Impact of treating obesity hypoventilation syndrome on body mass index.

STUDY OBJECTIVES: To evaluate the impact of positive airway pressure (PAP) therapy on body mass index (BMI) in patients with obesity hypoventilation syndrome (OHS) associated with obstructive sleep apnea (OSA). METHODS: A systematic review using the following terms: "obesity hypoventilation syndrome" AND "treatment" AND "randomized" using Cochrane Central Register of Controlled Trials, Medline and Web of Science was performed from the first data available until February 10, 2023. The inclusion criteria were: (1) original article; (2) adult OHS with concomitant OSA (apnea-hypopnea index or AHI ≥5 events/h); (3) randomized trial with PAP arm and standard care (control); (4) BMI evaluation at baseline and after the first months. We performed an individual participant data meta-analysis of randomized controlled trials. RESULTS: Our initial search retrieved 32 articles and 3 randomized studies fulfilled study criteria and were included in the final analysis, leading to a total of 342 participants. Patients were predominantly females (62%) and had OHS associated with at least mild OSA. As compared to baseline, a decrease in BMI was observed at study endpoint but this difference was not different intergroups (-0.50 ± 1.49 and -0.50 ±1.83, in control and PAP groups respectively (p=0.939)). Weight change was not associate with PAP adherence, OSA severity or use of supplemental oxygen. CONCLUSIONS: In contrast to treatment of eucapnic OSA with PAP that is associated with weight gain, treatment of OSA+OHS patients with or without PAP is associated with weight loss. Future studies are necessary to elucidate the mechanism by which weight loss occurs.

[Telemonitoring of patients with chronic respiratory failure in France]. / La télésurveillance du patient insuffisant respiratoire chronique en France : l'opportunité d'organiser une prise en charge efficiente.

The year 2023 is marked by the officialization in French law of medical telemonitoring. Adult patients suffering from severe chronic respiratory failure (CRF) and being treated non-invasive ventilation (NIV) and/or oxygen therapy in a home setting are eligible for telemonitoring, of which the costs are to be covered by French health insurance. Telemonitoring allows a medical professional to remotely interpret the data necessary for follow-up and, if necessary, to make decisions regarding management of a given patient. Its objectives are, at the very least, to stabilize the disease through appropriate monitoring, to improve efficiency and quality of care, and to improve that patient's quality of life. The objective of this synthesis is to review the current state of remote monitoring of CRF patients by identifying, through a narrative analysis of the literature, its current benefits and limitations, and to compare present-day telemonitoring with the guidelines of the official French health authority (Haute Autorité de santé) for its nationwide application.

Non-invasive ventilation in neuromuscular diseases: should we use higher levels of ventilatory support?

PURPOSE: In patients with COPD, one of the leading indications for domiciliary non-invasive ventilation (NIV), a major paradigm shift has been observed over the past decade in the method for adjusting NIV settings, with the use of sufficient ventilatory support to achieve a significant reduction in PaCO2. Whether this approach may be relevant to other populations, especially slowly progressive neuromuscular diseases (NMD), is unknown. METHODS: This study was conducted as a post hoc analysis from a previously published randomized controlled trial (NCT03458507). Patients with NMD treated with domiciliary NIV were stratified according to the level of ventilatory support: high-level tidal volume (HLVT; mL/kg of predicted body weight [PBW]) or high-level pressure support (HLPS), defined as a value above median value of the whole population (> 6.8 mL/kgPBW or 9.0 cmH2O, respectively). Primary outcome was mean nocturnal transcutaneous CO2 pressure (PtcCO2). Secondary outcomes included adherence to NIV, leaks, and side effects. RESULTS: Of a total of 26 patients, 13 were exposed to HLVT, with significantly lower nocturnal PtcCO2 (respectively 40.5 ± 4.2 vs. 46.3 ± 3.9 mmHg, p = 0.002). A linear correlation between VT (mL/kgPBW) and mean nocturnal PtcCO2 was evidenced (r = - 0.59, 95%CI [- 0.80; - 0.25], p = 0.002). No significant impact of HLVT was found on secondary outcomes. CONCLUSION: Despite the lack of power of this post hoc analysis, our results suggest that higher levels of ventilatory support are correlated with lower PtcCO2 in patients with NMD. Further studies are desirable to assess the extent to which the level of assistance influences PaCO2 evolution in patients with slowly progressive NMD, as well as in restrictive thoracic disorders.

