Clinical COPD phenotypes: a novel approach using principal component and cluster analyses

Classification of chronic obstructive pulmonary disease (COPD) is usually based on the severity of airflow limitation, which may not reflect phenotypic heterogeneity. Here, we sought to identify COPD phenotypes using multiple clinical variables. COPD subjects recruited in a French multicentre cohort were characterised using a standardised process. Principal component analysis (PCA) was performed using eight variables selected for their relevance to COPD: age, cumulative smoking, forced expiratory volume in 1 s (FEV(1)) (% predicted), body mass index, exacerbations, dyspnoea (modified Medical Research Council scale), health status (St George's Respiratory Questionnaire) and depressive symptoms (hospital anxiety and depression scale). Patient classification was performed using cluster analysis based on PCA-transformed data. 322 COPD subjects were analysed: 77% were male; median (interquartile range) age was 65.0 (58.0-73.0) yrs; FEV(1) was 48.9 (34.1-66.3)% pred; and 21, 135, 107 and 59 subjects were classified in Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages 1, 2, 3 and 4, respectively. PCA showed that three independent components accounted for 61% of variance. PCA-based cluster analysis resulted in the classification of subjects into four clinical phenotypes that could not be identified using GOLD classification. Importantly, subjects with comparable airflow limitation (FEV(1)) belonged to different phenotypes and had marked differences in age, symptoms, comorbidities and predicted mortality. These analyses underscore the need for novel multidimensional COPD classification for improving patient care and quality of clinical trials.

[Alveolo-interstitial pneumonia due to Temozolamide]

INTRODUCTION

Temozolomide is an alkylating agent approved for treatment of glioblastoma in association with radiotherapy.

CASE REPORT

We report the case of a 56 year old woman presenting with alveolo-interstitial pneumonia after treatment with Temozolomide. Initially she received induction treatment with Temozolomide and concomitant radiotherapy for bifocal high grade glioblastoma. A month later she received, as scheduled, the first course of Temozolomide maintenance chemotherapy. Grade II dyspnoea developed a few days later. High resolution computed tomography showed alveolo-interstitial opacities with basal predominance, associated with alveolar nodules. Broncho-alveolar lavage showed a lymphocytosis. No bacteria were isolated from microbiological samples. A final diagnosis of drug-induced pneumonia was based on the time sequence and absence of other causes.

CONCLUSION

There is little literature concerning the pulmonary toxicity of Temozolomide. However, our case report of drug-induced pneumonia and similar observations in the databases of regional pharmacovigilance centres suggest that this side effect should be included in the summary of product characteristics.

[Dyspnea and morphine aerosols in the palliative care of lung cancer]

OBJECTIVE

To evaluate the effectiveness of morphine aerosols in the treatment of dyspnoea in the palliative care of patients with lung cancer.

MATERIALS AND METHODS

During a randomised, double blind, cross-over study 12 patients receiving palliative care for lung cancer and suffering from dyspnoea despite conventional treatments were given, for two periods of 48 hours separated by a 24 hour wash-out period, 4 mls of morphine sulphate and 4 mls of normal saline 4 hourly by a jet nebuliser. Before and after each nebulisation respiratory rate and capillary oxygen saturation were measured and dyspnoea was quantified with the aid of a visual analogue scale by the patient and various other observers (doctors, students, nurses, care assistants and physiotherapists).

RESULTS

The aerosols of normal saline and morphine produced the same improvements in the dyspnoea scores independently of the mass nebulised. Furthermore the nebulisations did not produce any significant change in respiratory rate or oxygen saturation.

CONCLUSION

The fact that both aerosols lead to a similar improvement in dyspnoea scores suggests that humidification of the airways rather than a pharmacological action may be beneficial in the treatment of dyspnoea in terminally ill patients.

The effect of preoperative epidural morphine on postoperative analgesia in children

IMPLICATIONS

We examined the effects of preoperative epidural morphine associated with general anesthesia on postoperative morphine requirements. Twenty-one children older than 6 yr scheduled for major surgery were randomly assigned to two groups, a control group and an epidural group that received a single epidural morphine injection.

