Nonlinear ptychographic coherent diffractive imaging

Ptychographic Coherent diffractive imaging (PCDI) is a significant advance in imaging allowing the measurement of the full electric field at a sample without use of any imaging optics. So far it has been confined solely to imaging of linear optical responses. In this paper we show that because of the coherence-preserving nature of nonlinear optical interactions, PCDI can be generalised to nonlinear optical imaging. We demonstrate second harmonic generation PCDI, directly revealing phase information about the nonlinear coefficients, and showing the general applicability of PCDI to nonlinear interactions.

Ptychographic coherent diffractive imaging with orthogonal probe relaxation

Ptychography is a scanning coherent diffractive imaging (CDI) technique that relies upon a high level of stability of the illumination during the course of an experiment. This is particularly an issue for coherent short wavelength sources, where the beam intensity is usually tightly focused on the sample in order to maximize the photon flux density on the illuminated region of the sample and thus a small change in the beam position results in a significant change in illumination of the sample. We present an improved ptychographic method that allows for limited stability of the illumination wavefront and thus significantly improve the reconstruction quality without additional prior knowledge. We have tested our reconstruction method in a proof of concept experiment, where the beam instability of a visible light source was emulated using a piezo driven mirror, and also in a short wavelength microscopy CDI setup using a high harmonic generation source in the extreme ultraviolet range. Our work shows a natural extension of the ptychography method that paves the way to use ptychographic imaging with any limited pointing stability coherent source such as free electron or soft X-ray lasers and improve reconstruction quality of long duration synchrotron experiments.

[Bronchopleural fistula: a serious complication after thoracic surgery]

Postsurgical bronchopleural fistula (BPF) is a serious complication accompanied with a high mortality, requiring early and correct diagnosis. The acute form of BPF is usually a technical failure of the surgical stump requiring an immediate surgical reoperation. The subacute or chronic BPF is more difficult to diagnose because of non specific symptoms. It requires well targeted antibiotics depending on microbiology, an adequate drainage of the thoracic cavity and very often repeated surgical or endoscopic procedures.

[Bochdalek hernia: a rare cause of dyspnea and abdominal pain in adults]

We present here a case of a sixty year old man with a symptomatic hernia of Bochdalek. Its diagnostic was long to be established because this type of congenital diaphragmatic hernia is rare and mainly occurs in neonates. However when looking at a patient with dyspnea and lasting atypical abdominal pain, such a diagnosis has to be looked for, even if such a clinical entity is extremely rare in adults.

[Progress in bronchoscopy: ultrasound guided fine-needle aspiration (EBUS-TBNA)]

In case of lung cancer, evaluation of the extension disease is mandatory. Mediastinal nodes must also be evaluated: if a controlateral to the tumor node is metastatic (N3), surgery is no more indicated. As specificity of PET-CT scan is not satisfaying (78%), cytology or histology of a suspect node is necessary. Even if PT-CT scan is negative, node micrometastasis are not excluded. To investigate a mediastinal adenopathy, mediastinoscopy or mediastinotomy are gold standard. Cytoponction guided by ultrasonography (EBUS-TBNA) is a new method which has been proved to be efficient and safe, but necessating some expertise and regular practice. It could be a valuable alternative to mediastinoscopy.

[Pulmonary rehabilitation: a multidisciplinary and comprehensive intervention]

Pulmonary rehabilitation is an evidence-based, multidisciplinary and comprehensive intervention for chronic pulmonary diseases, adressed to symptomatic patients and to patients with impairment of activities of daily life. The major outcomes of this intervention are an increased exercise capacity, a decrease in dyspnea and thereby a better quality of life. Underweight patients may benefit from a caloric and protein supplementation. Smoking cessation programs should be integrated in any pulmonary rehabilitation program.

Bringing Chemical Data onto the Semantic Web

Present chemical data storage methodologies place many restrictions on the use of the stored data. The absence of sufficient high-quality metadata prevents intelligent computer access to the data without human intervention. This creates barriers to the automation of data mining in activities such as quantitative structure-activity relationship modelling. The application of Semantic Web technologies to chemical data is shown to reduce these limitations. The use of unique identifiers and relationships (represented as uniform resource identifiers, URIs, and resource description framework, RDF) held in a triplestore provides for greater detail and flexibility in the sharing and storage of molecular structures and properties.

