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Introduction: The aim of our study was to examine the practices and performance of a team working in a respiratory unit concerning the palliative care of patients with COPD, in a group of patients who died in hospital as a result of their disease., Methodology: The first step was focused on those patients who died in the respiratory care unit of the General Hospital of Saint-Nazaire during the year 2008 and who received end-of-life care, and the reasons for their death. In the second step, we selected and analysed retrospectively the records of patients who died from COPD. In the third step semi-directive interviews were held with a sample of nine care workers who were judged to be representative of the staff working in the respiratory ward of Saint-Nazaire Hospital. The interviews consisted of seven questions related to palliative practices and professional experiences acquired during the care of patients with COPD., Results: In a population of 51 patients who received end-of-life care during the year 2008, 34 were referred on account of lung cancer and only one was referred for COPD. Bronchial carcinoma was the main cause of death (36 cases) then COPD (16 cases) in a total of 92 deaths (2008). Retrospective analysis of the records of patients who died from COPD showed a limitation of care in 43% of cases, midazolam induced sedation in 43%, treatment with morphine in 37%, support for the family or relatives in 62% and some anticipated decisions in 6%. Analysis of the interviews showed that the subject of death is rarely or never discussed with these patients in contrast to patients dying from bronchial cancer., Conclusion: The practices of a respiratory team concerning palliative care in COPD patients appear to be limited to end-of-life care. This clearly reflects a need for palliative care education in workers of respiratory care units in order to deliver a global palliative approach at an earlier stage in the care of COPD patients and to improve communication concerning end-of-life treatments., (Copyright © 2012 SPLF. Published by Elsevier Masson SAS. All rights reserved.)

Introduction: Mucormycosis is a rare opportunistic fungal infection due to filamentous fungi of the order Mucorales in the class Zygomycetes. Rhino-cerebral and pulmonary manifestations predominate on account of the airborn spread of the spores. Gastro-intestinal, cutaneous and disseminated disease is less common. The principal risk factors are immuno-suppression and diabetic keto-acidosis., Case Reports: One case of fatal pulmonary mucormycosis and two cases of colonisation illustrate both the extreme severity of this disease and the diagnostic difficulties facing the physician. The ubiquitous nature of the organism leads to frequent colonisation and, moreover, the symptomatology readily mimics that of invasive pulmonary aspergillosis. The diagnosis of mucormycosis can only be confirmed by pathological and mycological examination of biopsy specimens. These requirements conflict with the need for urgent treatment with surgical debridement, amphotericin B and control of the underlying pathology. Sadly the mortality remains very high, between 50 and 80% in published series., Conclusion: Currently there is hope of new therapeutic approaches with posaconozole but the ineffectiveness of voriconozole and the echinocandines, used more and more against aspergillus, raises the possibility of an increase in mucormycosis by selection.

Sulfites are compounds which are mainly used in the agricultural, food and pharmaceutical industry as preservatives. The possibility of manifestations of acute hypersensitivity appearing after the ingestion or inhalation of sulfites has already been described several times, over the past twenty years. Amongst these manifestations and indeed the one that is most often present is bronchospasm, which can sometimes be severe. A few cases of occupational intolerance through contact eczema to sulfites have also been published. The idea of occupational asthma to metabisulphates is, on the other hand, extremely recent; its legal recognition only dates back to 1989. The authors present three new cases of occupational asthma to metabisulphites stressing the value of a specific provocation test and the different hypotheses for the pathogenesis of the disorder are reviewed. Preventative measures are always preferable to avoid the development of severe occupational asthma. In all cases, notification of occupational asthma is necessary.

The echographic study of the sub-costal pleura of 20 patients with occupational exposure to asbestos fibers and exhibiting pleural calcifications and thickenings on the chest X-Ray, allowed us to define the main semeiologic aspects of this pleural disease: horizontal striation and echo-poor thickenings of the sub-pleural region and irregularities of the pulmonary surface generating Ring-Downs. Comparison of this group with 20 normal subjects quantified this pleural thickening (pleural plaques: 5.5 +/- 2.09 mm, limit values: 3 to 12 mm). Our results are similar to those of the recent literature on this subject. The interest of the echographic study of the pleura in patients submitted to asbestos fibers is enhanced by the easy use of the echographic procedure.

Serum angiotensin conversion enzyme (serum ACE) is a dipeptidylcarboxypeptidase which activates angiotensin I to angiotensin II and inactivates bradykinine. It is a glycoprotein with an MW of 126,000 to 480,000. It is produced by all endothelial cells, and is located on the cell membrane. It is inhibited by EDTA (chelator of Zn-- cofactor), teprotide (snake venom nonapeptide) and captopril. Estimation of ACE has greatly benefitted from the use of synthetic tripeptides. An example is the method of Cushman and Cheung using hippuryl histidyl leucine. A raised serum ACE level in sarcoidosis has been demonstrated by Liebermann in 1975. The diagnostic value is limited by the existence of high levels in other pulmonary diseases (asbestosis, silicosis). Serum ACE levels in sarcoidosis are all higher when the disease is diffuse from a pulmonary and extrapulmonary standpoint. They decrease when the disease regresses spontaneously and rise if it worsens. Radiological improvement in pulmonary sarcoid lesions under the influence of corticosteroid therapy is accompanied by a fall in serum ACE levels. Persistence of this normalization as the dose is decreased is a favourable sign, whilst the reappearance of a high serum level may either reflect simple and isolated biological "rebound" or may accompany a recurrence of signs of the disease. Serum ACE measurement is thus an important factor in the surveillance of cases of treated sarcoidosis when the dose of corticosteroids is to be reduced.

