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Background: Continuous Positive Airway Pressure (CPAP) remains the reference treatment for moderate to severe forms of the Sleep Apnea/Hypopnea Syndrome (SAHS). Compliance to the treatment appears to be a key factor to improving health status of these patients., Methods: We conducted a multicenter, prospective, randomized, controlled, parallel group trial of standard support completed or not within 3 months of coaching sessions for newly diagnosed SAHS patients starting CPAP therapy. This study has been recorded by AFSSAPS with the RCB number: 2009-A01127-50 and received favourably by the Human Studies Committee in France. The coaching session consisted of 5 sessions of telephone-based counselling by competent staff. The primary outcome was the proportion of patients using CPAP more than 3 h per night for 4 months; the secondary outcome was mean hours of CPAP usage in the 2 groups., Results: Three hundred and seventy-nine patients fulfilled the inclusion criteria and were randomized. The percentage of patients using CPAP more than 3 h per night for 4 months was 65 % for the standard support group and 75 % for the coached group. This difference reached a statistical significance (χ2 = 3.97). The mean CPAP usage was increased in the coached group versus standard group. A difference of 26 min was observed (4 h34+/-2 h17 and 4 h08+/-2 h25 respectively, p = 0.04)., Conclusion: This study shows that SAHS patients who benefit from phone coaching are statistically more compliant to CPAP than a standard support group is. A simple phone coaching procedure based on knowledge of the disease and reinforcement messages about treatment benefits helps to improve CPAP adherence in SAHS patients., Trial Registration: NCT02435355.

Background: Lung transplant patients are characterized by a high use of healthcare resources and an elevated rate of hospitalization. In lung transplant recipients, spirometry home monitoring has been advocated for the early detection of acute infection and rejection of the allograft. We will test a new system that allows regular monitoring of the patient's pulmonary status at home after discharge from hospital., Methods: This study will be prospective and in addition to usual healthcare. The main aim of this feasibility study will be to evaluate the compliance of patients in performing three spirometric measurements per week. Patients will have received a lung transplant more than three months prior to entering the study. The home equipment will comprise a data transmitting box (Twitoo(®)) and a spirometer. A decrease of 10% from baseline in one or more parameters will generate an alarm, which will lead to the transplant physician calling the patient and possibly inviting him to the hospital., Expected Results: The feasibility will be considered as acceptable for an average compliance of 70%. The coefficient of variation and the number of spiro-measurements will be adjusted according to the results obtained., (Copyright © 2013 SPLF. Published by Elsevier Masson SAS. All rights reserved.)

Background: The most commonly used treatment for the sleep apnoea syndrome (SAS) is the application of constant positive airway pressure (CPAP) during sleep. Compliance is an essential element in the efficiency of CPAP. This is dependent on the quality of the management of care and on the education of the patients. With the emergence of telemedicine, telemonitoring of CPAP has been developed in France., Methods: This study will be observational and multicentered. The main aim is to evaluate the feasibility of CPAP telemonitoring in SAS patients (n=90). During the installation of the equipment, the patients will be instructed how to connect the CPAP Secure Digital card to a data transmitting box every week for two months. The actual number and frequency of remote-monitoring box connections will be recorded. The data transmission will be made to the study coordinator, the home care provider SADIR, by the way of a telemedicine platform, located in France., Expected Results: This study will allow measurement of the adherence of the patients to their CPAP treatment by telemonitoring using this new tool of data transmission and the impact of this on CPAP compliance., (Copyright © 2011 SPLF. Published by Elsevier Masson SAS. All rights reserved.)

Introduction: The most commonly used treatment for obstructive sleep apnea syndrome (OSA) is the application of continuous positive airway pressure (CPAP) during sleep. However compliance with this treatment is frequently below 70%., Methods: The main aim of this study was to evaluate the feasibility of an educational intervention (EI) delivered in phone calls made to OSA patients (n=66) treated with CPAP by a home care provider (SADIR). The educational intervention consisted of five sessions of telephone based counseling intervention by appropriately trained staff delivered on day 3, 10, 30, 60 and 90 after initiation of treatment. Secondary objectives were to compare, using a case-control design, CPAP compliance of OSA patients (n=133) with or without EI., Results: Ninety-eight percent of patients accepted the intervention to participate in the study. Fifty-seven patients (86%) received the full intervention program and 44 patients (66%) strictly respected the pre-defined timings per protocol. A higher adherence to CPAP at six months was observed in the EI group compared to patient without EI (94% versus 81%) (P<0.05). CPAP compliance at three months was 54minutes higher in the EI group compared to the control group (4h39±2h17 and 3h45±2h45 respectively) but this difference was not statistically significant., Conclusion: An educational intervention dispensed by phone is applicable and would have an impact on CPAP compliance. Its efficacy on long-term compliance has to be confirmed in a larger group using a randomized procedure., (Copyright © 2011 SPLF. Published by Elsevier Masson SAS. All rights reserved.)

