 1997 to December 31, 2003. RESULTS: Of 355 cases, 15.8% were women; the average age was 62 +/- 11. Mean smoking history was 50 +/- 24 pack years. Women were more likely to be non-smokers than men (16% and 1% respectively, p < 0.01) and were more likely to present at a young age (under the age of 50: 26.8% and 13.7% respectively, p < 0.05). Among women, adenocarcinoma was more frequent (41% vs. 25%, p < 0.05), and often presented with stage IV disease (74%). Squamous cell carcinoma occurred more frequently with increasing age (18.7% vs. 32.2% before and after the age of 60, p < 0.01). The median pre hospital, diagnostic and treatment delays were respectively 30, 10 and 9 days, the global delay from first symptom to treatment was 62 days. Surgery increased therapeutic delay by 20 days. CONCLUSION: Our results are complementary to those found in KBP-2000-CPHG study. Young women are diagnosed at a late stage. Influence of delays on prognosis is not proved and require others studies.

[Pulmonary nocardiosis and broncho-oesophageal fistula in a patient infected with HIV]. / Nocardiose pulmonaire et fistule broncho-oesophagienne chez un patient infecté par le VIH.

INTRODUCTION: We report a case of extensive pulmonary nocardiosis in a patient infected with HIV. CASE REPORT: It presented as bilateral cavitated masses and bulky necrotic mediastinal lymphadenopathy causing broncho-oesophageal fistulae. There was associated infection with Mycobacterium Avium. There was satisfactory progress following bipolar oesophageal isolation, nutrition via a jejunostomy and antibiotic therapy with co-amoxiclav. Healing of the fistulae after 11 months allowed surgical restoration of oesophago-gastric continuity. CONCLUSION: As with other bacteria, HIV can modify the clinical spectrum of nocardiosis.

[Home chemotherapy for lung cancer: a five year retrospective study]. / Chimiothérapie à domicile du cancer bronchique. Etude rétrospective sur cinq ans.

INTRODUCTION: We present the results of a five year retrospective study of chemotherapy delivered at home for patients suffering from non-small cell lung cancer. METHODS: In partnership with "hospital at home" we have developed mechanisms to improve safety: secured prescriptions, treatments confirmations transmitted by fax, designed specific chemotherapy file and approval of family doctor prior to administration. RESULTS: We treated 74 patients and administered 401 injections of which 72% were for Vinorelbine and 28% for Gemcitabine. These protocols corresponded to day 8 injections for Cisplatin-based double drug therapies in 47% of cases and to weekly single drug chemotherapies in 53%. CONCLUSIONS: Constraints regarding medical staff availability were exceeded by many advantages: better hospital bed management, guaranteed treatment, improvements in patients' quality of life and strengthening of links between hospital and community.

[Pleural trichomoniasis due to trichomonas tenax]. / Trichomonase pleurale à Trichomonas tenax.

Thoracic infections due to Trichomonas species often go unrecognised as they are seldom described in the literature. We describe a case that, to our knowledge, is the first reported case of empyema caused by this organism. A 59 year old man with metastatic adenocarcinoma of the lung developed a right pyopneumothorax following treatment with corticosteroids and radiotherapy. The pleural fluid was purulent and fetid, and contained large numbers of Trichomonas tenax amongst a mixed bacterial flora. Pleural drainage and antibiotic therapy with metronidazole, ciprofloxacin and gentalline were instituted immediately, but the patient died 4 days later. Trichomonas tenax is part of the normal oral floral and may on occasions colonize the airways. It can thus become involved during aspiration pneumonia or cause pleural infection following the rupture of a pulmonary abscess. Such infection tends to be associated with concurrent respiratory pathology or with immunodepression. The significance Trichomonas tenax when found in the airways is unclear and their pathogenic role is discussed.

Short-term and long-term epoprostenol (prostacyclin) therapy in pulmonary hypertension secondary to connective tissue diseases: results of a pilot study.

