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Resume L'asthme est l'une des maladies chroniques les plus frequentes chez les enfants. La presente etude vise a mieux connaitre les problemes poses par l'integration scolaire des enfants asthmatiques. Population et methodes Une etude transversale a ete realisee au cours de l'annee 1994 aupres de 4251 enfants de cinq a 14 ans scolarises en primaire et de leurs enseignants dans 188 classes de 26 ecoles tirees au sort a Grenoble et dans sa proche banlieue. Un premier questionnaire a ete rempli pour 3799 enfants par l'intermediaire de leurs parents. Il a permis l'identification de 191 enfants asthmatiques actifs (crise d'asthme ou traitement pour l'asthme dans la derniere annee). Les parents de 146 d'entre eux ont repondu a un deuxieme questionnaire evaluant la gravite de la maladie et ses retentissements et consequences a l'ecole. Les 186 enseignants des memes ecoles ont ete interroges sur leur connaissance de la maladie et la prise en charge des enfants asthmatiques dans le cadre scolaire. Resultats La prevalence cumulee de l'asthme est de 7,6 % et la prevalence instantanee des 12 derniers mois de 4,3 %. Seize pour cent des enfants asthmatiques rapportent un absenteisme scolaire lie a l'asthme de plus de six jours sur les six derniers mois. L'exercice physique est un facteur declenchant des crises pour 45,2 % d'entre eux et 21 % seulement prennent un traitement preventif de l'asthme induit par l'exercice. Neuf pour cent des enfants ont une dispense medicale d'education physique et sportive. Soixante-treize pour cent des parents ont informe l'enseignant de la maladie de leur enfant, mais les informations echangees ne sont que parcellaires. Parmi les enfants ayant un traitement antiasthmatique, seule la moitie a son traitement a disposition a l'ecole. Les connaissances qu'ont les enseignants sur l'asthme sont parcellaires, et 92,7 % souhaiteraient plus d'informations sur ce sujet. Quatre-vingt-trois pour cent d'entre eux ne connaissent pas l'existence de la circulaire ministerielle n∘ 93–248 du 22 juillet 1993 envisageant les conditions de la prise en charge des enfants atteints de maladies chroniques a l'ecole. Conclusion Lintegration scolaire des enfants asthmatiques reste difficile pour la prise des traitements et l'adaptation des activites scolaires et extrascolaires. La mise a disposition de fiches de liaison parents-medecins-enseignants pourrait ameliorer leur integration. Quand des difficultes persistent, la mise en place d'un projet d'accueil individualise, a l'initiative des parents et en collaboration avec le medecin traitant, le medecin scolaire et l'enseignant, peut permettre d'ameliorer la prise en charge et l'integration des enfants asthmatiques a l'ecole.

Study objective The cost and inconvenience of polysomnography make simplified techniques of screening desirable in the strategy of diagnosis of sleep apnea syndrome (SAS). We have evaluated, in a prospective study of 301 consecutive patients referred for suspected sleep disorders, an index (Δindex) that detects apneic events by quantifying arterial oxygen saturation (SaO 2 ) variability. Setting Regional sleep laboratory taking referrals from general practitioners and specialists. Design Classic polysomnography was the gold standard, with 15 apneas plus hypopneas per hour (RDI) being used as a threshold for definition of obstructive sleep apnea (OSA). Oximetry was recorded over the same night. Signal variability was quantified as a function of time, using digital processing of oximetric data. Sensitivity, specificity, and positive and negative predictive values of oximetry testing were calculated. A receiver operating characteristic (ROC) curve was constructed representing the comparative courses of sensitivity and 1-specificity at different thresholds of A index. Results Three hundred one patients were included (age, 56±12 years). Their RDI was 30±24. For a A threshold at 0.6, the sensitivity of oximetry for the diagnosis of OSA was 98% and the specificity was 46%. The positive and negative predictive values for diagnosing SAS were 77% and 94%, respectively. The three false-negative cases had a relatively high awake SaO 2 (97 vs 93.9±2.8%), a moderate RDI (23.3±1.6), and were less obese than the other patients (body mass index: 25±3 vs 33±8). The 58 false-positive cases had an RDI of 8±4, an awake SaO 2 of 93.1±3.6 vs 94.1±2.6 for the rest of the population (p=0.01). Finally, the false-positive cases had more airways obstruction (FEV 1 /VC=72±13 vs 77±15%; p=0.026). Using a A value of 0.8 leads to a sensitivity of 90% with 19 false-negative cases but with a higher specificity of 75%. Conclusions A nocturnal oximetry test with a A index below 0.6 is helpful in ruling out the diagnosis of SAS in patients being screened for this condition, as this yielded only three negative test results in 301 screening procedures.

