[Medicolegal litigation in cases of occupational lung disease: Some practical tips]. / Le contentieux médical en pathologie professionnelle respiratoire : conseils pratiques.

Recognition and compensation for occupational diseases (OD) is based on the principle of presumption of occupational origin, provided that the disease meets the medical and administrative condition detailed in an OD table appended to the French social security code. A complementary system calling upon a regional committee for recognition of respiratory diseases (CRRMP, in French) attends to cases in which the medical or administrative conditions pertaining to the disease are not fulfilled. Decisions of health insurance funds may be appealed, by employer and employee alike, within the statutory timelines. That said, recent reform of social security litigation and the law of modernization of the justice system have thoroughgoingly modified appeal and redress procedures. Challenge of a decision of non-recognition of the occupational nature of a disease is now addressed to the social pole of the judicial tribunal (JT), which can request the assistance of a CRRMP other than the one that issued the first opinion. As for technical challenges having to do with the date of consolidation (date of the injury) or the degree of partial permanent incapacity (PI), they are put forward in a mandatory preliminary settlement proposal addressed to an amicable settlement board (CRA, in French), whose decisions can be contested face to the social pole of the JT. All judgments regarding medical litigations of social security may be appealed. Information for patients on compensation procedures and available means of remedying decisions by social security is essential to the establishment of the initial medical certificate and to the sequencing of the different phases of expert appraisals, the objectives being to avoid administrative incoherence and inappropriate legal recourse.

[Diagnostic difficulties of chronic pulmonary berylliosis in France]. / Difficultés diagnostiques de la bérylliose pulmonaire chronique en France.

INTRODUCTION: The epidemiology of chronic beryllium disease (CBD) in France is poorly understood. The aim of this study was to determine the number of prevalent cases of CBD in France between 2010 and 2014. METHODS: We conducted a national survey using a specific questionnaire distributed by the professional pathology services. RESULTS: In total, 33 CBD cases were reported in France, with a diagnosis established between 1982 and 2014. 85% (28/33) of CBD cases resulted from professional exposure and mostly concerned foundry workers (39%). A definite diagnosis defined by the association of an abnormal beryllium lymphocyte proliferation test and of a granulomatous inflammatory response in the lung, was obtained in 29/33 cases (88%). The other cases were probable CBD, defined by a granulomatous lung disease with a beryllium exposure, but without evidence of beryllium sensitisation. The diagnosis of granulomatous disease was confirmed a mean of 4 years after the end of exposure. The median delay between diagnosis of a granulomatous disease and diagnosis of CBD was 2 years (range 0-38 years). A genetic predisposition was found in 14 of 17 tested patients (82%). CONCLUSION: In this study, we report 33 cases of CBD followed in France between 2010 and 2014. The poor understanding of CBD and the exposure leading to it, the late development after the end of exposure, the complexity of the diagnosis and the similarities with sarcoidosis may explain the small number of cases reported.

[Evaluation of permanent disability levels in occupational pulmonary diseases]. / Comment évaluer en 2019 les taux d'incapacité permanente des pathologies professionnelles pulmonaires ?

Compensation for occupational pulmonary diseases requires the establishment of guidelines based on standardized and objective criteria, in order to provide compensation that is as fair as possible to patients who suffer from them. A review of the elements necessary for the examination of an individual file was carried out by a working group. It is accepted that respiratory functional exploration is the key element in assessing the level of permanent disability in all of these conditions, with the exception of thoracic malignancies. Guiding scales have been developed for the respiratory impairment of three types of conditions: occupational asthma, thoracic malignancy, and other respiratory diseases. Additional criteria for increasing the permanent disability level are also proposed in order to take into account professional prejudice, in particular the possibility or not of continuing the occupational activity, in the same job or after changing to another. For certain respiratory diseases, a periodic reassessment of the initially attributed permanent disability level is recommended as well as the initial one at the time of definitive cessation of occupational activity.

[Cavitating pulmonary infarcts revealing thromboembolic pulmonary hypertension]. / Infarctus pulmonaires excavés révélant une hypertension pulmonaire post-embolique.

Several etiologies are involved in the pathogenesis of cavitating pulmonary disease including neoplastic, infectious or inflammatory processes. Another is pulmonary infarction associated with venous thromboembolism. The lung cavities tend to be located peripherally and are the result of pulmonary embolism. We report the case of a woman with chronic thromboembolic pulmonary hypertension (CTEPH), associated with familial thrombophilia, revealed by cavitating pulmonary infarcts. CTEPH is sometimes diagnosed during an episode of recurrent pulmonary embolism following previously unnoticed lesions. Thrombophilias such as isolated elevated factor VIII are risk factors for CTEPH.