Continuous intravenous epoprostenol improves exercise capacity, haemodynamics, and survival in severe primary pulmonary hypertension. Pulmonary hypertension can also be life-threatening in patients with connective tissue diseases. In a prospective open monocentre uncontrolled study, the effects of epoprostenol were evaluated in patients with severe pulmonary hypertension secondary to connective tissue diseases who were unresponsive to oral vasodilators (including calcium channel blockers) and continued to be in the New York Heart Association (NYHA) functional class III or IV despite conventional medical therapy. Seventeen patients received epoprostenol administered by a portable infusion pump associated with conventional therapy (oral anticoagulants, diuretics, supplemental oxygen). During the first six weeks of therapy, two (12%) patients died, of pulmonary oedema (n = 1) and severe sepsis (n = 1). In the fifteen remaining subjects, clinical and haemodynamic parameters improved significantly at six weeks. These patients were subsequently monitored for 80+/-48 (range 14-154) weeks after initiation of epoprostenol. Five (33%) patients died, of right heart failure (n = 2), severe sepsis (n = 2) or syncope (n = 1) and two patients were successfully transplanted 24 and 52 weeks after initiation of epoprostenol. Seven of the remaining eight patients had a persistent clinical improvement. Short-term epoprostenol therapy is effective in some patients with connective tissue diseases as demonstrated by better clinical status and haemodynamics at six weeks. However, this study reports several cases of early and late major complications including severe sepsis and pulmonary oedema. Additional information is needed to evaluate the benefit: risk ratio of long-term epoprostenol therapy in pulmonary hypertension secondary to connective tissue diseases.

Primary pulmonary hypertension associated with the use of fenfluramine derivatives.

Fenfluramine derivatives (Fds) are a well-established risk factor for primary pulmonary hypertension (PPH). We compared 62 Fd-PPH patients (61 women) evaluated in our center between 1986 and 1997 with 125 sex-matched PPH patients nonexposed to Fd referred during the same period (control PPH). In the Fd-PPH group, 33 patients (53%) used dexfenfluramine alone, 7 patients (11%) used fenfluramine alone, and 5 patients (8%) used both drugs. In 17 cases (27%), Fd use was associated with that of amphetamines. Most of the exposed patients used Fd for at least 3 months (81%). The interval between the onset of dyspnea and that of drug intake was 49+/-68 months (27 days to 23 years). At the time of diagnosis, Fd-PPH and control PPH were similar in terms of New York Heart Association functional class and symptoms. The two groups significantly differed only in terms of age (50+/-12 vs 40+/-14 years) and body mass index (28+/-6 vs 23+/-4). The two groups displayed similar severe baseline hemodynamics (total pulmonary vascular resistance: 32+/-12 vs 31+/-12 IU/m2), but the percentage of responders to acute vasodilator testing was higher in control PPH (27% vs 10%, p < 0.01). As a result, more patients were treated with oral vasodilators in the control PPH group (36% vs 16%, p < 0.01) and long-term epoprostenol infusion was more frequently used in the Fd-PPH group (52% vs 31%, p < 0.01). Overall survival was similar in the two groups with a 3-year survival rate of 50%.

Inhaled nitric oxide as a screening agent for safely identifying responders to oral calcium-channel blockers in primary pulmonary hypertension.

In a subset of patients with primary pulmonary hypertension (PPH), high doses of oral calcium-channel blockers (CCB) produce a sustained clinical and haemodynamic improvement. However, significant side-effects have been reported during acute testing with CCB. Therefore, to identify accurately patients who may benefit from long-term CCB therapy, there is a need for a safe, potent and short-acting vasodilator. The aim of this study was to compare the acute response to inhaled nitric oxide (NO) and oral high doses of CCB in 33 consecutive patients with PPH. A significant acute vasodilator response was defined by a fall in both mean pulmonary artery pressure and total pulmonary resistance by >20%. Ten patients responded acutely to NO, nine of whom responded acutely to CCB, without any complications. The 23 other patients failed to respond to NO and CCB. In these nonresponders, nine serious adverse events were observed with CCB (38%). There was no clinical or baseline haemodynamic feature predicting acute vasodilator response. Long-term oral treatment with CCB was restricted to the nine acute responders and a sustained clinical and haemodynamic improvement was observed in only six patients. In primary pulmonary hypertension, the acute response rate to high doses of calcium-channel blockers is low (27%). Serious adverse reactions to high doses of calcium-channel blockers during acute testing are frequently observed in nonresponders. It is concluded that nitric oxide may be used as a screening agent for safely identifying patients with primary pulmonary hypertension who respond acutely to calcium-channel blockers and may benefit from long-term treatment with these agents.