Long-term evolution of daytime somnolence in patients with sleep apnea/hypopnea syndrome treated by continuous positive airway pressure.

We demonstrated in a previous study that excessive daytime sleepiness (EDS) in patients who have sleep apnea/hypopnea syndrome (SAHS) and are undergoing continuous positive airway pressure (CPAP) treatment improved differently in two groups of patients: in group I, multiple sleep latency tests (MSLT) were normalized after 50 days of treatment (individual value > 10 minutes), whereas they remained low (individual value < 10 minutes) in group II, with a significant difference between groups. To evaluate the long-term evolution of daytime somnolence under nasal CPAP treatment, five patients from group I and seven patients from group II underwent a new polysomnography and MSLT 4 years after the previous study. Clinical, polysomnographic and MSLT results obtained at baseline before treatment (T1), after the initial 50-day period of CPAP treatment (T2), and after 4 years (T3) were compared. The significant difference in mean MSLT value between the two groups previously observed at T1 and T2 disappeared at T3 (group I: 12.4+/-5.9 minutes; group II: 9.7+/-5.9 minutes). We found that this long-term improvement in excessive daytime somnolence was independent of the initial MSLT value, the severity of SAHS, and the initial MSLT changes under nasal CPAP. Long-term MSLT evolution was significantly correlated to CPAP compliance. These results demonstrate that even in the absence of a significant increase in MSLT at the beginning of CPAP treatment, further improvement is still possible several years later, which may encourage the regular, long-term use of nasal CPAP by patients.

Atrial arrhythmia as a complication of nasal CPAP.

We report a case of supraventricular rhythm disorder occurring as a complication of nasal continuous positive airway pressure (CPAP) in sleep apnea syndrome treatment. The investigations showed a preexisting atrial vulnerability revealed by positive pressure ventilation, hemodynamic changes with decreased cardiac output, and a rise in the right atrial pressure. Such complications may develop further studies to evaluate cardiovascular repercussions of nasal CPAP.

Acute Q fever pneumonia: a review of 80 hospitalized patients.

STUDY OBJECTIVES: To emphasize epidemiologic, clinical, or radiologic characteristics whose detection could lead to an early diagnosis and to enhance therapeutic efficacy. PATIENTS: Eighty hospitalized patients from 1982 to 1996. DESIGN: The diagnosis of Q fever infection was serologically confirmed in all the patients (phase II Coxiella burnetii antibody) using the complement fixation test and/or the indirect immunofluorescence antibody test. RESULTS: Patients from rural and urban areas were noted in the same proportion; however, the usual epidemiologic factors such as contact with cats or farm animals were found in 40% of the patients. Mean age+/-SD was 49+/-20 years, and there was a higher sex ratio of male to female patients (1:3.44). We found a specific seasonal distribution since 80% of the cases occurred between February and May. Delay before referring to hospital was 8.2+/-7.8 days, while 69.3% of the patients received an antibiotic treatment that was mainly penicillin or cephalosporin. The dominant clinical features were dry cough and high fever, as the maximal temperature reached more then 40 degrees C in 58% of the patients. Digestive symptoms were rare. WBC count remained within normal range in 80% of the cases with a low proportion of lymphocytes in half of the patients, and the sedimentation rate was usually elevated (55+/-34 mm). Altered liver function consisted more frequently in an elevated level of alkaline phosphatase (70% of the cases) than transaminases, while hyponatremia was frequently mentioned (28.2% of the patients). We found radiologic evidence of unique lobar or segmental alveolar opacity involving more likely the lower lobes in 55 patients, and multiple or interstitial opacities in the others. Chest radiographs were considered normal in eight patients. The clinical response was favorable in all the patients with a reduction in fever 4.8+/-3.9 days after the start of treatment with the second antibiotic that included mainly erythromycin or quinolones, and chest radiographs returned to normal in 81% of the patients within the first month.

Predictive factors of long-term compliance with nasal continuous positive airway pressure treatment in sleep apnea syndrome.

The long-term acceptability of treatment with nasal continuous positive airway pressure (CPAP) was studied prospectively in 44 patients with obstructive sleep apnea syndrome. At 14 months on the average after starting treatment with CPAP, 30 patients (68 percent) were found to be compliant (characterized by use of the apparatus every night throughout the night, for more than 5 h per night). The daily use of nasal CPAP was significantly correlated to the initial apnea/hypopnea index (p = 0.013; r = 0.37), as well as to the percentage of light sleep (p = 0.045; r = 0.30) and slow-wave sleep (p = 0.037; r = -0.31) during the initial polygraphic recording. We found a strong correlation between the daily use of nasal CPAP and the difference in the apnea/hypopnea index (p = 0.025; r = -0.34), the difference in mean oxygen saturation during sleep (p = 0.013; r = 0.38), and the difference in hypersomnia scores (p = 0.006; r = -0.40) obtained before and after treatment by nasal CPAP. Thus, patients used CPAP much more if they had an initial significant clinical handicap and if they were aware of the beneficial effects of CPAP. Under these conditions, patients tended to use the apparatus for the optimal length of time, regardless of the side effects linked to the treatment. This ensured efficacy and the maintenance of good compliance. This study confirms the importance of supervision of the time counter, as well as regular encouragement of patients to use the treatment as long as possible each night, in order to extract a maximum benefit from treatment by nasal CPAP.

