The management of terminal illness: opinions of the medical and nursing staff in a Paris University Hospital.

The views of French physicians and nurses of the organization of palliative care have not been previously analyzed. We surveyed opinion on the care of the terminally ill in a 1,000-bed Paris university hospital. Data were obtained in 1992 by non-directed interviews of leading physicians and semi-directed interviews of nurses. Most physicians wished to managed terminal care in their departments. Patients and family preferences were considered in choosing the place for care. Treatment of hospitalized patients should be limited to relieving symptoms. Department heads and senior nurses agreed on most problems encountered in the management of care. The psychological burden borne by nurses was emphasized. Terminal care training and the possibility of consulting experts in palliative care were the main suggestions for improvement cited by both department heads and senior nurses. Integrating this knowledge into the planning process should result in improved care and in increased satisfaction for the care providers.

[Left single-lung allotransplantation with or without bronchial artery revascularization in pigs. Development of a model with a five-week survival]. / Allo-transplantation uni-pulmonaire gauche avec ou sans revascularisation artérielle bronchique chez le porc. Mise au point du modèle avec survie à cinq semaines.

After lung transplantation, immunological mechanisms are easier to understand if the pathologist can examine larger pieces of tissues than those obtained by endoscopic biopsies. The purpose of this study was to test the experimental left-lung transplantation in the pig, performed with or without bronchial arterial revascularization and with a survival of 5 weeks. Three animals were only thoracotomised (sham-operated), ten were allotransplanted without and nine with- bronchial arterial revascularization. To optimize survival several clinical and paraclinical parameters were used: laboratory, immunological, endoscopic and flowmetric examinations. Seven of the nineteen transplanted animals survived until the fifth week. Long-term survival is possible and depends mainly on the development of pulmonary sepsis. We observed an increase of the pulmonary vascular resistances and pressures in the allo-transplanted animals. In these animals, histologic examination showed lymphoplasmocytic infiltration in the interalveolar walls and the number of ciliated epithelial cells decreased on the main and lobar bronchi. Our observations suggest that CD8 lymphocytic infiltration is predominant on the bronchi after transplantation and that rejection may occur in the pig. Class 2 DR Swine Leukocyte Antigen does not seem to be expressed on the bronchi in the allo-transplanted pig after 5 weeks. Finally, it is very difficult to demonstrate the patency of bronchial arterial grafts after 5 weeks and therefore to prove the influence of revascularization.

Nasal mucociliary transport in healthy subjects is slower when breathing dry air.

We assessed the effect of dry air (DA) nasal breathing on nasal clearance rate in healthy nonsmoking subjects. We measured saccharin nasal transit time (SNTT), an index of mucociliary clearance rate, in eleven normal subjects (six males, five females) breathing either room air (RA) or DA through the nose in random order on six different study days. On each study day, the trial was conducted at the same time, in the same nostril, using a patent airway. DA was breathed through a light-weight, tight-fitting, nasal mask (SEFAM, France) for 30 min and SNTT was then measured immediately. Saccharin (250 micrograms) was deposited on the anterior part of the inferior turbinate under visual control and saliva was swallowed every 30 s thereafter. SNTT was the time elapsed between deposition and first perception of saccharin taste. The group-average SNTT on DA was 18.5 +/- 8.6 min which was significantly longer than on RA (11.9 +/- 5.3 min). Our findings suggest that dry air breathing results in excessive water loss by the nasal mucosa, which may in turn reduce nasal mucociliary clearance rate through changes in the rheological properties or adhesiveness of nasal mucus and/or slowing of ciliary beating.

[Behavioral disorders secondary to benzodiazepine therapy]. / Troubles comportementaux secondaires à la prise de benzodiazépines.

This report adds three cases to those previously published of paradoxical reactions to benzodiazepines. The clinical syndrome, more or less complete, is fairly stereotyped, with behavioural disorders, tendency to feelings of hostility and aggressiveness and total anterograde amnesia. Personal and environmental factors seem to play a prominent role in its development. The classical contra-indication of benzodiazepines following such reactions is discussed, and the hypothesis that mamillary-thalamic benzodiazepine receptors play a part in their genesis is envisaged.

Hemodynamic factors influencing arterial hypoxemia in massive pulmonary embolism with circulatory failure.

Arterial hypoxemia is a common finding in acute pulmonary embolism, and its severity is generally assumed to be proportional to the extent of pulmonary artery obstruction. We studied blood gases (during room air breathing and 100% oxygen breathing) and hemodynamic data is seven patients with massive pulmonary embolism and circulatory failure. All measurements were made before and 30 minutes after medical therapy of shock. We observed that a low cardiac output state can result in a misleading improvement in arterial oxygenation during massive pulmonary embolism, and that an improved circulatory status resulting from medical therapy (including inotropic drug infusion with or without blood volume expansion) can paradoxically increase arterial hypoxemia. We conclude that severity of arterial hypoxemia may not reflect the severity of pulmonary artery obstruction in acute pulmonary embolism if shock is present.

Immediate and middle-term cardiorespiratory effects of positive end-expiratory pressure in thirteen cases of non-haemodynamic pulmonary oedema.

Thirteen patients with severe acute respiratory failure were ventilated with positive end-expiratory pressure (PEEP) for 9 days. Haemodynamic measurements were performed after 15 min during 100% oxygen breathing, first with intermittent-positive pressure ventilation, secondly with positive end-expiratory pressure. The latter improved the Pa, O2 from 89 to 150 torr, decreased the QS/QT from 43% to 32% and decreased the Pa, CO2 from 37 to 34 torr; this improvement in gas exchange was accompanied by a decrease in cardiac index from 4.4 to 3.7 1 min-1m-2 without changing the systemic arterial pressure. Despite this beneficial effect on arterial blood oxygenation, it did not improve the survival rate of patients with severe acute respiratory failure.