On review of 115 poorly or undifferentiated lung cancers from 671 lung tumors resected over a 7-year period, we have found 38 cases of basaloid carcinoma. The cardinal histopathologic features distinguishing this tumor from other non-small cell lung cancers are a lobular growth pattern of small cells with moderately hyperchromatic nuclei, with no prominent nucleoli, and with scant cytoplasm, a high mitotic rate, and peripheral palisading. Basaloid carcinoma was present in a pure form in 19 cases and the other 19 tumors were of a mixed, but prominent, basaloid type associated with squamous cell carcinoma, large cell carcinoma, or adenocarcinoma. The immunophenotype of basaloid cancers was close to that of basal bronchial epithelial cells, with a low level of expression of low molecular weight cytokeratins. Staining for neuroendocrine markers was infrequent and inconsistent. Ultrastructural study showed an absence of neurosecretory granules and the presence of some squamous and/or glandular differentiation. This morphologic and immunologic phenotype suggests that basaloid carcinoma is derived from a pluripotent reserve cell or a basal bronchial epithelial stem cell. This unique histologic form of lung tumor has a poor prognosis, with a median survival rate of 22 months for stage I and II disease. This justifies classification of basaloid carcinoma as a distinct form of lung cancer, separate from small cell lung carcinoma.

Asthma is one of the most frequently encountered chronic illnesses in children. The aim of the present study was to investigate the problem of integration of asthmatic subjects at school by assessing the reactions of parents and teachers, and also by considering the medical aspects.A cross-sectional random study was carried out during autumn 1994 including 4,251 primary school children aged between five and 14 years, and including teachers from 188 classes and 26 schools in Grenoble and its inner suburbs. The first screening questionnaire was completed by the parents, and data on 3,799 children were obtained; from this, 191 currently asthmatic children were identified. One hundred and forty-six parents of the identified asthmatics subsequently answered a second questionnaire on the severity of the illness and its effects on school attendance and educational activities. The 186 teachers from the schools involved were interviewed about their knowledge of the disorder, and about what they knew of the treatment and management of asthmatic children in school.It was found that the cumulative prevalence of asthma amounted to 7.6%, and that the prevalence over the previous 12-month period was 4.3%. Sixteen percent of the asthmatic children reported an asthma-associated school absence of more than six days during the six preceding months. In 45.2% of cases, physical exercise was responsible for an asthmatic attack, but premedication was used in only 21% of cases. Nine percent of the children had obtained a medical certificate which exempted them from participating in sports activities and physical exercise. Seventy-three percent of the parents had informed the teachers of their child's illness, but the information communicated was incomplete. It was found that the teachers did not have a thorough knowledge of the disorder, but that many of them (92.7%) would appreciate further information on the subject and on its management. Eighty-three percent of the teaching staff were unaware that the ministerial circular No. 93-248 of 22 July 1993 had been issued on the proposed management of chronic disorders at school, advocating a combined effort on the part of the parents, the child's physician, the school doctors and the teachers in setting up a concerted plan of action.This study has demonstrated that the school integration of asthmatic children remains problematical both as regards treatment and the pursuit of indoor and outdoor school activities. Integration could be improved by using parent-doctor-teacher liaison forms, thereby maintaining closer communication regarding the child's needs. When this is not sufficient, an individualized asthma management plan could be introduced in collaboration with the parents, doctors and teachers, which might result in improved treatment and integration of asthmatic children in school.

International audience; Gluconeogenesis was studied in hepatocytes isolated from fasted rats submitted to 24 h of hypoxic exposure (inspired O2 fraction 0.1) or to room air. Hepatocytes from hypoxic rats compared with controls exhibited a lower gluconeogenic rate with lactate (5.1 +/- 0.3 vs. 7.2 +/- 0.3 mumol.min-1.g dry cells-1, P < 0.001) but not with dihydroxyacetone (9.1 +/- 0.3 vs. 9.4 +/- 0.4 mumol.min-1.g dry cells-1), suggesting involvement of the phosphoenolpyruvate-pyruvate cycle. Experiments with perifused hepatocytes from hypoxic and control rats showed a single relationship between phosphoenolpyruvate and glucose flux (JGlc) but two different curves when cytosolic oxalacetate was plotted against JGlc. The decreased phosphoenolpyruvate carboxykinase (PEPCK) activity in the hypoxic group (9.0 +/- 0.9 vs. 16.2 +/- 1.9 nmol.min-1.mg protein-1, P < 001) without change in the Michaelis constant further settled the involvement of this step. The significant decrease in PEPCK mRNA levels in livers from hypoxic rats led us to propose that in vivo hypoxic exposure inhibits gluconeogenesis at the PEPCK level by decreasing PEPCK gene transcription.

