[Lungs et diving]. / Poumons et plongée subaquatique.

Whilst underwater, the body is submitted to significant variations of the surrounding pressure according to the depth. These conditions modify the hemodynamic and the ventilatory mechanics considerably. Some repercussions, like pulmonary barotrauma, are related to simple physical phenomena. Others, like decompression sickness, are due to more com- plex processes. Breath-hold diving disrupts haematosis and can be complicated by alveolar haemorrhage and loss of consciousness. Acute pulmonary oedema during scuba-diving, breath-hold diving and swimming has been reported more recently. In case of pulmonary disorders scuba-diving is contraindicated most of the time. It is therefore highly recommended to seek medical advice to prevent problems.

[Redesigning Swiss ambulatory health care system]. / La PMU au carrefour des nouveaux chemins du système de santé.

Primary care medicine is first in line to meet the necessary changes in our health care system. Innovations in this field pursue three types of objectives: accessibility, quality and continuity of care. The Department of ambulatory care and community medicine of the University of Lausanne (Policlinique médicale universitaire) is committed to this path, emphasizing interprofessional collaboration. The doctor, nurse and medical assistant coordinate their activities to contribute efficiently to meet the needs of patients today and tomorrow. This paper also addresses how our department, as a public and academic institution, might play a major role as a health care network actor. A master degree dissertation in health management has started to identify the critical success factors and the strategic core competencies needed to achieve this development.

The use of dry powder inhaler devices by elderly patients suffering from chronic obstructive pulmonary disease.

UNLABELLED: Twenty-five COPD patients, aged 65years or above, were recruited to test their ability to use dry powder inhaler Handihaler (Boeringher-Ingelheim) and Aerolizer (Novartis). The results of a score created to evaluate the inhalation technique were compared with age, MMSE, Barthel Index, FEV(1), maximum inspiratory and expiratory pressures, and peak inspiratory flow (PIF). RESULTS: Dry powder inhalers were correctly used by 60% of the patients (15 out of 25). Among the capable ones, 13 out of 15 were aged less than 80 years (p< or =0.02), 13 out of 15 had a maximum inspiratory pressure greater or equal to 53cm H(2)O (p< or =0.001) and a PIF greater or equal to 120l/min (p< or =0.05). All skilled patients had a minimum MMSE of 25 (p< or =0.001). CONCLUSION: In a geriatric population, age, the decrease of maximum inspiratory pressure and PIF as well as cognitive functions, limit the use of dry powder inhalers.

[<< Torsade de pointe >> like EKG in a 88-year-old patient]. / Pseudotorsade de pointe chez une patiente âgée de 88 ans.

EKG may be difficult to perform in the elderly. Tremors may induce an EKG pattern suggestive of torsade de pointe. Unexpected good clinical tolerance and appropriate analysis of the EKG allow to correct the diagnosis.

[Pseudoachalasia due to amyloidosis treated by botulinum toxin]. / Pseudoachalasie liée à l'amylose traitée par toxine botulique.

INTRODUCTION: Pseudoachalasia mimics primary achalasia and can provoke serious complications in the elderly. CASE RECORD: A 84 years-old woman had dysphagia with recurrent pneumonia. Pseudoachalasia related to a multifocal primitive amyloidosis was diagnosed. Treatment with botulinum toxin injection during a gastric fibroscopy resulted in clinical improvement, still notable 15 months later. DISCUSSION: Botulinum toxin injection may be a useful tool in treatment of pseudoachalasia due to amyloidosis.

[Evaluation of the inspiratory muscle strength using the nasal pressure of the sniff]. / Evaluation de la force musculaire inspiratoire par la pression nasale lors du sniff.

The measurement of oesophageal pressure during maximal sniffs (Poes sniff) is useful to assess inspiratory muscle strength. The aim of this study was to develop a noninvasive test of inspiratory muscle strength based on the sniff manoeuvre. The sniff nasal inspiratory pressure (SNIP) was measured through a plug occluding one nostril during sniffs performed through the contralateral nostril. In 10 normal subjects and in 12 patients with neuromuscular or skeletal disorders, the SNIP reliably reflected the Poes sniff. Nasal mucosa congestion was induced in four normal subjects by nebulization of increasing doses of histamine. The SNIP accurately reflected Poes sniff when nasal congestion was moderate, but failed to do so when congestion was severe. Reference values of SNIP were established in a group of 160 healthy subjects aged 20-80 years. For both men and women, SNIP was negatively correlated with age, and was similar in the sitting and in the supine positions. SNIP was higher than maximal inspiratory pressure (P1 max) in most subjects, but the wide limits of agreement showed that these two methods are not interchangeable but complementary. The SNIP represents a useful noninvasive test of inspiratory muscle strength.

Sniff nasal inspiratory pressure. A noninvasive assessment of inspiratory muscle strength.

The measurement of esophageal pressure during maximal sniffs (sniff Pes) has been shown useful to assess inspiratory muscle strength. The aim of this study was to validate a noninvasive method for estimating sniff Pes. The sniff nasal inspiratory pressure (SNIP) was measured through a plug occluding one nostril during sniffs performed through the contralateral nostril. Sniff Pes was simultaneously measured with an esophageal balloon. Ten normal subjects performed 338 sniffs of variable intensity. The correlation coefficient of SNIP and sniff Pes was 0.99 +/- 0.01 (p < 0.001). The ratio SNIP/sniff Pes was 0.91 (range, 0.82 to 0.99) and the mean difference between the two measures (SNIP - sniff Pes) was -4.56 cm H2O (-1.2 to -8.6 cm H2O). Twelve patients with neuromuscular or skeletal disorders performed 181 maximal sniffs. The correlation coefficient of SNIP and sniff Pes was 0.96 +/- 0.04 (p < 0.001). The ratio SNIP/sniff Pes was 0.93 (0.77 to 1.07) and the mean difference (SNIP - sniff Pes) was -4.66 cm H2O (+0.47 to -14.26 cm H2O). Nasal mucosal congestion was induced by nebulization of increasing doses of histamine in four normal subjects. The ratio SNIP/sniff Pes was 0.93 (0.72 to 1.02) when nasal peak flow was > 100 L/min, and 0.49 (0.36 to 0.57 L/min) when nasal peak flow fell below 100 L/min. We conclude that SNIP provides a reliable and noninvasive estimation of sniff Pes in normal subjects and in patients with neuromuscular or skeletal disorders. The validity of this method may by impaired by severe nasal congestion.