[Adult asthma exacerbations in questions]. / Les exacerbations de l'asthme de l'adulte en questions.

In this article a French working party critically review the international literature to revise the definition, pathophysiology, treatment and cost of exacerbations of adult asthma. The various guidelines do not always provide a consistent definition of exacerbations of asthma. An exacerbation can be defined as deterioration of clinical and/or functional parameters lasting more than 24 hours, without return to baseline, requiring a change of treatment. No single clinical or functional criterion can be used as an early marker of an exacerbation. Innate and acquired immune mechanisms, modified by contact with infectious, irritant or allergenic agents, participate in the pathogenesis of exacerbations, which are accompanied by bronchial inflammation. In 2010, mortality is related to progression of exacerbations, often occurring before the patient seeks medical attention. The objective of treatment is to control asthma and prevent exacerbations. However, many factors can trigger exacerbations and often cannot be controlled. The efficacy of inhaled corticosteroids has been demonstrated on reduction of the number of exacerbations and the number of asthma-related deaths. This treatment is cost-effective, especially in terms of reduction of exacerbations.

[Compensation for occupational respiratory diseases in France]. / Réparation des maladies respiratoires professionnelles en France.

Respiratory physicians must be aware of the administrative procedures for the compensation of occupational diseases in order to advise their patients. These procedures for declaration, recognition and compensation are dependent on the patient's social insurance. However, the general principles of this insurance coverage are similar. They are based on a "mixed" system: 1) a presumed cause, when the disease appears on a government list published in the national record (Journal Officiel), and if all administrative and exposure criteria described in that list are met, 2) a case-by-case opinion, with certain limitations, if the presumed cause does not apply. However, these procedures do not apply to self employed workers who do not benefit from occupational disease social insurance. Furthermore, patients with asbestos-related diseases receive additional compensation, the criteria for which are reviewed here: compensation funds and anticipated retirement.

[Prevalence of smoking cessation during pregnancy according to trimester]. / Taux de sevrage tabagique chez la femme enceinte en fonction des trimestres.

OBJECTIVE: To investigate the smoking cessation period during pregnancy. PATIENTS AND METHODS: Questionnaire-based, descriptive study of 979 pregnant women in four regions of France. The variables analysed included the characteristics of the mother and neonate at delivery, the smoking habits of the mother before and during pregnancy, the perception of risk linked to smoking, and the reasons for giving up smoking. RESULTS: Eighteen percent of women smoked until delivery. Forty-five percent of women gave up smoking during pregnancy, usually in the first trimester. More precisely, about one woman who smoked out of 50 gives up in order to prepare pregnancy. The proportion of women who stop smoking in each of the three trimesters of pregnancy is 84,1, 8,8 and 7,1% respectively. DISCUSSION AND CONCLUSION: Most women appear to stop smoking before any intervention therapy is possible. The first contact with a midwife or an obstetrician takes place whereas smoking cessation is already successful.

[Obstetrical ultrasound screening and motivation to stop smoking]. / Echographies obstétricales et motivation à l'arrêt du tabac.

OBJECTIVES: To evaluate whether ultrasound screening during pregnancy increases the ability to stop or reduce smoking. MATERIALS AND METHODS: This multicenter questionnaire study was performed to describe smoking characteristics among pregnant women and evaluate the factors that influence the ability to reduce smoking during pregnancy. Questionnaire-based, descriptive study of 979 pregnant women in four regions of France. The variables analyzed included the characteristics of the mother and neonate at delivery, the smoking habits of the mother before and during pregnancy, and the reasons for giving up smoking. RESULTS: We report only results about ultrasound scan. One third of women, who smoked at the start of pregnancy, reported that ultrasound was a positive tool to enhance motivation to reduce smoking. CONCLUSION: Ultrasound screening may be a positive factor to reduce smoking. Our study focused on motivation could give a tool in this way. However most women who stop smoking during pregnancy do so in the first trimester (84%) mainly before the first ultrasound exam. Thus, the routine ultrasound scan itself does not seem to influence attitudes to stop smoking any further. But it may be included in comprehensive and individualised anti-smoking support.

Physiological effects of indomethacin and celecobix: an S-transform laser Doppler flowmetry signal analysis.