Sleep-disordered breathing is very common and is associated with an increased risk of cardiovascular disease, cardiac arrhythmia and stroke. There are two types of sleep apnea: obstructive and central. The objective of this review is to provide a broad perspective of the pathophysiological and clinical aspects of the two types of apnea and to discuss their cardiovascular adverse effects. The diagnosis of sleep apnea syndrome is based on polysomnography, and severity is measured with an apnea-hypopnea index that counts the total number of apneas per hour of sleep. Recent large epidemiologic studies have shown that sleep apnea affects about 16% of men and 5% of women between 30 and 65 years of age. Obstructive sleep apnea is characterized by abnormal collapse of the pharyngeal airway during sleep, snoring, vigorous inspiratory efforts causing frequent arousal, and excessive daytime drowsiness. Central sleep apnea with Cheyne-Stokes respiration is a form of periodic breathing with frequent periods of hyperventilation, and carries a poor prognosis in patients with heart failure. Obstructive apnea can also have substantial health consequences. Although the exact mechanism linking sleep apnea with cardiovascular disease is unknown, there is evidence that obstructive apnea is associated with a group of proinflammatory and prothrombic factors that are also important in the development of atherosclerosis. Nocturnal and daytime sympathetic activity is elevated after sleep apnea. Autonomic abnormalities include an increased resting heart rate, decreased cardiac rhythm activity, and increased blood pressure variability. Obstructive apnea is associated with endothelial dysfunction, increased C-reactive protein and cytokine expression, elevated fibrinogen levels and decreased fibrinolytic activity. Enhanced platelet activity and aggregation, leukocyte adhesion and accumulation of endothelial cells are common in both obstructive apnea and atherosclerosis. Surges in sympathetic activity, blood pressure, ventricular wall tension and afterload adversely affect ventricular function. Many studies have shown that patients with obstructive apnea have an increased incidence of daytime hypertension, and this syndrome is recognized as an independent risk factor for hypertension. Obstructive apnea is associated with myocardial ischemia (silent or symptomatic), acute coronary events, stroke and transient ischemic attacks, cardiac arrhythmia, pulmonary hypertension and heart failure. Central sleep apnea is frequent in severe heart failure. Most heart failure patients with pulmonary congestion chronically hyperventilate because of stimulation of vagal irritant receptors and central and peripheral chemosensitivity. When PaCO2 falls below the threshold required to stimulate breathing, the central drive to respiratory muscles and air inflow ceases and central apnea ensues. Apnea, hypoxia, CO2 retention and arousals provoke elevated sympathetic activity, increased afterload and elevated left ventricular transmural pressure, and promote the progression of heart failure. Tentative relationships have been identified between central apnea and markers of inflammation, oxidative stress and endothelial dysfunction. Recent mid-terms trials showed that nocturnal use of positive airway pressure in patients with the two types of apnea alleviates symptoms, reduces sympathetic activity, improves ventricular function and quality of life, and reduces daytime drowsiness. More studies are needed to understand the mechanisms underlying the relationship between sleep apnea and cardiovascular disease, but clinicians should be aware of this link and should attempt to identify patients with these syndromes.

This paper describes antivirals active against Myxovirus influenzae (influenza vaccine excluded), together with their indications in inter-pandemic and pandemic situations. Three kinds of antiviral drug, with different mechanisms of action, are active against Myxovirus influenzae: the adamantanes (amantadine and rimantadine); ribavirin; and neuraminidase inhibitors (zanamivir and oseltamivir). Amantadine is available in France but its indications are limited by its inactivity against influenza B virus, its adverse effects, and rapid onset of resistance. Ribavirin is administered by nebulization, exclusively in hospital, for severe cases. Neuraminidase inhibitors are effective on benign influenza; they are also well tolerated, active against subtypes A and B, and rarely elicit resistant mutants in vivo (exclusively seen with oseltamivir, mainly among children). According to their licensing terms, antivirals may be prescribed during epidemics, within 24-48 hours of typical symptom onset. They must not be used prophylactically in place of influenza vaccine, but may be useful when there is a familial or institutional index case, or during pandemics. Use in this latter situation would raise supply problems and, thus, the question of who should be treated first.

