[Early detection of COPD in occupational medicine in the Alpes-Maritimes]. / Détection précoce de la BPCO en milieu professionnel dans les Alpes-Maritimes.

INTRODUCTION: This study evaluated a standardized procedure aiming at early detection of COPD in a consecutive population of employees visiting occupational medicine. METHODS: A total of 2818 employees were included by 22 occupational physicians in 5 centers. Respiratory symptoms, smoking status, occupational exposures and socioprofessional categories were collected. Subjects with at least one symptom and/or risk factor underwent spirometry. RESULTS: In this population aged 39±12 years, 2603 patients were free of known asthma or COPD. The presence of at least one symptom was observed in 23.6 % of employees and was significantly associated with smoking status, occupational exposure to organic dust, gas fumes and vapors, and agriculture (P<0.0001). Airflow obstruction (FEV1/FVC < 0.70) was detected in 1.7 % of 1605 employees who underwent spirometry. With the inclusion of known COPD subjects (n=22), the prevalence reached 2.38 %. COPD was significantly associated with smoking intensity. Information on subsequent diagnosis was obtained in only two cases. The quality of spirometry was inadequate in 30 % of cases. Thirty-three percent of detected COPD subjects did not report any respiratory symptoms. CONCLUSION: The strategy used in this study (specific questionnaire plus spirometry) allowed detection of a few cases of previously undiagnosed COPD. Occupational physicians need specific training in spirometry and a better follow-up of care pathways is required to obtain diagnostic confirmation.

Circadian rhythm in gamma glutamyltranspeptidase and leucine aminopeptidase urinary activity in rats.

Urinary gamma glutamyltranspeptidase (GGT) and leucine aminopeptidase (LAP), renal tubular brush border enzymes, have been shown to be sensitive indicators of renal tubular functions. This study documents circadian rhythms in the urinary activity of GGT and LAP, statistically validated and quantified by the cosinor method, in 15 male Wistar rats standardized to a LD 12:12 illumination schedule (light from 0800 hr to 2000 hr) and fed ad libitum. The acrophase of the circadian rhythms in urinary GGT and LAP activity occurred at the end of the rest span of the animals: between 1730 and 1915 for GGT (depending on the mode of expression of the activity) and between 1700 and 1910 for LAP. Of striking resemblance in their timing, both these rhythms were also of large amplitude (about 50% of the mesor for urinary GGT activity and about 45% for LAP one). The circadian acrophases of urinary GGT and LAP activity led in timing the circadian rhythms in urine volume and creatinine excretion by about 13 hr. Such findings consistent with the circadian variations found by other investigators in GGT in kidney homogenates or in LAP in human urine thus reflect a periodicity in renal tubular function. The reasons for these circadian variations, still unknown at this time, are discussed. The influence recently demonstrated of the hormonal context on protein and enzyme synthesis at the tubule, and its phase relations to urinary enzyme excretion emphasize how much the circadian rhythm in urinary GGT and LAP activity is well included in the murine time structure.(ABSTRACT TRUNCATED AT 250 WORDS)

[What is the value of tracheobronchial fibroscopy in the assessment of esophageal cancer?]. / Que faut-il attendre de la fibroscopie trachéo-bronchique dans le bilan d'un cancer de l'oesophage?

The aim of this study is to evaluate the role of bronchoscopy in the assessment of resectability of esophageal carcinomas. From 1981 to 1986, 125 patients were referred for a carcinoma of the esophagus. Bronchoscopy was performed in 105 cases. Patients were classified into 3 groups: group I: normal bronchoscopy (58 cases: 55.2%); group II: compression, localized inflammation (35 cases: 33.3%); Group III: invasion (12 cases: 11.5%). Tracheo-bronchial abnormalities were found whatever the site of the esophageal carcinoma: 60% of cases for the upper third, 40% for the middle third and 36% for the lower third. They were significantly more frequent when the esophageal tumor was larger than 5 centimeters. Correlation with CT scan was good in 75% of cases. Sensitivity and specificity of these two exams were similar and they appeared to be complementary. In group I, resection was impossible or palliative for bronchial reasons in 10% of cases, while resection was impossible or palliative in 35% of cases in group II. Lastly, resection was curative in 73.5% of cases in group I and in only 39% of cases in group II. Bronchoscopy must be systematically performed in carcinoma of esophagus. It may predict the palliative nature of resection if abnormalities are present, and may contraindicate the resection when invasion of the bronchial tree is discovered.