Prediction of Properties from Simulations: A Re-examination with Modern Statistical Methods

We discuss models fit to data collected by Duffy and Jorgensen to predict solvation free energies and partition equilibria of drugs, organic molecules, aromatic heterocycles, and other molecules. These data were originally examined using linear regression, but here more recently developed statistical models are applied. The data set is complicated due to the presence of discrepant observations and also curvature in the response. In some cases it is possible to discard a small number of the observations to get good fit to the data, but, in others, discarding an increasing proportion of the observations does not improve the fit. Our general preference is to use robust parameter estimation which downweights to reduce the influence of discrepant observations on the fitted models. Models are selected for four responses using linear or more complicated representations of the explanatory variables, such as cubic polynomials, B-splines, or smoothers via generalized additive models (GAMs). Variables are chosen using the traditional approach of formal tests to assess contribution to the fit of a model, and resampling methods including bootstrap are also considered to assess the prediction error for given models. Results of our analysis indicate that GAMs are an improvement on linear models for describing the data and making predictions. In general robust regression models and GAMs have the smallest conditional expected loss of prediction over the four responses. In addition, robust regression models offer the advantage of identifying molecules that perform poorly in the fit. In general, models were identified that yielded an improvement of approximately 50% in the conditional expected loss of prediction compared with the original parametrization of Duffy and Jorgensen. It was also found that the use of cross-validation to compare models was unreliable, and bootstrapping is preferred.

[OSAS and driving capacity]

Obstructive sleep apnea syndrome (OSAS) is a very frequent clinical problem, sleepiness being one important symptom. Car driving necessitates attention and concentration. That why OSAS patients are at high risk of having car crash. But more than 60% of these patients will never have a car crash. CPAP treatment is very efficient also to correct this risk. Despite utilisation of driving simulator, we are actually unable to detect, in the OSAS population, the individual who will have a crash. To diagnose OSAS very early and to treat efficiently remain the key of security.

[Chronic cough: a practical approach]

Chronic cough (more than 8 weeks) is a frequent symptom (30 millions consultations/ year). The most encountered causes are: asthma, gastro-oesophageal reflux, post nasal drip. Practically we propose the following approach: 1. clinical history, physical examination, chest-X ray, spirometry; 2. to exclude a post infection cough or secondary to an ACEI; 3. in case of high clinical probability of asthma, post-nasal drip, gastro-oesophageal reflux, to treat adequately. In case of negative clinical probability or unsuccessful treatment, metacholine test, oesophageal studies, PEF recording, CT thorax, bronchoscopy, CT sinuses are the most useful tests, using clinical history as guide. Using such an approach, treatment is successful in the vast majority of cases.

[Drug-induced lung disease in general practice]

Adverse medical side effects are an important health issue causing morbidity and mortality. Lungs, being a complex system are also involved. Cough, bronchospasms and buccopharyngeal oedema are the main drug-induced reactions at the airways level. With regard to pulmonary parenchyma, this can result in almost all forms of interstitial lung disease such as usual interstitial pneumonia, non specific interstitial pneumonia, lung oedema, eosinophilic lung disease. Certain drugs are often involved and cause specific clinical pictures (amiodarone, methotrexate). Lung vasculature, pleura and thoracic wall can also be affected. Drug-induced pulmonary disease is an exclusion diagnosis and the main therapeutic action is to stop administration of the suspected drug. On the Internet www.pneumotox.com is a helpful tool for the clinical practice.

Bronchial asthma and self-management education: implementation of Guidelines by an interdisciplinary programme in health network

Asthma is a chronic disease generating very high costs even for Switzerland. Self-management education (SME) is effective and recommended as an integral part of management in the most recent guidelines on asthma treatment. Its aim is to reduce morbidity [hospitalisations (H), lost workdays (LW), emergency consultations (EC)] and improve quality of life (QOL) in these patients.