[The roles of patients in healthcare provision, training and research: A French perspective]. / Rôles des patients dans le système de santé, la formation et la recherche en santé : une perspective française.

In 2002, patients were transformed into users of the French health system. As this opinion piece demonstrates, in 2021 they may at least potentially participate more actively than before. They can convey their knowledge of a disease and its treatments, and voluntarily share their experience. They can intervene in user representation and therapeutic patient education, the objective being to increase the autonomy of one and all, patients and public, in the training of professionals, clinical research and evolution of the health system. The rationale for the involvement of patients and their roles in provision of care, training and clinical research are analyzed from a French perspective. The obstacles to overcome and improvements to be achieved are reviewed, the objective being to promote enhanced health democracy through increased patient engagement. In 2021, however, the role of patients in the design and implementation of therapeutic patient education (TPE) and in the development of medical studies curricula remains limited if not restricted; this is due not only to a lack of information, but also to the resistance of health professionals and universities. Patients could and should assume a major role, fostering evolution toward a more just and effective health care system.

[Factors associated with the type of mask used during nocturnal NIV in patients with neuromuscular disorders]. / Facteurs associés au masque de ventilation non invasive nocturne chez les patients neuromusculaires adultes.

In subjects with neuromuscular diseases (NMD), the choice of facemask is essential for successful long-term noninvasive ventilation (NIV). While nasal masks usually represent the first line of treatment, almost a third of our subjects with NMD use an oro-nasal interface. Factors associated with the choice of mask remain poorly understood. We provide an original analysis of a previous prospective, multi-centric, Franco-Belgian survey investigating the factors associated with the type of nocturnal mask used in 116 adult NMD subjects treated with NIV. In these patients oro-nasal mask use was more often associated with non-Duchenne muscular dystrophy, older subjects, higher body mass index, better upper limb autonomy allowing independent mask removal and shorter periods of ventilation. Controlled prospective studies are needed to compare the efficacy and tolerance of different interfaces in this specific population.

Epistasis in intra- and inter-gene pool crosses of the common bean.

Epistasis has been shown to have an important role in the genetic control of several quantitative traits in the common bean. This study aimed to investigate the occurrence of epistasis in intra- and inter-pool gene crosses of the common bean. Four elite lines adapted to Brazilian conditions were used as parents, two from the Andean gene pool (ESAL 686; BRS Radiante) and two from the Mesoamerican gene pool (BRSMG Majestoso; BRS Valente). Four F2 populations were obtained: "A" (ESAL 686 x BRS Radiante), "B" (BRSMG Majestoso x BRS Valente), "C" (BRS Radiante x BRSMG Majestoso), and "D" (BRS Valente x ESAL 686). A random sample of F2 plants from each population was backcrossed to parents and F1 individuals, according to the triple test cross. Three types of progenies from each population were evaluated in contiguous trials. Seed yield and 100-seed weight were evaluated. Dominance genetic variance was predominant in most cases. However, the estimates of genetic variance may be biased by the occurrence of linkage disequilibrium and epistasis. Epistasis was detected for both traits; however, the occurrence differed among the populations and between the two traits. The results of this study reinforce the hypothesis that epistasis is present in the genetic control of traits in the common bean and suggest that the phenomenon is more frequent in inter-gene pool crosses than in intra-gene pool crosses.

A wireless patch for sleep respiratory disorders applications.

