[Cervical pain radiating to the upper limb]. / Cervicalgies irradiant dans le membre supérieur gauche.

A 31 years old male, HIV negative, with past history of sarcoidosis with articular and pulmonary involvement, without immuno-suppressive therapy, presents two years later with cervical pain radiating to the upper limb. Cervical imaging shows several para vertebral collections and lytic bone lesions. A diagnosis of tuberculous osteo-arthritis is established based on imaging and mycobacterial data.

Un homme de 31 ans, HIV négatif, ayant des antécédents de sarcoïdose avec atteinte articulaire et pulmonaire, sans traitement immuno-supresseur, présente deux ans plus tard des cervicalgies à gauche avec irradiation au niveau du membre supérieur. L'imagerie cervicale documente plusieurs collections para-vertébrales ainsi que des lésions lytiques osseuses. Un diagnostic d'ostéo-arthrite tuberculeuse est posé sur base de l'imagerie et des prélèvements mycobactériologiques.

Acute coronary syndrome and platypnoea-orthodeoxia with thoracic and interauricular septal aneurysms.

OBJECTIVE: Platypnea-orthodeoxia is a rare syndrome characterized by dyspnea induced by the upright position and relieved by supine position and an arterial deoxygenation increased by the upright position which improves during recumbency. Several anatomical factors that can alter the atrial anatomy and facilitate shunting through an interatrial defect have been related to this syndrome. In many cases, this syndrome has been associated with patent foramen ovale (PFO) and right-to-left shunt. Rarely platypnea-orthodeoxia syndrome has been described associated with an aortic and with an interauricular septal aneurysm too. CASE PRESENTATION: We present a case of platypnea-orthodeoxia syndrome in a 85-year-old woman with patent foramen ovale, interauricular septal aneurysm and ascending aortic aneurysms who was admitted for an acute coronary syndrome which could be of embolic origin and was responsible for ventricular fibrillation during the transfer to the hospital. PFO closure was performed by percutaneous device and right coronary artery obstruction was treated by transluminal angioplasty and stenting.

[Management of chronic cough]. / La prise en charge de la toux chronique.

Chronic cough, defined as lasting more than 8 weeks, is a frequent and difficult problem. Since 1981, the north American group of Irwin and coworkers has proposed a diagnostic algorithm with chronic cough being explained in a vast majority of cases by three possible diagnoses: asthma, chronic rhino-sinusitis and gastrooesophageal reflux. This algorithm has been amended in order to include eosinophilic bronchitis and has further been severely criticized because of frequent failure in clinical practice. In 2008, Pavord and Chung have proposed to put the emphasis in chronic cough on non specific cough hyperreactivity, with the aetiological factors suggested by the Irwin group acting at most as modulating agents. Severe or persistent chronic cough should be quantitatively assessed, using for instance a visual analogue scale or a cough specific quality of life questionnaire. Where treatment for chronic cough is concerned, the sole definitely effective interventions are smoking cessation and discontinuation of a converting enzyme inhibitor. Long term inhaled steroids are also effective in case of eosinophilic cough (defined on basis of eosinophilia in induced sputum or increased level of exhaled NO). In case of chronic cough unresponsive to the hereinabove described management, an antitussive agent should be considered. As codeine is relatively ineffective, research about new antitussive agents should be encouraged.

CPAP with algorithm-based versus titrated pressure: A randomized study.

BACKGROUND: Our goal was to evaluate whether an algorithm-prescribed pressure is effective in sleep apnea-hypopnea syndrome (SAHS) patients requiring continuous positive airway pressure (CPAP). METHODS: SAHS patients with an apnea-hypopnea index (AHI)>20/h were selected for a parallel group randomized study including an in-sleep laboratory acute phase and a domiciliary chronic phase. After baseline polysomnography, patients had a second night polysomnography either with CPAP at the algorithm-calculated pressure, followed by home treatment at this pressure without any correction or adjustment (calculation group), or with auto-CPAP titration, followed by home treatment at the pressure judged to be optimal from the auto-titration (titration group). The primary outcome was the change in Epworth sleepiness scale (ESS) at 6 months. RESULTS: The calculated pressure (mean (SD)) was 7.0 (1.4) in the calculation group (n=33), while the optimal pressure was 7.0 (2.2)cmH(2)O in the titration group (n=36). During the 6-month treatment at home, the ESS decreased from 8.3 (4.9) to 5.4 (4.0) in the calculation group (n=20) and from 8.7 (5.4) to 6.4 (5.4) in the titration group (n=20) (between-group difference not significant). CONCLUSION: In these SAHS patients with moderate sleepiness treated with CPAP, we found no difference in effectiveness between an algorithm-based pressure and an auto-titrated pressure.

