[Cross-sectional study of school integration of asthmatic children in a general population sample]. / Etude transversale de l'intégration scolaire des enfants asthmatiques issus d'un échantillon de la population générale.

AIMS: Asthma is one of the most frequently encountered chronic illnesses in children. The aim of the present study was to investigate the problem of integration of asthmatic subjects at school by assessing the reactions of parents and teachers, and also by considering the medical aspects. POPULATION AND METHODS: A cross-sectional random study was carried out during autumn 1994 including 4,251 primary school children aged between five and 14 years, and including teachers from 188 classes and 26 schools in Grenoble and its inner suburbs. The first screening questionnaire was completed by the parents, and data on 3,799 children were obtained; from this, 191 currently asthmatic children were identified. One hundred and forty-six parents of the identified asthmatics subsequently answered a second questionnaire on the severity of the illness and its effects on school attendance and educational activities. The 186 teachers from the schools involved were interviewed about their knowledge of the disorder, and about what they knew of the treatment and management of asthmatic children in school. RESULTS: It was found that the cumulative prevalence of asthma amounted to 7.6%, and that the prevalence over the previous 12-month period was 4.3%. Sixteen percent of the asthmatic children reported an asthma-associated school absence of more than six days during the six preceding months. In 45.2% of cases, physical exercise was responsible for an asthmatic attack, but premedication was used in only 21% of cases. Nine percent of the children had obtained a medical certificate which exempted them from participating in sports activities and physical exercise. Seventy-three percent of the parents had informed the teachers of their child's illness, but the information communicated was incomplete. It was found that the teachers did not have a thorough knowledge of the disorder, but that many of them (92.7%) would appreciate further information on the subject and on its management. Eighty-three percent of the teaching staff were unaware that the ministerial circular No. 93-248 of 22 July 1993 had been issued on the proposed management of chronic disorders at school, advocating a combined effort on the part of the parents, the child's physician, the school doctors and the teachers in setting up a concerted plan of action. CONCLUSIONS: This study has demonstrated that the school integration of asthmatic children remains problematical both as regards treatment and the pursuit of indoor and outdoor school activities. Integration could be improved by using parent-doctor-teacher liaison forms, thereby maintaining closer communication regarding the child's needs. When this is not sufficient, an individualized asthma management plan could be introduced in collaboration with the parents, doctors and teachers, which might result in improved treatment and integration of asthmatic children in school.

[Giant thymic lipoma: anatomical, radiologic and clinical aspects]. / Thymolipome géant: aspect anatomo-radio-clinique.

We report the case of a 51-year-old man who presents with worsening dyspnea at exercise caused by a large thymic lipoma (6 kg). We present the clinical, radiological, and spiral CT scan features of this rare and benign tumor and correlate them with the pathologic findings.

Accuracy of oximetry for detection of respiratory disturbances in sleep apnea syndrome.

STUDY OBJECTIVE: The cost and inconvenience of polysomnography make simplified techniques of screening desirable in the strategy of diagnosis of sleep apnea syndrome (SAS). We have evaluated, in a prospective study of 301 consecutive patients referred for suspected sleep disorders, an index (delta index) that detects apneic events by quantifying arterial oxygen saturation (SaO2) variability. SETTING: Regional sleep laboratory taking referrals from general practitioners and specialists. DESIGN: Classic polysomnography was the gold standard, with 15 apneas plus hypopneas per hour (RDI) being used as a threshold for definition of obstructive sleep apnea (OSA). Oximetry was recorded over the same night. Signal variability was quantified as a function of time, using digital processing of oximetric data. Sensitivity, specificity, and positive and negative predictive values of oximetry testing were calculated. A receiver operating characteristic (ROC) curve was constructed representing the comparative courses of sensitivity and 1-specificity at different thresholds of delta index. RESULTS: Three hundred one patients were included (age, 56 +/- 12 years). Their RDI was 30 +/- 24. For a delta threshold at 0.6, the sensitivity of oximetry for the diagnosis of OSA was 98% and the specificity was 46%. The positive and negative predictive values for diagnosing SAS were 77% and 94%, respectively. The three false-negative cases had a relatively high awake SaO2 (97 vs 93.9 +/- 2.8%), a moderate RDI (23.3 +/- 1.6), and were less obese than the other patients (body mass index: 25 +/- 3 vs 33 +/- 8). The 58 false-positive cases had an RDI of 8 +/- 4, an awake SaO2 of 93.1 +/- 3.6 vs 94.1 +/- 2.6 for the rest of the population (p = 0.01). Finally, the false-positive cases had more airways obstruction (FEV1/VC = 72 +/- 13 vs 77 +/- 15%; p = 0.026). Using a delta value of 0.8 leads to a sensitivity of 90% with 19 false-negative cases but with a higher specificity of 75%. CONCLUSIONS: A nocturnal oximetry test with a delta index below 0.6 is helpful in ruling out the diagnosis of SAS in patients being screened for this condition, as this yielded only three negative test results in 301 screening procedures.