Conventional signal processing typically involves frequency selective techniques which are highly inadequate for nonstationary signals. In this paper, we present an approach to perform time-frequency selective processing of laser Doppler flowmetry (LDF) signals using the S-transform. The approach is motivated by the excellent localization, in both time and frequency, afforded by the wavelet basis functions. Suitably chosen Gaussian wavelet functions are used to characterize the subspace of signals that have a given localized time-frequency support, thus enabling a time-frequency partitioning of signals. In this paper, the goal is to study the influence of various pharmacological substances taken by the oral way (celecobix (Celebrex), indomethacin (Indocid) and placebo) on the physiological activity behaviour. The results show that no statistical differences are observed in the energy computed from the time-frequency representation of LDF signals, for the myogenic, neurogenic and endothelial related metabolic activities between Celebrex and placebo, and Indocid and placebo. The work therefore proves that these drugs do not affect these physiological activities. For future physiological studies, there will therefore be no need to exclude patients having taken cyclo-oxygenase 1 inhibitions.

Empirical mode decomposition applied to laser Doppler flowmetry signals : diagnosis approach.

Empirical Mode Decomposition (EMD) is a recently introduced tool for decomposing signals into so-called intrinsic mode functions (IMF). These IMF represent the data by means of oscillating waves with local zero mean. In some sense the decomposition can be compared with a time-varying filter bank, i.e., signals are decomposed using band limited filters with band widths that vary in time. The main attribute of EMD compared to other time-frequency tools is that it does not use any predetermined filters or transforms. It is therefore a self-contained method that preserves the physical properties in the separate IMF, explaining why it has been successfully applied in many engineering fields. This method is applied here on laser Doppler flowmetry signals and particularly on the hyperemia signals. Two interested hyperemia parameters are the maximum perfusion value and the corresponding time instant of appearance. Accurate values parameters are determined from the fifth IMF component. Computing these parameters allows us to improve diagnosis of some pathologies as peripheral arterial occlusive diseases.

Reactive airways dysfunction syndrome caused by bromochlorodifluoromethane from fire extinguishers.

Although the neurological and cardiovascular effects of Freons have been extensively described, the respiratory effects have been less well documented. We report four cases of occupational asthma following accidental exposure to bromochlorodifluoromethane (Halon 1211) due to release of the contents of a fire extinguisher. All subjects developed an irritative reaction of the upper airways and lower respiratory symptoms immediately after exposure. Non-specific bronchial hyperreactivity was present for at least two months in all subjects and was still present more than two years after exposure in one case. The diagnosis of reactive airways dysfunction syndrome can be adopted in at least three of these four cases.

[A patient with pulmonary endometriosis]. / Une observation d'endométriose pulmonaire.

A 30-year-old woman consulted for recent repeated episodes of hemoptysis occurring at the onset of the menses a few months after interruption of estrogen-progesterone treatment. This patient's only surgical history involved uterine curetage. She was a smoker and had cumulated 10 pack-years. Physical examination and chest x-rays were normal. Bronchial endoscopy and cytological examination of the bronchial aspiration were normal. Thoracic CT demonstrated an alveolar image in the right lower lobe. A second CT performed later after resolution of the episode of hemoptysis was normal. Laparoscopy was performed and visualized an endometrial nodule in the pelvis which was removed. The patient's clinical signs disappeared after treatment with triptoreline. Bronchopulmonary endometriosis is an uncommon condition. The main manifestations are catamenial hemoptysis during the first days of the menses. Chest pain is exceptional. Diagnosis may result from an incidental discovery. A traumatic intervention on the uterus is often found in the patient's history. The most commonly proposed pathogenic mechanism involves hematogenic migration following a uterine procedure. Imaging does not disclose specific signs and bronchial endoscopy is often normal but may demonstrate a tracheal or bronchial plaque of endometriosis, or exceptionally endometrial tissue in the endoscopy biopsies. LH-RH agonists remain the current treatment.

[Evaluation of occupational exposures in lung cancer]. / Evaluation des expositions professionnelles et cancer bronchopulmonaire.

Occupational lung cancers are underestimated by the number of cases compensated in the French National Insurance System. Rules of compensation of occupational diseases were recently modified in France. Therefore a study was conducted on incident cases of lung cancer in a general hospital in the Paris area. The aim was to evaluate the exposure to carcinogens using data of a detailed specific occupational questionnaire, and to determine the number of cases who could receive compensation. Two hundred and seven subjects (171 males, 36 females, mean age = 64.5 years) were eligible in 1996, and 122 had an occupational questionnaire. Definite exposure to one or more occupational carcinogens in at least one job was identified in 50 subjects, the most frequent agent was asbestos (42 subjects). Claim for compensation was done in 32 subjects, mainly for asbestos (30 subjects). This study emphasizes the frequency of occupational exposure to carcinogens, and the usefulness of systematic occupational questionnaire in subjects having lung cancer. Social and financial consequences are important for these subjects. Further studies are needed, with recruitement of control subjects to allow calculation of the attributable risk to occupational factors in lung cancer.