[Three pregnancies on nasal CPAP: a case report]. / Trois grossesses sous CPAP nasale: à propos d'une observation.

We report on a sleepy woman, suffering from morbid obesity, with a diagnosis of severe sleep apnea syndrome made at the age of 30 year, treated with nocturnal ventilatory support (nasal CPAP). The patient had an history of preeclampsia during a first pregnancy. In the following years, this patient remained very compliant with nasal CPAP, was no longer sleepy and was three times pregnant, without any complication.

[Drug therapies of COPD]. / Traitements médicamenteux de la BPCO.

In patients with COPD bronchodilators improve lung function to some extent and relieve dyspnoea. Within short-acting bronchodilators, ipratropium (anticholinergic agent) is as effective as salbutamol (sympathomimetic agent) with fewer adverse effects. Presently, maintenance therapy is based on long-acting inhaled bronchodilators. Tiotropium (anticholinergic agent) once a day has a better efficacy to adverse effects ratio than salmeterol or formoterol (sympathomimetic agents) twice a day. Inhaled steroids (fluticasone, budesonide) are also able to improve lung function slightly and to relieve symptoms, but have no beneficial effect on the accelerated rate of decline in lung function that characterizes COPD. A short course (10 days) of systemic steroids is useful to treat an exacerbation. On the other hand, potential toxicity of oral steroids is a definite contra-indication for maintenance therapy.

[Dyspnoea and perception of airway obstruction]. / Dyspnée et perception de l'obstruction des voies aériennes.

INTRODUCTION: Dyspnoea, defined as the perception of difficult or laboured breathing, is ideally quantified, using a visual analogue scale or a Borg scale. STATE OF THE ART: In recent years several studies have explored the correlation between dyspnoea and the degree of airway obstruction, in both healthy subjects and patients with asthma or COPD. In these studies dyspnoea was measured in baseline state, following induced broncho-constriction or during application of an external resistive load. Dyspnoea was measured using a previously validated scale or, in some studies, a simple numerical score. The lung function variables most frequently used to evaluate the degree of correlation with dyspnoea were FEV1, and PEF, although other variables were used in some studies. Despite this marked heterogeneity in the methods used, several studies strongly suggested that, in subjects with COPD, perceived subjective improvement after an inhaled bronchodilator agent correlated with improvement of inspiratory variables. In asthmatics, the major finding was that some subjects had a very poor perception of their level of airway obstruction, a potential risk factor for severe exacerbations. PERSPECTIVES: Further normative studies are needed to define how healthy subjects perceive airway obstruction. CONCLUSIONS: The relationship between dyspnoea and lung function in obstructive disorders has to be evaluated separately in asthmatics and in COPD patients.

High leg motor activity in sleep apnea hypopnea patients: efficacy of clonazepam combined with nasal CPAP on polysomnographic variables.

The association of sleep apnea hypopnea syndrome (SAHS) with high leg activity in the same patient is a dilemma for the physician, as clonazepam, used to treat periodic leg movement syndrome (PLMS) can aggravate apneas, while nasal continuous positive airway pressure (nCPAP) can exacerbate PLMS. The present study aimed to compare nCPAP alone (n), nCPAP combined with clonazepam (n+c) and clonazepam alone (c) in patients with mild to moderate SAHS associated with high leg activity. Fourteen patients with an apnea hypopnea index (AHI) between 10 and 50 h(-1) and a leg movement index with regard to time in bed [LMI (TIB)] > 15 h(-1) on baseline polysomnography (b) were recorded on three consecutive nights with n, n+c and c, respectively. Leg movements were detected, using actigraphy, and were subsequently categorized into periodic, apnea- or hypopnea-related and nonperiodic movements (defined as neither periodic nor related to a respiratory event). The three treatments were successful in improving breathing [AHI b 26.1 (3.2) n 11.8 (2.4) n+c 5.0 (0.7) c 14.9 (1.8) h(-1)], leg activity [LMI (TIB) b 391 (4.8) n 22.5 (4.4) n+c 23.9 (3.9) c 22.6 (3.7) h(-1)] and sleep fragmentation [stage shift index b 373 (2.6) n 28.6 (1.6) n+c 25.6 (1.8) c 26.6 (1.6) h(-1)]. All types of movements were reduced, the effect being significant for respiratory events related and nonperiodic movements. Combination therapy was more effective than nCPAP alone in reducing the AHI and in improving sleep efficiency. We conclude that in patients with mild to moderate SASH associated with high leg activity, nCPAP improves nocturnal breathing and clonazepam reduces leg activity. More unexpectedly nCPAP is beneficial on leg activity and clonazepam on breathing, probably through a decrease in sleep fragmentation. The best results are obtained with combination therapy.