[Practical and technical aspects of noninvasive ventilation]. / Aspects pratiques et techniques de la ventilation non invasive.

INTRODUCTION: Noninvasive ventilation refers to the delivery of positive pressure ventilation via a mask or "interface" rather than via an invasive conduit. Until recently, equipment for noninvasive ventilation was frequently custom-made to meet the needs of an individual patient. During the past 15 years, there have been significant advances in the equipment available for noninvasive ventilation. STATE OF THE ART: Interfaces that have been designed specifically for noninvasive ventilation are now commercially available from several manufacturers. Commonly used interfaces include nasal and full face masks, and mouthpieces. The main characteristics, and potential advantages and disadvantages of each interface are described. Portable volume-limited or pressure-limited ventilators are available for home noninvasive ventilation. As with critical care ventilators, home mechanical ventilators are capable of delivering a variety of modes of ventilation. Furthermore, they are lightweight and economical. Technical aspects of ventilator circuits are also discussed here and some practical considerations about selection and maintenance of materials are proposed. CONCLUSIONS: Although major technical advances have been made, optimal delivery of noninvasive ventilation requires knowledge of, and experience with, the application of the equipment used.

[Compliance with long-term respiratory assistance in patients with chronic respiratory insufficiency]. / Observance de l'assistance respiratoire au long cours chez l'insuffisant respiratoire chronique.

The domiciliary treatment of severe chronic respiratory failure (I.R.C.) by oxygen or assisted ventilation was accomplished by members of a recently created national organisation (ANTA-DIR, 1980). This work reports the results of a survey carried out in Nice on 19 patients (12 men and 7 women) followed for more than a year. A questionnaire was filled in at the home of each patient, primarily to assess the functional outcome and the level of compliance of the therapy prescribed. We noticed and 86% drop in the number of days spent in hospital over a 2 year period. An analysis of the diary cards on the use of respiratory equipment, as well as oxygen consumption compared to the therapy initially prescribed, allowed an analysis of the degree of patient compliance. This was very good in only 3 out of 19 subjects and on average the prescribed therapy was followed for only two thirds of the time. However, a functional evaluation using simple clinical criteria showed a discernible improvement in 11 patients, who had a better quality of life and a greater autonomy since coming under supervision.

[Diagnostic and therapeutic approach in thromboembolism disease. Reflexions apropos of 105 cases]. / Attitude diagnostique et thérapeutique au cours de la maladie thrombo-embolique. Réflexions à propos de 105 malades.

105 patients suffering from thrombo-embolic disease (MTE) were explored by venography of the lower limbs, ilio-vena cavography and pulmonary angiography at the time of the initial diagnostic work up. These examinations served as a control for the different therapies, anticoagulants, thrombolytics, curative and preventive surgery, separately (77 controls) or in association (92 controls). From the base-line vascular investigations it appears that the gravity of the pulmonary emboli was not correlated with either a proximal or distal site of venous thrombosis. From the results of controlled therapy there were significant differences between the efficacy of medical treatment at the level of the pulmonary artery and at venous level where the progression of phlebo-thrombosis was often seen. Recurrence of emboli and overall prognosis of the disease usually depended on the persistence of thrombi at venous level. Such a phlebo-thrombosis is rarely aggravated by techniques of partial interruption of the inferior vena cava (IPVCI) which ensure effective protection of the pulmonary circulation. The IPVCI often appears to be the only effective method of preventing recurrent pulmonary emboli, which has led us to reconsider its indications.

[Prevention of pulmonary embolism by the Kimray-Greenfield filter. 22 cases]. / Prévention de l'embolie pulmonaire grâce au filtre de Kimray-Greenfield. Vingt-deux cas.