Oxidative stress is a frequent mechanism involved in the pathogenesis of bronchopulmonary disease. The cause can be exogenous, in particular related to to atmospheric pollution and tobacco smoke, or endogenous, related to mobilization of inflammatory cells (macrophages and polymorphonuclear neutrophils). In this general review, we present work demonstrating this oxidative stress and activation of inflammatory cells. We discuss the effect of oxidative stress on the bronchial tree and the need to maintain an adequate balance between oxidants and anti-oxidants. This reviews focuses on experimental studies proving the anti-oxidant effect of NAC on glutathione synthesis and on different pharmacological models. We then discuss human trials, initially experimental then in different bronchopulmonary pathologies related to oxidative stress. Acetaminophen intoxication and pulmonary fibrosis are models for use of NAC. Recent work on COPD appears to show a decrease in exacerbations, improvement in symptoms and quality-of-life, and perhaps a reduction in the alteration of ventilatory function.

Infection plays an important role in COPD, particularly during exacerbations. The principal pathogens involved in exacerbations are viruses (influenza and parainfluenza virus, picornavirus, and respiratory syncytial virus). Bacteria (mainly Haemophilus influenzae, Streptococcus pneumoniae, Branhamella catarrhalis) are isolated from sputum in approximately 50% of exacerbations and 25% of patients with stable state. Recent data favor of a proinflammatory role of these bacteria in the natural history of the disease. The role of atypical pathogens like Chlamydia pneumoniae may be underestimated. Trials of antibiotic treatment have shown a slight but significant benefit, particularly in patients with recent-onset purulent sputum. The benefit is more significant in patients with stable severe obstructive disease. Guidelines have been published in industrialized countries on the use of antibiotics in this indication. The role of infections in the pathogenesis of obstructive lesions is controversial. Some authors have forwarded a "vicious circle" hypothesis, in which impairment of mucociliary clearance by tobacco smoke contributes to bronchial colonization by bacteria, and this further impairs mucociliary clearance and promotes airway epithelial injury. COPD is a major risk factor for community-acquired pneumonia.

Levofloxacine is a fluoroquinolone presenting good anti-pneumococcal activity, including against strains with reduced sensitivity to penicillin. Four randomized controlled studies have compared the efficacy of levofloxacine versus other antibiotics (amoxacillin-clavulanic acid, amoxicillin, ceftriaxone, ceftriaxone plus cefuroxime +/- erythromycin) for the treatment of acute community-acquired pneumonia in adults. Grouping the 1,738 analyzable patients in these four studies, a meta-analysis was performed on the sub-group of 275 patients with documented pneumococcal infection (86 with bacteriemia) in order to compare the efficacy of levofloxacine with that of the comparer antibiotics. The trials were homogeneous, allowing the meta-analysis. The overall rate of clinical success was 88.6% in the levofloxacine group and 86.7% in the comparer group. The interval of confidence for the difference in the rate of estimated clinical success was between -5.65% and +9.39%. Bacteriologically, the rate of eradication was 90.2% and 90.4% respectively with an interval of confidence for the difference between -7.83% and +7.36%. The results of this meta-analysis confirmed that the efficacy of levofloxacine for the treatment of acute community-acquired pneumococcal pneumonia is not inferior to that of the comparers; the interval of confidence for the difference in the estimated rate of success did not include the breaking point of non-inferiority (-10% set for the clinical studies) and included zero.

Strongyloides is an helminthic infection that may induce bronchospasm during systemic migration of larvae. We report a case of a 60 years old man originating from Caribbean who had corti-codependent asthma since 30 years. He was hospitalized for severe exacerbation that worsen when steroid dosage was increase. Sputum examination revealed the presence in great number of Larvae of Strongyloides stercoralis. A good clinical evolution was achieved after specific anti-helminthic treatment. Later on, it was even possible to stop completely steroid treatment. This clinical case demonstrates the interest to look for Strongyloides superinfection in asthmatic patients that worsen when receiving increasing dose of steroids. This is particularly important for patients who have resided, even many years earlier, in areas where intestinal helminthic infection are endemic.

