[Cervical pain radiating to the upper limb]

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.

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]

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.

[Three pregnancies on nasal CPAP: a case report]

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]

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]

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.

[The pneumology department]

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.

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.

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]

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]

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]

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]

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.

[Prevention of hypertensive crises in the perioperative period. Efficacy and safety of the use of urapidil]

Hypertension and tachycardia are frequently encountered in the perioperative setting. Aim of this study was to evaluate the efficacy and safety of Urapidil when used for prevention of perioperative blood pressure elevations. 348 patients, at risk for hypertensive crises, were randomly administered either Urapidil or "no treatment". Blood pressure and heart rate were measured the day before as well as immediately before intervention and were continuously monitored during the intraoperative period. This study has shown a pronounced and well tolerated antihypertensive effect of Urapidil during anaesthesia in these patients. The effect on diastolic values was specific for Urapidil, since systolic pressure was lowered also in the control group as a consequence of anaesthesia. Urapidil treatment resulted to be effective in preventing hypertensive reactions following algogenic stimulation. This becomes particularly evident towards the end of the operative period, when the hypotensive effect attributable to the anesthetic itself progressively decreases.

Sleep apnea after 1 year domiciliary nasal-continuous positive airway pressure and attempted weight reduction. Potential for weaning from continuous positive airway pressure

STUDY OBJECTIVE

To assess the effect of 1 year of therapy for sleep apnea syndrome (SAS) combining domiciliary nasal-continuous positive airway pressure (N-CPAP) and attempted weight loss on the severity of disease and to evaluate the potential for weaning from continuous positive airway pressure (CPAP).

METHODS AND PROCEDURES

Ninety-five patients having a baseline apnea hypopnea index (AHI) greater than 10/h were prescribed N-CPAP at home. Weight loss was attempted by dietary counseling and by single ring vertical gastroplasty in those patients with a body mass index (BMI) greater than 40 kg/m2. Subjects were asked to return after 1 year for a full-night polysomnography (PSG) without CPAP and the results were compared with baseline PSG.

RESULTS

Thirty-nine patients compliant to CPAP were evaluated. Weight had decreased from 108.3 +/- 29.0 to 99.7 +/- 17.7 kg as a result of dietary counseling (n = 36) or gastroplasty (n = 3). A significant improvement was found in AHI (66.5 +/- 28.7-->50.3 +/- 38.4/h; p < 0.05), maximal duration of apnea or hypopnea (66 +/- 22-->47 +/- 18 s; p < 0.001), minimal oxyhemoglobin saturation (62 +/- 16-->78 +/- 7%; p < 0.001), and stage shift index (SSI) (76 +/- 29-->62 +/- 28/h; p < 0.05). The drop in AHI correlated with the reduction in BMI (r = 0.47; p < 0.01) and with the decrease in SSI (r = 0.50; p < 0.001). Weaning from CPAP was proposed to six patients and succeeded in four (three with 29, 93, and 94 kg weight loss, respectively, and one subject with a normal unchanged weight).

CONCLUSION

In 39 patients with SAS, 1-year domiciliary N-CPAP combined with weight loss resulted in a significant improvement in breathing during sleep and in sleep fragmentation, as judged from PSG without CPAP. Four subjects were successfully weaned, three of whom had in parallel a substantial decrease in weight.

Perception of dyspnoea during acute changes in lung function in patients with either asthma or COPD

The aim of the study was to evaluate the relationship between several lung function indices and perceived dyspnoea during bronchoconstriction. Acute changes in lung function were induced by inhaled histamine followed by terbutaline, in 12 asthmatics and 12 subjects with chronic obstructive pulmonary disease (COPD). A bipolar visual analogue scale (VAS), allowing subjects to report either improvement or worsening when moving off from a 'nochange' midpoint, was used to rate shortness of breath. Large swings in ratings were seen in all asthmatics and in seven out of 12 COPD subjects (high perceivers). Using linear regression of VAS rating against parallel change in lung function, on a within-subject basis, the highest degree of correlation between dyspnoea and objective response was found to involve the change in specific inspiratory resistance (sRin) in the asthmatics. In the five low perceivers, the ability to discriminate an increase in airway obstruction, estimated as the VAS/change in lung function slope, was very poor. Using a stepwise multiple regression analysis, the sensation of dyspnoea was found to be significantly related to the FEV1 and the sRin in the asthmatics, to the inspiratory vital capacity and the maximal inspiratory flow at 50% FVC (MIF50) in the COPD subjects with high perception, and to the MIF50 in the COPD subjects with low perception.

