Oropharyngeal carcinoma in fanconi anemia patient - Radiation treatment, toxicity, and a year follow-up: Case report

Fanconi anemia (FA) is an inherited bone marrow failure disorder. In patients with FA, there is a high incidence of head and neck squamous cell carcinoma (HNSCC). As there is a defective DNA repair mechanism, radiotherapy (RT) or chemotherapy has an increased risk of toxicity in FA patients with HNSCC. We report the radiation treatment for oropharyngeal carcinoma in a FA patient. Our patient was treated with RT to a total dose of 60 Gy in 30 fractions. She developed grade 3 oral mucositis, grade 3 neutropenia, and thrombocytopenia at 20 Gy which resulted in treatment break of 11 days. She again developed grade 3 mucositis, grade 2 dermatitis, grade 3 thrombocytopenia, worsening of odynophagia at 44 Gy which resulted in a treatment break of 19 days. She completed RT and is now disease-free for 1 year with a good quality of life.

Effectiveness of abdominal compression in reducing internal target motion during conformal radiotherapy for carcinoma stomach - A pilot study

AIM

: To assess the effectiveness of abdominal compression in reducing internal target motion during conformal radiotherapy for stomach cancer.

MATERIALS AND METHODS

A pilot study was conducted on five patients who received adjuvant radiotherapy for stomach cancer. All the patients had surgical clips and were offered radiotherapy and concurrent chemotherapy as per the institutional protocol. An abdominal compression device was developed consisting of a triangular Styrofoam's plate and an inflatable air bladder that was positioned over the patients' abdomen. The pneumatic pressure was set according to the patients' comfort. On the simulation day, patients had two computed tomography (CT)-scanning sessions, with and without abdominal compression. Target volumes and organs at risk (OAR) were delineated on the CT images without compression. On the treatment day, fluoroscopy was acquired with onboard imager (OBI) and movements of surgical clips with and without compression analyzed with the help of a tracker software. Observed values with and without abdominal compression were compared.

RESULTS

Abdominal compression usage has reduced the mean breathing excursion (MBE) in medio lateral(ML) direction from 5.92mm to 4.15 mm and in cranio caudal direction (CC) from 11.3mm to 7.2mm. The range of reduction by 29.85% in the ML and 36.86% in CC direction. The average residual breathing excursion was 1.766 mm (SD = 1.33 mm) in the ML and 4.02 mm (SD = 2.18 mm) in the CC direction, respectively.

CONCLUSION

Abdominal compression was useful in reducing internal target motion during stomach cancer conformal radiotherapy. The device we developed is patient friendly and cost-effective.

Squamous cell carcinoma cervix with metastasis to pyloroduodenal region

Metastatic squamous cell carcinoma in the pyloroduodenal region is uncommon. Cases have been reported where carcinoma of the lung has presented with metastasis to the duodenum. We present here the case of a 57-year-old lady who was found to have a metastasis in pyloroduodenal region while on treatment for carcinoma cervix. The patient developed features of intestinal obstruction and endoscopy showed a growth extending from pyloric antrum to first part of duodenum up to the junction of first and second part. A biopsy was taken from the duodenal area and it was reported as metastatic squamous cell carcinoma. This is one of the few reported cases of hematogenous visceral metastasis from carcinoma cervix. Since the disease was found to be advanced and her performance status was poor, she was provided best supportive care.

Tongue weakness is associated with respiratory failure in patients with severe Guillain-Barré syndrome

OBJECTIVE

Swallowing impairment may worsen respiratory weakness and conduct to respiratory complications such as aspiration pneumonia in Guillain-Barré syndrome (GBS). We prospectively evaluate how tongue weakness could be associated to bulbar dysfunction and respiratory weakness in severe GBS patients.

MEASUREMENTS AND MAIN RESULTS

Tongue strength, dysphagia and respiratory parameters were measured in 16 GBS patients at intensive care unit (ICU) admission and discharge and in seven controls. Tongue strength was decreased in the GBS patients compared with the controls. At admission, patients with dysphagia and those requiring mechanical ventilation (MV) had greater tongue weakness. All the patients with initial tongue strength <150 g required MV during ICU stay. Tongue strength correlated significantly with respiratory parameters.

CONCLUSION

This study confirms the strong association between bulbar and respiratory dysfunction in GBS admitted to ICU. Tongue weakness may be present in GBS, especially during the phase of increasing paralysis, and resolves during the recovery phase. Tongue strength and indices of global and respiratory strength vary in parallel throughout the course of GBS. Further studies are needed to assess if, when used in combination with other respiratory tests, tongue strength measurement could contribute to identify patients at high risk for respiratory complications.

[Long term domiciliary mechanical ventilation in patients with neuromuscular disease (indications, establishment and follow up)]

Neuromuscular diseases represent a heterogeneous group of pathologies which common feature is the development of a restrictive ventilatory failure.

BACKGROUND

Respiratory insufficiency of neuromuscular origin manifests itself by functional symptoms that must be carefully searched for in the history, such as headaches, sleep disorders, or dyspnoea of effort, sometimes very mild, or in severe cases associated with orthopnoea. Follow up should be multi-disciplinary. On the respiratory level regular measurement of blood gases, vital capacity, maximum inspiratory and expiratory pressures as well as sleep studies, will detect the criteria for mechanical ventilation (hypercarbia > 45 mm Hg, nocturnal desaturation < 88%, vital capacity < 60%, PImax < 60 cm H2O).