In this multinational, randomized, double-blind study, the efficacy and safety of a 5 day course of moxifloxacin 400 mg orally od was compared with that of a 7 day course of clarithromycin 500 mg orally bd. in 750 patients with acute exacerbations of chronic bronchitis, characterized by at least two of the symptoms: sputum purulence, increased sputum volume or increased dyspnoea. Seven days after the end of therapy, clinical cure was achieved for 89% (287 of 322) of efficacy-evaluable patients in the moxifloxacin group and 88% (289 of 327) of patients in the clarithromycin group (95% CI, -3.9%, 5.8%). At follow-up (21-28 days post-treatment), the continued clinical cure rates were 89% (256 of 287) for moxifloxacin and 89% (257 of 289) for clarithromycin. A total of 342 pathogenic bacteria were isolated from the sputum of 287 patients. The most common pathogens were Haemophilus influenzae (37%), Streptococcus pneumoniae (31%) and Moraxella catarrhalis (18%). Seven days post-treatment, a successful bacteriological response was obtained for 77% (89 of 115) of patients in the moxifloxacin group and 62% (71 of 114) of patients in the clarithromycin group, indicating superiority of moxifloxacin (95% CI, 3.6%, 26.9%). Both treatments were well tolerated with few adverse events. This study demonstrated that for the treatment of acute exacerbations of chronic bronchitis a 5 day course of moxifloxacin 400 mg od was clinically equivalent and bacteriologically superior to a 7 day course of clarithromycin 500 mg bd.

The relationship between infections of the respiratory tract and exacerbations of pulmonary symptoms in individuals with asthma is well established on clinical grounds. Patients having an acute attack of asthma often give a history of a "cold" before the onset of the exacerbation. The identification rate of viruses during exacerbations of asthma (10-30%) is much higher than the viral identification rate generally found during asymptomatic periods in asthmatics (3%). The mechanisms whereby upper respiratory viruses might induce or contribute to attacks of asthma are currently unknown: epithelial damage, increased cytokines releasability, mouth breathing.... Influenza vaccination is recommended in patients with chronic pulmonary diseases. However, bronchial hyperreactivity has been reported after influenza vaccination in asthmatics. Reactions to these vaccines may be due to non-immunogenic impurities, which are not present in the more recently developed subunit vaccines. In spite of the lack of double-blind studies between subunit and killed influenza virus vaccines, and because of the potential bad prognosis of influenza infection on airway obstruction, influenza vaccination should be recommended in asthmatics with stable respiratory function but influenza vaccination rate remains low.

Metastatic pulmonary calcifications, unlike dystrophic calcifications, occur in the normal healthy lung. The radiological pattern is quite specific. The disease is commonly described in chronic renal failure with calcium disorders. The prognosis is totally unpredictable. In 1992, a 50 yr old man underwent a successful renal transplantation during the final stage of chronic renal failure. He subsequently developed asymptomatic diffuse nodular opacities, that were discovered in 1995. An open lung biopsy confirmed the diagnosis of metastatic pulmonary calcification. There was no calcium disorder in this patient. In contrast to the benign course of pulmonary calcification in most patients, some fulminant pulmonary calcifications complicating renal transplantation or hypercalcaemia have been described. Radiographic identification of such entities is important to permit correction of calcium disorders. Otherwise, the condition is a potentially progressive and fatal cause of respiratory failure.

The efficacy and safety of the methylprednisolone prodrugs methylprednisolone suleptanate and methylprednisolone sodium succinate were evaluated in a multicentre, randomised, double-blind, double-dummy parallel study of 88 patients hospitalised with acute asthma. Each study drug was administered as a bolus intravenous injection of 40mg methylprednisolone equivalents every 6 hours for 48 hours. Methylprednisolone 32mg was administered orally 6 hours after the last dose. Pulmonary function, medical events, and clinical laboratory values were assessed at predefined intervals before and during the 72-hour study. The primary response measure of pulmonary function was per cent predicted forced expiratory volume in one second (FEV1) at 48 hours. Secondary response measures were peak expiratory flow rate (PEFR) and FEV1/forced vital capacity (FVC) ratio. Although both drugs demonstrated within-group mean changes from baseline (starting at 6 hours) that were statistically significant for each response, there were no statistically significant differences between the two groups. The mean percent predicted FEV1 at 48 hours and mean per cent change from baseline were 64% and 13% (p < 0.0001) for the methylprednisolone suleptanate group and 67% and 17% (p < 0.0001) for the methylprednisolone sodium succinate group, respectively. The mean PEFR and FEV1/FVC ratio at 48 hours were 5.77 l/s and 73% for the methylprednisolone suleptanate group and 5.78 l/s and 76% for the methylprednisolone sodium succinate group, respectively. There were no clinically or statistically significant between-group differences in any of the safety parameters. In this study, methylprednisolone suleptanate and methylprednisolone sodium succinate have been shown to be therapeutically equivalent in the treatment of patients hospitalized with acute asthma.