Right to left shunts in the adult in their usual location are either intraarticular or intrapulmonary, and are often congenital. The acquired intrapulmonary shunt of the cirrhotic is now well defined by the hepatopulmonary syndrome. The major complication of right to left shunts are paradoxical pulmonary emboli which are often more severe than haemoptysis or chronic hypoxia. The diagnosis of intracardiac shunts as well as intrapulmonary shunts is now easier, thanks to transoesophageal ultrasound associated with contrast. Pulmonary angiography enables the treatment of arteriovenous fistula to be carried out by embolisation, and also avoids any surgery.

Toxocariasis is a frequent disease in children, but the severe clinical manifestations are rare in the literature (diffuse interstitial pneumonia with hypoxaemia and acute severe asthma). The diagnosis is made thanks to the reliability of serological techniques (the ELISA test and using antigen excretion-secretion tests of the larvae of Toxocara canis). The authors report a case of acute severe eosinophilic pneumonia whose outcome was rapidly favourable following steroid therapy; the existence of positive Toxocara canis serology with a contamination risk of the patient in the domestic environment leads us to integrate the clinical picture into the larva migrans syndrome.

The effects of supplemental oxygen (O2) versus air on working calf muscle metabolism were studied in seven patients with stable chronic obstructive pulmonary disease (COPD) and chronic hypoxemia (PaO2 = 57 +/- 3 SE mm Hg) and seven age-matched control subjects. Oxygen and air were randomly administrated at 24-h intervals, and O2 flow rate was adjusted to correct hypoxemia (PaO2 = 87 +/- 4 mm Hg) in the COPD group. The relative concentrations of ATP, phosphocreatine (PCr), inorganic phosphate (Pi), phosphomonoesters (PME), and the intracellular pH (pHi) were determined with 31P magnetic resonance spectroscopy at rest, during a graded standardized and localized exercise protocol (360 active plantar flexions), and during recovery. In resting muscle no significant effect of added O2 was demonstrable in each group with regard to pHi, Pi/PCr, and ATP/(PCr+Pi+PME) ratios. Mechanical data were similar between the two groups and between the two tests during the whole exercise. The indices of muscular oxidative metabolism (Pi/PCr and pHi at the end of exercise and recovering PCr resynthesis rate) were impaired in the COPD group compared with that in the control group during air (all p0.05). All these parameters were significantly improved with added O2 in the COPD group (p0.05), whereas no similar effects were observed in the control group. However, these beneficial effects were incomplete since the exercising Pi/PCr ratio remained higher in the COPD group than in the control group during added O2. This energetic muscular impairment could correspond to tissular damage related to chronic hypoxemia.

Forty-seven patients with unresectable non small cell lung carcinoma, 15 stage IIIA , 31 stage IIIB , 1 stage IV (cervical lymphadenopathy) were treated with a combination of three courses of chemotherapy and hypofractionated irradiation followed after 3 weeks by split course radiotherapy. Each course was repeated every 3 weeks with the following sequence: Cisplatinum (CDDP) (20 mg/m 2 ) was given in a 20-min infusion, followed by a 2-h infusion of 5-fluorouracil (5-FU) (400 mg/m 2 ) on days 1, 2, 5 and 6. Radiation with a dose of 3 Gy on the target volume was given on days 3 and 4 - in one fraction for the former 27 patients, in 2 fractions of 1.5 Gy for the latter 20 patients with a 6-h interval — after a 2-h infusion of 5-FU (400 mg/m 2 ). The results remain disappointing: the objective response rate was 53%, the median survival was 10 months for the series, and the one-year survival 47%. The median survival was 14 months for IIIA , 10 months for IIIB and IV . Regarding the therapeutic regimen there seems to be less morbidity with 2 fractions per day for which the median survival is nearly the same at 10 months (1 fraction/day) versus 12 months (2 fractions/day).

