Impact of biomass fuel smoke on respiratory health of children under 15 years old in Madagascar.

BACKGROUND: Children exposed to biomass used in households are at risk to develop diseases or respiratory symptoms. In Madagascar more than 95% of households use it daily. The main objective is to study the impact of chronic exposure to biomass on respiratory health of children under 15 years old in Madagascar. METHODS: Descriptive cross-sectional study conducted with questionnaires among urban and rural population of Antananarivo and Mahajanga provinces between 2016 and 2017. Variables were collected: number of hours spent in kitchen per day, respiratory symptoms and spirometric data. Categorized symptoms score and exposure index expressing chronic exposure to biomass were analyzed with multinomial logistic regression models. RESULTS: Of the 661 children included in the analysis, 27.7% had 1 respiratory symptom and 29.3% had 2 or more respiratory symptoms. Moderate exposure index (aOR=1.57; CI95%=[1.30-1.89]; p<0.001) and high exposure index (aOR=1.76; CI95%=[1.39-2.24]; p<0.001) were significantly associated with 1 respiratory symptom, adjusted with provinces, household members and visitors smoking, perceived discomfort related to air pollution and birthweight. Exposure index was not significantly associated with an increased risk of having 2 or more respiratory symptoms (p = 0.754). CONCLUSION: Respiratory symptoms were associated with exposure to biomass, living in coastal areas, birthweight, tobacco and perceived discomfort related to air pollution. Recommendations and actions must be implemented in order to improve respiratory health related to biomass among children.

New insights and improved strategies for the management of primary spontaneous pneumothorax.

The pathophysiology and management of primary spontaneous pneumothorax (PSP) are a subject of debate. Despite advances in the understanding of its etiopathogenesis and improvements in its management, implementation in clinical practice is suboptimal. In this manuscript, we review the recent literature with a focus on PSP pathophysiology and management. Blebs and emphysema-like changes (ELC) are thought to contribute to the pathophysiology of PSP but cannot explain all cases. Recent studies emphasize the role of a diffuse porosity of the visceral pleura. Others found a relationship between smoking, occurrence of a PSP and bronchiolitis, which could be the initial pathological process leading to ELC development. Recent or ongoing studies challenge the need to systematically remove air from the pleural cavity of stable patients, introducing conservative management as a valuable therapeutic option. Evidence is growing in favour of needle aspiration instead of chest tube insertion, when air evacuation is needed. In addition, ambulatory management is considered as a successful approach in meta-analyses and is under exploration in a large randomized study. Because of a high recurrence rate of PSP, the benefit of performing a pleurodesis at first occurrence is under evaluation with interesting but not generalizable results. Better identification of 'at risk patients' is needed to improve the investigation strategy. Finally, recent publications confirm the efficacy, security and cost-effectiveness of graded talc poudrage pleurodesis to prevent PSP recurrence. In conclusion, PSP pathophysiology and management are still under investigation. The results of recently published and ongoing studies should be more widely implemented in clinical practice.

Feasibility, acceptability and effectiveness of integrated care for COPD patients: a mixed methods evaluation of a pilot community-based programme.