The authors analyze seric levels of Angiotensin converting enzyme (A.C.E.) with the method of Cushman and Cheung in 200 cases of sarcoidosis, and 130 cases of various bronchopulmonary diseases. All values equal or greater than 35.3 u/ml are considered high (M + 2 DS, control: 71 cases, 23.3 +/- 5.99 u/ml). 67% of sarcoid cases reveal high levels, mainly radiologic stages II and forms with evidence of clinic dissemination. A significant decrease of seric levels is observed in cases with spontaneous radiologic improvements, and in cases with radiologic amelioration under corticotherapy. A not-significant increase of seric levels appears in cases with radiologic aggravation. Radiologic stable forms have a variable evolution of their seric levels. Less than 10% of tuberculosis, asthma, chronic bronchitis and interstitial pneumopathies reveal elevated levels, but the prevalence reaches 61% in pneumoconiosis. However, the observed values never get over 60 u/ml, seric levels over this range being only noted in sarcoidosis. So, the determination of seric A.C.E. level has a positive interest in the diagnosis of sarcoidosis and in following sarcoidosis evolution. Its prognostic significance yet is difficult to evaluate.

Two hundred ninety three patients with mediastinal and pulmonary sarcoidosis were assayed one or more than one time for seric angiotensin converting enzyme (SACE) using the method of Cushman and Cheung (substrate hippuryl-histidyl-leucin). Seventy one normal subjects and 163 patients with various broncho-pulmonary diseases excluding sarcoidosis were used as control. SACE is elevated in 67.2 p. 100 of the patients with sarcoidosis and reflects the intra and extrathoracic extend of the granuloma. Elevated levels of SACE in pneumoconiosis diminishes the diagnostic value of this test (as well as the presence of a normal SACE level in some sarcoid patients). There is no correlation between SACE and the percentage of lymphocytes in bronchoalveolar lavage fluid. SACE returns to normal in cases with spontaneous radiological improvement, and reaches more elevated levels in cases with worsening. An initial low level of SACE is usually a sign of a future good evolution. An initial high level is an argument for starting on steroid treatment. Repeated dosages of SACE are useful for monitoring the steroid posology at the end of the treatment and for deciding to stop it. Persistence of low levels allows to stop the treatment. Re-elevation of SACE may correspond to a radiological and clinical relapse or to an isolated and resolvent rebound.

The treatment of pulmonary TB due to bacilli sensitive to antituberculous treatment should lead to 100 p. 100 therapeutic success. However, this result implies a good bacteriological knowledge of the Koch bacillus, of antituberculous drugs, of therapeutic strategy, of the duration of treatment and, finally, of the reasons for failure. The association of isoniazide (5 mg/kg/day), rifampicin (10 mg/kg/day) and ethambutol (20 mg/kg/day for the first two months) sterilizes tuberculous lesions in 9 months. The introduction of a fourth antituberculous drug, pyrazinamide (35 mg/kg/day for the first two months) enables the duration of treatment to be reduced to 6 months without any loss of efficiency. Tuberculous relapses, sometimes due to polyresistant bacilli, pose difficult problems requiring detailed bacteriological studies of antibiotic sensitivity. Specific measures have to be taken (adaptation of dosage, contra-indications of certain drugs) with respect to the individual patient (elderly patients, pregnant or lactating women). Surgery has a role to play, especially in the treatment of sequellae. Admission to a sanatorium is reserved for infectious cases at the beginning of treatment and for patients living in poor conditions. The cover of social security is essential for successful treatment. Tuberculous is a compulsory notifiable disease.

A study of the genealogy of a 53 year old lady (A.M...) suffering from diffuse interstitial pulmonary fibrosis (FID) has revealed several cases of FID in her forbears and relations. Two brothers of A.M... died of histologically proven FID; FID was also discovered in one of their daughters. A sister died young of some unclassified respiratory problem. Two cousins died likewise at a young age of acute FID proven histologically. The level of spontaneous pneumothorax was particularly elevated in this family which represented a clinical peculiarity when compared to sporadic FID. The most probable mode of transmission of familial FID is autosomal dominant with variable penetrance. The HLA group seen in A.M... showed the A2 and B12 alleles. The B12 allele was also present in the niece of A.M...

A 35 year-old woman exhibited a stenotic lesion of the right pulmonary artery with a severe inflammatory syndrome. A diagnosis of Takayasu arteritis was made, although no aortographic abnormality was present. Involvement of pulmonary arteries during the course of Takayasu arteritis is frequent, but a localisation of the disease to the pulmonary arterial tree alone is a very rare condition.