Formoterol aerosol, a long-acting new beta 2-mimetic was administered over a year at a dose of 12 micrograms twice daily, to 62 chronic obstructive bronchitics of mean age 66 +/- 6 years and of whom the basal VEMS was at 12,801 +/- 0.59. Clinical tolerance of the product was good with undesirable effects in 13 patients, the most frequent being shaking. No untoward effect was seen on systolic or diastolic arterial pressure, or the heart rate over successive visits at 1, 3, 6, 9 months and one year. Electrocardiographic surveillance found in only four patients electrical abnormalities that may be due to Formoterol, these were patients without previous cardiac problems but of advanced mean age. Functionally, a significant improvement of basal VEMS was noticed from the 6th month. The VEMS improved significantly after administration of 12 micrograms on successive visits, without tachyphylactic signs. Well tolerated, with functional benefits, Formoterol is a promising product amongst the long-acting beta 2-mimetics. Its usefulness and limitations in the basic treatment of these chronic bronchopathies remains to be defined.

We report a case of esophageal fistula of a tubercular mediastinal adenopathy revealed by melena and which was diagnosed partly by means of endoscopy and partly by scanning after carrying out endoscopic fistulography. Endoscopic ultrasound, which was carried out as a complementary examination, confirmed this diagnosis.

Nine patients, 4 with chronic obstructive pulmonary disease (COPD) and 5 with obstructive sleep apnoea syndrome (OSAS) were monitored during sleep, rest and exercise. Left ventricular ejection fraction (LVEF) was investigated using gated equilibrium 99mtechnetium ventricular scintigraphy during rapid eye movement (REM) sleep, during exercise, and during wakeful rest. Control wakeful rest periods used for comparison with a study state (either REM sleep or exercise) were always selected during the same circadian segment as that state. Myocardial stress thallium-201 scintigraphy was performed during, and 4 h after, exercise, and results were compared to a daytime rest period. Several patients had myocardial hypoperfusion despite a normal electrocardiographic (ECG) treadmill test. During REM sleep, all patients exhibited a significant change in LVEF (greater than 5%) compared to wakefulness. During exercise, 5 subjects increased their LVEF normally (greater than 5%) and 4 (1 COPD, 3 OSAS) decreased it. All patients had a similar change (increase or decrease) during REM and at maximal exercise. Our results suggest that REM sleep in COPD and in OSAS can produce a myocardial stress as great as that produced by exercise. We conclude that REM sleep, like exercise, is a state in which morbidity may become higher and that it may account for mortality in COPD and OSAS patients with compromised myocardial circulation.

Superior vena caval syndrome (VCS), is easily recognised in the advanced case, however in the early case without clinical signs its detection is much less easy. New techniques of medical imagery such as IRM and above all computer tomography (TDM) have shown an increasing place in the daily clinical practice of the respiratory physician; these enable an early diagnosis to be made and a work up of the aetiology of the syndrome of VCS. With TDM the obstruction of the VCS appears the sign of direct obstruction (thrombosis or extrinsic compression) and of a collateral venous circulation deriving some anastomoses from the brachio-cephalic venous trunk (TVBC) and the azygos system, the VCS and the inferior vena cava (VCI), the two TVBC at the junction of the median line principally by the suprasternal network and finally these portal systemics, by the veins from the anterior wall of the trunk and the accessory portal veins of the round ligament. IRM introduced more recently enables a direct vision of the causal lesion endo or extra luminally, enabling an early detection of the syndrome by showing signs of a slow down of the venous flow. But the detection of a collateral circulation seems more difficult to demonstrate by this method.

We have seen four cases of granular cell tumor (Abrikossoff's tumour) and it is recalled that these tumours are most often discovered fortuitously by bronchoscopy in the tracheo-bronchial region because they have a non specific clinical presentation. The cytological and histological characteristics enable an accurate diagnosis but there are problems posed as to the histogenesis of these tumours. With a tumour with a slow progression regular surveillance with regular biopsies seems preferable as in certain cases the tumour regresses spontaneously or disappears after ablation with the forceps. A good alternative approach is destruction of the tumours with a laser in certain complicated forms which enables one to avoid surgical excision.