At present, the Kimray-Greenfield filter appears to be the best intraluminal method for preventing thromboembolism, as it is simple, effective and innocuous. The authors report their experience in the first 22 cases. They were surprised by the frequent problems encountered in installing the filter, especially by the femoral route. Two accidents occurred during the procedure: a filter introduced through the jugular vein migrated as soon as it was released, and a patient developed sudden and irreversible coma during passage of the guiding instrument behind the clavicle. Cavographies performed in 10 patients after one month or more disclosed two thromboses of the inferior vena cava and a tipped-over filter. Eight filters remained permeable. No recurrence of pulmonary embolism was observed.

[Indwelling transtracheal sound for oxygen administration in the patient with hypoxic chronic respiratory insufficiency]. / Sonde transtrachéale à demeure pour administration d'oxygène chez l'insuffisant respiratoire chronique hypoxique.

A new technique for administering oxygen to patients with severe chronic respiratory failure is reported. It consists of introducing a catheter, 2 mm in diameter, into the trachea between the second and third tracheal rings under local anesthesia. The technique was used in a 70-year old patient with severe chronic obstructive lung disease and resulted in significant reduction of dyspnoea, improvement in general condition with a weight gain of 6 kg in 6 months, and a 15 mmHg increase in arterial partial oxygen pressure for the same oxygen flow rate. This technique appears to be indicated for patients with chronic respiratory failure whenever dyspnoea is not adequately reduced by oxygen given through a nasal tube.

[Primary pulmonary arterial hypertension. Effects of vasodilators apropos of a case with a pulmonary biopsy]. / Hypertension artérielle pulmonaire primitive. Effets des vasodilatateurs à propos d'une observation avec biopsie pulmonaire.

A patient with primary pulmonary artery hypertension diagnosed by pulmonary arterial catheterisation, angiography and lung biopsy was the subject of several therapeutic trials of vasodilators. The short term and long term results over the next four years were on the whole disappointing. The type of study protocole used is discussed, as are the risks and cost.

[Impact of acute respiratory failure on survival of COPD patients managed with long-term non-invasive ventilation and oxygen therapy]. / Impact de la décompensation respiratoire aiguë sur la survie des BPCO prises en charge au long cours par ventilation non invasive et oxygénothérapie.

Our study aimed to assess the impact of acute respiratory failure (ARF) on survival of patients with chronic obstructive pulmonary disease (COPD) receiving long-term oxygen therapy (LTOT) plus nasal intermittent positive pressure ventilation (NIPPV). Survival was analysed retrospectively in 24 patients with severe COPD initiated to NIPPV in addition to LTOT. Fourteen patients were established on NIPPV following exacerbation of acute respiratory failure which has required mechanical ventilation (group 1). Ten patients (group 2) have never been hospitalized for ARF. Comparison of clinical details at baseline, 6 months, 1, 2, and 3 years for the two groups failed to reveal any difference with the exception of prior episodes of ARF. The probability of survival at 3 years was 65% (95% confidence interval [CI] 43-86) for the overall population, 46% (95% CI 15-77) in group 1, and 74% (95% CI 42-105) in group 2. The difference between the two groups was statistically significant. We show that ARF requiring mechanical ventilation appears to be a factor that is negatively correlated with survival for patients treated by LTOT plus NIPPV. This data suggests that NIPPV should be tried before ARF arising in COPD patients who present a deterioration in chronic respiratory failure with hypercapnia.

[Dyspnea with hypoxemia in a case of cirrhosis with portal hypertension]. / Dyspnée avec hypoxémie dans un cas de cirrhose avec hypertension portale.

Following insertion of a Leveen's valve after surgical portocaval anastomosis, a male patient with alcoholic cirrhosis developed dyspnoea with hypoxaemia. An interstitial syndrome was present in the lower lobes. Other findings were: polycythaemia (Hb 20 g/100 ml), subnormal spirometric values, decrease in CO transfer capacity, normal pulmonary compliance, absence of intracardiac shunt and pulmonary arterial hypertension and absence of bronchial or alveolar lesions on a surgical lung biopsy. Blood gas measurements and radioisotope explorations led to the conclusion that the patient had an anatomical shunt predominant in the lower parts of the lungs, associated with a shunt effect and a transfer disorder. The anatomical shunt was due to pulmonary arteriovenous microfistulae, some of which were visualized by superselective angiography. Catheterization of the portocaval anastomosis eliminated any shunt between the portal system and the pulmonary veins.