QUESTION UNDER STUDY: The aim of this study was to assess the feasibility, acceptability and effectiveness of a pilot COPD integrated care programme implemented in Valais, Switzerland. METHODS: The programme was adapted from the self-management programme Living Well with COPD, and included the following elements: self-management patient-education group sessions, telephone and medical follow-ups, multidisciplinary teams, training of healthcare professionals, and evidence-based COPD care. A process and outcome evaluation of the pilot phase of the programme was conducted by means of qualitative and quantitative methods. Reach (coverage, participation rates), dosage (interventions carried out), fidelity (delivered as intended) and stakeholders' acceptance of the programme were evaluated through data monitoring and conduct of focus groups with patients and healthcare professionals. Effectiveness was assessed with pre-post analyses (before and after the intervention). The primary outcome measures were; (1) generic and disease-specific quality of life (36-Item Short Form Health Survey, Chronic Respiratory Questionnaire); and (2) hospitalisations (all-cause and for acute exacerbations) in the past 12 months. Secondary outcomes included self-efficacy, number of exacerbations and exercise capacity. Finally, controlled pre-post comparisons were also made with patients from the Swiss COPD Cohort for three common outcome measures (dyspnoea [mMRC score], number of exacerbations and smoking status). RESULTS: During the first 2 years of the programme, eight series of group-based education sessions were delivered to 57 patients with COPD in three different locations of the canton of Valais. Coverage objectives were achieved and attendance rate at the education sessions was high (83.6%). Patients' and healthcare professionals' reported a high degree of satisfaction, except for multidisciplinarity and transfer of information. Exploration of the effectiveness of this pilot programme suggested positive pre-post results at 12 months, with improvements in terms of health-related quality of life, self-efficacy, exercise capacity, immunisation coverage and Patient Assessment of Chronic Illness Care score. No other outcome, including the number of hospital admissions, differed significantly after 12 months. We observed no differences from the control group. CONCLUSIONS: The evaluation demonstrated the feasibility and acceptability of the programme and confirmed the relevance of mixed method process evaluation to adjust and improve programme implementation. The introduction of multidisciplinary teams in a context characterised by fragmentation of care was identified as the main challenge in the programme implementation and could not be achieved as expected. Despite this area for improvement, patients' feedback and early effectiveness results confirmed the benefits of COPD integrated care programmes emphasising self-management education.

Factors associated with cessation of smoking among Swiss adults between 1991 and 2011: results from the SAPALDIA cohort.

INTRODUCTION: Smoking is still the most preventable cause of disease and premature death in Switzerland, as elsewhere. We aimed to assess the main determinants of smoking cessation in the population-based cohort of SAPALDIA (Swiss Cohort Study on Air Pollution and Lung and Heart Diseases in Adults). METHODS: The SAPALDIA study was initiated in 1991 with 9651 participants aged 18 to 60 years from eight areas (S1). Follow-up assessments were conducted in 2002 (S2; 8047 participants) and 2010/11 (S3; 6088 participants). At each survey, detailed information on health and potential health-related factors was collected and lung function measured. Using logistic regression, we assessed predictors of smoking cessation between S1 and S2 and between S2 and S3. RESULTS: In both periods, highest educational level (summary odds ratio [OR] 1.49, 95% confidence interval [CI] 1.08-2.06; ref. lowest level), FEV1/FVC <0.5 (OR 6.19, 95% CI 2.44-15.7, ref. FEV1/FVC ≥0.7), higher age in men (OR 1.02, 95% CI 1.01-1.03, per year) and overweight (OR 1.38, 95% CI 1.16-1.64) were significant predictors of smoking cessation. Nicotine dependence (OR 0.97, 95% CI 0.96-0.98, per cigarette smoked a day) and female sex between age 45 and 60 (e.g., OR 0.74, 95% CI 0.61-0.91, at age 50) were negatively associated with smoking cessation. Moreover, smokers at S2 reporting a diagnosis of depression were less likely to quit smoking by S3 (OR 0.53, 95% CI 0.30-0.93). CONCLUSIONS: Prospective tobacco control policies in Switzerland should be addressed to women, younger persons and persons of lower education.

Spontaneous pneumothorax: time to rethink management?

There are substantial differences in international guidelines for the management of pneumothorax and much geographical variation in clinical practice. These discrepancies have, in part, been driven by a paucity of high-quality evidence. Advances in diagnostic techniques have increasingly allowed the identification of lung abnormalities in patients previously labelled as having primary spontaneous pneumothorax, a group in whom recommended management differs from those with clinically apparent lung disease. Pathophysiological mechanisms underlying pneumothorax are now better understood and this may have implications for clinical management. Risk stratification of patients at baseline could help to identify subgroups at higher risk of recurrent pneumothorax who would benefit from early intervention to prevent recurrence. Further research into the roles of conservative management, Heimlich valves, digital air-leak monitoring, and pleurodesis at first presentation might lead to an increase in their use in the future.

ERS task force statement: diagnosis and treatment of primary spontaneous pneumothorax.