Evaluation of closed sterile prefilled humidification.

A closed sterile prefilled humidifier ('Aquapak 310') and a multiple-use humidifier ('Nebal 2') were evaluated in hospital departments to determine their susceptibility to bacterial contamination and cost. No bacterial contamination was found in the 389 samples of 'Aquapak 310' water. However, 54/164 (32.9%) samples of 'Nebal 2' water were found to be contaminated. Pseudomonas aeruginosa was the bacterium most often isolated. The cost analysis was highly influenced by the average use time. In the haemodialysis and respiratory medicine departments the average use times for the 'Aquapak 310' +/- SD were 61.6 +/- 36.2 days and 4.1 +/- 1.7 days, respectively. Using the 'Aquapak 310' system, there was a 51% financial saving in the haemodialysis department but a 2% loss in the respiratory medicine department. In these two departments we found a similar cost saving as far as staff time was concerned (88% vs. 89%). The major difference came from the cost of consumables: 26% saving in the haemodialysis department vs. 70% loss in the respiratory medicine department. Use of the prefilled sterile humidifiers represents a three-fold benefit, a lower infection risk for the patient, an important financial saving in the haemodialysis department and a decreased staff work load.

[Value of nifedipine in respiratory failure related to obstructive chronic bronchitis during treatment over 6 months]. / Intérêt de la nifédipine dans l'insuffisance respiratoire liée aux bronchites chroniques obstructives au cours d'un traitement de six mois.

We studied the simultaneous effects of nifedipine on the pulmonary circulation and blood gases in 12 patients with pulmonary hypertension secondary to obstructive chronic bronchitis. Measurements were carried out at rest and during stress, initially then one hour after administration of 20 mg of nifedipine sublingually. They were repeated in a similar fashion after a 6-month treatment with 60 mg/day (group II) (30 mg/day in case of intolerance) (group I). The results of the immediate effect of nifedipine are in favor of a passive pulmonary vasodilatation secondary to the systemic vasodilatation. After six months of treatment, the pulmonary vasodilatation persists, but is associated with a decreased motor pressure indicating a more specific and more active pulmonary vasodilating effect of long-term nifedipine, especially during stress; this results in the improvement of the performance of the right ventricle without harmful effect on the blood gases. However, these results should be interpreted with caution on account of the small number of patients, the large interindividual variations and the absence of a reference population.

[Sclerosing intravascular bronchiolo-alveolar tumor]. / Tumeur sclérosante intravasculaire bronchiolo-alvéolaire.

We report the case of a 56 year old female who was admitted to hospital in 1980 for assessment of disseminated nodular pulmonary opacities. The histological examination of a prescalene node biopsy showed features which were compatible with sarcoidosis. No treatment was given. In 1987 a discrete increase in the pulmonary nodules was noted. In 1989 effort dyspnoea occurred and there were pains in the right lower chest and an evening fever. The chest X-ray showed a right sided pleurisy and an increase in the size of the nodules with mediastinal lymphadenopathy. A histological examination of a pulmonary nodule, which was taken at an open lung biopsy enabled the diagnosis of a broncho-alveolar sclerosing intravascular tumour to be established. This is a rare tumour which has a slow evolution occurring most often in middle aged females. In 50% of cases the discovery is fortuitous. Besides patients present with non-specific symptoms. The radiological examination reveals multiple nodular opacities which are diffuse and 0.5 to 1.5 cm in diameter. Currently these tumours do not benefit from any particular therapy.

[Pharmacology of nicotine]. / Pharmacologie de la nicotine.

Nicotine has a small molecular weight and is absorbed via the mucosa (Guccal or nasal), the pulmonary alveoli and the skin. The phenomenon of autotitration explains how a dependent smoker can unconsciously change his method of smoking to maintain a steady nicotine level. Nicotine leads to a liberation of catecholamines by acting on the nervous system through the intermediary of nicotine receptors. There is increased vigilance and powers of intellectual concentration, an awakening reaction and some anxiolytic and euphoriant effects. From the cardiac stand point there is an increased heart rate and blood pressure, as a result of the sympathomimetic effects. Elimination is via the kidneys as unchanged nicotine, cotinine and 1'-N-oxide of nicotine. Nicotine has an addictive action and is capable of inducing pharmacological dependency, tolerance and withdrawal syndrome in cases of abrupt cessation. A knowledge of the pharmacology of nicotine is important in the process of stopping smoking.