The aim of this study was to determine the effects of captopril combined with oxygen therapy on pulmonary hemodynamics and gas exchange in chronic obstructive pulmonary disease (COPD) patients with pulmonary hypertension. Eleven subjects, with severe airflow obstruction (FEV1/FVC: 42 +/- 11%) and chronic respiratory failure (PaO2: 54 +/- 6 mm Hg, PaCO2: 46 +/- 8 mm Hg) treated with long-term oxygen, underwent two successive hemodynamic and arterial gas studies, at rest and during exercise. All the studies were performed whilst the patients were breathing oxygen, at rest and during exercise and 1 h after intake of 12.5 mg of captopril. The second study was performed in 9 out of the 11 patients after 8 weeks of treatment with 12.5 mg captopril 3 times daily. At rest, there was no significant effect of captopril. Mean pulmonary arterial pressure (PAP) showed a trend towards decrease after 8 weeks treatment. During exercise, there was a statistically significant decrease of mean PAP, pulmonary capillary wedge pressure and total pulmonary vascular resistance, without any deleterious effect on blood gases. However, the clinical significance of these variations during exercise is poor. We conclude that a low dose of captopril associated with oxygen therapy has no significant clinical effect on pulmonary hemodynamics at rest and during exercise in COPD.

The clinical, radiological, physiological and pathological features were studied in 6 cases of idiopathic bronchiolitis obliterans organized pneumonia (BOOP). Patients characteristically had a history of exertional dyspnea, cough, fever, weight loss, bilateral radiographic shadowing, elevated ESR and hypoxemia. Corticosteroids were effective; however, one patient died of cytomegalovirus pneumonia. The pathological features, distinguished by the presence of granulation tissue plugs extending from bronchioles into alveolar ducts and alveoli, are described in detail. The place of BOOP within the broad spectrum of bronchiolitis obliterans between small airways disease and usual interstitial pneumonia is discussed.

We present an anatomical-clinical analysis of ten cases of benign pleural fibroma. This tumour was discovered in a systematic fashion in 8 of the 10 cases and fortuitously in one. Recent radiological examinations enabled the diagnosis to be suspected. Computerised tomography most often precisely identified the pleural topography and imagery by nuclear magnetic resonance in one case visualised fibrous tissue (with a zone of low signals on the scale in T2). The final diagnosis was achieved at the same time as the treatment when an exploratory thoracotomy was performed. In all the cases there was a tumour composed of fusiform cells covered by normal epithelium coming from the viscera pleura 8 times out of 10. The ultrastructure examination and immunohistochemistry of the fusiform cells (Vimentin plus, EMA-, KL1-) allowed for a differentiation of these tumours of connective tissue origin from tumours of mesothelial origin. These analyses constitute an argument in favour of the fibroblastic origin of pleural fibromas.

Twenty-six asthmatic patients who were hospitalised following an acute asthmatic attack and who had a peak expiratory flow of less than 50% predicted, without hypercapnia, received 5 mg. of salbutamol delivered by a micronebulizer LSA on admission (HO). At H1, 10 mg of additional salbutamol were nebulised in cases where there had been an increase of less than 20% of the PEF. At H2, all the subjects received steroid therapy. Group 1 in which success was defined by an increase of 20% of peak flow judged at H1 and H2, and group II where the increase in peak flow was less than 20%. Group II benefited at H2 by treatment with theophylline or salbutamol intravenously given in a randomised fashion. At H8 the 2 treatments were associated in group II in cases of failures. 15 men, and 11 women aged 40 +/- 17 suffering from severe asthma (65% of Charpin Stage IV) were included. The mean peak flow at HO was 32 +/- 9% of the predicted PEF. 21 subjects, or 81% improved their peak flow by more than 20% at H2. The toleration for salbutamol was very good from the cardiovascular point of view. At HO there was no clinical criteria nor peak flow assessment which would enable one to predict the failures from nebulized salbutamol for a given subject. Nevertheless a level of dyspnoea of greater than 5 on Borg's scale and a peak flow of less than 150 l/min made failure likely.(ABSTRACT TRUNCATED AT 250 WORDS)

From a analysis of 36 personal observations of Wegener's Granulomatosis and a review of the literature, we have studied the clinical manifestations and laboratory and histopathological findings of the disease. We emphasize the importance of antibodies against neutrophil cytoplasm and surgical pulmonary biopsy in affirming the diagnosis.