[Ilio-inguinal Ilio-hypogastic nerve block with a single puncture: an alterantive for anesthesia in emergency inguinal surgery]

The authors describe the anaesthetic procedure for a strangulated hernia repair needing resection and anastomosis of the small bowel in an adult patient. This procedure was performed with an ilio-inguinal/ilio-hypogastric nerve block according to a paediatrical simplified technique with a single puncture. For this patient who had relative contraindications for central blocks, this regional technique allowed to avoid general anaesthesia with its gastric aspiration and predictible difficult intubation risks. This block associated with a very light sedation was sufficient for all the surgical procedure, and postoperative analgesia was efficient over 3 hours. This simplified nerve block, better than the conventional approach for the clinical practice, represents a recommended alternative for hernia repair in emergency for high risk patients who could have a general anaesthesia or a central block.

Comparison of recovery after intermediate duration of anaesthesia with sevoflurane and isoflurane

BACKGROUND

The purpose of this study was to compare recovery from anaesthesia after sevoflurane and isoflurane were administered to children for more than 90 min.

METHODS

After parental informed consent and ethical committee approval, children aged between 2 months and 6 years, ASA I or II, were randomly allocated to sevoflurane (n=20) or isoflurane (n=20) groups. Halogenated agents were discontinued following skin closure and patients were ventilated mechanically with 100% oxygen until minimum alveolar concentration (MAC) values awake were obtained (endtidal concentrations 0.6 MAC for sevoflurane and 0.4 MAC for isoflurane). Effective perioperative analgesia was provided by a caudal block.

RESULTS

The mean (+/- SD) duration of anaesthesia was 132 +/- 38 min and 139 +/- 49 min for sevoflurane and isoflurane, respectively. Early recovery occurred sooner in the isoflurane group (time to extubation was 16 +/- 7 min and 11 +/- 5 min, P<0.01; Aldrete's score at 0 min was 5.5 +/- 1.5 and 7.4 +/- 1.8, P<0.001, respectively). But the time to be fit for discharge from recovery room was similar at 136 +/- 18 min and 140 +/- 20 min, respectively.

CONCLUSIONS

After intermediate duration of anaesthesia administered to children for up to 90 min, isoflurane and sevoflurane allow recovery after approximatively the same lapse of time.

[Syringomyelia discovered in the course of peridural anesthesia]

Neurological symptoms after epidural anaesthesia suggest complications due to anaesthetic procedure. We report the case of a child who underwent perineal surgery in a gynaecological position under general and epidural anaesthesia, who experienced the day after surgery hypoesthesia of the whole left lower limb without any motor deficit. Magnetic resonance imaging excluded spinal compression, but revealed syringomyelic cavity extending from T9 to T11. Electromyogram evaluation was normal. Clinical signs completely vanished within 24 hours. This case emphasizes that the apparition of neurological signs after central nerve blocks is not only a complication of regional anaesthesia, but may reveal unknown neuropathy or result from surgical position or surgical procedure. Meticulous neurological examination, magnetic resonance imaging and electromyogram are immediately required.

[Serum procalcitonin and respiratory tract infections]

The aim of our study was to evaluate the prognostic value of serum procalcitonine (PCT) assay in adult respiratory infections. Forty-nine patients admitted with pleurisy, community-acquired pneumonia, tuberculosis, infection were included in this prospective study. PCT was assayed on admission and discharge. Biological and clinical parameters of gravity were also evaluated. Twenty patients had elevated PCT of more than 0.50 ng/ml. In 29 patients, PCT was undetectable. The serum PCT level was normal in the patients with tuberculosis, infection, pneumocytosis. PCT did not correlate with the biological and clinical markers of the disease severity but the evolution of PCT correlated with the evolution of C-reactive-protein (r = 0.58, p < 0.05). PCT seems to be an early marker of the evolution of respiratory infections, but it does not help to establish prognosis. Further studies are necessary to assess the potential value of PCT in more severe respiratory infections requiring assisted ventilation.

[Emergency computed tomography in a general hospital center]

This retrospective study was performed to precise indications of emergency CT in a general hospital over a 30 months period. We tried to determine, with help of prior studies, the indications for CT of the brain in the management of acute meningitis, acute headache, and in the management of head injury. In acute meningitis, there is no evidence to recommend CT of the brain before lumbar puncture, except to identify patients at increased risk of cerebral herniation. The imaging study of choice in subarachnoid hemorrhage is non enhanced CT scan. This exam has to be performed in case of acute headache. The CT evaluation of patients with minor head injury remains controversial.

[Sever acute pulmonary edema after peri-anesthetic laryngospasm in a newborn infant]

Severe acute pulmonary oedema following peranaesthetic laryngospasm in a newborn. The authors report a case of severe acute pulmonary oedema secondary to a laryngeal spasm in a 3-week-old neonate, immediately after induction of anaesthesia with halothane. After emergency tracheal intubation, the infant experienced a severe, life-threatening pulmonary oedema requiring prolonged intensive care. Such a secondary time course is unusual. Usually pulmonary oedema has a favourable outcome after oxygen administration and maintenance of positive expiration pressure, except in the neonate.