METHOD

Integrated programme with educational platforms (two-language booklet), SME in 66 patients (30 m, 36 f) with interdisciplinary quality team (pneumologists, primary care physicians, pharmacists, specialised nursing staff), QOL questionnaire. Measurement of morbidity parameters 12 months before and after SME. Measurement of QOL before and 12 months after SME.

RESULTS

Hospitalisations fell from 35 to 8%*, EC from 88 to 53%*. and LW from 39 to 14%* (*p <0.001). Overall, SME resulted in a health cost saving of CHF 202,510 in terms of LW and CHF 131,200 in terms of days in hospital, i.e. a total of CHF 333,710. Costs saved per patient were CHF 5,056 per year. QOL improved with the following scores: overall QOL 4.5 +/- 0.9 to 5.2 +/- 0.9*; activities 4.5 +/- 0.9 to 5.2 +/- 0.9*; symptoms 4.2 +/- 1.1 to 5.2 +/- 1.1*; emotions 4.9 +/- 1.1 to 5.6 +/- 1*; environment 4.5 +/- 1.4 to 4.9 +/- 1.3* (*p <0.001).

CONCLUSION

SME by interdisciplinary health network is effective. It brings a steep fall in costs for asthma treatment by cutting back hospitalisations and lost workdays and by improving the asthmatics' quality of life. It should be recognised and better supported by the health system.

Bronchial asthma and self-management education: implementation of Guidelines by an interdisciplinary programme in health network

Asthma is a chronic disease generating very high costs even for Switzerland. Self-management education (SME) is effective and recommended as an integral part of management in the most recent guidelines on asthma treatment. Its aim is to reduce morbidity [hospitalisations (H), lost workdays (LW), emergency consultations (EC)] and improve quality of life (QOL) in these patients.

METHOD

Integrated programme with educational platforms (two-language booklet), SME in 66 patients (30 m, 36 f) with interdisciplinary quality team (pneumologists, primary care physicians, pharmacists, specialised nursing staff), QOL questionnaire. Measurement of morbidity parameters 12 months before and after SME. Measurement of QOL before and 12 months after SME.

RESULTS

Hospitalisations fell from 35 to 8%*, EC from 88 to 53%*. and LW from 39 to 14%* (*p <0.001). Overall, SME resulted in a health cost saving of CHF 202,510 in terms of LW and CHF 131,200 in terms of days in hospital, i.e. a total of CHF 333,710. Costs saved per patient were CHF 5,056 per year. QOL improved with the following scores: overall QOL 4.5 +/- 0.9 to 5.2 +/- 0.9*; activities 4.5 +/- 0.9 to 5.2 +/- 0.9*; symptoms 4.2 +/- 1.1 to 5.2 +/- 1.1*; emotions 4.9 +/- 1.1 to 5.6 +/- 1*; environment 4.5 +/- 1.4 to 4.9 +/- 1.3* (*p <0.001).

CONCLUSION

SME by interdisciplinary health network is effective. It brings a steep fall in costs for asthma treatment by cutting back hospitalisations and lost workdays and by improving the asthmatics' quality of life. It should be recognised and better supported by the health system.

Treatment of primary spontaneous pneumothorax by simple talcage under medical thoracoscopy

Medical thoracoscopy under local anesthesia with simple talc poudrage is a safe and cost-effective technique to prevent recurrences in the case of primary spontaneous pneumothorax. Pathogenesis of primary spontaneous pneumothorax, i.e. a pneumothorax occurring without any underlying lung disease, remains unclear; there is no proof that the air leak leading to air escape into the visceral pleura is located in blebs or bullae visualized during the procedure. Therefore we do not have any evidence that blebs or small bullae cauterization or resection adds any further benefit to pleurodesis. Pulmonologists doing thoracoscopic talc pleurodesis should learn to better control pain due to thoracoscopic talcage as it has been shown that thoracoscopic talcage is not more painful than a chest tube drainage in patients providing they receive at least some opioids. There is also a debate on the best surgical approach to treat pneumothorax but minithoracotomy with pleurectomy remains the gold standard although more expensive and associated with some morbidity or mortality.