Background: The purpose of this study was to identify factors on which European general practitioners (GPs) base their decisions to admit to hospital patients with lower respiratory tract infections (LRTI)., Methods: A survey was carried out from December 1993 to January 1994 to identify factors that affect GPs' decisions to admit to hospital patients with LRTI by collecting data on 2056 patients from 605 GPs in France, Germany, Italy, Spain, and the UK., Results: Only 93 (4.5%) of the patients included in the study were admitted to hospital. Univariate analysis showed that age > 60 years, institutionalisation of the patient, concomitant diseases, cardiac insufficiency, asthma, a diagnosis of pneumonia, and clinical signs such as chest pain, cyanosis, tachypnoea and hypotension significantly (odds ratio (OR) > 2.0, p < 0.002) influenced the decision to admit to hospital. No influence could be shown for sex, smoking habits, history of bronchiectasis or chronic bronchitis, the presence of fever, chills, myalgia, cough or purulent sputum, and the diagnoses of acute bronchitis, influenza or exacerbation of chronic bronchitis. In the multivariate analysis only the presence of chest pain (OR 2.3, 95% confidence interval (CI) 1.5 to 3.5), cyanosis (OR 4.1, 95% CI 2.4 to 7.1), dyspnoea (OR 4.9, 95% CI 3.1 to 7.9), and hypotension (OR 2.9, 95% CI 1.6 to 5.2), as well as a diagnosis of pneumonia (OR 6.6, 95% CI 4.3 to 10) (all p < 0.00001) remained as factors that significantly affected the decision to admit to hospital., Conclusions: Clinical signs of severe infection and a diagnosis of pneumonia are the main factors that induce GPs to admit patients with LRTI to hospital in Europe.

In a double-blind, placebo-controlled trial, patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) were randomly allocated to oral treatment with sparfloxacin (200 mg loading dose followed by 100 mg once daily) or amoxycillin/clavulanic acid (500 mg/125 mg tds) for a total treatment duration of 7 to 14 days. Patients were evaluable if they had a FEV1/FVC ratio of less than 70% at stable state and presented with a suspected infectious exacerbation defined as increases in dyspnoea, sputum volume and sputum purulence. The primary efficacy variable was the overall success (defined as disappearance or improvement of dyspnoea and reductions in sputum volume and purulence) at end of treatment and follow-up. Overall efficacy was assessed in both the intent-to-treat (728 patients) and the evaluable (351 patients) populations. At the end of treatment and follow-up, success rates were identical for the sparfloxacin (87.3% and 78.7%) and amoxycillin-clavulanic acid (88.8% and 79.8%) treatment groups. Similar figures were found for the intent-to-treat population. The analysis of drug safety was similar for both treatment groups. The most frequently encountered pathogens were Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Sparfloxacin appeared superior for bacteriological eradication of Haemophilus influenzae, and Moraxella catarrhalis. Sparfloxacin in a single daily dose appears at least as effective as amoxycillin/clavulanic acid in the treatment of patients with acute exacerbations of COPD.

Pulmonary nocardiosis is a respiratory infection which is usually described in the immunocompromised. We report three cases in patients suffering from chronic airflow obstruction. In two cases there was a parenchymal disorder and in one case bronchial suppuration without involvement of the alveolar region. The diagnosis was made in all cases by bacteriological examination from specimens obtained at fiberoptic bronchoscopy. The outcome was favourable in all three cases after appropriate treatment. These observations underline the diversity of the clinical forms of respiratory nocardiosis. Furthermore, it demonstrates their possible occurrence in non-immunocompromised patients and the need to look for this germ specifically in long drawn infections. A bacteriological diagnosis is vital to start early and appropriate antibiotic therapy which should be prolonged because of the risk of recurrence and disseminated infection.