STATE OF THE ART

The establishment of mechanical ventilation is a major decision for patients with neuromuscular disease because of the important physical, psychological, social and sometimes financial consequences. The patients and their family must be instructed precisely in order to obtain the best possible observation and compliance. The establishment requires a stay in hospital of several days to optimise the choice of ventilator, its settings, and connections. The link with the organisation managing the domiciliary ventilation is fundamental in ensuring follow up after discharge from hospital. Techniques of cough assistance must be taught to each neuromuscular patient requiring mechanical ventilation.

CONCLUSION

Ventilation of neuromuscular patients requires careful evaluation of the indications and rigorous follow up by a multidisciplinary team with wide experience of this type of disease.

Critical incidents related to invasive mechanical ventilation in the ICU: preliminary descriptive study

OBJECTIVES

To establish a preliminary list of critical incidents (CIs) associated with mechanical ventilation and to describe a CI reporting method.

DESIGN

A list of CIs was established based on a consensus among ICU caregivers. The list was compared to CIs collected prospectively during a predefined study period.

SETTING

The clinical observations were conducted in two intensive care units.

PATIENTS

All patients receiving mechanical ventilation were included.

MEASUREMENTS AND RESULTS

The list of CIs included death and 62 other CI types categorized as immediately life-threatening, secondarily life-threatening, or non-life-threatening. The observational study identified 527 CIs in 137 patients. Virtually all non-life-threatening CIs were ascribed to failure to comply with safety rules or to equipment failure and 40% of life-threatening CIs to the course of the disease or to patient-related factors. The match between CI types on the list and CI types observed in the ICUs was excellent.

CONCLUSIONS

Use of our reporting method to create a CI database in a multicenter study including ICUs with varying recruitment patterns may help to identify markers suitable for routine continuous use as part of a quality-assurance program.

[Corticotherapy in severe infectious states]

Septic shock is one of the leading cause of death in modern countries. Scientists have made huge improvement in the understanding of mechanisms of inflammation, and the sequence of activation of the various pro and anti-inflammatory markers is now well known. By contrary, physicians have failed to improve survival from septic shock, in spite of the development of specific targets of the various points of the cytokine cascade sought to have a key role in host survival to sepsis. Corticosteroids were among the first anti-inflammatory drugs, which have been tested in high quality randomised controlled trials. These trials clearly showed that patients with septic shock are unlikely to benefit from a short course of a large dose of an anti-inflammatory steroid. More recent findings highlighting the role of the integrity of the hypothalamic-pituitary -adrenal axis to appropriately respond to a septic insult, have led to a reappraisal of the use of steroids in septic shock. Several high quality randomised controlled trials have evaluated the efficacy and safety of a prolonged treatment with low dose hydrocortisone in severe sepsis. These trials strongly suggested that this strategy of corticotherapy reduced the morbidity of septic shock and may favourably affect survival from septic shock.

Intravenous immune globulins in patients with Guillain-Barré syndrome and contraindications to plasma exchange: 3 days versus 6 days

Plasma exchange is contraindicated in 10 to 20% of patients with Guillain-Barré syndrome (GBS). The optimal schedule for intravenous immune globulin (IVIg) therapy has not yet been established in these patients. The objective was to compare the efficacy and safety of two IVIg treatment durations in patients with GBS with contraindications for plasma exchange. In this randomised, double blind, multicentre phase II trial conducted in seven French centres, patients with GBS with severe haemostasis, unstable haemodynamics, or uncontrolled sepsis were randomly assigned to 0.4 g/kg/day IVIg for 3 or 6 days. The primary outcome measure was the time needed to regain the ability to walk with assistance. Thirty nine patients were included from March 1994 to May 1997, 21 in the 3 day group and 18 in the 6 day group. Time to walking with assistance was non-significantly shorter in the 6 day group (84 (23-121) v 131 days (51-210), p=0.08); the difference was significant in ventilated patients (86 days (13-151) in the 6 day group v 152 days (54-332) in the 3 day group; p=0.04). The prevalence and severity of IVIg related adverse effects were comparable between the two groups. In conclusion, in patients with GBS and contraindications for plasma exchange, especially those who need ventilatory assistance, IVIg (0.4 g/kg/day) may be more beneficial when given for 6 days rather than 3 days.

[Electrophysiologic study of 10 cases of Miller Fisher syndrome]

The association of ophthalmoplegia, ataxia and areflexia was described by Miller Fisher in 1956. It is postulated as a variant of the Guillain Barré syndrome. We report 10 Miller Fisher syndrome patients admitted in an intensive care unit between June 1990 and February 1999 who were selected according to clinical criteria of Ropper and Wijdicks. All patients had motor and sensory nerve conduction studies and electromyography, nine had visual and brainstem auditory evoked potentials and two had short latency somatosensory evoked potentials. Peripheral neuropathy was found in all patients. All had sensory nerve changes and some were severe. Motor nerve conduction abnormalities were observed in 7 only cases with moderate increase of F latency in 3 cases and compound muscle action potential reduction in 3 other cases. In the last case, motor conduction abnormalities was more severe, characterized by conduction velocity slowing in both distal and proximal sites and by temporal dispersion of action potentials. All brainstem auditory evoked studies were normal. In 4 patients, MRI studies were normal. These data support that brainstem is preserved in MFS. Only one patient had visual evoked potential abnormalities. Optic neuropathy is debated in Miller Fisher and in Guillain Barré syndrome. As a conclusion, in MFS peripheral neuropathy is always present with severe sensitive changes and moderate motor changes (This is different as compared to Guillain Barré syndrome according to electrophysiological data). We did not find involvement of brainstem in our patients with Miller Fisher syndrome.