Site distribution in resin beads as determined by confocal Raman spectroscopy

Scanning confocal Raman spectroscopy was used to study the distribution of reactive sites within a resin bead used for solid-phase synthesis. The distribution of NH2 groups in aminomethylated polystyrene resin (APS) was determined by doping with varying amounts of 4-cyanobenzoic acid. The extent of loading was determined by both elemental analysis and ninhydrin assays. The spatial distribution of the coupled 4-cyanobenzamide within the bead was determined to an in-plane resolution of 1 microm and depth resolution of about 4 microm, using the strong Raman CN stretching vibrational transition at 2230 cm(-1). Dry and swollen beads were studied and the distribution was found to be essentially uniform throughout the bead in all cases.

Management and outcome of patients undergoing thoracic surgery in a regional chest medical centre

BACKGROUND AND OBJECTIVE

The main objective of this study was to assess mortality and morbidity after thoracic surgery in a medical centre, without resident chest surgeons and anaesthesiologists, and to determine specific risk factors.

METHODS

A prospective cohort study using a local database which includes patients' clinical characteristics, results of preoperative investigations, surgical and anaesthesia data and all postoperative complications was undertaken. Two hundred and seventy-three consecutive patients undergoing thoracic surgery from 1992 to 1999 were studied. The referral chest medical centre was without resident thoracic surgeons or anaesthesiologists; postoperative care was led by local chest physicians according to standardized protocols and in close collaboration with university-based surgeons and anaesthesiologists.

RESULTS

The majority of patients had lung cancer (71%) and underwent resection of at least one lobe (62%). Thirty-day mortality rate was 2.2% and one or more complications occurred in 74 patients (27%). Three patients had to be transferred to a university hospital for further treatment. Univariate predictors of complications included age (> 70 years), history of smoking, body mass index, as well as the extent and duration of surgery. After multiple logistic regression analysis, smoking (current or past), prolonged surgery (>120 min) and major lung resection (pneumonectomy or bilobectomy) remained the only independent risk factors.

CONCLUSIONS

Overall perioperative mortality and morbidity rates did not exceed those reported from large teaching hospitals. In selected patients, thoracic surgery can be safely performed in a specialized chest medical centre without on-site surgeons and anaesthesiologists.

Exercise capacity and extent of resection as predictors of surgical risk in lung cancer

Lung resection remains the most effective treatment for non-small cell lung cancer (NSCLC). However, there is no consensus about reliable operative risk assessment in these patients. The aim of this study was to identify predictors of postoperative complications and death after lung resection for NSCLC. In this prospective trial, 125 of 142 (88%) consecutive NSCLC patients from 1990 to August 1997 had complete data sets. All underwent functional assessment including spirometry and cardiopulmonary exercise tests and lung resection via thoracotomy. Complications occurred in 31 of 125 (25%) patients including 2 (1.6%) deaths. On logistic regression analysis, only maximal oxygen uptake (V'O2,max) x kg body weight(-1) expressed as a percentage of the predicted value (p<0.0001) and the estimated extent of lung tissue resection (p=0.02) were independent predictors of postoperative complications. Six of seven patients with a V'O2,max x kg body weight(-1) of <60% pred, but only eight of 65 with values >90% pred, exhibited postoperative complications. Maximal oxygen uptake and the estimated extent of lung tissue resection are independent predictors of postoperative complications. These simple parameters should be integrated into the preoperative decision analysis for operability in patients undergoing lung resection for lung cancer.

Perioperative mortality and major cardio-pulmonary complications after lung surgery for non-small cell carcinoma

OBJECTIVES

A database of patients operated of lung cancer was analyzed to evaluate the predictive risk factors of operative deaths and life-threatening cardiopulmonary complications.

METHODS

From 1990 to 1997, data were collected concerning 634 consecutive patients undergoing lung resection for non-small cell carcinoma in an academic medical centre and a regional hospital. Operations were managed by a team of experienced surgeons, anaesthesiologists and chest physicians. Operative mortality was defined as death within 30 days of operation and/or intra-hospital death. Respiratory failure, myocardial infarct, heart failure, pulmonary embolism and stroke were considered as major non-fatal complications. Preoperative risk factors, extent of surgery, pTNM staging, perioperative mortality and major cardiopulmonary complications were recorded and evaluated using chi-square statistics and multivariate logistic regression.