[Quantifying dyspnea]

Several methods have been proposed in the recent years to quantitate dyspnoea in healthy subjects or patients. Dyspnoea can be serially assessed on exercise, using either a visual analogue scale or a Borg scale, and is usually analyzed in relation to ventilation, which defines a dyspnoea threshold and a dyspnoea/ventilation slope. Inhaled bronchodilators, oral morphine, continuous (or inspiratory) positive airway pressure or respiratory rehabilitation programmes are able to decrease the dyspnoea/ventilation slope in patients with chronic obstructive pulmonary disease, while atenolol and pneumectomy have a deleterious effect. Measurement of dyspnoea in everyday life is feasible using the oxygen cost diagram or the baseline dyspnoea index; these indices are responsive to therapy, e.g. to oral theophylline in patients with chronic obstructive pulmonary disease. Dyspnoea measured at rest is a marker for evaluating the perception of added loads (open scale) or acute bronchoconstriction in normals or patients; in the latter it may also reflect the perception of the degree in baseline ventilatory impairment or that of acute bronchodilation (bipolar visual analogue scale). Some respiratory patients being poor perceivers, methods able to improve the perception of airway obstruction are desirable in these individuals.

[Induced expectoration or endoscopic samples in case of bronchopulmonary infection?]

The aim of this study was to compare induced sputum versus bronchoscopy in a non selected population. An induced sputum and a bronchoscopy with aspiration of secretions and bronchoalveolar lavage (BAL) were proposed to 30 patients with suspected lower respiratory tract infection, including 14 subjects with AIDS. Induced sputum failed in 3 patients, while endoscopy could not be performed (contra-indication, refusal or failure due to lack of cooperation) in 7 patients; a technical failure for BAL was observed in 3/23 cases. Contamination by oral germs was significantly less frequent with BAL (4/20) than with aspiration (15/23) or induced sputum (17/27). A relevant pathogen was cultured from induced sputum in 7/27 cases (3 mycobacteria, 4 usual pathogens) from aspiration in 3/23 cases (one mycobacterium, 2 usual pathogens) and from BAL in 4/20 cases (one mycobacterium, 3 usual pathogens). These results suggest that induced sputum is a promising method when difficulties in performing bronchoscopy are expected (severe respiratory insufficiency, psychiatric disease, lack of cooperation).

Dyspnoea and flow-volume curve during exercise in COPD patients

The purpose of this study, in patients with chronic obstructive pulmonary disease (COPD), was to examine the relationship of dyspnoea, rated on a visual analogue scale (VAS), to 1) tidal ventilatory variables measured on exercise and 2) pre-exercise lung function. Twenty one patients (forced expiratory volume in one second (FEV1) mean (SD) 1.19 (0.32) l) were studied. During a preliminary test, the maximal workload was assessed and the upper end of the VAS was anchored. On the study day, the tidal flow-volume curve on exercise was monitored and dyspnoea was assessed serially every minute. In each individual, the relationship of dyspnoea to various tidal ventilatory variables was studied using linear regression analysis; results were reported squared correlation coefficients, slopes and dyspnoea thresholds. Subsequently, the relationship of slopes and thresholds to pre-exercise lung function was examined. In all patients, dyspnoea showed a close correlation with ventilation, tidal volume, breathing frequency and tidal flow. The tidal peak inspiratory flow was the best individual predictor of dyspnoea with a median r2 of 0.91. Patients with the poorest pre-exercise lung function exhibited the highest rates of increase in dyspnoea and the lowest thresholds, the strongest correlation being observed between the dyspnoea/ventilation slope and pre-exercise maximal peak inspiratory flow (r2 = 0.54). In conclusion, for individual COPD patients dyspnoea on exercise is closely related to inspiratory flow. The degree of pre-exercise ventilatory impairment accounts, at most, for only half of the variation in dyspnoea perception between subjects.