Mechanism of gluconeogenesis inhibition in rat hepatocytes isolated after in vivo hypoxia.

Gluconeogenesis was studied in hepatocytes isolated from fasted rats submitted to 24 h of hypoxic exposure (inspired O2 fraction 0.1) or to room air. Hepatocytes from hypoxic rats compared with controls exhibited a lower gluconeogenic rate with lactate (5.1 +/- 0.3 vs. 7.2 +/- 0.3 mumol.min-1.g dry cells-1, P < 0.001) but not with dihydroxyacetone (9.1 +/- 0.3 vs. 9.4 +/- 0.4 mumol.min-1.g dry cells-1), suggesting involvement of the phosphoenolpyruvate-pyruvate cycle. Experiments with perifused hepatocytes from hypoxic and control rats showed a single relationship between phosphoenolpyruvate and glucose flux (JGlc) but two different curves when cytosolic oxalacetate was plotted against JGlc. The decreased phosphoenolpyruvate carboxykinase (PEPCK) activity in the hypoxic group (9.0 +/- 0.9 vs. 16.2 +/- 1.9 nmol.min-1.mg protein-1, P < 001) without change in the Michaelis constant further settled the involvement of this step. The significant decrease in PEPCK mRNA levels in livers from hypoxic rats led us to propose that in vivo hypoxic exposure inhibits gluconeogenesis at the PEPCK level by decreasing PEPCK gene transcription.

[Right to left shunts in the adult]. / Les shunts droite-gauche de l'adulte.

Right to left shunts in the adult in their usual location are either intraarticular or intrapulmonary, and are often congenital. The acquired intrapulmonary shunt of the cirrhotic is now well defined by the hepatopulmonary syndrome. The major complication of right to left shunts are paradoxical pulmonary emboli which are often more severe than haemoptysis or chronic hypoxia. The diagnosis of intracardiac shunts as well as intrapulmonary shunts is now easier, thanks to transoesophageal ultrasound associated with contrast. Pulmonary angiography enables the treatment of arteriovenous fistula to be carried out by embolisation, and also avoids any surgery.

[Acute eosinophilic pneumonia and the larva migrans syndrome: apropos of a case in an adult]. / Pneumopathie éosinophilique aiguë et syndrome de Larva migrans. A propos d'un cas chez un adulte.

Toxocariasis is a frequent disease in children, but the severe clinical manifestations are rare in the literature (diffuse interstitial pneumonia with hypoxaemia and acute severe asthma). The diagnosis is made thanks to the reliability of serological techniques (the ELISA test and using antigen excretion-secretion tests of the larvae of Toxocara canis). The authors report a case of acute severe eosinophilic pneumonia whose outcome was rapidly favourable following steroid therapy; the existence of positive Toxocara canis serology with a contamination risk of the patient in the domestic environment leads us to integrate the clinical picture into the larva migrans syndrome.

Muscular metabolism during oxygen supplementation in patients with chronic hypoxemia.

The effects of supplemental oxygen (O2) versus air on working calf muscle metabolism were studied in seven patients with stable chronic obstructive pulmonary disease (COPD) and chronic hypoxemia (PaO2 = 57 +/- 3 SE mm Hg) and seven age-matched control subjects. Oxygen and air were randomly administrated at 24-h intervals, and O2 flow rate was adjusted to correct hypoxemia (PaO2 = 87 +/- 4 mm Hg) in the COPD group. The relative concentrations of ATP, phosphocreatine (PCr), inorganic phosphate (Pi), phosphomonoesters (PME), and the intracellular pH (pHi) were determined with 31P magnetic resonance spectroscopy at rest, during a graded standardized and localized exercise protocol (360 active plantar flexions), and during recovery. In resting muscle no significant effect of added O2 was demonstrable in each group with regard to pHi, Pi/PCr, and ATP/(PCr+Pi+PME) ratios. Mechanical data were similar between the two groups and between the two tests during the whole exercise. The indices of muscular oxidative metabolism (Pi/PCr and pHi at the end of exercise and recovering PCr resynthesis rate) were impaired in the COPD group compared with that in the control group during air (all p < 0.05). All these parameters were significantly improved with added O2 in the COPD group (p < 0.05), whereas no similar effects were observed in the control group. However, these beneficial effects were incomplete since the exercising Pi/PCr ratio remained higher in the COPD group than in the control group during added O2. This energetic muscular impairment could correspond to tissular damage related to chronic hypoxemia.