[Alveolar hypoxemic interstitial pneumonia related to rituximab therapy]. / Une pneumopathie alvéolo-interstitielle hypoxémiante associée à la prise de rituximab.

INTRODUCTION: Rituximab is indicated for the treatment of low-grade lymphoma. Pulmonary toxicity related to rituximab is exceptional. CASE REPORT: Here we report a patient with non-Hodgkin lymphoma treated with "CHOP" chemotherapy (cyclophosphosphamide, adriamycin, vincristine and prednisolone) and rituximab who developed an interstitial pneumonia with acute respiratory failure. The differential diagnosis of this clinical and radiological diagnosis is discussed. CONCLUSION: Although cases of interstitial pneumonia associated with rituximab are rare, they may be severe and thus any patient experiencing respiratory symptoms on this therapy should be monitored closely.

[Comparison of volume preset and pressure preset ventilators during daytime nasal ventilation in chronic respiratory failure]. / Etude comparative de respirateurs à régulation de volume et à régulation de pression au cours de la ventilation nasale diurne en situation d'éveil dans l'insuffisance respiratoire chronique.

Both volume preset and pressure preset ventilators are available for domiciliary nasal ventilation. Owing to their technical characteristics, it has been suggested that impaired ventilatory mechanics might cause a drop in the tidal volume (Vt) delivered by pressure preset devices, thereby placing mechanical ventilation at risk of inefficacy. We have assessed two ventilator systems (one pressure preset and one volume preset) with regard to the tidal volume and end-tidal carbon dioxide tension (PetCO(2)) changes that may be achieved in a group of awake patients with stable chronic respiratory failure (CRF). Eleven patients with stable CRF were ventilated in the assist/control mode for two consecutive one-hour periods. One ventilator was tested each hour, in random order. The VIGIL'AIR(R) system was used to record Vt, Respiratory Rate (RR), and Inspiratory/Expiratory ratio (I/E). The deviation E (E=preset value - measured value) was calculated for each measurement. Changes in PetCO(2) and arterial oxygen saturation were determined respectively by a capnometer and a pulse oximeter. Comparison of the mean deviation of Vt calculated for the two ventilators revealed a difference in patients with chronic obstructive pulmonary disease (COPD). The deviation was greatest with the pressure preset ventilator (PPV), which gave mean measured values higher than the mean preset values. The same comparison failed to reveal any difference in restrictive CRF. Comparison of the volume preset and pressure preset ventilators for RR, I/E and PetCO(2) did not reveal any difference. Compared to the volume preset ventilator, the efficacy of PPV to ventilate is not affected by the restrictive or obstructive nature of CRF. Our results show that pressure-preset ventilator is an adequate alternative to the volume-preset device for daytime non invasive ventilation in chronic respiratory insufficiency.

[Amoxicillin as a 1st choice: 275 acute focal pneumopathies treated on an outpatient basis]. / Amoxicilline en première intention: 275 pneumopathies aiguës en foyer traitées en ville.

From December 1986 to January 1988, 100 General Practitioners and Pneumologists working outside hospital included in open unmatched series 275 patients who were diagnosed as having pneumonia at home. The study consisted of 53.2% men with an average age of 49.3 plus or minus 19.3. Their temperature on the first day (J1) was in 72.7% of cases greater than 38.5 degrees Centigrade. The doctors felt that the general state was good in 66.5% of the cases. Cough was present in 83.5% of cases but was dry in one out of every two. The patients received Amoxycillin in a dose of 2 grams per day orally (66.9%), or by injection (33.1%). On the third day (J3) 90% of the patients had a temperature below 38.5 degrees Centigrade. Their general state was improved in 94.6% of cases. The diagnosis of pneumonia at home was confirmed radiologically on 219 of the films available, confirming the good specificity of the clinical diagnosis of pneumonia at home. Ten patients were hospitalised. The apparent treatment of Amoxycillin was given in 247 cases (89.8% of cases). In 28 cases (10.2%) the treatment was changed by the addition or substitution of a Macrolide (15), or another antibiotic (5), and in 80 cases a change of treatment was not specified. 25 of these 28 cases were reviewed on the 14th day (J14) and no failures were observed after the change of treatment. In 247 patients in whom the treatment with Amoxycillin was followed 336 were reviewed on the 15th day and there had been four failures. Three were intolerant to the drug and there was one relapse.(ABSTRACT TRUNCATED AT 250 WORDS)