Nocturnal mechanical ventilation for chronic hypoventilation in patients with neuromuscular and chest wall disorders

BACKGROUND

Chronic alveolar hypoventilation is a common complication of many neuromuscular and chest wall disorders. Long term nocturnal mechanical ventilation is used to treat an increasing number of patients.

OBJECTIVES

To examine the efficacy of nocturnal mechanical ventilation in relieving hypoventilation related symptoms in patients with neuromuscular or chest wall disorders.

SEARCH STRATEGY

Search of the Cochrane Neuromuscular Disease Group register for randomized trials and enquiry from authors of trials and other experts in the field.

SELECTION CRITERIA

Types of studies: quasi-randomized or randomized controlled trials

TYPES OF PARTICIPANTS

patients with neuromuscular or chest wall disorder-related stable chronic hypoventilation of all ages and all degrees of severity. Types of interventions: any type and any mode of nocturnal mechanical ventilation. Types of outcome measures: Primary: short term and long term reversal of hypoventilation related clinical symptoms Secondary: unplanned hospital admission rate, one year mortality, short term and long term reversal of day time hypercapnia, improvement of lung function and improvement of sleep breathing disorders.

DATA COLLECTION AND ANALYSIS

We identified four randomized trials. One author extracted the data and another checked them. Individual data were available from the authors of the largest study.

MAIN RESULTS

The four eligible trials included a total of 51 patients. The risk difference (proportion of patients) of no improvement of hypoventilation related clinical symptoms in the short term following nocturnal mechanical ventilation was significant and favoured treatment, -0.417 (95% CI -0.639 to -0.194). However, there was significant heterogeneity across the studies (p<0.001). Similarly, the risk difference of no reversal of day time hypercapnia in the short term following nocturnal ventilation was significant and favoured treatment, -0.635 (95% CI -0.874 to -0.396). The weighted mean difference of nocturnal mean oxygen saturation percent was 5.5 (95% CI 1.5 to 9.4) more improvement in patients treated with nocturnal mechanical ventilation. For the primary and most of the secondary outcome measures there was no significant difference between nocturnal mechanical ventilation and no ventilation in the long term, except for one-year mortality. Indeed, the risk difference of death one year following implementation of nocturnal mechanical ventilation was significant and favoured treatment, -0.259 (95% CI -0.478 to -0. 041). However, there was significant heterogeneity across the studies (p<0.001). Most of the secondary outcomes were not assessed in the eligible trials. No data could be summarised for the comparisons between invasive and non-invasive mechanical ventilation, between intermittent positive pressure and negative pressure ventilation, and between volume-cycled and pressure-cycled ventilation.

REVIEWER'S CONCLUSIONS

Current evidence about the therapeutic benefit of mechanical ventilation is weak, but consistent, suggesting alleviation of the symptoms of chronic hypoventilation in the short term, and in two small studies survival was prolonged. Mechanical ventilation should be offered as a therapeutic option to patients with chronic hypoventilation due to neuromuscular diseases. Further larger randomized trials are needed to confirm long term beneficial effects of nocturnal mechanical ventilation on quality of life, morbidity and mortality, to assess its cost-benefit ratio, and to compare the different types and modes of ventilation.

Inappropriate sympathetic activation at onset of septic shock: a spectral analysis approach

The autonomic cardiovascular control was investigated in 10 patients with septic shock, 10 patients with sepsis syndrome, and six tilted healthy subjects. Overall variability, high- and low-frequency components (AUC, HF, and LF, beats/min(2)/Hz or mm Hg(2)/Hz) from heart rate (HR), systolic (SBP) and diastolic (DBP) blood pressures spectra were obtained from 5-min recordings. LF(HR)/HF(HR) and the square root of LF(SBP)/LF(HR) (alpha) were used as indices of sympathovagal interaction and baroreflex control of the heart, respectively. Compared with tilted control subjects and patients with sepsis syndrome, septic shock is characterized by reduction in: (1) HR variability, i.e., decreased AUC(HR) (p = 0.007), LF(HR) (p = 0.002), and LF(HR)/HF(HR) (p = 0.0002); (2) DBP variability, i.e., decreased AUC(DBP) (p = 0.003) and LF(DBP) (p = 0.001), (3) alpha (p = 0.003). In septic shock, LF(HR)/HF(HR), alpha, and LF(DBP) correlated with mean blood pressure (r = 0.67, p = 0.04, r = 0.64, p = 0.03, and r = 0.88, p = 0.0008, respectively), and with plasma norepinephrine levels (r = -0.65, p = 0.03, r = -0.79, p = 0.006, and r = -0.69, p = 0.03, respectively). In conclusion, onset of septic shock is characterized by high concentrations of circulating catecholamines but impaired sympathetic modulation on heart and vessels, suggesting that central autonomic regulatory impairment contributes to circulatory failure.