[The pneumology department]. / Le Service de Pneumologie.

The department of pneumology of the Erasme hospital exists since 25 years. The basic clinical activities include pulmonary function testing (7,500 patients per year), endoscopy, including interventional endoscopy (1,500 patients per year), thoracic oncology, allergology, rehabilitation and aid to smoking cessation. The following expertise fields have been largely developed: lung transplantation, treatment of cystic fibrosis in collaboration with the children's hospital Reine Fabiola, occupational.

Does an IV bolus of methylprednisolone relieve dyspnea in asthma exacerbations?

STUDY OBJECTIVES: To assess whether IV methylprednisolone exerts a specific early effect on dyspnea in patients with an exacerbation of asthma. DESIGN: Randomized, placebo-controlled, double-blind crossover trial. SETTING: Medium-sized university general hospital. PATIENTS: Twenty-five asthma patients attending the chest clinic with spontaneous complaints of increases in dyspnea and with a Borg scale dyspnea rating >/= 1 at rest. INTERVENTIONS: At 0 min, IV methylprednisolone (125 mg) vs saline solution; at 60 min, 5 x 500 microg terbutaline inhaled from an inhaler device. MEASUREMENTS AND RESULTS: Change in dyspnea was assessed with bipolar visual analog scale (VAS) (much more short of breath, -100%; much less short of breath, + 100%), FEV(1), and visual memory (using the Benton visual retention test). Eighteen subjects (mean age, 61 years) completed the study. At 5 min and 60 min, shortness of breath improved with no statistically significant difference between saline solution and methylprednisolone. The mean (SD) VAS rating at 60 min was 29% (39%) on the day that saline solution was administered and 36% (25%) on the day the steroid was administered. FEV(1) and Benton score did not significantly change from baseline on either study day. Shortness of breath and FEV(1) improved following terbutaline administration, with no significant difference between the days on which saline solution and the steroid were administered. In the seven subjects who were randomized to receive methylprednisolone on the first day, baseline dyspnea rated on the Borg scale was significantly lower on the second day (first day: median, 3; range, 3 to 4; second day: median, 2; range, 0.5 to 3; p = 0.040). CONCLUSIONS: We conclude that in patients with an exacerbation of asthma, an IV bolus of methylprednisolone does not reduce dyspnea more than saline solution after 5 min and 60 min.

Mild to moderate sleep respiratory events: one negative night may not be enough.

STUDY OBJECTIVES: Reports on the reproducibility of apnea-hypopnea indexes (AHIs) across sequential polysomnography (PSG) sessions are conflicting, leading to a lack of clear recommendations on the optimal use of this technique: is one night of monitoring sufficient or is a second night required in order to safely reject the diagnosis? DESIGN: Retrospective comparison of two consecutive nights. SETTING: Sleep unit of a tertiary-care facility. PATIENTS: Two hundred forty-three subjects with suspected sleep apneas. INTERVENTIONS: Two sequential PSG sessions in a sleep unit. MEASUREMENTS AND RESULTS: Using analysis of covariance for repeated measures, with age and body mass index as covariates and gender as a cofactor, a classic first-night effect was found for sleep variables. In addition, a night effect was demonstrated for sleep respiratory variables. Moreover, the high variability of AHIs showed that many patients had their condition diagnosed on only one of the two nights, and more often on the second night than on the first. The gain in detection by adding a second night when the results of testing on the first were negative was between 15% and 25%, according to the AHI obtained on night 1. CONCLUSIONS: Considering the disability associated with sleep apnea/hypopnea syndrome, as well as its global cost for society, the present study shows that it is worth performing two consecutive PSG sessions or at least a second one when the result of the first one is negative in all patients admitted for apnea detection.

Compliance with nasal continuous positive airway pressure assessed with a pressure monitor: pattern of use and influence of sleep habits.

