Revue francaise des maladies respiratoires最新文献

A lymphocytic alveolitis is a common stage in a group of interstitial pulmonary disorders, where the lymphocytes accumulating in the alveoli play a major pathogenic role by their regulatory function or through their effects on the inflammatory reaction; controlling the outcome to healing, chronicity or fibrosis. Studies on lymphocytes obtained by bronchoalveolar lavage enable different parameters to be determined whose semiological value is discussed from information acquired in in vitro models of lymphocyte activation. These models show the need for activating signals acting in a sequential manner on cells whose function and mode of response are extraordinarily diversified. Three successive phases may be defined at the time of activation: first a membrane stage consisting of changes in the lipids (metabolism of arachidonic acid) and the cytoskeleton of the cell, a second stage corresponding to the start of the "blastic transformation" with the production of lymphokines with an increase in protein and RNA content (phase G1), then a third stage of DNA synthesis (phase S-G 2) preceding cell division; it is needed for the expression of new markers of differentiation. Nowadays the joint study of the phases of the cell cycle and the expression of antigenic differentiation, identified by monoclonal antibodies within a heterogeneous population, benefit from techniques of flow cytometry. These methods, combined with a measure of mediator production (interleukines) or of non-specific markers of activation liberated by T or B lymphocytes or by macrophages ought to succeed in defining the evolutionary stages or the immune-clinical types of alveolitis. Finally these methods allow the development of cellular immunopharmacology which should lead to new treatments.

The mortality due to respiratory disease was studied in France between 1970 and 1974 as well as in seven other countries in the European Economic Community. The French results were presented as an index of mortality by cause of death, enabling a comparison of the mortality in different groups of the population. Data was supplied for 7 diagnostic groups defined according to List A of the International Classification of Diseases. The population studied consisted of men and women between 15 to 64 years, classified according to residence (urban or rural) and profession (agricultural worker or not). In addition the indices of mortality for farmers or agricultural employees were compared to men of the same social class, for the same period. The comparisons between the urban and the rural background revealed an excess mortality for respiratory tuberculosis, lung cancer, bronchitis, emphysema and asthma for those in urban areas. In the rural environment an excess mortality was noted for acute respiratory diseases in both men and women; this was also found comparing agricultural to non-agricultural workers. Lastly, if one compared agricultural and non-agricultural workers of the same social class, deaths due to acute and chronic respiratory infections were higher in the agricultural workers. These results show the relative importance already stressed in other studies, of acute respiratory diseases in agricultural workers.

The cell populations in the alveoli are exposed to the environment and react differently to each type of challenge (mineral particles, toxic gases, infections, antigenic substances. . .). Amongst the best studied of these irritant factors is tobacco smoke which in the long term leads to a number of changes both in the distribution of alveolar cells and also their function and morphology. Amongst acute and sub-acute pathogens, bacterial infections produce a rapid poly-morpho-nuclear neutrophilia and then a lymphocytosis; oxygen and oxidising agents in general lead to a neutrophilia which amplifies the pulmonary parenchymal changes related to the release of toxic metabolites of oxygen. The inhalation of antigenic substances also disturbs the behaviour of alveolar cells: activation of macrophages in the presence of allergy in those sensitized to IgE and immediate attraction of neutrophils preceding a T lymphocyte alveolitis in hypersensitivity pneumonia. It is possible to categorise several patterns of reaction in intra-pulmonary cells when challenged by some insult, a direct cytotoxic action, the accumulation of inflammatory cells and immunological competence corresponding to the concept of "a neutrophil alveolitis" or a "T cell alveolitis" with the development of emphysematous lesions. An understanding of the cellular make-up present in the alveoli when reacting to an external pathogen enables a better approach to the pathophysiological mechanisms in question.

Oxygen therapy is justified both on theoretical grounds and by clinical studies. Chronic hypoxia bodes ill for the system and is a prognostic factor in pulmonary disease. Low flow oxygen therapy has not shown any risk of pulmonary toxicity from anatomical or physiological studies. Clinical studies have shown that the correction of hypoxaemia by long term oxygen therapy improves exercise tolerance, mental state, the general sense of well being, polycythaemia, pulmonary hypertension, the quality of sleep, and finally the prognosis. But long term oxygen therapy is costly and requires patient co-operation and close supervision. It should be reserved for hypoxic patients in a stable state: the exact degree of hypoxaemia at which oxygen therapy is permissible cannot be defined precisely and depends on other criteria (such as polycythaemia, pulmonary arterial hypertension, nocturnal desaturation). Account should be taken of the PaCO2 level and the cause of the disease in deciding the oxygen flow. Polycythaemia, pulmonary arterial hypertension, nocturnal desaturation despite a normal waking PaO2, may represent some indications for oxygen therapy but further studies are necessary.