A peripheral neuropathy has been reported in patients with chronic respiratory insufficiency due to chronic obstructive pulmonary disease (COPD). It is mainly characterized by axonal degeneration, secondary demyelination and abnormal endoneurial vessels. The pathogenesis of these lesions remains obscure. To investigate whether relationships exist between neuritic and vascular lesions, a qualitative and quantitative ultrastructural study was performed on nerve biopsies in 13 patients with chronic respiratory insufficiency due to COPD, and in 9 normal controls without pulmonary lesions. A computer-assisted multiple regression analysis taking into account clinical, electrophysiological, biological and morphometric parameters was performed. Statistically significant differences in the endoneurial structure of microvessels were: (1) thickening of the basement membrane; (2) narrowing of the lumen; (3) mural pericytic debris deposits, occurring in the COPD group. In the latter, hypercapnia correlated positively with nerve fibers lesions (P = 0.03) and endothelial area (P = 0.03). No correlations were found between age and other parameters. These findings highlight the fact that the microangiopathy in peripheral nerves in patients with COPD may be diffuse and essentially due to hypoxia and reduction in blood flow, as in diabetic neuropathy.

In order to determine the frequency and the characteristics of neuropathies in chronic respiratory insufficiency, a systematic study of 43 patients affected by a chronic obstructive pulmonary disease was performed. In addition to neurological and electrophysiological examinations (including 6 nerve conduction studies on median, ulnar and peroneal nerves and EMG of 4 to 8 muscles), nerve and muscle biopsies (of the superficial peroneal nerve and lateral peroneus brevis muscle) were performed in 13 cases. Polyneuropathies were found in 74% patients: but mild in 39%, severe in 35%. Most were subclinical or poorly symptomatic. We determined the importance and distribution of abnormalities on the different nerves. From this we established that neuropathies are mixed but predominantly of the axonal type. Axonal degeneration and demyelination were confirmed by nerve biopsy; muscles presented neurogenic atrophy. Statistical analysis showed that the duration of hypoxemia was related to neuropathy. The pathogeny of these neuropathies is discussed.

Twenty patients with unresectable non-small cell lung carcinoma, 15 stage III and 5 stage IV (supraclavicular lymphadenopathy) were treated with a combination of three courses of chemotherapy and hypofractionated irradiation followed after 3 weeks by split-course radiotherapy. Each course was repeated every 3 weeks with the following sequence. Cis-platin (CDDP) (20 mg/m2) was given in a 20-min infusion, followed by a 2-h infusion of 5-fluorouracil (5-FU) (400 mg/m2) on days 1, 2, 5 and 6. Radiation with a dose of 3 Gy on the target volume was given on days 3 and 4, after a 2-h infusion of 5-FU (400 mg/m2). Split course of irradiation consisted of 16 Gy in 5 fractions repeated after 3 weeks interval. The objective response rate was 75%. Median follow-up was 24 months, the median survival was 14 months. The 1-year survival was 53% and the 2-year survival was 16%.

Waldenstrom’s macroglobulinemia was diagnosed in a patient suffering from recurrent lymphocytic pleurisy. Ultrastructural studies of the pleura showed the features of Lennert’s lymphoplasmacytoid immunocytoma. Computerized assisted tomodensitometry revealed a retroperitoneal growth surrounding the right kidney and squeezing the thoracic lymphatic duct.

Authors bring forth the results of the determination of CO2 ductances in 28 patients : 14 cases of pulmonary arterial thrombosis, 7 cases of diffuse interstitial fibrosis recognizing various etiologies, 4 cases of endothoracic sarcoidosis and 3 cases of pure restrictive syndrome due to functional amputation of some territories. The global CO2 ductance is lowered in 24 cases. In each one of these cases the PACO2 determination makes possible to decompose the global ductance into a ventilatory ductance and a circulatory ductance. The circulatory ductance is lowered in the case of pulmonary arterial thrombosis; the ventilatory component is lowered in the case of restrictive syndromes and in the case of diffuse interstitial fibrosis. For what concerns the pulmonary arterial thrombosis, authors discuss then the value of the information contained in the expression of the CO2 arterial-alveolar gradient on the one hand, and in the circulatory component of the ductance on the other hand. At last, the determination of the ductances appears interesting in the supervision of the course of various diseases.