The aim of the study was to assess compliance with nasal continuous positive airway pressure (N-CPAP) at home in patients with obstructive sleep apnoea syndrome (OSAS) and to search for predictors of compliance. We studied a cohort of 106 consecutive patients (91 men, 15 women) with a median apnoea hypopnoea index of 62.4 (range 21-132) h(-1), equipped at home with a Rem+ Soft device (Sefam, France), including a pressure monitor and a real-time clock. During the third and fourth months of treatment, the patients used their machine a median of 88% of days (16-100%), with a mean effective use of 5.6 (1.3-11.2) h per effective day. Residual apnoea index on N-CPAP, as recorded by the monitor, was 1.5 (0.3-27.6) h(-1). Mean clock-time for starting with N-CPAP was 23 h 54 min (21 h 34-01 h 42). The mean effective use per effective day correlated negatively with the minimal (and the mean) level of oxyhaemoglobin saturation (r(s) = -0.24, P < 0.05) while the percentage of days the machine was used correlated negatively with the percentage of slow wave sleep (r(s) = -0.22, P < 0.05) at baseline polysomnography. In a subset of 30 subjects, earlier start on N-CPAP correlated with longer use of the device in 22 patients (median r--0.48). We conclude that a pressure monitor allows reporting on compliance in terms of regularity (% of days the machine is used) and length of sleep on N-CPAP (effective use per effective day). These compliance variables show modest correlations with baseline polysomnographic features. Late bedtime should be discouraged as it might decrease compliance.

[The treatment of asthma]. / Traitement de l'asthme.

As asthma is a chronic, predominantly inflammatory process, maintenance therapy must be emphasized. It consists in most patients to regularly inhale a steroid agent (fluticasone or budesonide), in combination with non pharmacological interventions and occasional inhalation, as needed, of a short-acting sympathomimetic agent. When single therapy with an inhaled steroid is not sufficiently efficient, adding a long-acting sympathomimetic agent (salmeterol or formeterol) is recommended. Treatment of acute asthma includes repeated administration, at short interval, of an inhaled sympathomimetic agent (salbutamol or terbutaline) combined with oxygen and a systemic corticosteroid.

[Diagnosis of pulmonary embolism]. / Diagnostic de l'embolie pulmonaire.

A good knowledge of clinical presentation and of risk factors for pulmonary embolism is mandatory to improve adequate clinical suspicion. Some recent improvements in diagnostic strategy have to be emphasized. A low D-dimer level has a good negative predictive value to rule out pulmonary embolism. Ventilation-perfusion lung scan is the most often used imaging technique. In case of non diagnostic scan, serial non invasive search for deep vein thrombosis in the limbs is recommended by some experts at least in patients with good cardio-respiratory reserve, pulmonary angiography being recommended otherwise. Spiral CT allows direct demonstration of clots, being hardly less sensitive than pulmonary angiography except for subsegmental emboli. Future perspectives include the use of spiral CT as first choice procedure, as well as magnetic resonance imaging.

Disabling dyspnoea in patients with advanced disease: lack of effect of nebulized morphine.

The purpose of this placebo-controlled, double-blind, randomized study was to assess the effect of nebulized morphine on dyspnoea perceived at rest by patients with advanced disease. Seventeen hospital in-patients with disabling dyspnoea received isotonic saline or morphine via nebulization for 10 min through a mouthpiece, combined with oxygen via nasal prongs. On four consecutive days, they were given one of the four following treatments in random order: saline with 2 L x min(-1) oxygen; 10 mg morphine with 2 L x min(-1) oxygen; 20 mg morphine with 2 L x min(-1) oxygen; and 10 mg morphine without oxygen (prongs fixed, no flow). Dyspnoea was assessed on a bipolar visual analogue scale (VAS) (-100% much more short of breath, +100% much less short of breath), and arterial oxygen saturation (Sa,O2) and respiratory frequency (fR) were recorded at the end of nebulization and 10 min later. In 14 subjects who completed the study, mean VAS ratings 10 min after the end of nebulization ranged +30 to +43%, with no significant difference between the four study days (VAS 20 mg morphine minus VAS saline, 95% confidence interval (95% CI) -6 to +8%). Sa,O2 significantly increased on the 3 days with supplemental oxygen, and remained stable on the zero flow day. Respiratory frequency significantly decreased on the 4 days, with a trend to correlation between VAS rating and parallel change in respiratory frequency (Spearman's rank correlation coefficient (r(s))=0.46; p=0.09). We conclude that the subjects benefited from saline or morphine via a placebo effect and/or a nonspecific effect, and that nebulized morphine had no specific effect on dyspnoea.

[Sleep apnea and nocturnal ventilatory assistance (nCPAP): 5-year experience in the conventional system]. / Apnées du sommeil et assistance ventilatoire nocturne (nCPAP): cinq ans d'expérience dans le systeme conventionnel.