[Pleural and subsequent peritoneal effusions of pancreatic origin. Pleural talc treatment as a cause?]. / Epanchements pleural et péritonéal successifs d'origine pancréatique. Le talcage pleural en cause?

A new case is described of a recurrent pleural effusion during the course of chronic pancreatitis. The diagnosis of the effusion was not established and a pleural talcage was performed. The pleurisy did not recur but a peritoneal effusion subsequently appeared. The potential responsibility of the pleural talcage was discussed.

[Value of the test of unilateral pulmonary artery blocking in the preoperative evaluation of bronchial cancer]. / Intérêt de l'épreuve de blocage unilatéral d'une artère pulmonaire dans le bilan pré-opératoire du cancer bronchique.

Results of the test of unilateral blockage of a pulmonary artery (UBPAT) were compared with those of respiratory function tests in the pre-operative investigation of 31 patients with bronchial cancer. Results were also compared with functional tolerance of patients treated by pneumonectomy. Follow-up hemodynamic explorations were performed postoperatively in eight of these patients. Values for pulmonary artery pressure obtained during the UBPAT appear to be much more discriminatory than the ventilatory parameters studied for predicting functional tolerance following pneumonectomy. Apart from some complexity in its performance this test appears to be a valid one, when associated with pulmonary angiography, for pre-operative investigation of bronchial cancer patients at high functional risk.

[Migration of the Kimray-Greenfield filter when inserting it]. / Migration d'un filtre de Kimray-Greenfield lors de sa mise en place.

Authors have reported a case of the migration of the Kimray-Greenfield filter to the right ventricle immediately after its release in the inferior vena cava. The delay in the spreading out of the filter seems to have been caused by its insertion into a coagulum formed in the socket guiding in through. This incident often encountered in pulmonary thromboembolism and caused by blood hypercoagulability, justifies higher precautions when inserting the filter.

[Long-term beta adrenergic antagonists in spastic bronchopathies]. / Les antagonistes bêta-adrénergiques au long cours dans les bronchopathies spastiques.

Beta-blockers are usually contra-indicated or reluctantly prescribed in cases of chronic obstructive bronchopathy. The aim of this study is firstly to show their tolerance in the long term in this pathology when the condition is stable and secondly to judge their efficacy in controlling side effects caused by bronchodilators (trembling, tachycardia) which are often administered at the same time. This study concerned 21 patients: 8 asthmatics and 13 spastic bronchitics, treated over a period of 4 months in a cross-over, double-blind test by 2 cardio-selective beta-blockers (2 months: betaxolol, 2 months atenolol). During the study, respiratory tolerance proved to be good and side effects of bronchodilators were controlled.

[Intravenous theophylline in the treatment of asthma attacks]. / La théophylline par voie intra-veineuse dans le traitement des attaques d'asthme.

Intravenous administration of theophylline for acute asthmatic attacks treatment requires statistical adjustment of the dosage. In the absence of a residual level the former one is of 6 mg/kg for the loading dose and 0.6 mg/kg/h for the maintenance dose. In case of non estimated residual rate, it's possible either not to use the loading dose, or to use a reduced dosage of 3 mg/kg. In both cases, the maintenance dose is 0.7 mg/kg/h. In future, rapid theophylline dosage technics should allow a more appropriate adaptation in emergency treatment.

[Significance and evaluation of theophyllinemia in clinical medicine]. / Intérêt et valeur en clinique de la théophyllinémie.

The theophyllinemia variations depend upon some factors: -observance of treatment, time of blood swab posology, laboratory technic, concomitant drugs, method of adaptation selected and the mean of administration. The theophylline title is a very important biologic parameter, necessary to the asthma treatment survey through such drug. Daily posology may be adapted to this titrate.