Treatment of the adult Guillain-Barré syndrome: indications for plasma exchange

The Guillain-Barré syndrome is the most common cause of acute flaccid paralysis. Currently, 5% of patients die and 10% are left with severe motor sequelae at one year. Multidisciplinary teams, trained to specific treatments, are required to manage these patients. Oral and intravenous steroid treatment of GBS has been disappointing. Two large randomized clinical trials comparing plasma exchange (PE) to standard supportive treatment have shown a short-term and a one-year benefit of PE. Appropriate number of exchanges and indications of PE are now more precisely known. Patients with mild forms of the disease (able to walk) should receive two PEs, while a further two exchanges should be done in case of deterioration or in advanced forms (loss of walking ability, mechanical ventilation). A greater number of exchanges does not appeared beneficial. More recently, two randomized trials produced some evidence that intravenous immune globulin (IVIg, 0.4 g/kg daily for five days) and PE had equivalent efficiency in advanced forms. The combination of PE with IVIg did not yield a significant advantage, but did increase cost and risk. In advanced forms, the choice between PE and IVIg depends on the contraindications of each treatment.

Mechanisms underlying effects of nocturnal ventilation on daytime blood gases in neuromuscular diseases

The hypothesis that, in neuromuscular and chest wall diseases, improvement in central respiratory drive explains the effects of night-time ventilation on diurnal gas exchanges was tested. The effects at 6 months, 1, 2 and 3 yrs of intermittent positive pressure ventilation (IPPV) on arterial blood gas tension, pulmonary function, muscle strength, sleep parameters, respiratory parameters during sleep and ventilatory response to CO2 were evaluated in 16 consecutive patients with neuromuscular or chest wall disorders. As compared with baseline, after IPPV daytime arterial oxygen tension (Pa,O2) increased (+2.3 kPa at peak effect) and arterial carbon dioxide tension (Pa,CO2) and total bicarbonate decreased (-1.8 kPa and -5 mmol x L(-1), respectively) significantly; vital capacity, total lung capacity, maximal inspiratory and expiratory pressures and alveolar-arterial oxygen gradient did not change; the apnoea-hypo-opnoea index and the time spent with an arterial oxygen saturation (Sa,O2) value <90% decreased (-24 and -101 min, respectively), sleep efficiency and mean Sa,O2 increased (+16% and +5%, respectively); and ventilatory response to CO2 increased (+4.56 L x min(-1) x kPa(-1)) significantly. The reduction in Pa,CO2 observed after IPPV correlated solely with the increase in the slope of ventilatory response to the CO2 curve (r=-0.68, p=0.008). In neuromuscular or chest wall diseases, improvement of daytime hypoventilation with nocturnal intermittent positive pressure ventilation may represent an adaptation of the central chemoreceptors to the reduction of profound hypercapnia during sleep or reflect change in the quality of sleep.

[Guillain-Barré syndrome: from the original description to the modern concepts]

Since the original report, acute paralysis and albuminocytologic dissociation have remained hallmarks of the Guillain-Barré syndrome but the initially described favorable outcome with complete motor recovery is not always observed. Guillain-Barré syndrome can be complicated by early respiratory distress, dysautonomia and late functional impairment. The conduction block induced by acute demyelination accounts for the spontaneous neurological improvement. On the other hand, early axonal damage or sustained demyelination can be responsible for residual deficit. The cause and mechanism of the disease still remain unclear. For these patients, general care is essential and should be provided in appropriate hospital units. Today, specific treatment consists of either plasma exchange or high-dose intravenous immunoglobulins; the choice depends on their respective contraindications.

Impaired pressor sensitivity to noradrenaline in septic shock patients with and without impaired adrenal function reserve

AIMS

To investigate the relationship between adrenal gland function and pressor response to noradrenaline in septic shock.

METHODS

Basal cortisol level, noradrenaline--mean arterial pressure dose-response curve and cortisol response to intravenous corticotrophin bolus were obtained in nine patients fulfilling usual criteria for septic shock and in six normal volunteers. In patients with septic shock, dose-response curve to noradrenaline was determined a second time 60 min after a 50 mg intravenous hydrocortisone bolus.

RESULTS

As compared with controls, patients with septic shock had increased basal cortisol levels (mean+/-s.d.: 1564+/-818 vs 378+/-104 nmol l(-1) , P=0.002, 95% confidence interval for difference in means: [452, 1920]) and a blunted cortisol response to corticotrophin (403+/-461 vs 1132+/-195 nmol l(-1), P=0.008, [-1163, -2951). Five patients had impaired adrenal function reserve. As compared with controls, septic patients displayed a moderate and non significant decrease in pressor sensitivity to noradrenaline (P=0.112). As compared with patients with adequate adrenal response, patients with impaired adrenal function reserve showed a significant decrease in pressor sensitivity to noradrenaline (P=0.038). In septic patients, hydrocortisone improved pressor response to noradrenaline (P=0.032). This effect was more marked in patients with impaired adrenal function reserve so that, as compared with patients with adequate response, the difference was no longer significant (P=0.123).

CONCLUSIONS

In septic shock, impaired adrenal function reserve may partly be accounted for by the depressed pressor sensitivity to noradrenaline. The latter may be substantially improved by physiological doses of hydrocortisone.