This paper presents a conformable wireless patch and its mobile application for physical activity, spO2 and pCO2 recording associated to digital biomarkers that aim at providing the clinicians with a reliable computer-aided diagnosis tool for rapid and continuous monitoring of sleep respiratory disorders. Each part of the system is described and results are presented and discussed. The reflectance sp02 sensor has been tested in vivo on several body sites and several subjects then compared to a reference device. The electrochemical tcpO2 sensor has been validated in vitro. Based on these physiological parameters, the proposed algorithms to automatically identifying sleep respiratory events are compared to a reference index.

[Nocturnal monitoring of home non-invasive ventilation: Contribution of simple tools such as pulse-oximetry, capnography, built-in ventilator software and autonomic markers of sleep fragmentation]. / Monitorage nocturne de la ventilation non invasive à domicile : l'apport d'outils simples tels que l'oxymétrie de pouls, la capnographie, les logiciels intégrés des ventilateurs et les marqueurs autonomiques de fragmentation du sommeil.

Complex respiratory events, which may have a detrimental effect on both quality of sleep and control of nocturnal hypoventilation, occur during sleep in patients treated by non-invasive ventilation (NIV). Among these events are patient-ventilator asynchrony, increases in upper airway resistance with or without increased respiratory drive, and leaks. Detection of these events is important in order to select the most appropriate ventilator settings and interface. Simple tools can provide important information when monitoring NIV. Pulse-oximetry is important to ensure that an adequate SpO2 is provided, and to detect either prolonged or short and recurrent desaturations. However, the specificity of pulse-oximetry tracings under NIV is low. Transcutaneous capnography discriminates between hypoxemia related to V/Q mismatch and hypoventilation, documents correction of nocturnal hypoventilation, and may detect ventilator-induced hyperventilation, a possible cause for central apnea/hypopnea and glottic closure. Data provided by ventilator software helps the clinician by estimating ventilation, tidal volume, leaks, rate of inspiratory or expiratory triggering by the patient, although further validation of these signals by independent studies is indicated. Finally, autonomic markers of sympathetic tone using signals such as pulse wave amplitude of the pulse-oximetry signal can provide reliable information of sleep fragmentation.

Respiratory muscle endurance training in obese patients.

OBJECTIVE: Increased respiratory muscle work is associated with dyspnea and poor exercise tolerance in obese patients. We evaluated the effect of respiratory muscle endurance training (RMET) on respiratory muscle capacities, symptoms and exercise capacity in obese patients. DESIGN: A total of 20 obese patients hospitalized for 26 ± 6 days to follow a low-calorie diet and a physical activity program were included in this case-control study. Of them, 10 patients performed RMET (30-min isocapnic hyperpnea at 60-80% maximum voluntary ventilation, 3-4 times per week during the whole hospitalization period: RMET group), while the other 10 patients performed no respiratory training (control (CON) group). RMET and CON groups were matched for body mass index (BMI) (45 ± 7 kg m(-2)) and age (42 ± 12 years). Lung function, respiratory muscle strength and endurance, 6-min walking distance, dyspnea (Medical Research Council scale) and quality of life (short-form health survey 36 questionnaire) were assessed before and after intervention. RESULTS: Similar BMI reduction was observed after hospitalization in the RMET and CON groups (-2 ± 1 kg m(-2), P < 0.001). No significant change in lung function and respiratory muscle strength was observed except for vital capacity, which increased in the RMET group (+0.20 ± 0.26 l, P = 0.039). Respiratory muscle endurance increased in the RMET group only (+52 ± 27%, P < 0.001). Compared with the CON group, the RMET group had greater improvement in 6MWT (+54 ± 35 versus +1 ± 7 m, P = 0.007), dyspnea score (-2 ± 1 versus -1 ± 1 points, P = 0.047) and quality of life (total score: +251 ± 132 versus +84 ± 152 points, P = 0.018) after hospitalization. A significant correlation between the increase in respiratory muscle endurance and improvement in 6MWT distance was observed (r (2) = 0.36, P = 0.005). CONCLUSIONS: The present study indicates that RMET is feasible in obese patients and can induce significant improvement in dyspnea and exercise capacity. RMET may be a promising tool to improve functional capacity and adherence to physical activities in this population, but further studies are needed to confirm these results.