Cardiac morphology and function in arterial hypertension. The effects of a new multifactorial hypotensive agent: urapidil

It has been recognized as increasingly important to determine whether antihypertensive agents, while satisfactorily lowering the blood pressure, at the same time adversely or positively affect the cardiac hemodynamic profile. On theoretical grounds, one would expect that an ideal hypotensive drug should decrease blood pressure by decreasing total peripheral resistances, without affecting cardiac output, and should normalize left ventricular hypertrophy without deteriorating systolic or diastolic left ventricular function. We here briefly review the effects of urapidil on these variables in patients under chronic treatment investigated in a series of studies employing echocardiography. The results of the studies are in fair agreement and indicate a blood pressure decrease already after one month of treatment, due to a decrease of peripheral resistances, without changes in heart rate. A clear trend towards a reduction of cardiac hypertrophy during the treatment is suggested by the significant decrements of the indices measured. One study also suggests that right ventricular wall thickness may be reduced. Left ventricular dimensions remained unchanged in all except one study. Systolic and diastolic function indices were also unchanged during the first 6 months of treatment and, in one study, improvement was found after 12 months of treatment. Taken together these results suggest that urapidil lowers blood pressure favorably, affecting cardiac morphology and function.

How do patients with either asthma or COPD perceive acute bronchodilation?

The purpose of this study was to assess the perception of bronchodilation, as a change in shortness of breath on a bipolar visual analogue scale (VAS), in 16 asthmatics and 20 subjects with COPD. Bronchodilation was gradually induced by five consecutive terbutaline inhalations (cumulated dose 800 micrograms). The subjects were categorized into high and low perceivers, on the basis of a cut-off of 25% VAS line length (after the fifth inhalation). The quality of perception was studied on a within-subject basis by linear regression analysis of VAS ratings against changes in lung function, and was characterized in terms of strength of correlation (squared correlation coefficient, r2), slope, and VAS axis intercept. Fourteen out of 16 asthmatics, and 13 out of 20 COPD subjects, were high perceivers. In the COPD group, the high perceivers had a larger objective response--particularly in inspiratory vital capacity--than the low perceivers. The strongest correlation between subjective and objective response was obtained in asthmatics when the improvement in shortness of breath was evaluated against the decrease in specific inspiratory resistance (median r2 = 0.831). In COPD low perceivers, subjective and objective response were unrelated, while COPD high perceivers differed from the asthmatics by larger intercepts. The perceptual characteristics were unrelated to the degree of baseline obstruction, whilst a modest relationship (r = 0.51) was found between the increase in forced expiratory volume in one second (FEV1) and r2 of the VAS/delta FEV1 analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

How do patients with either asthma or COPD perceive acute bronchodilation?

The purpose of this study was to assess the perception of bronchodilation, as a change in shortness of breath on a bipolar visual analogue scale (VAS), in 16 asthmatics and 20 subjects with COPD. Bronchodilation was gradually induced by five consecutive terbutaline inhalations (cumulated dose 800 micrograms). The subjects were categorized into high and low perceivers, on the basis of a cut-off of 25% VAS line length (after the fifth inhalation). The quality of perception was studied on a within-subject basis by linear regression analysis of VAS ratings against changes in lung function, and was characterized in terms of strength of correlation (squared correlation coefficient, r2), slope, and VAS axis intercept. Fourteen out of 16 asthmatics, and 13 out of 20 COPD subjects, were high perceivers. In the COPD group, the high perceivers had a larger objective response--particularly in inspiratory vital capacity--than the low perceivers. The strongest correlation between subjective and objective response was obtained in asthmatics when the improvement in shortness of breath was evaluated against the decrease in specific inspiratory resistance (median r2 = 0.831). In COPD low perceivers, subjective and objective response were unrelated, while COPD high perceivers differed from the asthmatics by larger intercepts. The perceptual characteristics were unrelated to the degree of baseline obstruction, whilst a modest relationship (r = 0.51) was found between the increase in forced expiratory volume in one second (FEV1) and r2 of the VAS/delta FEV1 analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Perceived effect on shortness of breath of an acute inhalation of saline or terbutaline: variability and sensitivity of a visual analogue scale in patients with asthma or COPD