[Guillain-Barré syndrome in the adult: therapeutic aspects]

The Guillain-Barré syndrome is the most common cause of acute flaccid paralysis. The current mortality is 5%, while severe motor sequelae persist after one year in 10%. Multidisciplinary teams, trained in all specific treatments, are required to treat these patients. Oral and intravenous steroids have proved ineffective. Two large randomized clinical trials comparing plasma exchange (PE) with no treatment have shown a short-term and a 1-year benefit. The appropriate number of exchanges and the indications are now more precisely known. In the mild form (walking possible) patients should receive two PEs; a further two exchanges should be done in the event of deterioration or in advanced forms (loss of walking ability, mechanical ventilation). More exchanges are not beneficial. Recently two new randomized trials have produced evidence that intravenous immunoglobulin (IVIg) (0.4 g/kg/day for 5 days) was as effective as 5 PEs in advanced forms. The combination of PE with IVIg did not confer a significant advantage but increased the costs and risks. In advanced forms the choice between PE and IVIg depends on the contraindications for each treatment.

[Treatment of Guillain-Barré syndrome in adults: role of plasma exchange]

PURPOSE

To review recent data on treatment of Guillain-Barré syndrome, especially indications of plasma exchange.

DATA SYNTHESIS

Guillain-Barré syndrome is the most common cause of acute flaccid paralysis. The current mortality is 5%, sever motor sequelae persist after 1 year in 10% of cases. Multidisciplinary teams are required to treat these patients, trained to all specific treatments. Oral and intravenous steroids have proven ineffective. Two large randomized clinical trials comparing plasma exchange (PE) with no treatment have shown a short-term and a 1-year benefit. Appropriate number of exchanges and indications are now more precisely known. In mild form (walking possible), patients should receive two PEs. A further two exchanges should be done in case of deterioration or in advanced forms (loss of walking ability, mechanical ventilation). More exchanges are not beneficial. Recently two new randomized trials have produced evidence that intravenous immune globulin (IVIg) (0.4 g/kg/d for 5 days) were as effective as five PEs in advanced forms. The combination of PE with IVIg did not confer a significant advantage, while increasing cost and risks.

CONCLUSION

The combination of PE with IVIg did not confer, in advanced forms, the choice between PE and IVIg depends of the contra-indications of each treatment.

[Treatment of Guillain-Barré syndrome by plasma exchange: proposal of a therapeutic strategy]

Although the favorable effect of plasma exchange (PE) has been demonstrated in Guillain-Barré syndrome, the optimal number of PE and management at different degrees of gravity remain to be ascertained. A new controlled multicentric trial is therefore being conducted since 1986. Mid-term results show that 2 PE give better results than 0 in patients who are still able to walk. Inversely, 6 PE do not give better results when ventilatory assistance was initially required. It is therefore logical to propose 2PE as early as possible. Two supplementary PE can be used in case of disease progression. Use of high dose immunoglobulins is not justified except when PE is contraindicated.

Immunoglobulin A levels in bronchial samples during mechanical ventilation and onset of nosocomial pneumonia in critically ill patients

Local immunoglobulins play a key role in host defense against lung infection. We investigated the pattern of evolution of bronchial albumin, IgA, and IgG levels in ventilated ICU patients in relation to nosocomial pneumonia. Immunocompetent, critically ill patients underwent serial blood and bronchial protein determinations on Day 1 (intubation day), and on Days 3, 7, 10, and 14. The variations in proteins levels were compared with corresponding Day 1 values in the whole population, and between patients who developed lung infections (Group A) and the remaining population (Group B). Forty-four patients were included into the study. In the whole population, when compared with the baseline value, bronchial IgA/albumin ratio increased significantly (Day 3, +58%, p = 0.04); Day 14, +171%, p < 0.01), but serum IgA/albumin and serum and bronchial IgG/albumin ratios did not change significantly. In Group A, the increase in the IgA/albumin ratio was less than in Group B (Day 3, +15% versus +87%, p = 0.04; Day 14, +29% versus +210%, p < 0.01). No significant differences were observed between the two groups for bronchial and plasma albumin and IgG levels and for bronchial polymorphonuclear elastase levels. Bronchial IgA production was enhanced in ventilated patients. A reduction in this enhanced bronchial IgA production might account for the development of nosocomial pneumonia.

Sleep-related respiratory disturbances in patients with Duchenne muscular dystrophy

Sleep-related respiratory disturbances (SRD) in patients with muscle diseases may have significant clinical implications, because the patients frequently die at night. The aims of the study were to :1) assess the presence and severity of sleep-related respiratory disturbances in patients with Duchenne muscular distrophy (DMD); and 2) investigate the relationship of sleep-related respiratory disturbances to daytime symptoms and pulmonary function. We studied six clinically stable patients with Duchenne muscular dystrophy, mean age (+/- SD) 18 +/- 2 yrs. Vital capacity was 27 +/- 19% of predicted and daytime arterial oxygen tension (PaO2) was 10.9 +/- 1 kPa (range 8.9-12.4 kPa). The presence of daytime somnolence, insomnia, headache, nightmares and/or snoring was recorded. Four patients (67%) showed symptoms that suggest sleep-related respiratory disturbances. At night, the apnoea-hypopnoea index (AHI) was 11 +/- 6. The patients with more symptoms during the daytime had the highest AHI scores. Most of the apnoeas (85%) were central, particularly during rapid eye movement (REM) sleep. Sleep architecture was well-preserved. Arterial desaturation (> 5% below baseline) occurred during 25 +/- 23% of total time. AHI correlated with daytime PaO2, and AHI in REM sleep correlated with age. A stepwise multivariate analysis showed that PaO2 and, to some extent, the degree of airflow obstruction were significantly correlated with AHI. We conclude that sleep-related respiratory disturbance are frequently present in patients with Duchenne muscular dystrophy. Therefore, physicians should look for symptoms related to sleep-related respiratory disturbances in these patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Randomised trial of preventive nasal ventilation in Duchenne muscular dystrophy. French Multicentre Cooperative Group on Home Mechanical Ventilation Assistance in Duchenne de Boulogne Muscular Dystrophy