Combination of 5-FU cisplatinum and hypofractionated irradiation followed by split-course radiotherapy in 47 patients with unresectable non small cell lung cancer.

Forty-seven patients with unresectable non small cell lung carcinoma, 15 stage IIIA, 31 stage IIIB, 1 stage IV (cervical lymphadenopathy) were treated with a combination of three courses of chemotherapy and hypofractionated irradiation followed after 3 weeks by split course radiotherapy. Each course was repeated every 3 weeks with the following sequence: Cisplatinum (CDDP) (20 mg/m2) was given in a 20-min infusion, followed by a 2-h infusion of 5-fluorouracil (5-FU) (400 mg/m2) on days 1, 2, 5 and 6. Radiation with a dose of 3 Gy on the target volume was given on days 3 and 4--in one fraction for the former 27 patients, in 2 fractions of 1.5 Gy for the latter 20 patients with a 6-h interval--after a 2-h infusion of 5-FU (400 mg/m2). The results remain disappointing: the objective response rate was 53%, the median survival was 10 months for the series, and the one-year survival 47%. The median survival was 14 months for IIIA, 10 months for IIIB and IV. Regarding the therapeutic regimen there seems to be less morbidity with 2 fractions per day for which the median survival is nearly the same at 10 months (1 fraction/day) versus 12 months (2 fractions/day).

[Long-term tolerability of formoterol in chronic obstructive bronchopathies]. / Tolérance à long terme du Formotérol chez des bronchopathes chroniques obstructifs.

Formoterol aerosol, a long-acting new beta 2-mimetic was administered over a year at a dose of 12 micrograms twice daily, to 62 chronic obstructive bronchitics of mean age 66 +/- 6 years and of whom the basal VEMS was at 12,801 +/- 0.59. Clinical tolerance of the product was good with undesirable effects in 13 patients, the most frequent being shaking. No untoward effect was seen on systolic or diastolic arterial pressure, or the heart rate over successive visits at 1, 3, 6, 9 months and one year. Electrocardiographic surveillance found in only four patients electrical abnormalities that may be due to Formoterol, these were patients without previous cardiac problems but of advanced mean age. Functionally, a significant improvement of basal VEMS was noticed from the 6th month. The VEMS improved significantly after administration of 12 micrograms on successive visits, without tachyphylactic signs. Well tolerated, with functional benefits, Formoterol is a promising product amongst the long-acting beta 2-mimetics. Its usefulness and limitations in the basic treatment of these chronic bronchopathies remains to be defined.

Basal cell (basaloid) carcinoma of the lung: a new morphologic and phenotypic entity with separate prognostic significance.

On review of 115 poorly or undifferentiated lung cancers from 671 lung tumors resected over a 7-year period, we have found 38 cases of basaloid carcinoma. The cardinal histopathologic features distinguishing this tumor from other non-small cell lung cancers are a lobular growth pattern of small cells with moderately hyperchromatic nuclei, with no prominent nucleoli, and with scant cytoplasm, a high mitotic rate, and peripheral palisading. Basaloid carcinoma was present in a pure form in 19 cases and the other 19 tumors were of a mixed, but prominent, basaloid type associated with squamous cell carcinoma, large cell carcinoma, or adenocarcinoma. The immunophenotype of basaloid cancers was close to that of basal bronchial epithelial cells, with a low level of expression of low molecular weight cytokeratins. Staining for neuroendocrine markers was infrequent and inconsistent. Ultrastructural study showed an absence of neurosecretory granules and the presence of some squamous and/or glandular differentiation. This morphologic and immunologic phenotype suggests that basaloid carcinoma is derived from a pluripotent reserve cell or a basal bronchial epithelial stem cell. This unique histologic form of lung tumor has a poor prognosis, with a median survival rate of 22 months for stage I and II disease. This justifies classification of basaloid carcinoma as a distinct form of lung cancer, separate from small cell lung carcinoma.