Cyclosporin pharmacokinetics in heart-lung transplant recipients with cystic fibrosis. Effects of pancreatic enzymes and ranitidine.

Cyclosporin (CsA) is currently the main immunosuppressive agent used in organ transplantation with considerable improvement in graft survival. Oral CsA solution is highly lipophilic, and its bioavailability may be reduced in cystic fibrosis (CF) heart-lung transplant recipients with pancreatic, gastrointestinal, and hepatic insufficiency. The bioavailability of oral CsA solution in 7 CF transplant recipients (5 male and 2 female with a mean age of 27 years and a mean weight of 49 kg) and 3 non-CF heart-lung recipients (1 male and 2 female with a mean age of 41 years and a mean weight of 60 kg) was studied. Following intravenous CsA administration, the kinetic curves were similar with no significant difference in the volume of distribution and clearance of CsA demonstrated between the CF and non-CF groups. The mean daily dose of oral CsA in 7 CF subjects (23.3 mg.kg-1) was significantly higher than the 3 non-CF heart-lung recipients (4.8 mg.kg-1). The mean maximum blood concentration of CsA for the oral dose was 776 ng.ml-1 for the 7 CF subjects, which was comparable with the mean peak values of 789 ng.ml-1 for the 3 non-CF control subjects. Poor enteral absorption of CsA probably accounts for the significantly lower mean bioavailability in the 7 CF subjects (14.9%) compared with the 3 non-CF control subjects (39.4%). The effects on the bioavailability of oral CsA solution by pancreatic enzymes (Creon) and histamine-2 antagonist (ranitidine) were also evaluated in the 7 CF subjects. No significant difference was demonstrated.

[The pulmonary manifestations of diving accidents]. / Manifestations pulmonaires des accidents de plongée.

Scuba diving is associated with risks of drowning, lung barotrauma and decompression sickness. In case of near-drowning, irreversible neurologic lesions or death may follow an acute hypoxemia or a cardiopulmonary arrest. Therefore, victims of drowning should benefit from an immediate and prolonged cardiopulmonary resuscitation. Lung barotrauma are due to the failure of expanding lung gases to escape during ascent; they are likely to be complicated by arterial gas embolism. They can follow a panic ascent even from a shallow depth. Most of decompression procedures induce the formation of asymptomatic venous gas bubbles, normally filtrated and eliminated by the lungs. In case of massive intravenous bubbling, the filtering capacity of the lungs can be overwhelmed and the lung microcirculation damaged up to the point of provoking a cardio-respiratory failure.

[Neuroradiological studies in diving accidents]. / Investigations neuroradiologiques dans les accidents de plongée.

In case of a type II decompression sickness (with cerebrospinal injury), the decision on how to structure a prompt hyperbaric treatment rests on an anamnesis and the clinical investigation. In looking for an associated contingent barotrauma, one has to be satisfied with an X-ray of thorax and abdomen. The myelopathy which results from a decompression mishap with medullary involvement forms a very peculiar clinical entity defined by a fascicular injury at several levels. For several years now, clinical radiologists resort to a new medical imaging technique: Nuclear Magnetic Resonance (NMR-)Imaging. For the first time, this technique allows the imaging of intramedullary lesions due to a decompression accident. Other neuroradiological investigations (such as myelography, spinal tomodensitometry, medullary angiography, isotopic tests) are without merit for evaluating decompression accidents with medullary involvement. NMR-Imaging has the potential too, of revealing ischemic cerebral injuries, even if the clinical brain impairment is often silent and therefore overlooked. The role of NMR-Imaging for evaluating cerebrospinal aspect of decompression accidents is not yet finalized. However, NMR-Imaging will give without any doubt a boost to the pathophysiological knowledge of decompression mishaps.

[Heart-lung transplantation, single lung and both lungs]. / La transplantation coeur-poumons, unipulmonaire et bipulmonaire.

Following the improvement in surgical techniques and immunosuppression regimens as well as a better selection of recipients, an increasing number of heart-lung, single lung and double lung transplantations have been performed within the last decade. In the early stages, most candidates had advanced pulmonary hypertension. More recently, patients with end-stage lung disease have been successfully transplanted. Providing the allografts remain free of complications, long-term survivors may benefit of well preserved pulmonary function. However, acute rejection, obliterative bronchiolitis and infections are still a major cause of morbidity and mortality.

[Scuba diving: barotrauma, decompression sickness, pulmonary contra-indications]. / Plongée subaquatique: barotraumatismes, maladie de décompression, contre-indications pulmonaires.

The practice of scuba diving is associated with two specific medical problems: barotrauma directly related to changes in ambient pressure, and decompression sickness related to the uptake and the release of inert gases by the body. Neurological symptoms are frequent in severe diving accidents. They may arise following either barotrauma or decompression sickness, and often require urgent treatment in a hyperbaric chamber. Asthma, chronic obstructive pulmonary disease, and spontaneous pneumothorax increase the risk of lung barotrauma and represent contraindications to diving.