Duchenne muscular dystrophy (DMD) is the most common muscular dystrophy in children. Paralysis of respiratory muscles causes a decrease in forced vital capacity (FVC) from age 12 years, and death occurs between 20 and 25 years old and is usually related to respiratory insufficiency. Uncontrolled studies suggest that early home use of nasal intermittent positive-pressure ventilation (NIPPV) in DMD patients free of respiratory failure could limit progression of the restrictive syndrome and therefore improve survival because efficacy of preventive NIPPV has not been demonstrated in a controlled trial, we undertook a randomised multicentre study in which 70 patients with DMD were included. Patients were free of daytime respiratory failure and FVC was between 20 and 50% of predicted values. At least 6 h of nocturnal NIPPV (n = 35) was compared with conventional treatment (n = 35). During a mean follow-up of 52 months, 10 patients died, 8 in the NIPPV group and 2 in the control group (p = 0.05, log-rank test). No differences were observed between the two groups for occurrence of hypercapnia, decrease of FVC below 20% of initial values, or use of necessary mechanical ventilation. Preventive NIPPV did not improve respiratory handicap and reduced survival of DMD patients. Use of NIPPV for preventive purposes should be avoided in patients with FVC between 20 and 50% of predicted values.

[Evaluation of hospital care. An experiment at the Public Assistance Hospitals in Paris]

Since 1990 the Assistance Publique--Hôpitaux de Paris (AP-HP) developed a policy of health care assessment in agreement with the implications of the law of July 31, 1991. The department of Evaluation of health care, in close collaboration with the local Committees which operate in most of the hospitals of AP-HP, performed during the last three years about fifty studies dealing with two main topics: professional procedures and quality of care. Through three specific selected studies, the authors emphasize the requirements of an assessment policy to efficiently contribute to the improvement of quality of care.

Plasma exchange morbidity in Guillain-Barré syndrome: results from the French prospective, randomized, multicenter study. The French Cooperative Group

OBJECTIVES

To describe all adverse events occurring during plasma exchange sessions in adult patients with the Guillain-Barré syndrome. To analyze these events with regard to the technical modalities and biological changes induced by sessions, and to try to identify a population at high risk for adverse events.

DESIGN

Double-blind, randomized, prospective, multicenter trial.

SETTING

A total of 28 French and Swiss intensive care units.

PATIENTS

The study is based on 220 patients allocated either to plasma exchange (n = 109) or not (n = 111). This study focused on 105 patients who received at least one plasma exchange, with replacement fluid secondly allocated by randomization to albumin, or fresh frozen plasma. A total of 105 patients underwent 390 plasma exchanges. Fifty-five patients received albumin (208 sessions) as replacement fluid, and 50 patients received fresh frozen plasma (182 sessions).

INTERVENTIONS

Prospective monitoring of patients for each session including technical modalities, adverse effects, and biological parameters.

MEASUREMENTS AND MAIN RESULTS

A total of 253 adverse incidents were recorded. At least one adverse incident occurred in 39% of plasma exchange sessions among 80 (76%) patients. In 15 patients, plasma exchange treatment had to be discontinued because of severe intolerance (six patients, including three patients with severe bradycardias), intercurrent complications, mainly infections (four patients), and technical difficulties. One patient with pneumococcal septicemia and pneumonia died during the second plasma exchange session. Fresh frozen plasma was associated with more adverse incidents than albumin (135 vs. 118, p = .008). The occurrence of adverse events was also related to the preplasma exchange hemoglobin level assessed before the session (p = .04). Otherwise, the frequency of adverse effects did not depend on technical modalities (type of equipment, anticoagulation). Age, sex, previous history, neurologic severity, and the need for mechanical ventilation, as assessed on inclusion in the study, did not modify the risk of adverse effects. Finally, occurrence of bradycardia did not rely on initial neurologic severity.

CONCLUSIONS

These results confirm that fresh frozen plasma should be abandoned as replacement fluid in plasma exchanges of Guillain-Barré syndrome patients. They also underline the need for close monitoring of patients during sessions and, especially, the respect of treatment contraindications. Some adverse incidents could be attributed to the underlying disease rather than to the plasma exchange session.

[Methods of investigating orthostatic hypotension]

Orthostatic hypotension, which is common mainly in the elderly, is in many cases related to hypovolemia and/or vasodilators intake. However, when an impairment of the autonomic nervous system is suspected, orthostatic hypotension severity and mechanism may be investigated. The most common tests are the head upright tilt-test and the Valsalva manoeuvre. Both of them examine the baroreflex system as a whole, and become non invasive tests with the development of finger arterial blood pressure continuous measurement. Each part of the baroreflex system may be investigated separately. So, cardiac vagal responses to ocular compression, to carotid sinus massage, to respiratory change or to atropine infusion, may be tested. On the other hand, sympathetic efferent pathways may be stimulated in a variety of ways, such as isometric exercise, cutaneous cold, mental arithmetic, norepinephrine infusion, or tiltest. None of these tests should be applied systematically, but according to the clinical features.