By evaluating the statistics of the cause of death, the current reports of antituberculous clinics and the information gathered from the tuberculosis registers of certain departments, an epidemiological survey in France shows that there were 2,048 deaths due to tuberculosis in 1981 (3.8 per 100,000). The level is steadily falling; these were 8.2/100,000 in 1970. It is the same for morbidity, the incidence of all forms of tuberculosis was 54 0/0000 in 1972 and 26.9 in 1980. In the register in the Bas-Rhin the level fell from 70.5 to 30.4, in the Rhône from 41.6 to 14.4 and in the Hautes Pyrénées from 22.2 (in 1973) to 15.3. In the Bas-Rhin the prevalence has fallen steadily: 233.3 in 1972 to 97.7 in 1979. Foreigners are five times more affected than the French by respiratory forms and 8 times more for extra-respiratory tuberculosis. Those who came from Black Africa are the most affected.

Seven cases of pulmonary hemangiopericytoma (presumed to be primary v.i.) are reported. Personal observations on these cases combined with 43 already described in the literature allow certain characteristics of the disorder to be accurately defined. Clinically, primary pulmonary hemangiopericytoma raises the aetiological problem of a peripheral solitary tumour beyond endoscopic vision. Until the present time the diagnosis has always been made by thoracotomy. Transpleural pulmonary biopsies may allow a preoperative diagnosis. Silver stains and electron microscopy enable an anatomo-pathological diagnosis. Histological studies can neither distinguish between benign and malignant forms nor differentiate between primary or metastatic hemangiopericytoma. For this reason there is always a long period of doubt whether the tumour is primary; only prolonged survival of the patients after excision will confirm whether the tumour was a primary or not. Treatment is essentially surgical. It seems that new techniques in radiotherapy (high energy) and new possibilities of chemotherapy (with Adriamycin) are capable of improving the prognosis of the malign form. However, such a therapeutic strategy remains to be defined as these tumours are so rare.

The medico-social aspects of respiratory handicap pose some perplexing problems, notably in their recognition, rigorous evaluation and in the granting of social security benefits. The clinical and respiratory function data should be standardised and classified according to type and significance of respiratory disease and also according to the degree of co-operation and understanding of the patient. The respiratory handicap should be evaluated after considering the functional disability engendered by the disorder and their socio-professional repercussions. The abnormality in the lungs should be measured by resting tests; the degree of disability by exercise studies; the socio-professional handicap by ergonometric tests to assess the scale of the demands and requirements of family and social and professional life, indeed the cultural and economic style of the individual concerned. Such combined studies would enable recognition of severe chronic respiratory handicap leading to decisions for exemption certificates, such as cases of severe respiratory failure in patients requiring supplementary treatment for oxygen therapy or assisted ventilation. The benefits and grants offered to those with respiratory handicaps would involve a number of rights relating to: care, work, costs of replacement of workers in the event of prolonged sick leave or the benefits of an invalidity pension. There will be other allowances such as invalidity cards, lodging special studies and other rights particularly relating to lodging and special equipment. The present scale is difficult to use both because of its lack of specificity and its ill-chosen terminology. For better balance between the handicap and the benefits offered, a common and more flexible system, with a printed table should be at hand for the doctor to use for certain decisions: long term illness, period of invalidity or early retirement because of medical incapacity. Within each table a sub-section should exist to allow for certain aspects of legislation (accidents at work, occupational illness or rights under common law) at the same time certain adjustments may be necessary which take into account the patient, degree of autonomy life style and social and cultural level. A pilot study of respiratory handicap, to standardise tests, and co-ordinate the planning of the medical and social interactions for a better grasp of the disorder and greater uniformity of the regulations within each disablement benefit system as well as between various other social security regimes would be desirable.

We report the case of a 27 year old man admitted to hospital for investigation of radiological opacities of recent origin. A diagnosis of mycotic aneurysms was made on a surgical biopsy. Although a right sided endocarditis could not be detected clinically, a trial of antibiotic therapy was instituted. However, no improvement occurred. The patient died, following a massive pulmonary haemorrhage. The necropsy revealed an active right sided endocarditis with multiple aneurysms of the intra-pulmonary arteries.

The relapse rate after short course chemotherapy is usually assessed by cases that are available for analysis, with a delay which rarely exceeds 3 years from the time of instituting therapy. This level may be disputed if too many are lost to follow up or non-compliers appearing late. To understand the true failure rate we strove to trace every patient in a trial carried out between 1969 and 1973, consisting of three groups of patients treated with the same chemotherapy: Isoniazid (450 mg/day), Rifampicin (600 mg/day) given every day but for differing durations: 6 months (Group A), 9 months (Group B), 12 months (Group C), with either daily Ethambutol or Streptomycin in addition for the first three months. Amongst the 356 patients in the trial 86 were eliminated for failure to comply with the protocol, either due to a mishap or change of treatment. Amongst the 270 remaining patients, 248 were traced with a mean delay of post-therapy follow up of 101 months for patients still living and of 72 months for patients who had died in the intervening period, but of non-tuberculous disease. In the 242 old patients whose disease could be evaluated, the number of bacteriological relapses was 4/81 (6.2 %) in group A, and 2/85 (2.3 %) in group B and 2/76 (2.6 %) in group C. There was no significant differences between the groups. From these results it is seen that the Isoniazid/Rifampicin combination given daily for 6 months is a powerful combination with few failures. Maintaining such chemotherapy for 12 months does not seem to yield substantial gains. In conclusion nine months of chemotherapy with this regime offers a sufficiently ample guarantee of cure.