Primary spontaneous pneumothorax (PSP) affects young healthy people with a significant recurrence rate. Recent advances in treatment have been variably implemented in clinical practice. This statement reviews the latest developments and concepts to improve clinical management and stimulate further research.The European Respiratory Society's Scientific Committee established a multidisciplinary team of pulmonologists and surgeons to produce a comprehensive review of available scientific evidence.Smoking remains the main risk factor of PSP. Routine smoking cessation is advised. More prospective data are required to better define the PSP population and incidence of recurrence. In first episodes of PSP, treatment approach is driven by symptoms rather than PSP size. The role of bullae rupture as the cause of air leakage remains unclear, implying that any treatment of PSP recurrence includes pleurodesis. Talc poudrage pleurodesis by thoracoscopy is safe, provided calibrated talc is available. Video-assisted thoracic surgery is preferred to thoracotomy as a surgical approach.In first episodes of PSP, aspiration is required only in symptomatic patients. After a persistent or recurrent PSP, definitive treatment including pleurodesis is undertaken. Future randomised controlled trials comparing different strategies are required.

Spirometer Replacement and Serial Lung Function Measurements in Population Studies: Results From the SAPALDIA Study.

The Swiss Cohort Study on Air Pollution and Lung and Heart Disease in Adults (SAPALDIA), a population cohort study, used heated-wire spirometers in 1991 and 2002 and then ultrasonic spirometers in 2010 revealing measurement bias in healthy never smokers. To provide a practical method to control for measurement bias given the replacement of spirometer in long-term population studies, we built spirometer-specific reference equations from healthy never smokers participating in 1991, 2002, and 2010 to derive individualized corrections terms. We compared yearly lung function decline without corrections terms with fixed terms that were obtained from a quasi-experimental study and individualized terms. Compared with baseline reference equations, spirometer-specific reference equations predicted lower lung function. The mean measurement bias increased with age and height. The decline in forced expiratory volume in 1 second during the reference period of 1991-2002 was 31.5 (standard deviation (SD), 28.7) mL/year while, after spirometer replacement, uncorrected, corrected by fixed term, and individualized term, the declines were 47.0 (SD, 30.1), 40.4 (SD, 30.1), and 30.4 (SD, 29.9) mL/year, respectively. In healthy never smokers, ultrasonic spirometers record lower lung function values than heated-wire spirometers. This measurement bias is sizeable enough to be relevant for researchers and clinicians. Future reference equations should account for not only anthropometric variables but also spirometer type. We provide a novel method to address spirometer replacement in cohort studies.

Serum bilirubin is associated with lung function in a Swiss general population sample.

Bilirubin is a strong antioxidant. Increased serum levels have been associated with lower respiratory disease and mortality risk. We studied the association of bilirubin with lung function in the Swiss study on Air Pollution and Lung Disease in adults (SAPALDIA) cohort. Associations between natural logarithmised bilirubin and forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), FEV1/FVC and mean forced expiratory flow between 25%-75% of FVC (FEF25-75%) were tested using multiple linear regression in the whole study population (n=4195) and strata of ever-smoking and high body mass index (BMI, defined by the highest distribution quartile). Associations were retested with single nucleotide polymorphism rs6742078, a genetic determinant of bilirubin. High bilirubin levels were significantly associated with higher FEV1/FVC and FEF25-75% overall. Upon stratification, significant associations persisted in ever-smokers, amounting to 1.1% (95% CI 0.1-2.2%) increase in FEV1/FVC, and 116.2 mL·s(-1) (95% CI -15.9-248.4 mL·s(-1)) in FEF25-75% per interquartile range of bilirubin exposure in smokers with high BMI. Associations were positive but nonsignificant in never-smokers with high BMI. Similarly, rs6742078 genotype TT was associated with increased FEV1/FVC and FEF25-75%. Our results suggest a possible protective role of bilirubin on lung tissue, which could be important for prevention and therapy.

Primary malignant achromic melanoma of the lung.

Currently, less than thirty cases of primary malignant melanoma of the lung have been reported in the literature. Thus, strict criteria for diagnosis have been published and include: malignant melanoma associated with bronchial epithelial changes; a solitary lung tumor; no prior history of skin, mucous membrane, intestinal or ocular melanoma; and absence of any other detectable tumor at the time of diagnosis. In this article we present a case of melanoma of the lung without evidence of extra-pulmonary disease.