Breathing disorders during sleep in myasthenia gravis

Twenty consecutive patients (16 women and 4 men), with a mean age of 40 years, who were diagnosed and treated for myasthenia gravis were enrolled in a prospective investigation aimed at determining the amount of respiratory disturbance occurring during sleep while they received treatment. Patients were clinically evaluated to determine body mass index, presence of upper airway anatomical abnormalities, level of functional capacity and activity scored from 1 to 5, and presence of sleep-related complaints. They underwent daytime pulmonary function tests, determination of maximal static inspiratory pressure, measurement of transdiaphragmatic pressure, and measurement of arterial blood gas levels. Polygraphic monitoring during sleep, evaluating respiration and oxygen saturation, was also performed. Results indicated that in the studied population, all subjects had evidence of daytime diaphragmatic weakness as demonstrated by transdiaphragmatic pressure measurements, independent of the degree of autonomy and functional capacity and activity level reached. Older patients with moderately increased body mass index, abnormal total lung capacity, and abnormal daytime blood gas concentrations were the primary candidates for development of diaphragmatic sleep apneas and hypopneas, and oxygen desaturation of less than 90% during sleep. However, these clear indicators were not found in all subjects with sleep-related disordered breathing. Rapid-eye-movement sleep was the time of highest breathing vulnerability during sleep. Sleep-related complaints may also help identify subjects at risk for abnormal breathing during sleep, even when daytime functional activity is judged normal.

Incidence and causes of carbon monoxide intoxication: results of an epidemiologic survey in a French department

The purpose of this study was to estimate the incidence, mortality, and causes of carbon monoxide intoxications in France. A survey was conducted in the department of the Hauts-de-Seine, which is representative of the French population. Data were collected through a headquarters that had direct contact with all department emergency organizations and to a technical laboratory. During the 3-y study, 735 cases that were related to 291 events were reported. Thirty-six patients died. The average incidence of carbon monoxide intoxications was 17.5 per 100,000 inhabitants. Poisoning was caused by fires in 36 events and by car exhausts in 12. For the remaining events, causes were determined as follows for 196: water heaters (57%), boiler (20.5%), coal stove (9%), brazier (4%), cooker (2%), heating device (1.5%), and miscellaneous (6%). The main mechanisms of intoxication were a defective device, poor ventilation, or poor evacuation of combustion gases. Carbon monoxide intoxication occurs frequently in France, and preventive actions are warranted.

[Guillain-Barré syndrome. Recent clinical and therapeutic aspects]

Guillain-Barré syndrome is an acute primary polyradiculoneuritis. A prototype of demyelinating disease, its essential characteristic is that it spontaneously evolves towards recovery from paralysis. Yet the vital and functional prognosis may be compromised in severe cases. Death and motor sequelae are particularly to be feared when the maximum deficit is severe and the maximum paralysis phase is prolonged. Cardiovascular vegetative disorders are also more frequent in these extended types. Symptomatic treatment rests on close supervision of the patients during the paralysis extension phase. Transferring the patient to an intensive care unit is mandatory as soon as disorders of deglutition and/or a significant decrease of vital capacity appear. Plasma exchange is the only treatment proven to be effective. It must be carried out early on in patients whose deficit is severe enough to interfere with walking and for whom this treatment is not contra-indicated. Fresh frozen plasma must not be used as replacement solution: it creates more incidents and complications than diluted albumin and has no additional beneficial effect on the course of the neurological disease.

Acute carbon monoxide intoxication and hyperbaric oxygen in pregnancy

Modalities of oxygen therapy for pregnant women intoxicated with carbon monoxide (CO) are ill defined. Hyperbaric oxygen (HBO) is presumed to be hazardous to the pregnancy. On the other hand CO entails anoxic injuries in the mother and fetus. We have entered 44 pregnant women who sustained an acute carbon monoxide poisoning at home, into a prospective study in order to assess HBO tolerance. They were treated within 5.3 +/- 3.7 h (range: 1-12) of the intoxication with a combination of 2 h of HBO at a pressure of 2 atmospheres absolute (ATA) and 4 h of normobaric oxygen, irrespective of the clinical severity of the intoxication and of the age of pregnancy. Six patients were lost to obstetric follow-up. Only 2 patients sustained a spontaneous abortion: 1 within 12 h and 1 within 15 days of the intoxication. Thirty-four women gave birth to normal newborns. Finally 1 elected to undergo abortion for reasons unrelated to the intoxication and 1 gave birth to a baby with Down's syndrome. There is no evidence that HBO was involved with either abortion of our study. We conclude that HBO may be carried out in pregnant women acutely intoxicated with carbon monoxide.