RESULTS

Complete data were obtained in 621 cases. The overall operative mortality was 3.2% (n = 19). Cardiovascular complications (n = 10), haemorrhage (n = 4) and sepsis or acute lung injury (n = 5) were incriminated as the main causative factors. In addition, there were 13 life-threatening complications (2.1%) consisting in strokes (n = 4), myocardial infarcts (n = 5), pulmonary embolisms (n = 1), acute lung injury (n = 1) and respiratory failure (n = 2). Four independent predictors of operative death were identified: pneumonectomy, evidence of coronary artery disease (CAD), ASA class 3 or 4 and period 1990-93. In addition, the risk of major complications was increased in hypertensive patients and in those belonging to ASA class 3 or 4. A trend towards improved outcome was observed during the second period, from 1994 to 97.

CONCLUSION

Our data demonstrate that perioperative mortality is mainly dependent on the extent of surgery, the presence of CAD and provision of adequate medical and nursing care. Preoperative testing and interventions to reduce the cardiovascular risk factors may help to further improve perioperative outcome.

[Value of thoracoscopy and talc pleurodesis in diagnosis and palliative treatment of malignant pleural mesothelioma]

Malignant pleural mesothelioma (MPM) remains a disease of very poor prognosis despite all new therapeutic approaches. We describe here 13 cases with MPM. The main symptoms at presentation were dyspnea (12/13) followed by weight loss (7/13), cough (3/13) and thoracic pain (2/13). On chest X-ray, all patients had pleural effusion associated with pleural thickening in 8/13 cases (62%). A definitive diagnosis was brought by thoracoscopy in 11/12 cases (diagnostic sensitivity 92%). In one patient, thoracoscopy was technically impracticable because of very important obesity. By thoracoscopic talc pleurodesis, we were able to control the pleural effusion in all patients with suppression of dyspnea (11). The mean survival after diagnosis was 6.8 +/- 5.0 months (range 1-16). At the present time, we believe that thoracoscopy is well indicated in any suspicion of MPM not only for diagnosis but also for palliative treatment of this pleural disease. However, there is a need for well controlled studies to improve the outcome of MPM.

[Chronic obstructive pulmonary disease patients undergoing home oxygen therapy: a study of clinical parameters, nutritional status and ambulatory capacity]

AIM OF THE STUDY

The aim of the study was to document the nutritional status and the calorie demands of patients suffering from severe chronic airflow obstruction (BPCO) who were on continuous domiciliary oxygen therapy (OCD) and to correlate this information with the clinical picture, the severity of the respiratory disease and the daily distance walked, this to be measured in a prospective manner.

PATIENTS AND METHODS

Fifty clinically stable patients with chronic airflow obstruction on continuous oxygen therapy for 33 months (range 4-106) in whom the following measures were made at home: pulmonary function, maximal static inspiratory and expiratory pressure (PIMAX and PEMAX), strength of hand, grip, the mean distance walked daily (wearing a pedometer for one week), body mass index (IMC), and the body composition by electrical bio-impedence and calorie requirements.

RESULTS

Thirty four per cent of patients presented with an excessive body mass (IMC > 27 kg/m2), 42 per cent had normal nutrition (IMC 20-27 kg/m2) and 24 per cent were malnourished (IMC < 20 kg/m2). Malnourished patients had, in a statistically significant manner, airflow obstruction of greater severity and a lower oxygen saturation and a PEMAX as well as a lower daily distance compared to over weight subjects. However, their net calorie requirements were markedly higher (39 +/- 5 Kcal/kg/j) compared to patients having normal weight (29 +/- 11 kcal/kg/j) or excess weight (25 +/- 8 kcal/kg/j). From the clinical standpoint no malnourished patient fulfilled the clinical criteria of chronic bronchitis. By contrast 61 per cent of subjects with normal nutrition and 94 per cent of subjects with excessive weight were chronic bronchitics.