[Initiation of long-term non-invasive ventilation at home: current practices and expected issues. Surveys from the CasaVNI working party]. / Mise en route d'une ventilation non invasive : pratiques actuelles et évolutions attendues. Enquêtes du groupe de travail CasaVNI.

INTRODUCTION: At the initiative of the Antadir Federation, the expert group CasaVNI has undertaken a study of the current situation and the medium term outlook of the initiation of long term non-invasive ventilation (NIV) in France and other countries. METHODS: Three surveys have been undertaken: (1) the first concerning the modalities of installation and surveillance of long-term NIV in France, (2) a second concerning the same modalities in other countries, (3) a third concerning the current prevalence and expected incidence of long-term NIV over the next few years. RESULTS: The initiation of long-term NIV takes place in hospital in the majority of cases (France 76%, elsewhere 79%) and the surveillance mainly at a day hospital (France 59%, elsewhere 43%). Despite the interrogation of many sources, the working party has been unable to determine the exact incidence and prevalence of patients receiving long-term NIV in France. CONCLUSION: With regard to the initiation of long-term NIV, clinical studies and guidelines are still necessary to validate the alternatives that will permit a response to the increasing demand while maintaining high standards.

[Management of central sleep apnea]. / Conduite à tenir devant un syndrome d'apnées du sommeil central.

Central sleep apnea is highly prevalent in association with heart failure, some neurological diseases and chronic opioids use. There are two main categories of central sleep apnea respectively related with different underlying conditions. Some hypocapnic patients exhibit respiratory control system instability and central apnea occurs when PaCO(2) falls below the threshold for apnea during sleep. The other group are patients with chronic hypercapnia mainly in the context of neuromuscular disorders or obesity hypoventilation syndrome. All these patients should be assessed by recording blood gases, polysomnography and ventilatory responses to CO(2). Cardiologic assessment should include pro-brain natriuretic factor (pro-BNP) and cardiac echography whereas neurological examination requires brain imaging and/or electromyography. Ventilatory supports used for treating central sleep apnea are non-invasive ventilation and servo-assisted ventilation in hypercapnic and hypocapnic patients respectively.

Intermittent hypoxia and sleep-disordered breathing: current concepts and perspectives.

There are three major types of sleep-disordered breathing (SDB) with respect to prevalence and health consequences, i.e. obstructive sleep apnoea syndrome (OSAS), Cheyne-Stokes respiration and central sleep apnoea (CSR-CSA) in chronic heart failure, and obesity hypoventilation syndrome (OHS). In all three conditions, hypoxia appears to affect body functioning in different ways. Most of the molecular and cellular mechanisms that occur in response to SDB-related hypoxia remain unknown. In OSAS, an inflammatory cascade mainly dependent upon intermittent hypoxia has been described. There is a strong interaction between haemodynamic and inflammatory changes in promoting vascular remodelling. Moreover, during OSAS, most organ, tissue or functional impairment is related to the severity of nocturnal hypoxia. CSR-CSA occurring during heart failure is primarily a consequence of cardiac impairment. CSR-CSA has deleterious consequences for cardiac prognosis and mortality since it favours sympathetic activation, ventricular ectopy and atrial fibrillation. Although correction of CSR-CSA seems to be critical, there is a need to establish therapy guidelines in large randomised controlled trials. Finally, OHS is a growing health concern, owing to the worldwide obesity epidemic and OHS morbidities. The pathophysiology of OHS remains largely unknown. However, resistance to leptin, obesity and severe nocturnal hypoxia lead to insulin resistance and endothelial dysfunction. In addition, several adipokines may be triggered by hypoxia and explain, at least in part, OHS morbidity and mortality. Overall, chronic intermittent hypoxia appears to have specific genomic effects that differ notably from continuous hypoxia. Further research is required to fully elucidate the molecular and cellular mechanisms.

