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A questionnaire survey was performed on the use of investigations and their impact on treatment of adult lower respiratory tract infection in the community. Data on the management of 2,056 such infections were obtained simultaneously from general practitioners in France, Germany, Italy, Spain and the UK. Diagnostic tests were only performed in 29% of cases. Chest radiographs were performed most frequently (22%), followed by peripheral blood white cell count (15%) and microbiological examination of sputum (7%), with major differences being found in the frequency of these tests both by clinical diagnosis and country. A change in initial antibiotic therapy was made in 12% of cases, with use of investigation being significantly linked to such changes. Second- and third-line antibiotics were significantly different to first-line therapy, with macrolides the most frequently prescribed second-line and quinolones the most frequently prescribed third-line antibiotics.

A survey of first-line antibiotic prescription in community-acquired lower respiratory tract infection (LRTI) by general practitioners (GP) was carried out simultaneously, using the same methodology in France, Germany, Italy, Spain and the UK. Data were obtained from 2,056 patients and 605 GPs. There was no antibiotic prescription in 17% of all LRTIs and 13% of community-acquired pneumonia (CAP) in the five countries taken together; and in 32% of all LRTIs and in 23% of CAP in Germany. Of patients with acute bronchitis, exacerbation of chronic bronchitis and viral lower respiratory tract infection, 87, 92 and 71% received antibiotics, respectively. The most frequent prescriptions were penicillins in France and the UK, third-generation cephalosporin in Italy, tetracycline in Germany and macrolide in Spain. The daily dosage of aminopenicillin prescribed was: 41% or = 1.5 g and or = 3 g. In Italy, 53% of all antibiotics were injected in all LRTIs, and 71% in CAP; in contrast, antibiotic injection was lower than 2% both in the UK and Germany, with an average of 14% in the five countries combined. We conclude that there are variations in antibiotic prescription by GPs in Western Europe; differences are likely to be multifactorial, but could, in part, be explained by differences in health systems and sources of information available to GPs.

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.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.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.

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% (p0.0001) for the methylprednisolone suleptanate group and 67% and 17% (p0.0001) 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.

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.Numerous cases of immediate hypersensitivity to latex have been reported since 1979 involving household and surgical gloves, condoms, and sounds, usually with minor cutaneous symptoms; however, severe symptoms have also been reported during general anesthesia. A 34-year-old woman was hospitalized in October 1989 for Quincke's edema an generalized urticaria, accompanied by acute dyspnea, a few minutes after protected sexual intercourse. Clinical examination was normal with respect to respiration; however, an edema of the eyelids and generalized urticaria was found, which was treated with antihistamines and corticotherapy. The notion of a previous anaphylactic shock during an arteriography in August 1989 and contact urticaria of the hands when using surgical gloves was suggested, as she was an assistant pediatric nurse. Allergic tests indicated seasonal rhinitis. Cutaneous tests for pneumallergens according to the technique of Prick indicated polysensitivity to pollens, as papules of 4-4.5 mm size formed. Cutaneous test with a commercial latex extract was positive, producing a papule of 6 mm. Also tests with different latex-based products (surgical gloves, Durex and Trepharm brand condoms) were strongly positive, producing papules of 6.5 mm and 8.5 mm, respectively. The specific IgE (gamma-E globulin) to latex was of class 3 (8.3 PRU/ml). In the majority or cases reported, besides the positivity of skin tests, the specific IgEs were identified in the serum by the technique of RAST. The incriminated product was the latex derivative of Hevea brasiliensis. Therefore, the existence of allergy to latex was responsible for these symptoms of anaphylactic nature.

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.

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.

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.

A series of 125 CT-guided thoracic punctures performed over a 20-month period is reported. The only complications were pneumothorax in 14 cases, 5 of which were drained, and 1 case of hemomediastinum. For the diagnosis of malignancy the sensitivity of the method was 82%, its specificity 100% and its effectiveness 74%. The level of sensitivity rose to 86% in the last 90 cases. This method is an additional contribution to exploration of the lungs. In trained hands it gives rise to few complications and should result in a histological diagnosis in a large number of cases.

Thirty observations done on infants formed the base of a review of the literature on the epidemiology, the clinical signs and the physiopathological mechanisms of passive smoking (PS). The main signal was a chronic cough but in infants under 12 months, PS also provoked, as well, an "asthmatoid bronchitis", progressing relentlessly since the coming out of maternity ward, in relation with the maternal tobacco addiction. In these patients, examinations failed to disclose the different causes of recurring respiratory infections. Among the granulocytic tests, only the spontaneous migration of neutrophil polykaryocytes in the absence of chemotactic stimulus was significantly lowered, by comparison with the controls. The authors did a review on epidemiological surveys done to this day; they revealed a direct relationship between the parent's addiction to tobacco and the frequency of recurring respiratory disorders. It was particularly evident when the mother smoked and the child was under 12 months. At this age it was independant from the infection eventually transmitted by the parent's cough. The constituants of tobacco smoke probably have a depressive action over the regional or perhaps the general means of immunitary defense as it is suggested by the decrease of leukocyte migration noted in parents with PS. It is therefore necessary in our country to define the true risks of PS in infants thanks to well organized epidemiological surveys and to obtain the means of an efficient preventive policy.

Polymorphonuclear (PMN) functions were assessed in 55 patients with asthma or bronchial bacterial infection to evaluate the systemic phagocyte capability of patients with bronchopulmonary diseases. Random migration, nitroblue tetrazolium dye reduction, and Candida killing activity were markedly decreased in the 2 types of patients studied. PMN dysfunction was more pronounced in the most affected and heavily treated patients. Considering both the rare occurrence of congenital polymorphonuclear defects and the age of the patients studied we concluded that the PMN abnormalities observed were secondary to the onset of respiratory disease. This impairment of circulating phagocytes may contribute to the rise of a systemic susceptibility to infection able to aggravate the underlying bronchopulmonary disease.

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.

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.

Six observations of post-traumatic acute respiratory insufficiency of alveolar origin are reported briefly. Three of them have been attributed to a Mendelson's syndrome. This authors showed that diagnosing these lung diseases by acid inhalation is particularly difficult in casualties. It is a diagnosis by elimination which no certainty can prop. These post-traumatic Mendelson's syndrome are serious and difficult to prevent. In the three cases reported two accidents occurred during or immediately after an intubation. The systematic use of an efficient anti-acid could be recommended in all serious casualities.

The authors report the 3 first cases of human syngamosis due to Mammomonogamus sp. in La Guadeloupe (French West Indies). After a review of the papers published on the previous 79 world-wide cases, they point out that this parasitic disease is restricted to the West Indies/South America area, and discuss the problem of the contamination mode; they claim that chronic cough is a constant signal symptom which suggests syngamosis in subjects who are native from, or have travelled in the endemic area.

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.