Denoising of the uterine EHG by an undecimated wavelet transform

We propose two original methods of denoising of the uterine electrohysterography (EHG) signal by wavelets. This external electrophysiological signal is corrupted by electronic, electromagnetic noises and by the remaining electrocardiogram of the mother. The interfering signals have overlapping spectra. Therefore, a classical filtering is unusable. Wavelets should be a very well-suited denoising tool. The first proposed method uses the algorithm "à trou" with nonsymmetrical filters. The computation is rapid and the results are satisfying compared to the classical denoising techniques. The second algorithm is an improvement of the first method. It uses orthogonal wavelets and the result of the thresholding corresponds to the average of all circulant shifts denoised by a decimated wavelet transform. Results are compared to traditional denoising algorithms by wavelet (orthogonal, maximally decimated). The proposed algorithms are more efficient on simulated signals as well as on uterine EHG.

[Eruption after the 1st dose of standard antitubercular chemotherapy. Thoughts on pyrazinamide]

We report 3 cases of rash after the first dose of antituberculosis polytherapy, thus raising questions concerning the procedures to be followed.

CASE REPORT

Three patients developed a pruritic rash 1 hour after the first dose of isoniazide, rifampicine, pyrazinamide and ethambutol given simultaneously. The eruption did not recur after readministration of isoniazide and rifampicine successively. Pyrazinamide, which was readministered last (at the full dose in one case and at progressive doses in the two others), induced a recurrence in two of them. Pyrazinamide was definitively withdrawn in one patient with recurrence and slower pyrazinamide readministration allowed continuation of treatment in the other two patients.

CONCLUSION

Since pyrazinamide appeared to be responsible for rash following the first administration of antituberculosis polytherapy, a protocol for readministration of the 4 drugs is suggested. If the responsibility of pyrazinamide is confirmed it should be readministered very slowly.

Reactive oxygen intermediates as regulators of TNF-alpha production in rat lung inflammation induced by silica

Exposure to mineral dusts such as silica has been associated with progressive pulmonary inflammation and fibrosis. There is evidence that the release of reactive oxygen intermediates (ROI) and cytokines by alveolar macrophages (AM) is involved in lung injury associated with silica exposure. However, the chronology and relationship between these two mediators are poorly understood. In this study, an animal model of silicosis has been used, allowing simultaneous follow-up of lung histopathologic state, AM TNF-alpha production at the protein (biologic assay) and mRNA (reverse transcriptase-PCR) levels, and the release of ROI (luminol-dependent chemiluminescence), after bronchoalveolar lavages. In particular, it has been shown that intratracheal instillation of silica (50 mg/kg) in rats led to fibrosis characterized by cellular interstitial infiltrates with granulomas, and in AM, it led to 1) an early and continuous increase in 12-O-tetradecanoylphorbol-13-acetate- or zymosan-triggered ROI production (days 1, 3, 14, and 28 post-treatment), and 2) a rise of TNF-alpha mRNA expression and protein secretion on days 3 and 14. A free radical scavenger pretreatment (N-ter-butyl-alpha-phenylnitrone) reversed lung histopathologic changes and decreased AM ROI production and TNF-alpha expression at the level of mRNA. These findings suggest that ROI production is an important primary event determining the silica-induced inflammatory process. ROI may act in an autocrine or paracrine manner and regulate TNF-alpha production by a mechanism promoting gene expression. The critical role of this cytokine in the pathogenesis of silicosis was confirmed by anti-TNF-alpha Ab treatment.

Reactive oxygen intermediates as regulators of TNF-alpha production in rat lung inflammation induced by silica