Azithromycin is a molecule of the macrolide family, belonging to the azalides class. Several of its characteristics allow for its use in the treatment of the community-acquired lower respiratory tract infections. Commonly isolated pathogens in bronchial infections are most frequently H. influenzae, S. pneumoniae, M. catarrhalis, C. pneumoniae and M. pneumoniae, and more rarely or in the context of a particular background, S. aureus, Gram negative bacteria and L. pneumophila. MIC90 of these germs is generally low or slightly elevated, displaying an inhibitory activity of the azithromycin on these bacteria. Nevertheless, the frequency of macrolide-resistant S. pneumoniae is not negligible and this germ must be considered as inconstantly susceptible to the macrolide family. Pharmacokinetics studies evidenced from high to very high azithromycin concentrations in the pulmonary tissues, reaching values well above MIC of pathogens commonly isolated. Given the long half-life, these concentrations persist a long time after oral administration. As azithromycin concentrates much in polymorphonuclear leucocytes, they release azithromycin after having migrated into the infectious site by chimiotactism, thus allowing to increase the antibiotic concentration at infection site. These requirements have been confirmed in vivo in animal models and in clinical studies. Two experimental models on macrolide susceptible S. pneumoniae, and H. influenzae evidenced a better activity of azithromycin in comparison to other macrolides tested against these two germs.

The tachykinin substance P (SP) is present in lung sensory nerve endings and may be released after neurogenic stimulation. Its role in the pathogenesis of asthma is still unclear. Nevertheless, it may play a major role in airway neurogenic inflammation. Alveolar macrophages are the predominant cells of the airway space and are involved in various types of airway inflammation. We studied guinea pig alveolar macrophage response to SP and other related peptide (C- and N-terminal sequences, NK1-receptor agonist) stimulation. Alveolar guinea pig macrophages were recovered by bronchoalveolar lavage (BAL). Macrophage reactive oxygen intermediate (ROI) production was studied by luminol-dependent chemiluminescence with several concentrations of SP and related peptides. Eicosanoid synthesis after stimulation was evaluated by thin-layer chromatography (TLC) and enzyme-linked immunosorbent assay (ELISA). SP, C-terminal sequence, and NK1-receptor agonist significantly increased ROI production by alveolar macrophages (P < 0.01). NK1-agonist and C-terminal sequence modified arachidonic acid metabolism and induced a significant increase in prostaglandin (PG)D2 synthesis (211% and 66%, respectively). We concluded that SP and related peptides directly affect guinea pig alveolar macrophages by inducing the production of inflammatory metabolites.

Treatment of healthy volunteers by Ribomunyl, whether or not in association with in vitro antibiotics (amoxicillin or josamycin), has been earlier demonstrated to be an efficient stimulant of PMN functions (adhesion and migration). This second double-blind study versus placebo was performed on 17 patients with acute respiratory infections (placebo group: eight subjects; Ribomunyl group: nine subjects). Ribomunyl treatment (four days) associated with antibiotherapy (amoxicillin) induced a significant increase of PMN adhesion (p = 0.014) with no significant effect of the placebo (p = 0.30) and no significant difference between the initial level of PMN adhesion of the two groups (placebo-Ribomunyl).

Reports of allergy to latex have been increasingly frequent during the last few years. The culprit is the natural Hevea Brasiliensis latex which is present in numerous latex-containing materials for daily use. Clinical manifestations are usually benign. Systemic manifestations have been reported mainly in general anaesthesia. We report a case of severe anaphylactic manifestations that occurred during a condom-protected sexual intercourse. The responsibility of latex for this accident was demonstrated by skin and biological tests.

The frequent association of sleep apnea syndrome and essential hypertension led to think of sleep apnea as an etiology of hypertension, especially as a good correlation has been found between the severity of both diseases. Moreover, treating the apnea syndrome results in a decrease of blood pressure. The aim of our study is to depict the outlines of a severe hypertensive individual with sleep apnea by comparing 9 men primarily referred to the hypertension clinic with refractory hypertension and finally found to have sleep apnea (study group) to 23 men whose diagnosis of sleep apnea was made in the pulmonary unit (controls). Fifteen of these were hypertensives. Mean age of the study group was 47 +/- 7 years vs 60 +/- 11. Controls were less overweighted: BMI = 33 +/- 6 kg/m3 vs 39 +/- 5. Mean blood pressure was 171 +/- 16/107 +/- 4 mmHg in the study group vs 157 +/- 19/92 +/- 12 mmHg in controls. Prevalence of glucose metabolism disorders was significantly greater in the study group: 6 patients with maturity onset diabetes and 3 with proven glucose intolerance, vs respectively 4 and 6 controls. Triglycerides were elevated in both groups whereas mean cholesterol was slightly above normal values. Six patients of the study group could have an echocardiogram which showed left ventricular hypertrophy (mean left ventricular mass index = 206 +/- 31 g/m2 after the Penn convention).(ABSTRACT TRUNCATED AT 250 WORDS)