The purpose of the study was to validate a bipolar visual analogue scale (VAS) to assess the perceived effect on shortness of breath of an acute inhalation and to search for differences in perception between asthmatics and subjects with chronic obstructive pulmonary disease (COPD). Thirty two subjects with airway obstruction and a diagnosis of either asthma (n = 16) or COPD (n = 16) received three consecutive inhalations of isotonic saline, followed by two inhalations of 400 micrograms terbutaline. Saline was perceived by asthmatics as a slight improvement: VAS (median, 95% confidence interval) 9%, 0-18% of line length. COPD subjects could be separated into two subgroups: "high perceivers" (n = 8, VAS 43%, 33-53%) and "low perceivers" (n = 8, VAS 5%, 3-7%). The median intrasubject coefficient of variation of the three post-saline VAS ratings was 19.4% (asthma), 12.5% (COPD high perceivers), and 14.5% (COPD low perceivers). After terbutaline, asthmatics had, by selection, a larger increase in forced expiratory volume in one second (FEV1) than COPD subjects. However, for other indices (expiratory specific resistance, inspiratory vital capacity and maximal inspiratory flow at 50% forced vital capacity) the changes were smaller in COPD low perceivers than in both asthmatics and COPD high perceivers. The parallel improvement in VAS was 24%, 20-39% (asthma), 15%, 6-25% (COPD high perceivers) and 1%, -1-8% (COPD low perceivers). The most sensitive index was FEV1 in asthmatics, vital capacity in COPD subjects, VAS being among the most sensitive indices in the former, but among the least sensitive in the latter. We conclude that the sensitivity of this VAS to bronchodilation is better in asthmatics than in COPD subjects. The latter can however be separated into subgroups with high and low level of perception.

Perceived effect on shortness of breath of an acute inhalation of saline or terbutaline: variability and sensitivity of a visual analogue scale in patients with asthma or COPD

The purpose of the study was to validate a bipolar visual analogue scale (VAS) to assess the perceived effect on shortness of breath of an acute inhalation and to search for differences in perception between asthmatics and subjects with chronic obstructive pulmonary disease (COPD). Thirty two subjects with airway obstruction and a diagnosis of either asthma (n = 16) or COPD (n = 16) received three consecutive inhalations of isotonic saline, followed by two inhalations of 400 micrograms terbutaline. Saline was perceived by asthmatics as a slight improvement: VAS (median, 95% confidence interval) 9%, 0-18% of line length. COPD subjects could be separated into two subgroups: "high perceivers" (n = 8, VAS 43%, 33-53%) and "low perceivers" (n = 8, VAS 5%, 3-7%). The median intrasubject coefficient of variation of the three post-saline VAS ratings was 19.4% (asthma), 12.5% (COPD high perceivers), and 14.5% (COPD low perceivers). After terbutaline, asthmatics had, by selection, a larger increase in forced expiratory volume in one second (FEV1) than COPD subjects. However, for other indices (expiratory specific resistance, inspiratory vital capacity and maximal inspiratory flow at 50% forced vital capacity) the changes were smaller in COPD low perceivers than in both asthmatics and COPD high perceivers. The parallel improvement in VAS was 24%, 20-39% (asthma), 15%, 6-25% (COPD high perceivers) and 1%, -1-8% (COPD low perceivers). The most sensitive index was FEV1 in asthmatics, vital capacity in COPD subjects, VAS being among the most sensitive indices in the former, but among the least sensitive in the latter. We conclude that the sensitivity of this VAS to bronchodilation is better in asthmatics than in COPD subjects. The latter can however be separated into subgroups with high and low level of perception.

Dyspnoea assessed by visual analogue scale in patients with chronic obstructive lung disease during progressive and high intensity exercise

BACKGROUND

A study was carried out to determine whether rating of dyspnoea by means of a visual analogue scale during a progressive exercise test is affected by the subject's awareness of the progressive nature of the protocol.

METHODS

Nineteen patients with chronic obstructive lung disease (FEV1 mean (SE) 1.06 (0.07) 1) were studied. A preliminary incremental test was carried out with a work rate increasing by 10 watts every minute until the subject could no longer exercise, to determine the maximum work load (Wmax) and to anchor the upper end of the visual analogue scale. This was followed by two exercise tests performed one day apart in randomised sequence, with two different protocols. One was a 12 minute protocol that included two sudden bursts of three minute high intensity exercise, up to the subject's Wmax, each preceded by three minutes of low level exercise. The other test was a conventional three minute incremental test lasting 12 minutes. On both study days the only information given to the subject about the temporal profile of load was that a change would be made every three minutes. The relation between dyspnoea, as assessed by the visual analogue scale, and ventilation, measured during high intensity or progressive exercise, was studied.

RESULTS

The mean (SE) rates of increase of dyspnoea with increasing ventilation (% of line length 1(-1) min) obtained by linear regression analysis were similar for the two tests (2.86 (0.20) for progressive exercise and 2.87 (0.25) for high intensity exercise); it was 2.59 (0.25) for the initial burst of high intensity exercise when the data on this were analysed separately. In six subjects with stable disease studied again two months later the reproducibility of the rating of dyspnoea was reasonably good for both protocols.