Exposure to mineral dusts such as silica has been associated with progressive pulmonary inflammation and fibrosis. There is evidence that the release of reactive oxygen intermediates (ROI) and cytokines by alveolar macrophages (AM) is involved in lung injury associated with silica exposure. However, the chronology and relationship between these two mediators are poorly understood. In this study, an animal model of silicosis has been used, allowing simultaneous follow-up of lung histopathologic state, AM TNF-alpha production at the protein (biologic assay) and mRNA (reverse transcriptase-PCR) levels, and the release of ROI (luminol-dependent chemiluminescence), after bronchoalveolar lavages. In particular, it has been shown that intratracheal instillation of silica (50 mg/kg) in rats led to fibrosis characterized by cellular interstitial infiltrates with granulomas, and in AM, it led to 1) an early and continuous increase in 12-O-tetradecanoylphorbol-13-acetate- or zymosan-triggered ROI production (days 1, 3, 14, and 28 post-treatment), and 2) a rise of TNF-alpha mRNA expression and protein secretion on days 3 and 14. A free radical scavenger pretreatment (N-ter-butyl-alpha-phenylnitrone) reversed lung histopathologic changes and decreased AM ROI production and TNF-alpha expression at the level of mRNA. These findings suggest that ROI production is an important primary event determining the silica-induced inflammatory process. ROI may act in an autocrine or paracrine manner and regulate TNF-alpha production by a mechanism promoting gene expression. The critical role of this cytokine in the pathogenesis of silicosis was confirmed by anti-TNF-alpha Ab treatment.

[Disappearance of emphysematous bullae after infectious episodes]

The authors report 3 cases of peri-emphysematous lung infection associated with the development of air-fluid level in pre-existing emphysematous bullae. Prolonged observation revealed that both bullae and fluid disappeared completely or partially after short antibiotic treatment. The review of literature show that this favourable evolution has not often been described and that these pictures must be to differentiate from lung abscess.

Balloon dilatation and self-expanding metal Wallstent insertion. For management of bronchostenosis following lung transplantation. The Toulouse Lung Transplantation Group

Here we report our experience on the use of balloon dilatation or self-expandable metal Wallstent implantation, or both, for the management of twelve bronchial stenoses in ten lung transplant recipients during the past two years. Both techniques were carried out endoscopically, under fluoroscopic guidance and without general anesthesia. Both methods were straightforward, well tolerated, and resulted in immediate symptomatic and functional improvement. The first-line treatment relied on Wallstent insertion (n = 4) or on balloon dilatation (n = 8). Early restenosis occurred in four of eight dilated stenoses and subsequently led to Wallstent insertion. Following Wallstent implantation, growth of granulation tissue occurred in one case and necessitated repeated balloon dilatations inside the stent during the following months. On two occasions, the stenosis was located such that the lower end of the Wallstent overlapped the upper lobe bronchus orifice. This necessitated laser therapy to eliminate the filaments of the stent crossing the lobar orifice, preventing subsequent obstruction. Laser therapy was followed, in one case, by a fibroinflammatory stenosis which was successfully treated by balloon dilatation inside the prosthesis. At the time of writing, the mean +/- SE of the follow-up after Wallstent implantation is 15.3 +/- 2.7 (range: 6 to 32) months. Most Wallstent prostheses are overgrown with bronchial epithelium. We conclude (1) that self-expanding metal Wallstent implantation is a safe procedure and good alternative to silicone stent insertion for the treatment of bronchostenosis following lung transplantation, provided granulomas are not present and (2) that balloon dilatation, although possibly leading to recurrences, can be used to allow inflammatory tissue to mature or to dilate restenoses inside the Wallstent.

Self-expandable prostheses in the tracheobronchial tree

Under endoscopic and radiologic control, two types of self-expandable metal prostheses were implanted in tracheobronchial lesions to help reestablish airway caliber. Thirty-nine metal stent prostheses (6-20 mm in diameter) and 35 Gianturco stents (30 mm in diameter) were used in 55 adult patients with 62 lesions of the trachea (n = 33) or bronchi (n = 29). All lesions except one were endoscopically confirmed to be noninflammatory. Immediately after implantation, radiologic and endoscopic studies verified reestablishment of a satisfactory airway diameter in all patients. At a mean follow-up of 10.35 (range, 3-27) months, improvement in the respiratory status of 49 of the 55 patients (89%) was maintained and tolerance of the device was excellent. For the Wallstent endoprosthesis, the six complications observed at endoscopy were successfully treated. The Gianturco stent, however, led to a high rate of complications: 30% of cases had migration and/or rupture of the metallic mesh, potentially leading to obstruction or wall perforation; one case of respiratory distress was fatal. This procedure offers rapid epithelialization and incorporation of the device into the tracheobronchial wall.