Thirty patients with chronic obstructive pulmonary disease (COPD) and 15 healthy volunteers have been studied to assess the value of measuring right ventricular ejection fraction (RVEF) at rest with a perfusion of krypton-81m (81mKr). With this perfusion, equilibrium RVEF can be measured in a 30 degrees right anterior oblique projection, avoiding a superimposition of cardiac cavities. The average RVEF of the patients with COPD was significantly lower than that of the normal patients (36.3 +/- 9.3% vs 52.6 +/- 3.9%; p less than 0.001). An inverse linear relation was found between mean pulmonary artery pressure (Ppa) and RVEF (r = -0.543; p less than 0.01). The RVEF in a group of 15 patients with COPD and pulmonary hypertension (Ppa greater than 20 mmHg), averaged 30.4 +/- 7.26%, which was significantly lower than that of the other 15 COPD patients with normal Ppa, whose RVEF averaged 42.3 +/- 7.1% (p less than 0.01). Taking a RVEF value less than or equal to 35% as an indicator of pulmonary hypertension, the sensitivity was 80% and specificity was 75%, the predictive value for a positive test was 75%, and for a negative test was 80%. A positive but weak correlation was found between RVEF and PaO2 (r = 0.52; p less than 0.01), SaO2 (r = 0.41; p less than 0.05) and the forced expiratory volume in one second (FEV1) (r = 0.40; p less than 0.05). No correlation was found between RVEF and prior history of right cardiac insufficiency, PaCO2, pH, the ratio FEV1/vital capacity, ECG signs of cor pulmonale and left ventricular ejection fraction.(ABSTRACT TRUNCATED AT 250 WORDS)

A simple method is described which allows easy determination of neuroendocrine (NE) differentiation in human broncho-pulmonary tumor models grown in heterotransplanted nude mice. Enolase (EC 4.2.1.11) isoenzyme composition is studied using the electrophoretic method in xenograft tumor homogenates. The relatively large amount of alpha gamma and gamma gamma isoenzymes (neuron-specific enolase (NSE] is indicative of the neuroendocrine differentiation level of these tumors. The gamma gamma isoenzyme is present at a high level (M +/- SE: 10 +/- 2%) in all NE tumor models and absent in non NE tumor models. The alpha gamma isoenzyme is found in a significantly higher proportion in NE tumor models (30 +/- 2%) than in non NE tumor models (9 +/- 2%) (p less than 0.001). Moreover it is possible to discriminate between human and mice isoenzymes to estimate the proportion of mouse tissue hat is present in the xenograft.

Ninety-nine patients, who had never previously taken inhaled steroids were enrolled in a randomized, single-blind, parallel study, the aim of which was to compare the efficacy and safety of flunisolide inhalation, 500 meg twice daily, with beclomethasone dipropionate inhaler 100 meg four times daily for the treatment of chronic asthma. The treatment period was for 6 weeks. The patients were examined clinically at entry, week 3 and week 6 and both treatment groups showed a marked improvement in almost all parameters during the course of the study. Flunisolide was statistically significantly superior to beclomethasone dipropionate for wheezing at week 6, coughing at week 6 and chest tightness at weeks 3 and 6. The number of asthma attacks per day decreased significantly more with flunisolide treatment than with beclomethasone dipropionate. The over-all evaluation of efficacy by both doctors and patients also showed flunisolide to be superior to beclomethasone dipropionate. In several other parameters there was a trend shown favouring flunisolide, and beclomethasone dipropionate did not show a superiority over flunisolide in any efficacy parameter. Both drugs were well-tolerated, with unpleasant taste being the most frequent complaint in the flunisolide group. No patient in either group withdrew from the study because of adverse events. In this study, flunisolide inhaler was more effective than beclomethasone dipropionate inhaler for the treatment of chronic asthma exhibited by patients who had never been treated with inhaled steroids.

Waldenström's macroglobulinemia was diagnosed in a patient suffering from recurrent lymphocytic pleurisy. Ultrastructural studies of the pleura showed the features of Lennert's lymphoplasmacytoid immunocytoma. Computerized assisted tomodensitometry revealed a retroperitoneal growth surrounding the right kidney and squeezing the thoracic lymphatic duct.

The authors report the results obtained with one single daily dose of 10 mg/kg of a long-acting theophylline preparation administered in the evening to asthmatic patients previously treated with the same dose twice a day. Twenty-seven patients presenting with airway obstruction reversible by beta-stimulants entered the study; their mean FEV1 value was 57% of the expected value, and diffuse sibilances were present; paroxysmal attacks occasionally occurred, particularly at night. No significant difference was found between the two dosage regimens with regard to symptomatic improvement, adjuvant drug consumption, and plasma theophylline levels 12 hours after the evening dose. The classical side-effects of theophylline therapy were not increased by the once-a-day regimen. It is concluded that one dose of theophylline per day is effective in the treatment of nocturnal asthma.

Two new cases of rheumatic pelvispondylitis associated with bilateral fibrosis of the pulmonary apex are reported and published data are reviewed. The clinical, radiological, evolutive and diagnostic features of this probable pulmonary manifestation of rheumatic spondylitis are described, and the pathogenesis is discussed.