CONCLUSION

In the group of patients with severe airflow obstruction on domiciliary oxygen, 25 per cent were malnourished and this was in spite of netly increased calorie consumption which is superior to their theoretical need. This suggests that the solution of increasing supplements to their dietary requirements would be a difficult to realise. These subjects presented also with a more marked ventilatory handicap and a clinical picture characterised by the absence of the classical signs of chronic bronchitis.

End-stage cystic fibrosis: improved diabetes control 2 years after successful isolated pancreatic cell and double-lung transplantation

Over a period of years, insulin-dependent diabetes and respiratory insufficiency developed in a 35-year-old patient with end-stage cystic fibrosis. After waiting more than 4 years while receiving maintenance treatment with continuous liquid O2 and nasal ventilation, the patient underwent double-lung and pancreatic islet cell transplantation. Subsequently, the patient has enjoyed a normal life with full employment and much better control of his diabetes. Pancreatic islet cell transplantation is a simple and innocuous technique easily added to the end of lung transplantation. These new pancreatic cells, although locally injected, are still secreting more than 2 years later as assessed by repeated C-peptide measurements.

Health-related quality of life in patients under long-term oxygen therapy: a home-based descriptive study

Long-term home oxygen therapy (LTOT) improves survival of hypoxic patients with chronic respiratory insufficiency. However, the health-related quality of life (HRQL) of these patients, when LTOT is initiated, is severely impaired. The present study aims to describe the health-related quality of life (HRQL) of patients under LTOT, assessed at home, to identify parameters relevant to HRQL, and to describe changes over a 1-yr period. Seventy-nine patients (aged 68 +/- 11 years, under LTOT for 34 +/- 24 months) underwent pulmonary function testing, measurement of average daily distance walked, SaO2, dyspnoea scores (Borg scale and oxygen-cost diagram), and Hospital Anxiety and Depression scores. After 1 yr, measurements were repeated, and HRQL was measured with the St George Respiratory Questionnaire (SGRQ). Forced expiratory volume in 1 s (FEV1% of predicted) was 36 +/- 19; SaO2 (room air) was 87 +/- 5%, daily distance walked was 1202 +/- 1140 m; 21% suffered from anxiety and 27% from depression. After 1 yr, pulmonary function tests, dyspnoea or prevalence of anxiety or depression were unchanged. Mortality was high (31% 1-yr mortality). Daily distance walked (rho = -0.55, P = 0.01 vs. SGRQ) and number of days spent in hospital (rho = 0.5, P = 0.01 vs. SGRQ) were the parameters with the highest correlation with HRQL scores. Quality of life was poor in these patients, with high rates of emotional disorders. Restoring and maintaining sufficient exercise capacity for everyday life activities through outpatient rehabilitation programmes and support for emotional disturbances should be major goals in the care of these patients.

Treatment of complicated spontaneous pneumothorax by simple talc pleurodesis under thoracoscopy and local anaesthesia

BACKGROUND

Complicated (recurring or persistent) spontaneous pneumothorax requires treatment either by talc pleurodesis with bullae electrocoagulation or, more aggressively, by thoracotomy or video-assisted thoracoscopic surgery. However, the relative merits of bullectomy, pleurectomy, and pleurodesis have not yet been established in the treatment of spontaneous pneumothorax.

METHODS

The complications, duration of drainage, length of hospital stay, and immediate and long term success rate of treating complicated spontaneous pneumothorax with talc pleurodesis under local anaesthesia supplemented with nitrous oxide were studied.

RESULTS

Talc pleurodesis was performed in 93 patients without serious complication (two benign arrhythmias, two subcutaneous emphysema, two pneumonia, one bronchospasm). The procedure was immediately successful in 90 patients (97%) with a median duration of drainage of five days (range 2-40) and a median length of hospital stay of 5.2 days (range 3-40). After a mean follow up duration of 5.1 (range 1-9.4) years in 84 cases the long term success rate was 95%, although six cases developed a small localised recurrence of spontaneous pneumothorax which did not require further surgery. Macroscopic staging at thoracoscopy was only carried out in the last 59 cases of whom 10 (17%) had bullae with a diameter of > 2 cm. In this group of patients the risk of definitive failure requiring surgery was significantly higher than in those patients without such bullae (odds ratio 7; confidence interval 3.7 to 13.3; p = 0.03), although eight of these patients did not require thoracotomy. Total lung capacity was reduced immediately after talc pleurodesis (mean (SD) 75 (23)% predicted at 10 days) but had improved to 95 (14)% predicted at 12 months.