We report a case of thrombo-embolic disease in which we were able to detect the presence of serum antiphospholipid auto-antibodies. The existence of antiphospholipid auto-antibodies has already been described in cases of recurrent thrombo-embolism. The thrombogenic role is only partially explained, but would for the greater part be linked to an action on the fibrolytic activity of the vascular parietal wall. Amongst these antibodies one can find amongst others VDRL, antiprothrombinase and anticardiolipin. The association of other stigmata of auto immunity is not rare, especially disseminated lupus erythematosus (LED). When phospholipids are found in an isolated fashion in cases of recurrent thrombo-embolism they produce the syndrome of antiphospholipids. The long term prognosis of this syndrome has not yet been established but the risk of a secondary systemic disease developing justifies a clinical follow up and regular blood checks.

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.

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

Every thromboembolic manifestation, especially in young subjects, calls for an aetiological study in which haemostasis is evaluated primarily with assays of physiological coagulation inhibitors: protein C, protein S and antithrombin III. Protein C deficiency is found in 6 to 7% of thromboembolic manifestations. We report the case of a 21-year old man who had phlebitis followed by pulmonary embolism without facilitating factors. Protein C level was 50% of normal value (0.50 IU/ml). The patient received heparin, subsequently replaced by oral anticoagulants after a long period of overlap between the two treatments. The outcome was favourable. Family investigation yielded a history of thromboembolic accidents in several members of the family, some of whom were protein C deficient (50% of normal value). Protein C synthesis is vitamin K-dependent. Protein C deficiency is transmitted as an autosomal dominant trait. Normal values range from 0.65 to 1.35 IU/ml. Clinically, 25% of the patients are said to be asymptomatic. The first thrombotic accidents occur in young subjects (mean age 29 +/- 14 years). Several points emerge from this case: full evaluation must be performed, especially in young subjects; family investigation consolidates the diagnosis and enables symptomatic protein C deficient patients to be treated and thrombotic manifestations to be prevented by effective anticoagulant therapy in high-risk situations; a prolonged period of heparin-oral anticoagulant overlap is needed to avoid cutaneous necrosis.

It is very uncommon to find several cases of sarcoidosis in the same family. In the majority of published reports, only 2 persons are involved in each family. Genetic predisposition is probably, but its true importance as compared with environmental conditions is uncertain owing to the lack of epidemiology studies. We report 3 cases of sarcoidosis in the same family. In 2 of these cases (2 black sisters) the clinical set up was similar, consisting of multivisceral sarcoidosis involving the lung and mediastinum, the skin and the peripheral lymph nodes and muscles, with poor general condition and dependence on, or resistance to corticosteroids. Although the two sisters lived in different countries for several years and despite the 4-year age difference between them, the disease began in both cases at the age of 40 years. The history of this family is exemplarily in favour of a genetic predisposition and suggests than the penetrance of genetic transmission is underevaluated. Systematic pulmonary clinical and radiological examinations performed in the relatives of patients with sarcoidosis might provide information on the true incidence of familial cases. Studies of the genetic equipment of these familial cases would perhaps constitute a line of research aimed at determining the pathogenesis of the disease.

We report a study using Doppler echocardiography looking for pulmonary arterial hypertension (HTAP) in 36 patients presenting with chronic airflow obstruction (BPCO) who are in a stable state. 18 of these (group 1) had confirmed HTAP by right heart catheterisation which had been done the day before and was defined as a mean pulmonary arterial pressure (PAPm) of greater than 20 mm of mercury. The other 18 patients (group 2) did not have HTAP at rest. The systolic ejection flow and the duration of the peak (expressed in msec) was analysed at the time of each examination. The Doppler data was compared between the two groups of patients and also with the results obtained in ten healthy subjects. The Doppler examination was successfully performed in 35 patients in spite of a poor echographic window in 86% of cases. When there was HTAP, the systolic ejection flow had a triangular aspect which contrasted with the dome shaped appearance of the normals. In group 1 the peak time was significantly shortened (p less than 0.01) compared to group 2 and to the healthy subjects. On the other hand there was no linear correlation between the value of the peak time and the level of HTAP measured by the catheter. Thus the severity of HTAP could not be precisely measured using these parameters. In considering that the peak time is normally greater than 100 msec, the sensitivity and specificity of the Doppler examination for the detection of HTAP during the course of BPCO are 90 and 88% respectively, which appears to be superior to the values obtained using other non invasive methods in the diagnosis of HTAP.