CONCLUSION

The results suggest that in most patients with chronic obstructive lung disease the assessment of exercise induced dyspnoea by means of a visual analogue scale during a progressive exercise test is not affected by the subject's awareness of the progressive increase in work intensity.

Increased ether lipid cytotoxicity by reducing membrane cholesterol content

Ether-linked glycerophospholipids (ether lipids, EL) are selectively toxic and anti-proliferative agents against cancer cells in vitro. The reason for such selectivity is not completely clear. Their mechanism of action is mediated through an interaction with the plasma membrane and the membrane lipid composition may modulate it. As a continuation of previous reports, we now present data showing that cholesterol concentration modulates EL toxicity in the K562, U937 and MOLT4 leukemic cell lines in vitro. Cells become sensitive to otherwise ineffective doses of EL when their cholesterol content is lowered. Cell cholesterol levels were reduced by exposure to an egg lipid mixture (neutral glycerides, phosphatidylcholine and phosphatidylethanolamine, AL721). The data contribute to an understanding of the EL mechanism of action on membranes and suggest that the cellular cholesterol concentration must be considered a major factor in modulating the cytotoxic effects of EL.

Cross-resistance pattern of cell lines selected for resistance towards different cytotoxic drugs to membrane-toxic phospholipids in vitro

The synthetic ether lipids ET-18-OCH3 and BM41.440 and a derivative, hexadecylphosphocholine, were tested for inhibition of [3H]-thymidine uptake into a Chinese hamster ovarian cell line (AUXBl) and its multidrug-resistant subline selected for colchicine resistance (CHRC5). The activity of all three compounds against the multidrug-resistant subline was equal to or higher than that against the parent line. The same result was found for their activity against a human leukemic lymphoblastic cell line (CEM/O) and its methotrexate-resistant subline (CEM/MTX). In contrast, two multidrug-resistant cell lines selected for resistance to Adriamycin, the mouse leukemia cell line P388/ADR and the murine sarcoma cell line S180/ADR, expressed modest cross-resistance to the lipids as measured by thymidine uptake. Experiments performed using the trypan-blue dye-exclusion assay yielded comparable results, although this system revealed a slightly different sensitivity in showing the cytotoxicity of the drugs. By this assay, modest cross-resistance for ET-18-OCH3 and BM41.440 to Adriamycin was found only after 24 h incubation and decreased after 48 h incubation, with almost equal sensitivity to both drugs being shown by the parental (P388/W) and resistant lines (P388/ADR). Furthermore, findings from a human tumor-cloning assay were in accordance with these data, although they did not indicate cross-resistance for the P388/ADR cell line. These results suggest that certain ether lipids and derivatives might represent valuable anticancer drugs warranting further study in the setting of resistant disease.

Role of cell cholesterol in modulating antineoplastic ether lipid uptake, membrane effects and cytotoxicity

Membrane-interactive ether lipids (EL) exert toxic and antiproliferative effects on cancer cells in vitro. They appear to be selectively more toxic to cancer cells than to normal cells and thus they are ideal candidates for bone-marrow purging procedures. However, no conclusive explanation has yet been provided for this property. We now present some data indicating that the cholesterol concentration in the incubation medium modulates EL toxicity against the HL60 leukemic cell line in vitro. Furthermore, model membranes richer in cholesterol take up EL more slowly, and cell cholesterol enrichment of HL60 cells counteracts EL biophysical membrane interaction, but not toxicity, in our experimental model. However, the K562 cell line, a leukemia line less sensitive to EL toxic action, has higher levels of cell cholesterol. Our data provide evidence to explain differences in sensitivity to EL among different cell types and contribute to the understanding of the mechanism of action of EL.