CONCLUSIONS

This study shows that simple thoracoscopic talc pleurodesis under local anaesthesia is a safe and effective treatment for complicated spontaneous pneumothorax. However, patients with bullae of > 2 cm in diameter have a greater risk of treatment failure.

[Dangerous complication of transtracheal oxygen therapy with the SCOOP(R) system]

A portable oxygen system in combination with transtracheal O2 delivery (SCOOP(R)) permits patients with respiratory failure optimal mobility and facilitates longterm oxygen therapy. This report describes a 70 year old female with COPD that developed acute respiratory distress 18 days after inserting PRESCOOP(R) and 11 days after changing to SCOOP 1 catheter. Catheter stripping had not revealed any pathology. Flexible bronchoscopy showed a mucus ball at the catheter tip leading to a 80% stenosis of the trachea. Trials to remove the ball with forceps and a loop were not successful until a rigid bronchoscop was inserted. Up to 10% of patients develop mucus ball formation with SCOOP 1 catheter which remains in situ for 6 weeks. In patients with high risk of mucus formation (high O2 flow, viscous mucus, low FEV1) the manufacturers of SCOOP recommend catheter stripping. We consider a control bronchoscopy being safer 1 week after changing from PRESCOOP to SCOOP because one patient has been reported to have died of this complication and our patient has developed a near fatal situation.

Bronchial provocation with cat allergen: correlation between the individual IgE-CRIE pattern and the occurrence of a late allergic reaction

Twenty-one mild asthmatic patients allergic to cat dander underwent a bronchial provocation test (BPT) with a cat extract. An early allergic response (EAR) was observed in all 21 patients and a late allergic response (LAR) in 8/21 patients. In the EAR, the patients with subsequent LAR had a greater fall in FEV1. Their baseline FEV1, and total dose of inhaled allergen were not significantly different from patients who did not develop a LAR, but their serum specific IgE level was higher. Crossed immunoelectrophoresis (CIE) of the same cat extract showed that it contained eight different proteins. An IgE-CRIE was obtained from all 21 patients, using radiolabelled anti-IgE and autoradiography. Radiolabelled standards allowed a semiquantitative scoring of the radiostaining. The CRIE pattern of the eight patients with LAR showed a higher score of radiostaining and a greater number of proteins bound to IgE. The two major allergen cat albumin and Fel dI bound equally to IgE of patients with and without LAR whereas another protein (antigen No. 7) bound to IgE of 100% of patients with LAR but of only 38% of patients without LAR. These data suggest that the pattern of the IgE response to specific proteins of a cat extract may be related to the occurrence of LAR after BPT with this allergen.

[Campaign against smoking and the general practitioner. Evaluation of a simple method allowing immediate measurement of compliance with smoking cessation in the physicians office]

Recently, the Swiss Medical Association and the Swiss Federal Office for Public Health started a campaign against smoking. Portable carbon monoxide (CO) devices measuring alveolar CO concentration are now available. It is important to know how accurate they are in discriminating smokers (S) from nonsmokers (NS) in different environmental conditions. We administered a smoking questionnaire and measured alveolar CO concentration in 241 people living in an urban area (PU) and 112 people living in a mountain area (PM). Smoking prevalence was 39% in PU and 17% in PM. Alveolar CO concentration was significantly higher in S than in NS (27 +/- 11, 11 to 60, vs. 14 +/- 9, 4 to 52, p < 0.01 in PU and 23 +/- 13, 4 to 48, vs. 9 +/- 7, 4 to 46, p < 0.01 in PM). We found significantly higher CO-values in NF of PU than PM (p < 0.01). This test has a sensitivity of 80%, a specificity of 78%/79% (PU/PM) and a predictive positive value of 74%/80% (PU/PM). The cut-off point has to be adapted depending on the environmental exposure (PU: 15 ppm, PM: 10 ppm CO). Alveolar CO measurement is a cheap accurate method whose results are immediately available to the general practitioner in his fight against smoking. This method merits higher application.