Two cases of Goodpasture's syndrome with severe pulmonary haemorrhage and normal renal function are described. In spite of minor (patient 2) or even no (patient 1) biological or light microscopic signs of glomerulonephritis, immunofluorescence of immunoglobulin G (IgG) was strongly positive in a linear fashion along the glomerular basement membranes in both patients. We suggest that renal biopsy in patients with apparently idiopathic pulmonary haemorrhage may lead to an early diagnosis of Goodpasture's syndrome. It is not possible in this disease to recognize on presentation those patients who will remit spontaneously and those who will undergo severe disease. The deadly evolution for patient 1 and some cases in the literature lend support to the notion that cytostatics and plasma exchange must be added to corticosteroids, even if pulmonary haemorrhage is not active and renal function is normal at the time.

In a multicenter trial conducted with patients suffering from chronic bronchopathy, Biostim, an immunomodulating compound of biological origin has been studied using the double-blind placebo-controlled method for prevention of respiratory tract infections. One hundred and ten patients from 10 french pneumology health centers entered the study. The treatment was administered at random in three sequences of 8 days a month for 3 months (2 mg/day the first month, 1 mg/day the second and third months). Patients were separated into 2 groups regarding severity of the disease: group I (non complicated chronic bronchitis); group II (obstructive chronic bronchitis with or without respiratory failure). Patients were examined during 6 months with a monthly appraisal of number, duration and treatment clinically defined infectious episodes. The study of propensity to infections with respect to severity of the disease in patients given placebo showed a significantly lower number of infectious episodes in group I when compared to group II. In the group I (patients suffering from simple chronic bronchitis), no significant difference could be noted between placebo and Biostim but, at all events, the low frequency of episodes makes it difficult to evidence a protective effect in such a group. In contrast, with patients presenting a high infectious risk (group II), one can observe in Biostim treated patients compared with placebo group a significant decrease of infectious episodes and a larger number of patients standing free of episodes throughout the whole period of trial. Tolerance to Biostim has revealed itself satisfactory.

Several immunologic abnormalities exist in patients with active sarcoidosis. Impairment of in vivo and in vitro cellular immunity is well known. Humoral immunity disorders are characterized by increase in polyclonal serum immunoglobulin, existence of circulating immune complexes and auto-antibodies. In the serum, these abnormalities are nearly the same than disorders observed during auto-immune diseases. We report 2 cases of patients where active sarcoidosis was associated with auto-immune disease. Then we discuss the relationship which could exist between the 2 types of diseases. The first patient was a woman (aged 66 years). She presented an active sarcoidosis and clinical symptoms of sclerodermia. The second patient, a man (aged 24 years), presented active sarcoidosis diagnosed 4 years ago. He had never received any treatment. Thrombopenic purpura occurred suddenly and needed steroid therapy. Antibodies to platelets were found in the serum. These associations raise some questions: 1) are they only fortuitous? such cases are rare but their frequency is perhaps underestimated; 2) could any common abnormalities of the immune response explain the emergence of the 2 diseases? 3) could one of the diseases favour emergence of the other? This hypothesis seems possible only if sarcoidosis is the initial disease. Eventually these associations also raise difficult therapeutic problems and must incite to explore precisely the immunity of patients with active sarcoidosis.

The pleuro-pulmonary pathology of asbestos, top most of silicates, is today well known. Other silicates, talcum powder, clays, micas essentially, are exploited and commercialized. Their pathology is less well known and often contradictory because of the heterogeneity of the inhaled minerals. All can contain large quantities of quartz and some varieties of talcum and a considerable proportion of asbestos fibres. These minerals can provoke severe pneumoconioses, silicoses and asbestoses respectively. Some relatively pure products do not contain these contaminants. In case of intense and prolonged dust inhaling, they can produced an impressive pneumoconiosis with relatively mild clinical signs as shown by the series of 27 cases of pneumoconiosis from the french talcum powder as reported by the authors. The chemical nature and electronic structure of different silicates are very similar. It raises the question of the noxious effect of asbestos and the relative innocuousness of other minerals of the same family, and wether the fibrous structure alone is implicated.

The authors discuss the epidemiological problems of legionnaire's disease. Although Legionella is known to proliferate in watery environments, the origin and extension of sporadic cases and the factors responsible for bacterial spread remain unclear. The problem of prevention has also to be resolved.