Trial of normobaric and hyperbaric oxygen for acute carbon monoxide intoxication

The value of hyperbaric oxygen in the treatment of acute carbon monoxide intoxication was assessed in 629 adults who had been poisoned at home in the 12 h before admission to hospital. In patients without initial impairment of consciousness (group A) the effect of 6 h of normobaric oxygen (NBO) (group A0, n = 170) was compared with that of 2 h of hyperbaric oxygen (HBO) at 2 atmospheres absolute (ATA) plus 4 h NBO (group A1, n = 173). At the 1 month follow-up 66% of A0 and 68% of A1 patients had recovered. In patients with initial impairment of consciousness the effect of one session of HBO (group B1, n = 145) was compared with that of two sessions (group B2, n = 141); all group B patients also received 4 h of NBO. At 1 month of follow-up 54% group B1 and 52% group B2 patients had recovered. The 7 patients left with neuropsychiatric sequelae (3 B1, 4 B2) and the 4 who died (2 B1, 2 B2) had all presented with coma. HBO was not useful in patients who did not lose consciousness during carbon monoxide intoxication, irrespective of their carboxyhaemoglobin level, nor were two sessions of HBO in patients who sustained only a brief loss of consciousness. The prognosis is poorest for those presenting with coma; the trial needs to be pursued in this group of patients until the power of the study is sufficient to demonstrate the value or otherwise of HBO.

A transient state model for analysing ventilatory status in a randomized clinical trial

We designed a randomized clinical trial to determine the efficacy of plasma exchange in Guillain-Barré syndrome, an acute neurological disease leading to paralysis in previously healthy subjects. Some patients require temporary mechanical ventilation during the course of the disease. Ventilatory status was analysed using a three-state model with a transient state defined by use of temporary mechanical ventilation, and the probability of being mechanically ventilated modelled as a function of time since randomization. The plot of this function reflects the effect of plasma exchange on ventilatory status showing that fewer plasma-exchanged patients than controls required ventilatory assistance and that the duration of assistance was shorter. Similar functions can be used in a more general framework when the response criterion includes a transient state.

[Long-term effects of plasma exchange in myasthenia. Results of a randomized study]

A randomized study was carried out in 14 myasthenia patients to compare the long-term effects of two therapeutic regimens. Group I patients received prednisone 1 mg/kg/24 h for one month, then in decreasing dosage; in case of failure at the end of the first month, cyclophosphamide 2 mg/kg/24 h was added to the prednisone treatment. Group II patients received the same treatment associated with 3 plasma exchanges over a 10-day period; these were continued, if required, at the rate of once a week. The minimum follow up was one year. The results (greater improvement in muscular strength and vital capacity) were better after one month in group I and thereafter similar in both groups. However, the mean daily dose of prednisone was higher in Group I. The number of exacerbations of myasthenia was greater in group II (11 versus 2 in group I over a 24-months period). The mean fall in anti-R Ach ab was about the same in both groups. This study confirms the rapid effectiveness of plasma exchanges and their value in severe myasthenia. The higher incidence of exacerbations in Group II was probably due to a rebound phenomenon and points to the need for combined immuno-suppressive treatment.

[A fortultousness association: Bartter's syndrome and chondrocalcinosis (author's transl)]

Two adults patients presenting Bartter's syndrome have been studied for 9 years in one case, 7 years in the other. Both were affected with chondrocalcinosis. This association does not seem to be coincididental but suggests a pathogenic link between Bartter's syndrome and chondrocalcinosis; the two patients presented hypomagnesemia which, inhibiting intrasynovial pyrophosphatase, induces calcium pyrophosphate crystals deposits on fibrocartilages. Otherwise, excessive daily urinary excretion of PG E2 and PG F2 alpha was found in both patients. Indomethacin (150 mg daily) decreased urinary excretion of PG to normal values in the two cases, Kalaemia was completely normalized in one case, partially in the other.

Membrane oxygenators for acute respiratory insufficiency. Clinical use in 11 patients

Extracorporeal circulation with a membrane oxygenator (ECMO) was used in 11 patients with acute respiratory insufficiency who did not respond to conventional treatment. By pass was veno-arterial in every case, seven times with femoral artery return, three times with axillary artery return, and once with both femoral and axillary return. Five patients died on ECMO. Six patients were taken off ECMO and two of them are long-term survivors. In nine cases ECMO allowed short-term control of respiratory failure. The respective roles of oxygen supply from ECMO and the haemodynamic changes incurred by its use are discussed. Although use of ECMO for long periods seems less hazardous now, present results are restricted by the lack of therapy for the underlying pulmonary lesions.

[Periodic familial paralysis with hypokalemia. Hemodynamic and metabolic studies: favourable effect of acetazolamide (author's transl)]

The same protocol was used three times to produce a paralytic episode in a typical case of periodic familial paralysis with hypokalemia. This consisted of an effort together with a perfusion of hypertonic glucose serum and insulin. The first test provoked an attach of hypokalemic tetraplegia. The second test, two months after treatment with 500 mg daily of acetazolamide, produced no reaction. In the third test, the metabolic acidosis caused by acetazolamide was reduced by the injection of sodium bicarbonate, and a stronger effect than in the first test was observed. This confirms the efficacy of acetazolamide as a preventive treatment for paralytic attacks; the most reasonable hypothesis being that it acts through the metabolic acidosis that it induces. Metabolic and hemodynamic studies were carried out during the provoked attacks. Cardiac output and oxygen consumption are increased, while pulmonary capillary pressure and periopheral resistance are reduced. Diastolic pressure is lower when measured by an arm-cuff but shows no change when direct readings are taken in the blood-vessels. These results suggest that there is an increase in cellular energy needs, or that the smooth muscle in the vessel walls is paralyzed. The two tetraplegic attacks in tests 1 and 3 were associated with a metabolic acidosis, which is explained by a simultaneous transfer, though in the opposite direction, of H+ and K+ ions; the intra-cellular pH, as measured by the D.M.O. technique, was acid when there was not an attack, and this increased during paralysis.