[A rare cause of upper digestive tract hemorrhage: an esophageal fistula in mediastinal tuberculous adenopathy]. / Une cause rare d'hémorragie digestive haute: la fistule oesophagienne d'une adénopathie médiastinale tuberculeuse.

We report a case of esophageal fistula of a tubercular mediastinal adenopathy revealed by melena and which was diagnosed partly by means of endoscopy and partly by scanning after carrying out endoscopic fistulography. Endoscopic ultrasound, which was carried out as a complementary examination, confirmed this diagnosis.

Changes in left ventricular ejection fraction during REM sleep and exercise in chronic obstructive pulmonary disease and sleep apnoea syndrome.

Nine patients, 4 with chronic obstructive pulmonary disease (COPD) and 5 with obstructive sleep apnoea syndrome (OSAS) were monitored during sleep, rest and exercise. Left ventricular ejection fraction (LVEF) was investigated using gated equilibrium 99mtechnetium ventricular scintigraphy during rapid eye movement (REM) sleep, during exercise, and during wakeful rest. Control wakeful rest periods used for comparison with a study state (either REM sleep or exercise) were always selected during the same circadian segment as that state. Myocardial stress thallium-201 scintigraphy was performed during, and 4 h after, exercise, and results were compared to a daytime rest period. Several patients had myocardial hypoperfusion despite a normal electrocardiographic (ECG) treadmill test. During REM sleep, all patients exhibited a significant change in LVEF (greater than 5%) compared to wakefulness. During exercise, 5 subjects increased their LVEF normally (greater than 5%) and 4 (1 COPD, 3 OSAS) decreased it. All patients had a similar change (increase or decrease) during REM and at maximal exercise. Our results suggest that REM sleep in COPD and in OSAS can produce a myocardial stress as great as that produced by exercise. We conclude that REM sleep, like exercise, is a state in which morbidity may become higher and that it may account for mortality in COPD and OSAS patients with compromised myocardial circulation.

Effects of captopril combined with oxygen therapy at rest and on exercise in patients with chronic bronchitis and pulmonary hypertension.

The aim of this study was to determine the effects of captopril combined with oxygen therapy on pulmonary hemodynamics and gas exchange in chronic obstructive pulmonary disease (COPD) patients with pulmonary hypertension. Eleven subjects, with severe airflow obstruction (FEV1/FVC: 42 +/- 11%) and chronic respiratory failure (PaO2: 54 +/- 6 mm Hg, PaCO2: 46 +/- 8 mm Hg) treated with long-term oxygen, underwent two successive hemodynamic and arterial gas studies, at rest and during exercise. All the studies were performed whilst the patients were breathing oxygen, at rest and during exercise and 1 h after intake of 12.5 mg of captopril. The second study was performed in 9 out of the 11 patients after 8 weeks of treatment with 12.5 mg captopril 3 times daily. At rest, there was no significant effect of captopril. Mean pulmonary arterial pressure (PAP) showed a trend towards decrease after 8 weeks treatment. During exercise, there was a statistically significant decrease of mean PAP, pulmonary capillary wedge pressure and total pulmonary vascular resistance, without any deleterious effect on blood gases. However, the clinical significance of these variations during exercise is poor. We conclude that a low dose of captopril associated with oxygen therapy has no significant clinical effect on pulmonary hemodynamics at rest and during exercise in COPD.

[Tracheo-bronchial granular cell tumors. Apropos of 4 cases]. / Les tumerus trachéo-bronchiques à cellules granuleuses. A propos de quatre observations.

We have seen four cases of granular cell tumor (Abrikossoff's tumour) and it is recalled that these tumours are most often discovered fortuitously by bronchoscopy in the tracheo-bronchial region because they have a non specific clinical presentation. The cytological and histological characteristics enable an accurate diagnosis but there are problems posed as to the histogenesis of these tumours. With a tumour with a slow progression regular surveillance with regular biopsies seems preferable as in certain cases the tumour regresses spontaneously or disappears after ablation with the forceps. A good alternative approach is destruction of the tumours with a laser in certain complicated forms which enables one to avoid surgical excision.

[The role of new medical imaging technics (TDM and MRI) in the diagnostic strategies of superior vena cava syndrome]. / Place des nouvelles techniques d'imagerie médicale (TDM et IRM) dans la stratégie diagnostique du syndrome de la veine cave supérieure.