Doppler ultrasound assessment of the effects of ketamine on neonatal cerebral circulation

The effects of a single dose of 5 mg.kg-1 of ketamine administered intravenously to 10 critically ill preterm infants prior to epicutaneo-caval catheterization were analyzed using pulsed-wave Doppler ultrasound. The infants weighed between 670 and 1,885 g and their gestational ages ranged from 26 to 33 weeks. Arterial pressure (MAP), cardiac output (CO), transcutaneous oxygen pressure (TcPO2), transcutaneous carbon dioxide pressure (TcPCO2), end-diastolic velocity (EDV), peak systolic velocity (PSV), mean arterial velocity (MAV) of the cerebral anterior artery as well as Pourcelot's resistance index (PRI) were measured before and after injection of the drug. We observed a significant decrease in arterial pressure at 2 min after injection while heart rate and CO did not vary significantly. TcPO2 and TcPCO2, also remained unchanged throughout the period of measurement. EDV, PSV, and MAV did not vary significantly nor did PRI. As this drug provides major comfort to the baby during painful procedures and considerably facilitates difficult thin vessel catheterization, we believe that it may be used in such conditions.

[Effects of cotrimoxazole on some macrophage functions: microbicide, tumoricide, production of free oxygen radicals, prostaglandins and leukotrienes]

In order to demonstrate an immunomodulating effect of cotrimoxazole, we investigated its influence on some macrophage (M phi) functions in culture: P815 tumor cells killing, Toxoplasma gondii killing, production of free oxygen radicals by luminol-dependent chemiluminescence, prostaglandins and leukotrienes secretion evaluated after incorporation of tritiated arachidonic acid. In vitro, cotrimoxazole inhibited in a dose-dependent fashion the chemiluminescence of murine resident peritoneal or guinea pig alveolar M phi. Production of prostaglandin (PG) 6-keto-F1 alpha, PGF2 alpha, and 5-hydroxyeicosatetraenoic acid by resident peritoneal M phi was also inhibited. However, PGD2 synthesis by alveolar M phi was enhanced. A second study was performed on peritoneal M phi, resident or elicited in vivo by one intra-peritoneal injection of an extract from Mycobacterium Tuberculosis membranes and obtained from mice pretreated or not by cotrimoxazole per os. Resident M phi from cotrimoxale-treated animals showed increased production of leucotriene B4 compared to M phi from controls. 6-keto-PGF1 alpha and free oxygen radicals production by elicited M phi was greatly enhanced by cotrimoxazole whereas thromboxane B2 was reduced. Finally cotrimoxazole enhanced intracellular killing of Toxoplasma gondii and cytotoxicity for tumor cells P815 by resident but not by elicited M phi. It is concluded that cotrimoxazole can modulate MO activation and some M phi functions involved in immune homeostasis. This data could help to understand why an antibiotic such as cotrimoxazole, which is known to be frequently used in immunocompromised hosts, is also efficient in Wegener's granulomatosis.

[Therapeutic modalities in pulmonary tuberculosis]

In 1990, specific antituberculous chemotherapy can cure almost 100 p. cent of patients with pulmonary tuberculosis in France, provided practitioners follow strict therapeutic rules and patients' compliance with treatment is perfect. A single standard treatment is proposed for those patients whose tuberculosis has never previously been treated; it consists of a six months' course of isoniazid (5 mg/kg/day) and rifampicin (10 mg/kg/day); combined with ethambutol (20 mg/kg/day) and pyrazinamide (30 mg/kg/day) during the first two months. This treatment must be administered under regular medical supervision, and it must be prolonged for some time after cure has been obtained. In case of relapse or in some special situations (e.g. pregnant women, HIV positive patients, serofibrinous pleurisy, complex anatomico-clinical forms of the disease) treatment is more difficult, but it should always give favourable results.

[Alveolar macrophages and antibiotics. Review]

Although alveolar macrophages play a key role in pulmonary defence against infections, little is known about interactions of these cells with antibiotics. In vitro, some drugs fail to enter alveolar macrophages readily; in contrast, other antimicrobial agents (clindamycin, erythromycin, ethambutol) are highly concentrated by these cells, as well as josamycin, erythromycin and spiramycin in vivo. Moreover, clindamycin, erythromycin, chloramphenicol, rifampin and pefloxacin lead to an increased phagocytosis by alveolar macrophages, either by compromising bacterial antiphagocytic components or stimulating proper phagocytic activity of the cell. The influence of antibiotics upon mechanisms of microorganisms destruction (production of oxygen metabolites, oxygen independent system), upon regulation of lymphocyte functions (interleukin 1, prostaglandin E2) or other secretory activities (enzymes, modulators of cell activities, various bioactive products) have not been extensively studied and require further investigations.