The reimbursement of nasal continuous positive airway pressure (nCPAP) by the Belgian social security, via a conventional system, has made since 1991 this treatment available to an increasing number of patients having moderate to severe sleep apnoea hypopnoea syndrome (SAHS). We have reviewed our experience in prescribing domiciliary nCPAP from 1991 to 1995. Three hundred twenty-five subjects with SAHS, predominantly male (89%) and/or obese (77%) subjects, have benefited. Mean use of nCPAP machine, assessed by reading the time counter, amounted 4.7 h per 24 h, with only 23% of non-compliant patients (use < 3 h per 24 h). In 205 patients nCPAP was effective in controlling SAHS-related symptoms. Cure, with successful weaning from nCPAP, was obtained in 16 patients, as a result of marked weight loss in 13 of them. Forty-six non-compliant subjects were not allowed by the physician to go on, and 40 subjects left nCPAP because of intolerance. Finally, 10 patients abandoned nCPAP because of inefficacy, ascribed to some associated condition, being predominant, and 8 patients died. Our results suggest that domiciliary nCPAP is an effective treatment for SAHS in a majority of subjects, but that this kind of treatment is prescribed lifelong, unless there is a marked weight loss. The Belgian conventional system, as it requires a regular follow-up, contributes to keep non-compliance within acceptable limits.

[The treatment of morbid obesity with gastroplasty]. / Traitement de l'obésité morbide par gastroplastie.

Morbid obesity is related to a severe decrease in life expectancy. No medical or dietary treatment offers an alternative to control hypertension, apnea syndrome, orthopedic diseases, ..., caused by overweight. With respect to a serious preoperative evaluation and a severe selection (psychologic, dietetic, ...) Silastic Ring Vertical Gastroplasty is considered in our experience (more than 300 cases) and in the literature as the gold standard for surgical treatment of obesity. The long term follow-up (24-66 months) of 100 consecutive operated patients shows a positive response on hypertension (96%), apnea syndrome (92%), diabetes (85%), gastroesophageal reflux (76%), orthopedic diseases (74%) and cardiorespiratory insufficiency (74%). Considering our experience in the medical and surgical management of patients operated in our department or referred from other centers for complications after different procedures, we actually propose SRVG as the treatment of choice for morbid obesity.

Tissue plasminogen activator, tissue plasminogen activator inhibitor and lipoprotein(a) in patients with coronary, epiaortic and peripheral occlusive artery disease.

In order to evaluate the relationship between the presence of atherosclerotic disease, documented by angiography, and the fibrinolytic profile, 262 consecutive patients affected by coronary (n = 90), epiaortic (n = 60) and peripheral (n = 104) artery disease have been included in the study. Twenty-two healthy subjects were used as controls for laboratory parameters determination. All patients were classified on the basis of the presence (S+) or absence (S-) of clinically significant stenosis, according to specific scoring systems. Lipoprotein(a), plasminogen activator inhibitor (PAI-1), tissue plasminogen activator (t-PA) and the PAI-1/t-PA ratio were significantly lower in controls than in coronary, epiaortic and peripheral artery disease patients. However, the levels of these parameters were not statistically different between S+ and S- subjects. These results confirm the association between lipoprotein(a), PAI-1 and t-PA levels and the presence of atherosclerotic disease independently of the arterial districts considered, while they do not appear to be directly linked to the severity of the morphological disease.

Clinical profile of ioversol. A metaanalysis of 57 randomized, double-blind clinical trials.

RATIONALE AND OBJECTIVES: The authors characterize the clinical profile of ioversol, specifically in terms of radiographic efficacy and clinical tolerance. METHODS: Metaanalysis of data from all available randomized, double-blind trials, comparing ioversol with other nonionic contrast media in indicated procedures was conducted. A total of 3854 adult patients were studied (1931 ioversol, 1923 reference) from 57 clinical trials. RESULTS: Ioversol was considered diagnostic in 99.3% of examinations, with good to excellent enhancement quality in 89.3% of cases. In comparative evaluations, there was a 24% odds reduction of the investigator's nondiagnostic judgment and a 15% odds reduction of poor to fair quality in favor of ioversol. For tolerance, 20.2% and 3.3% of patients in the ioversol group reported moderate to severe sensation of heat and pain with a 10% odds reduction and a 3% odds increase, respectively. The incidence of drug-related adverse events was low: 76 (3.3%) patients in the ioversol group and 62 (2.9%) patients in control group. No statistically significant differences were noted. CONCLUSION: Based on these findings, the high-contrast efficacy and patient tolerance make ioversol a suitable agent, equivalent to other nonionic contrast media.