Superior vena caval syndrome (VCS), is easily recognised in the advanced case, however in the early case without clinical signs its detection is much less easy. New techniques of medical imagery such as IRM and above all computer tomography (TDM) have shown an increasing place in the daily clinical practice of the respiratory physician; these enable an early diagnosis to be made and a work up of the aetiology of the syndrome of VCS. With TDM the obstruction of the VCS appears the sign of direct obstruction (thrombosis or extrinsic compression) and of a collateral venous circulation deriving some anastomoses from the brachio-cephalic venous trunk (TVBC) and the azygos system, the VCS and the inferior vena cava (VCI), the two TVBC at the junction of the median line principally by the suprasternal network and finally these portal systemics, by the veins from the anterior wall of the trunk and the accessory portal veins of the round ligament. IRM introduced more recently enables a direct vision of the causal lesion endo or extra luminally, enabling an early detection of the syndrome by showing signs of a slow down of the venous flow. But the detection of a collateral circulation seems more difficult to demonstrate by this method.

Pulmonary histiocytosis X with mediastinal lymph node involvement.

In this report, we describe a patient with the classic histology of pulmonary histiocytosis X, who had bilateral reticulonodular densities and mediastinal lymph node involvement. The diagnosis was confirmed by the use of electron microscopy and immunohistochemical markers (PS100, HLA-DR, and CD1), which allowed us to recognize the lymph node infiltration of X histiocytes. An association of mediastinal lymph node enlargement with pulmonary histiocytosis X has been reported but it has never been histologically documented.

[Can oximetry contribute to the detection of apnea? The use of a mathematical analysis of the oximetry signal]. / L'oxymétrie peut-elle contribuer à la détection des apnées? Apport du traitement mathématique du signal oxymétrique.

The aim of this study was to test the efficacy of nocturnal oximetry as a means of continuous recording of SaO2 in the identification of apnoeic events in the recognition of non-apnoeic desaturation. The oscillations of SaO2 in relation to successive periods of apnoea during the course of the sleep apnoea syndrome (SAS) or with apnoeic episodes in patients with chronic airflow obstruction (BPCO) or restricted disease, were identified using a new delta index quantifying the variations of SaO2 during the night. 26 successive patients in whom there was an indication for nocturnal oximetry were included in a prospective study comparing nocturnal oximetry and polysomnography during 34 nights. In the apnoeic patients we found a strong correlation (r = .85. p. less than .01) between the apnoeic period and the delta index. In BPCO the number of apnoea was correlated with the delta index (r = .96. p. less than .01). A minimal threshold of the delta index fixed at 1.5 was satisfactory for detecting apnoea if the initial SaO2 was less than 93%. The value of the adequate for affected detection ought to be fixed at .8 (95% sensitivity) when the initial SaO2 was greater than 93%. A detection of apnoeic events thus seems possible by this method.

[Effect of nebulized salbutamol in 26 patients hospitalized for asthma attack]. / Effets du salbutamol nébulisé chez 26 sujets hospitalisés pour attaque d'asthme.

Twenty-six asthmatic patients who were hospitalised following an acute asthmatic attack and who had a peak expiratory flow of less than 50% predicted, without hypercapnia, received 5 mg. of salbutamol delivered by a micronebulizer LSA on admission (HO). At H1, 10 mg of additional salbutamol were nebulised in cases where there had been an increase of less than 20% of the PEF. At H2, all the subjects received steroid therapy. Group 1 in which success was defined by an increase of 20% of peak flow judged at H1 and H2, and group II where the increase in peak flow was less than 20%. Group II benefited at H2 by treatment with theophylline or salbutamol intravenously given in a randomised fashion. At H8 the 2 treatments were associated in group II in cases of failures. 15 men, and 11 women aged 40 +/- 17 suffering from severe asthma (65% of Charpin Stage IV) were included. The mean peak flow at HO was 32 +/- 9% of the predicted PEF. 21 subjects, or 81% improved their peak flow by more than 20% at H2. The toleration for salbutamol was very good from the cardiovascular point of view. At HO there was no clinical criteria nor peak flow assessment which would enable one to predict the failures from nebulized salbutamol for a given subject. Nevertheless a level of dyspnoea of greater than 5 on Borg's scale and a peak flow of less than 150 l/min made failure likely.(ABSTRACT TRUNCATED AT 250 WORDS)