Lung function, maximum and submaximum exercise testing in COPD patients: reproducibility over a long interval

This study was designed to investigate the reproducibility and clinical relevance of several lung function and exercise test indices in a sample of patients with stable severe chronic obstructive pulmonary disease (COPD). Twenty subjects (ages 67.8 +/- 2.0 years, forced expiratory volume in 1s, [FEV1] 39.7 +/- 2.8% predicted) receiving conventional medical therapy and pulmonary rehabilitation were tested 4 times at 1 month intervals. Testing procedures included lung function (inspiratory vital capacity [IVC], FEV1, plethysmographic functional residual capacity [FRC], specific conductance of the airways (sGaw), single breath transfer factor divided by the alveolar volume [TL/VA]); incremental, progressive, symptom-limited, cycle exercise (maximum work load [Wmax], maximum heart rate [HRmax], maximum ventilation [VEmax], maximum oxygen uptake [VO2max]); and 2 modes of submaximum exercise (12 min walking test [12 MWD] and endurance cycle test). The mean of the absolute value of the individual patient, session-to-session, variation was found to be 0.131 for FEV1, 102 ml/min for VO2max. The within-subject variability was the smallest for HRmax and IVC (mean intrasubject coefficient of variation, [CV intra] 5.0 and 6.5%) and the greatest for TL/VA, the work performed during the endurance cycle test (EW) and sGaw (CV intra 16.5, 19.4, and 22.7%), while it was reasonably low (8.1-10.2%) for all the other variables studied. Calculation of the F ratio of the intersubject variance to the residual (total minus intersubject) variance, interpreted as a signal-to-noise, ratio, yielded the following, in decreasing order: TL/VA, EW, VEmax, VO2max, IVC, FEV1, HRmax, Wmax, sGaw, 12 MWD, FRC. If we assume that a useful variable should combine a low within-subject variability (CV intra less than or equal to 10%) with a high signal-to-noise ratio, we conclude that, among all the variables studied, IVC, FEV1, VEmax, and VO2max are those with the greatest clinical potential for functional assessment in patients with COPD.

[Sleep apnea syndrome : multidisciplinary management. Apropos of a preliminary experience]

The authors describe a multidisciplinary approach for patients with sleep apnea syndrome. During the first year 40 patients with obstructive sleep apnea documented by polysomnographic recordings were managed. Therapy proposed to the patient included weight loss and abstention from sedatives at night as sole treatment (n = 12) or, more often, combined with nasal and/or throat surgery (n = 21) or nasal continuous positive airway pressure (NCPAP) during sleep (n = 7). NCPAP was by far the most effective in reversing apneas but in view of its cost for the patient and its constraining aspects was proposed solely to those patients with the most severe apnea syndromes.

[Left ventricular function in obstructive chronic bronchopneumopathy]

Left ventricular (LV) function was studied, using echocardiography, radionuclide angiography and right catheterization, in 20 patients (mean age 60.9 +/- 1.5 years) with severe stable chronic obstructive pulmonary disease (COPD) and without known heart disease. The diagnosis of LV failure, suspected on clinical grounds in 8 of these patients, was confirmed by raised pulmonary capillary wedge pressure (PCWP) in only one patient. Nineteen subjects had normal PCWP and LV ejection fraction (LVEF) values, radionuclide LVEF and end diastolic LV dimension being the most powerful discriminators between the single abnormal patient and the others. Echocardiograms of sufficient quality were obtained in 11 out of the 19 normal patients and constantly showed LV dimensions in the lowest part of the normal range. The stroke volume index (SVI) - cardiac output being measured by thermodilution - was found to be decreased in 9 of 14 patients with normal LVEF values. We conclude that in patients with severe COPD (1) LV failure is quite unfrequent and the empirical use of digitalis should not be recommended, (2) radionuclide angiography is the most useful procedure for routine evaluation of LV function and (3) a decreased SVI is frequently found in patients with a small LV cavity and a normal LVEF, suggesting some degree of diastolic dysfunction of the left ventricle.

Sympathomimetics in acute severe asthma: inhaled or parenteral, nebulizer or spacer?

It is accepted today that all patients with acute asthma should be treated with a sympathomimetic, irrespective of previous therapy. This short review addresses the question of the optimal mode of administration of these drugs in acute severe asthma. Inhaled sympathomimetics are as effective as subcutaneous adrenaline, or intravenous salbutamol or terbutaline, and, as they produce fewer side-effects, are recommended as the best mode of administration. However, self-medication with a ready to use subcutaneous preparation may be indicated in those patients prone to very abrupt attacks. The conventional mode of inhalation therapy in acute asthma is nebulization, but equally effective bronchodilatation may be obtained with metered-dose inhalers combined with valved spacers. Tachypnoeic patients unable to perform a conventional inhalation manoeuvre can use one-way valve inhalation devices with repeated tidal breaths. Finally, sequential or even continuous inhalation techniques have recently been advocated, particularly in patients with impending respiratory failure.