[Alveolar proteinosis: a cause of immunodeficiency]. / Protéinose alvéolaire: une maladie fascinante et un facteur d'immunosuppression peu connu.

Alveolar proteinosis is a rare disease, characterized by accumulation of surfactant in alveoli. Various forms have been identified (congenital, secondary or auto-immune). Treatment is to be reserved for patients that experience moderate to severe symptoms. It requires whole lung lavages, in order to clear the alveoli from the proteinaceous material. Macrophages dysfunction plays a crucial role in the development of the disease and causes immunodeficiency, which in turn can promote opportunistic infections, in patients a priori thought to be immunocompetent.

Primary spontaneous pneumothorax: a diffuse disease of the pleura.

Primary spontaneous pneumothorax (PSP) is by definition not associated with any underlying lung disease. However, this does not mean that there is no underlying pathological process. It has become increasingly apparent over recent years that PSP is associated with diffuse and often bilateral abnormalities within the pleura and is not simply a disease caused by ruptured blebs/bullae. The pathological process includes emphysema-like changes, pleural porosity and inflammation. In this review, we summarise the recent advances in our understanding of the pathogenesis of PSP and discuss how this relates to management strategies for patients with PSP.

Titrated sedation with propofol for medical thoracoscopy: a feasibility and safety study.

BACKGROUND: Bispectral index (BIS) is a valuable tool for assessing the depth of sedation and guiding the administration of sedative drugs. We previously demonstrated the benefits of BIS-guided propofol sedation in patients undergoing flexible bronchoscopy. OBJECTIVE: To examine the feasibility and safety profile of propofol sedation in patients undergoing medical thoracoscopy (MT). METHODS: Patients undergoing MT for diagnostic evaluation or treatment of pleuropulmonary diseases were enrolled over a 2-year period. Nurses and chest physicians were trained by anesthetists to provide analgosedation, to detect and correct cardiopulmonary disturbances. The level of sedation was optimized individually by titrating the propofol infusion according to the BIS and clinical evaluation. Patients' clinical data, procedure time, medications and any adverse events were recorded. RESULTS: Fifty-three patients (60% male) with a median age of 62 years (range 19-84 years) underwent MT. The operative procedure lasted a median time of 28 min (range 9-112 min). The median doses of anesthetic drugs were 145 mg of propofol (range 20-410 mg) and 84 µg of fentanyl (range 0-225 µg). Hemodynamic disturbances occurred in 39 patients (bradycardia n = 4, tachycardia n = 12, hypotension n = 34) and required drug administration in only 4 cases. Hypoxemic events (n = 4) resolved upon gentle patient stimulation (verbal command, chin lift, oral cannula). All patients could be discharged from the recovery unit within 105 min after the procedure. CONCLUSIONS: BIS-guided propofol sedation is a safe method that might replace midazolam sedation in MT and can be managed by well-trained nonanesthesiologist personnel.

[Health promotion from the 20th to the 21th century. The Valais Ligue for fighting tuberculosis--a visionary model started in 1951]. / Promotion de la santé du XXe au XXIe siècle. La Ligue valaisanne pour la lutte contre la tuberculose, un modèle visionnaire en 1951 déjà.

At the beginning of the twentieth century, tuberculosis was really a plague. Many people had been mobilised to successfully fight against this infectious disease. Valais, a Swiss alpine canton developped then an original concept of health promotion by involving all the health partners including a specialised hospital under the auspices of the local Health Departement. Such a model named then Ligue pulmonaire contre la tuberculose, celebrates his 60th anniversary. Its present name is Valais Health Promotion, i.e., a proactive health network very unique in Switzerland. It assumes many tasks of public health in clinical as well as in preventive medicine. These two components strongly facilitate the insertion of this organisation into the reality of this population to fulfil many challenging tasks with efficacy.

[Medical thoracoscopy]. / Thoracoscopie médicale.

Medical thoracoscopy (MT) remains a mini-invasive and very efficient technique to diagnose pleural diseases. In case of pleural effusion of unknown etiology its diagnostic yield is higher than 90%. MT also allows to perform cheap and successful pleurodesis by simple talc insufflation in case of recurring pneumothorax and invalidating malignant pleural effusion with very poor quality of life despite repeated thoracocentes.