[Sacral tuberculous osteitis]. / Ostéite tuberculeuse sacrée.

The authors report a case of a 5 year old child suffering from isolated sacral tuberculosis which presented as sudden and total loss of function of the left leg. The rarity of this bony site, and the recurrence at nine months of a presacral abscess after 9 months of anti-tuberculous treatment in an HIV negative child, vaccinated with BCG, justify the presentation of this observation.

[High school students and tobacco. A survey of 630 students in Poitiers]. / Les lycéens et le tabac. A propos d'une enquête chez 630 lycéens de Poitiers.

A survey of high school pupils and their attitudes to tobacco was carried out by an anonymous auto questionnaire by 630 pupils at the Alienor Aquitaine Lycee in Poitiers in April 1991. The population study had the following characteristics: 30% were boys, 70% were girls. The mean age was 18 +/- 1.31 years. The proportion of regular smokers (at least one cigarette per day, every day) was 33.9% in boys and 34.9% in girls. The boys had smoked on average 10.7 cigarettes per day for 3.5 years and the girls 9.1 cigarettes per day for 2.9 years. The smoker above all, used light colour tobacco (with filters 98%) but 29% only bought mild cigarettes. On the other hand 55% of the subjects wished to stop smoking. There was no statistically significant relationship between the smoking habits of the pupils and that of their parents on the one hand or on the regular participation in a sport, on the other. However, boarders smoked a lot more than the other pupils. The knowledge of the dangers of smoking were imperfectly understood, in particular, for chronic bronchitis, myocardial infarction, small birth weight of the newborn and cancer of the bladder. The changers of passive smoking were known by 91.6% of the pupils. Finally this study explored the opinion of the lycee pupils as regards to the six measures in the propaganda against smoking and on seven methods of information relating to the dangers of tobacco.

[Desquamative interstitial pneumopathy: a rare form of diffuse interstitial pneumopathy]. / La pneumopathie interstitielle desquamative: une forme rare de pneumopathie interstitielle diffuse.

Desquamative interstitial pneumonia (PID) is a rare disorder initially described by Liebow in 1965. It is characterised by the presence of an interstitial pneumonia consisting of minimal lesions of interstitial fibrosis and by the accumulation of a rich intraalveolar cellular material principally composed of macrophages. Numerous aetiologies have been found particularly that due to long term Nitrofurantoin. We report the observation of a 57 year old patient, a cigarette smoker, in whom the diagnosis of PID was made after histological examination of a lung biopsy. Based on this observation the pathogenesis and possible different aetiologies of PID are discussed.

[Differences in efficiency of continuous positive pressure respiration on the diurnal somnolence of patients with sleep apnea/hypoapnea syndrome]. / Inégalité d'efficacité de la pression positive continue (PPC) sur la somnolence diurne des patients atteints de syndrome d'apnées/hypopnées du sommeil (SAHS).

Diurnal hypersomnia was studied in sixteen patients suffering from the sleep apnoea/hypopnoea syndrome (SHAS) Group I, and seventeen snorers Group II. The groups were studied in their basal state then after 51 +/- 14 days of continuous positive pressure (CPP) in Group I with the aid of clinical scores and of multiple latency tests of sleeping episodes (TLME). The patients in Group I presented with increased and pathological diurnal somnolence (TLME = 3.9 +/- 2.45 min) associated with disturbances of oxygen saturation during the course of sleep (a significant reduction of the mean SaO2) and of the pattern of sleep (significant reduction in light slow sleep at the expense of deep slow sleep, with a significant increase in the index of brief arousals). We have found a positive correlation between the initial TLME and the mean SaO2 during the course of sleep (p < 0.05; R = 0.51) without any correlation with other polysomnographic parameters. At the time of the final assessment, the improvement in TLME in the patients of Group I was significant (p < 0.001). However, in a sub-group of patients (BR: n = 7) the TLME were returned to normal using CPP (16.4 +/- 2.21 min) while those in patients in the second sub-group (MR: n = 9) the TLME remained below ten minutes on CPP (6.18 +/- 1.88 min). In the BR subgroup which presented with the most elevated mean initial TLME levels the amplitude of the rise of TLME between the two groups was significantly larger. No initial polysomnographic difference existed between the two sub-groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[Role of the leukotrienes in asthma]. / Rôle des leucotriènes dans l'asthme.

Leukotrienes (LT), which are derived from arachidonic acid and have similar chemical structures to the prostaglandins, have recently been shown to contain most of the biological activity previously attributed to "Slow Reacting Substance of Anaphylaxis" (SRS-A). LTC4, LTD4 and LTE4 have potent bronchoconstrictor actions. LTE4 causes very long-lasting bronchoconstriction. LTB4 has inflammatory properties and possesses powerful chemotactic activity on leukocytes, especially neutrophil polymorphonuclear cells. The involvement of leukotrienes in the pathogenesis of bronchial asthma rests on a diversity of experimental evidence. The recent physiopathological approaches raise the hope of new therapeutic avenues in the treatment of asthma.