Retroperitoneal silicosis mimicking pancreatic carcinoma in an Alpine miner with chronic lung silicosis

A miner, known to have had lung silicosis for 30 years, was investigated for abdominal pain. A retroperitoneal mass was found, in which histological examination showed an inflammatory reaction to silica.

[Thoracoscopy: diagnostic and therapeutic use]

From 1986 to 1989, we performed 74 thoracoscopies in 70 patients (37 persisting or relapsing pneumothoraces, 30 chronic pleural effusions, 3 primary pleural tumors, 2 chylothoraces, 1 empyema, 1 persisting bronchopleural fistula). 29 supplementary diagnoses were established by thoracoscopy: 11 carcinomas, 4 cases of pleural tuberculosis, 12 of nonspecific pleurisy, 1 pleural fibroma, and 1 hamartoma. Pleurodesis was done with talc under thoracoscopy with success in 32/34 cases of pneumothorax (94%) and in 19/20 patient with chronic pleural effusion (95%). Talc was also successful in 2 instances of chylothorax and the bronchopleural fistula. The empyema was successfully treated by drainage under thoracoscopy and local instillation of streptokinase. Altogether, we recorded 3 deaths in the 30 days following thoracoscopy in 3 plurimetastatic patients. No other major complication was observed. The procedure is a well tolerated tool for diagnosis and treatment of pleural diseases. The indication should however be established with care in debilitated plurimetastatic patients.

Bronchodilating efficacy of an open-spacer device compared to three other spacers

BACKGROUND

Spacers devices are commonly used in aerosol therapy; however, they are bulky and require regular cleaning. A compact open spacer (OS, Synchroner, Fisons, UK) has been developed to overcome this problem. We compared bronchodilator efficacy associated with its use to efficacy of same dose via three other spacers: Volumatic (Glaxo Laboratories), Nebuhaler (Astra Laboratories), Inspirease (Key Pharmaceuticals).

MATERIALS & METHODS

Sixteen asthmatics (greater than 20% reversibility of FEV1) took part in the study. In random order, they used a different device on each of the 4 study days to inhale 2 puffs of a combination aerosol (1 mg reproterol and 2 mg sodium cromoglycate, Aarane). We recorded results of spirometry before and 5, 30, and 60 minutes after bronchodilator inhalation.

RESULTS

At each time, we found no significant difference in bronchodilation.

CONCLUSION

OS is as efficient as other commonly used spacers to produce bronchodilation resulting from a conventional dose of reproterol.

[The treatment of acute cardiac insufficiency: toward a physiopathological approach]

The development of new inotropic or vasodilator agents, with different spectra of action makes possible a physiological approach to the treatment of acute cardiac failure. The choice depends on the functional disturbances measured and is then adapted to the response obtained. In the most serious cases, where pharmacological treatment proves insufficient, there need be no hesitation in using invasive methods which were formerly reserved for the treatment of cardiogenic shock. Systematic application of therapeutic formulae gives way to rational selection of the agent best adapted to the particular conditions brought about by a specified cardiopathy in a given patient.

Fatal cardiac arrhythmias and shock following yew leaves ingestion

A 40-year-old woman presented with vomiting and abdominal pain following voluntary ingestion of 150 yew leaves. She developed ventricular conduction defects and arrhythmias unresponsive to medical treatment after admission. She expired five hours after yew ingestion from irreversible cardiogenic shock. More attention should be given to this rare but severe intoxication for which no effective therapy is known.

[Chylothorax: treatment using talc pleurodesis]

Chylothorax is a rare complication of lymphoma with a poor prognosis. The treatment is not well established. We report a case of lymphoma complicated by bilateral chylothorax in which, despite optimal chemotherapy and radiotherapy, pleural effusion persisted. Pleuroscopy was performed under local anesthesia, followed by pleural instillation of pure talc. The immediate result was satisfactory and six months later there was no recurrence of chylothorax. Talc pleurodesis appears to be a simple and safe way of treating chylothorax resistant to conventional therapy.