Use of wavelets to accurately determine parameters of laser Doppler reactive hyperemia.

Laser Doppler flowmetry (LDF) is a noninvasive method to monitor skin perfusion and is very useful in studying reactive hyperemia signals. For this latter case, the determination of peak flow (pLDF) and time to peak flow (tpLDF) is of great interest in discriminating between subjects with peripheral arterial obliterative diseases and those who are healthy. However, the myogenic mechanism provokes marked oscillations on all LDF signals. Therefore, an accurate detection of the parameters is very difficult. The present study shows that wavelets are a powerful tool to overcome this drawback. Six different processes using several wavelets are tested on 44 signals recorded on 11 healthy volunteers. The results prove that thresholding coefficients of a multilevel wavelet decomposition does not allow a valuable computation of the parameters but that the reconstruction of the approximation branch is an efficient method to accurately determine pLDF and tpLDF. Using this latter method, mean results for a 3-min occlusion give pLDF = 46.80 a.u. and tpLDF = 17. 08 s. For a 2-min occlusion, pLDF and tpLDF are 39.19 a.u. and 11.63 s, respectively. For a 1-min occlusion, the results give pLDF = 36. 01 a.u., tpLDF = 8.48 s. Eventually, for a 30-s occlusion they give pLDF = 33.86 a.u. and tpLDF = 5.60 s. These results can now be compared with those obtained on pathological subjects.

Simplified model of laser Doppler signals during reactive hyperaemia.

Laser Doppler flowmetry (LDF) is a non-invasive method to measure tissue blood flow. During reactive hyperaemia, the LDF signal increases to a peak and then returns to a resting value. A simplified model is developed to explain these variations. The emphasis is on simulating the effects occurring rather than on trying to mimic the anatomical structure of the microcirculation. A single blood vessel is therefore analysed. The increasing value of blood velocity is studied, and vasodilatation as well as vasoconstriction are taken into account. The model parameters are calculated using wavelets. For a 2-min occlusion on a healthy subject, the radius of the vessel is initially 15 microns, increasing to 24.6 microns at the peak, reached 14 s after the release of the occlusion. The model shows that the high value of the LDF signal during the initial phase of reactive hyperaemia is produced by an increasing number of erythrocytes in a cross-section, due to vasodilatation rather than an increase in moving blood cell velocities. Moreover, the rapidity of the vasodilatation and vasoconstriction effects determine the rapidity of the signal variations. The paper aims to give a basic solution to develop a numerical model.

Does peripheral blood T-lymphocyte population distribution in sarcoidosis provide a prognostic clue?

In its pulmonary form, sarcoidosis generally resolves spontaneously, but it may lead to fibrosis of the lung. The clinical, radiological and functional tests, as well as activity markers such as the serum angiotensin converting enzyme, intrathoracic uptake of 67Gallium and the cytological data provided by bronchoalveolar lavage are only the expressions at any given time of a disease which is constantly progressing and only partly express its evolutive potential. The authors studied the distribution of T-lymphocyte subsets in the peripheral blood and from bronchoalveolar lavage. 32 patients were included in the study. They were suffering from acute or chronic sarcoidosis of the mediastinum and lungs and were divided into 2 groups according to clinical, radiological and pulmonary function criteria; Group A (n = 19) included regressive forms (minimum follow up 2 years) and group B (n = 13) the progressive untreated forms. Lymphopenia with a decrease in the percentage of CD3 cells was found in both groups. The percentage of CD4 cells is significantly lower in group B (28 +/- 11%) than in group A (45 +/- 8%) (p < 0.01) or in the control population (46 +/- 8%) (p < 0.01). The percentage of CD8 cells is higher in group B (30 +/- 8%) than in group A (18 +/- 6%). This results in a CD4/CD8 ratio which is significantly reduced in group B (1 +/- 0.5) when compared with group A (2.72 +/- 0.8) (p < 0.01) and the control group (2.17 +/- 0.8) (p < 0.01), the difference between group A and the controls being minimal.(ABSTRACT TRUNCATED AT 250 WORDS)