[False asthmas of the adult]. / Les faux asthmes de l'adulte.

Many conditions may simulate asthma, particularly tracheobronchial lesions that are dominated by tumoral stenoses, laryngeal anomalies and cardio-vascular diseases. At the time of the initial assessment of all sibilant dyspneas, certain other complementary examinations should systematically be made: pulmonary radiography, ORL examination and exploration of respiratory function.

[Mode of action of corticoids in asthma]. / Mode d'action des corticoïdes dans l'asthme.

Generally speaking, corticosteroids exert their effects on cells through genomic and non genomic mechanisms. They both suppress and enhance numerous biological phenomena. In asthma, corticosteroids act at different levels. They: inhibit chemical mediators, whether these are performed, like histamine, or newly formed, like arachidonic acid metabolites (prostaglandins and leukotrienes) or the platelet-activating factor (PAF); restore the sensitivity of beta-adrenergic receptors to sympathomimetic drugs; exert a powerful anti-inflammatory effect, notably reducing bronchial mucus secretion; reduce bronchial hyperreactivity and modify the bronchial response to bronchoconstrictors; act on respiratory function and gas exchanges. Many effects of corticosteroids in asthma involve the synthesis of proteins, such as lipomodulin (or macrocortin) which inhibits phospholipase A2, a key-enzyme in the synthesis of numerous chemical mediators derived from membrane phospholipids. The multiple effects of corticosteroids account for their broad spectrum of activity and their effectiveness against both acute and chronic manifestations of asthma.

[Occupational asthma in the rural environment]. / L'asthme professionnal en milieu rural.

Occupational asthma is frequent among farmers. Allergens, physio-pathological mechanisms and respiratory disorders are varied. Medico-legal problems (diagram n. 45 of occupational diseases) are recalled. The authors then describe the main allergens (plants, animals and chemical substances) they have met among farmers. Finally, some special aspects that depend on the occupation are discussed.

[Occupational bronchopulmonary pathology caused by woodworking: diagnostic approach]. / Pathologie broncho-pulmonaire professionnelle due au travail du bois: démarche diagnostique.

Woodworkers have a varied breathing pathology, with involvement of the upper airways mainly by ethmoidal cancers and rhinitis, tracheo-bronchitis with asthma, hypersensitivity pneumonitis due to wood moulds. The physiopathological mechanisms are numerous and often intricate: physical mechanism due to the irritant effect of wood dust, toxic mechanism caused by chemical substances which are present in wood dust or come from wood preservation products, immunological and allergic mechanism in which different allergens are concerned. Breathing pathology is the subject of 2 tables (No. 47 and 36) among those concerning occupational diseases. Lung function tests play an important role in the diagnosis of these diseases, with their 3 main objectives: search for airway obstruction, evaluation of bronchial hyperreactivity by means of non-specific challenge tests, and specific challenge tests performed in a laboratory or on the work site.

[Auscultation of pulmonary rales, from Laënnec to phonopneumography]. / L'auscultation des râles pulmonaires, de Laënnec à la phonopneumographie.

The invention in 1819 of the stethoscope by Laënnec was followed by the first classification of pulmonary adventitial sounds. A number of new nomenclatures based upon acoustic principles have subsequently been suggested. Phonopneumography consists of the recording of respiratory sounds and their breakdown into different harmonics by frequential analysis. Broadly speaking, a distinction is drawn between continuous sounds, including sibilants and rhonchi, and discontinuous sounds, covering crepitations and coarse rales.

[Bilateral chylothorax after mild trauma: apropos of a case]. / Chylothorax bilatéral après un traumatisme minime: à propos d'un cas.

The authors report a new case of bilateral chylothorax predominant on the left side, which occurred after movements of body trunk hyperextension in a 52-year old woman without any notable history. The clinical signs revealing the lesion were left thoracic pain and dyspnoea. The effusion had been preceded by a painless and transient left cervical tumefaction. The outcome was favourable after two left pleural draining punctures and rest.

[The role of inhalation chambers in the treatment of asthma]. / Place des chambres d'inhalation dans le traitement de l'asthme.

Inhalation chambers (spacers), interposed between the aerosol doser and the patient's mouth take 3 forms: lengthened tubes, large volume plastic sacs and conical chamber in the shape of a pear. Their chief advantages are: A greater proportion of the drug reaches the airways, as the deposition in the oropharynx is reduced. Co-ordination of lung and hand, a major obstacle to the correct use of aerosol-dosers, is no longer necessary.