Sympathomimetics in acute severe asthma: inhaled or parenteral, nebulizer or spacer?

It is accepted today that all patients with acute asthma should be treated with a sympathomimetic, irrespective of previous therapy. This short review addresses the question of the optimal mode of administration of these drugs in acute severe asthma. Inhaled sympathomimetics are as effective as subcutaneous adrenaline, or intravenous salbutamol or terbutaline, and, as they produce fewer side-effects, are recommended as the best mode of administration. However, self-medication with a ready to use subcutaneous preparation may be indicated in those patients prone to very abrupt attacks. The conventional mode of inhalation therapy in acute asthma is nebulization, but equally effective bronchodilatation may be obtained with metered-dose inhalers combined with valved spacers. Tachypnoeic patients unable to perform a conventional inhalation manoeuvre can use one-way valve inhalation devices with repeated tidal breaths. Finally, sequential or even continuous inhalation techniques have recently been advocated, particularly in patients with impending respiratory failure.

Synthesis and biological evaluation of ether-linked derivatives of phosphatidylinositol

The synthesis of two novel glycero-3-phosphoinositol ether lipid analogues, rac-1-O-octadecyl-2-O-methylglycero-3-phospho-myo-inositol 6 (an ether lipid analogue of rac-1-O-octadecyl-2-O-methylglycero-3-phosphocholine; ET-18-OMe) and rac-1-O-octadecyl-2-O-acetylglycero-3-phospho-myo-inositol 11 (an ether lipid analogue of platelet-activating factor), is described. The two target compounds and the synthetic intermediates were evaluated for inhibition of HL60, BG1, and BG3 human malignant cells in vitro and inhibition of protein kinase C. Tumor inhibitory activity was found for compounds 6 and 11 in all systems but not for their synthetic intermediates. However, compounds 6 and 11 as well as the synthetic intermediates 5 and 13, but not 9, exhibited protein kinase C inhibitory activity.

Membrane damage in leukemic cells induced by ether and ester lipids: an electron microscopic study

This paper reports a scanning electron microscopy (SEM) study of different leukemic cell lines exposed to 1-octadecyl-2-methyl-rac-glycero-3-phosphocholine (ET-18-OMe). This is an ether lipid analog of platelet activating factor (1-alkyl-2-acetyl-sn-glycero-3-phosphocholine) which inhibits neoplastic cell growth in vitro and in vivo and is believed to exert its action through an interaction with the plasma membrane. In this paper evidence of the morphological alteration of leukemic cell membranes due to the exposure to varying concentrations of ET-18-OMe in vitro and in vivo is presented. This membrane damage consists of formation of blebs and holes, and the severity of these two phenomena correlate with the degree of cell viability loss. These alterations were analyzed in comparison to those induced by the known and structurally related permeabilizing agent, lysophosphatidylcholine, an ester lipid.

Effects of antineoplastic ether lipids on model and biological membranes

Differential scanning calorimetry and electron spin resonance were utilized to measure the effects of di-ether glycerophospholipid analogs (EL) on the physical properties of model membranes and on the membrane fluidity of HL60 leukemic cells. 1-Octadecyl-2-methyl-rac-glycero-3-phosphocholine (ET-18-OMe) and 1-thiohexadecyl-2-ethyl-rac-glycero-3-phosphocholine (ET-16S-OEt) lower the transition temperature of dimyristoylphosphatidylcholine vesicles in a range of concentrations between 0.5 and 15 mol %. Studies conducted on the interaction of EL with a wide spectrum of different phospholipids, namely dipalmitoylphosphatidylcholine, 1-hexadecyl-2-palmitoylphosphatidylcholine, dipalmitoylphosphatidylethanolamine, and dielaidoylphosphatidylethanolamine confirmed the ability of EL to effect the physical properties of model membranes. Changes in calorimetric enthalpy were observed only with phosphatidylethanolamine-containing phospholipids. ET-18-OMe and ET-16S-OEt increased the membrane fluidity of HL60 leukemic cells labeled with the fatty acid spin label probe 5-nitroxystearate. These data demonstrate the ability of EL to partition into phospholipidic domains and to change their physical properties. Furthermore, they affect the membrane fluidity of whole cells. These effects indicate an interaction between EL and the plasma membrane which may be of importance in determining the cytotoxic activity against tumor cells exerted by EL.