[Home pulmonary rehabilitation: results in a cohort of 37 patients with respiratory handicap]. / Mise en oeuvre et bilan d'un réentraînement à l'effort à domicile chez 37 patients avec handicap respiratoire.

INTRODUCTION: The purpose of this open, prospective, non-controlled study is to evaluate the feasibility and effect of 10 weeks of home-based exercise retraining on a cyclo-ergometer in respiratory patients. METHODS: 75 patients are consecutively referred. 37 patients, (75% COPD), took part in the programme, 38 (51%) did not. Nine dropped out, five had missing data, therefore the analysis is of 23 patients. RESULTS: There was a significant improvement in Quality of life (CRQ) (p=0,02), in endurance and in work rate on the bicycle (p<0.001). There is a correlation between the increase in work rate on the bicycle and the improvement in quality of life (p=0.01, r=0.5). When the patients are divided according to the level of improvement in work rate on the cycle-ergometer (mild 0 to 10% improvement; moderate 11 to 49% and strong > 50%) we find that only mild improvement is found in those with a low initial work rate. CONCLUSION: We confirm the effectiveness of home based training, this being feasible in one out of two patients referred. Co-morbidity and the psycho-social situation were the main exclusion factors. The improvement in effort capacity could be an important determinant of quality of life. Cyclo-ergometer could required too great an effort for training more severe patients.

[Closed locked nailing of complex femoral fractures in adults. Apropos of 68 cases]. / Enclouage verrouillé des fractures complexes de la diaphyse fémorale de l'adulte. A propos de 68 cas.

Complex fractures of the femoral shaft rise problems due to high energy trauma with major soft-tissues injuries and bone comminution so increasing operative difficulties, risk of infection and delayed union. Our aim was to appraise the outcome of these problems when using a closed intramedullary locked nailing. There were 52 men and 16 women. Aged 16 to 83 years. 52 patients had multiple-injuries. There were 17 open fractures. The 68 cases were subdivided according to a classification in 3 types. Stable fractures type A and B1 were excluded. The shaft was divided into 5 zones. Patients were initially treated by skeletal traction closed nailing was performed 1-36 days later (average 9.5). All patients were reviewed until complete healing. Final follow-up was 6 to 35 months postoperatively (average 15). A dynamisation was performed in 19 cases at a average delay of 12 weeks. Sixty six of the 68 fractures united. Open fractures united after 26.4 weeks, in average and closed fractures after 23.25 weeks (p < .05). There was no correlation between time of surgery following the injury and the delay of healing. Shortening was noted in 4 cases. 8 patients had an angulation 5-15 degrees of in the varus or the valgus plane. 3 patients (4.4 per cent) had more than 5 degrees of angulation in the AP plane. An external rotation deformity of 10-35 degrees was noted in 4 patients. The incidence of deformities was the main problem. It could be minimize by a precise technique. Mobility of the knee was the other problem, but it appeared generally to depend much more on knee injury than on femoral fracture.

[Modifications of occlusal and axial morphology in removable partial denture]. / Modifications des morphologies occlusales et axiales en prothèse partielle adjointe.

The axial and occlusal preparation of the teeth is necessary to the sustentation, the stabilization and retention of a removable partial denture. The preparations by subtraction concern the axial and occlusal surfaces. The creation of guided surfaces within the enamel of the proximal surfaces, always start before the realisation of the occlusal boxes. The preparation by addition using composites present an esthetic and economic solution to the remodeling of the axial contour of the teeth. This promising technique has however no long term results.