In order to validate xenografted small cell lung carcinomas (SCLC) for biological studies, the authors established 12 lung neuroendocrine (NE) tumors (eight typical SCLC and four atypical NE tumors [ANE]) by heterotransplantation onto nude mice. Their characterization was performed using serial ultrastructural, enzymatic, and immunohistochemical methods on primary tumors and after xenografts. These were subclassified into epithelial (one), neuroendocrine (three), and multidifferenciated (eight) types. The phenotypic characters (cytokeratins, neurofilaments, neurone-specific enolase) and the proliferative rate (Ki 67 labelling) of original tumor were maintained until the last passage studied. Although further acquisition of subsets of cytokeratin or neurofilaments was observed in some cases, the authors could not detect any morphologic and/or biological spontaneous change comparable to those described in in vitro cell lines. In addition, ANE are not quite identical to variant subclasses described in vitro. The authors conclude that the stability of heterotransplanted SCLC is an advantage in further biological studies.

The authors report a case of Pancoast and Tobias syndrome due to a hydatic cyst on the apex of the left lung. This parasitosis is together with tuberculosis and least infrequent benign etiology of Pancoast and Tobias syndrome. In our observation it was a young cyst without complications as opposed to previously reported cases.

In patients with sleep apnoea syndrome abnormalities of the upper airways may play a major role in the genesis of apnoea. Three cases are presented which illustrate the part played by hypertrophy of the tonsils in a child and by stenosis of the pharynx in an adult and of the larynx in another adult. All three patients were cured by surgical correction of these abnormalities. The physiopathology of alveolar hypoventilation, present in one of the three patients, is discussed in relation to the effects of pure oxygen inhalation on the patient's ventilation.

22 patients with severe respiratory insufficiency were treated by definitive tracheostomy for intermittent ventilatory assistance. Early mortality is heavy (9/22 before three months). After three months, the respiratory condition of patients improved greatly and survival rate is good. Tracheostomy is too often delayed and realized at the bad time of a severe acute respiratory failure.

Pneumoconiosis was diagnosed in 10 patients working in a silicon factory. The exposure time varied between seven and thirty-five years. All patients had only slight or no symptoms, except one presenting an important dyspnea. The radiologic study showed an interstitial syndrome. The functional lung test revealed a restrictive syndrome. Seven patients underwent fibroscopy with alveolar washing and transbronchial biopsy. A surgical biopsy was performed in two patients. The histological lesions showed an accumulation of alveolar and interstitial macrophages and the existence of fibrous interstitial micronodules. The ultrastructural study revealed an interstitial fibrosis. The macrophages contained numerous dense, homogenous small spheres of amorphous structure, composed of silicon and oxygen. These spheres represent amorphous silica smoke particles. Less than 1% of the particles are crystalline silica. Thus, the amorphous silica particles seem to be responsible for the histological and radiological lesions observed.

If diagnosis of chronic thromboses of pulmonary arteries is usually easy at the stage of confirmed chronic pulmonary heart, it is not so when dysponea is the only symptom of the disease. The authors report 30 cases of chronic thrombosis and remark that if respiratory alkalosis is very frequent, hipoxemia is often missing. On the other hand they observe 27 times out of 28 an increase of CO2 alveoloarterial difference; measuring the CO2 difference appears a safe and reliable test for detecting chronic thrombosis. It should take place in every systematic complete examination of unexplained dyspnoea.

Hypoxic vasoconstriction is one of the main determinants of pulmonary arterial hypertension in C.O.P.D. The authors study in two groups of respiratory insufficiency patients (82 C.O.P.D. and 46 non-C.O.P.D.) correlations between mean pulmonary arterial pressure (PAP) and gasometric values. They show that: --no correlation exists in the patients who suffer from a restrictive syndrome; --in the obstructive patients, correlations are poorer between PAP and PaO2 or PvO2 than between PAP and a factor made up of these two parameters, according to the percentage of their theoretical values.

Twenty patients with severe and chronic respiratory insufficiency (SaO2 less than or equal to 80% - PaCO2 greater than or equal to 50 mmHg) were treated with intermittent ventilatory assistance. They used volumetric apparatus 2 to 8 hours a day, during at least 6 months (22 months +/- 13). Respiratory status never improved strikingly, on the contrary most of the time it worsened and patients needed other ventilatory technics and/or died (11 of 20). This technic of ventilatory assistance does not seem to really change the prognosis of these patients in a severe and chronic state.