Increased Rheumatoid Factor production in patients with severe COVID-19.

BACKGROUND: Searching for Rheumatoid Factors (RF) in patients with coronavirus disease (COVID-19) has rarely been described. OBJECTIVES: To investigate the association between RF isotypes (IgM, IgA, and IgG) and different clinical presentations of COVID-19 in a series of Tunisian patients. STUDY DESIGN: Eighty-two COVID-19 patients were enrolled in this study. Symptomatic cases were recruited from the Department of COVID-19 and the intensive care unit (ICU) of the University Hospital of Mahdia, Tunisia, from January 2021 to March 2021. Different RF isotypes were assessed using a commercial enzyme-linked immunosorbent assay (ELISA). RESULTS: Forty-one patients (50%) had RF of any isotype. Thirty-two patients (39%) were tested positive for RF-IgM. Symptomatic forms of the disease were associated with RF-IgM positivity (p = 0.005). The mean concentration of RF-IgM was higher in the severe form than in the moderate and asymptomatic forms (p = 0.006). CONCLUSIONS: Our study suggests that the production of RF-IgM isotype is increased in patients with severe COVID-19.

[Prognostic factors in idiopathic pulmonary fibrosis in a tunisian cohort]. / Facteurs pronostiques au cours de la fibrose pulmonaire idiopathique : étude d'une cohorte tunisienne.

We present data on prognostic factors in a Tunisian cohort of people with Idiopathic pulmonary fibrosis. INTRODUCTION: Idiopathic pulmonary fibrosis (IPF) has a poor prognosis, with a median survival in patients with the condition of only 3 to 5 years. Previous studies have identified a number of prognostic factors in this chronic pulmonary disease. METHODS: We conducted a retrospective study, including patients with idiopathic pulmonary fibrosis (IPF) who were diagnosed at the Pneumology Department of the University Hospital Fattouma-Bourguiba, Monastir, between 1991 and 2014. The aim of this study was to compare clinical, radiological, pulmonary functional predictors of survival in IPF in a Tunisian cohort with those of previous studies. RESULTS: This study included 126 patients. Their mean age was 66 years, with a male predominance (68.3%). Respiratory function tests revealed a restrictive ventilatory deficit in 72.6% of cases. The median survival of our study population was 22.5 months [6.7-49.5]. In univariate analysis, factors associated with a poor prognosis were: lower baseline values of TLC, FCV and DLco, level of dyspnea assessed by mMRC scale, hypoxemia at diagnosis, the degree of desaturation during exercise, a higher annual decline of FVC and DLco, acute respiratory distress and also the GAP score. In multivariate analysis, independent prognostic factors were: baseline DLco, level of dyspnea, desaturation at exertion and the annual decline of the DLco. CONCLUSION: Lower baseline DLco, the level of dyspnea, desaturation on exercise, and annual decline in DLco are all associated with a poor prognosis in IPF.

[Contribution of high fidelity simulation to training in respiratory medicine]. / Apport de l'apprentissage par la simulation dans l'enseignement de la pneumologie.

INTRODUCTION: Simulation maintains patient safety by limiting the risk of errors. In the medical field, simulation is a method of learning that is developing more and more in the acute specialties but it is still not widespread in the field of respiratory medicine. OBJECTIVE: To evaluate the efficacy of high fidelity simulation as a teaching tool in respiratory medicine. METHODS AND POPULATION STUDIED: This was a prospective and descriptive study including students who had high fidelity simulation training sessions during their traineeship in respiratory medicine. Simulation learning took the form of four teaching sessions. The included students were assessed at the beginning and end of each session by a pre-test and post-test. Student satisfaction was assessed at the end of each session. RESULTS: Comparing the average student score before and after the simulation session showed an improvement in post-test scores. This improvement was statistically significant for all four scenarios. The majority of students, 60% (N=13), were satisfied with the progress of their internship in the Respiratory Department. CONCLUSION: High fidelity simulation is a teaching method that allows the acquisition and/or optimization of several skills. Nevertheless, this method remains undeveloped in respiratory medicine.

[Asthma control and quality of life]. / Contrôle de l'asthme et qualité de vie.

INTRODUCTION: The assessment of asthma control is based on objective measures: clinical, pharmacological and spirometry. However subjective component may be also necessary for assessing asthma control. OBJECTIVES: To study the feasibility and clinical value of the assessment of the quality of life of patients with asthma by the SF-36 (Medical Outcomes Study Short Form) and the possible existence of a correlation between controlled asthma and a better quality of life. PATIENTS AND METHODS: A prospective study that included 167 patients with asthma in a stable condition. Control of asthma and SF-36 were established three months after the inclusion of patients. RESULTS: The SF-36 was lower in the uncontrolled group in all areas of the physical component and the difference was significant in the "limitation related to physical activity" and "perceived health". In the mental component, the score was lower in "mental health" and the "limitation due to mental state" in the group with uncontrolled asthma and the difference was significant only in the limitation due to mental state (P=0.043). CONCLUSION: The quality of life of asthmatic patients is correlated to the control of this disease.

[COPD characteristics in subjects carrying the rare alpha-1 antitrypsin variant PIMMmalton]. / Aspects de la BPCO chez les porteurs de la mutation déficitaire rare de l'alpha-1 antitrypsine PIMMmalton.

INTRODUCTION: Several studies have investigated the clinical feature of COPD in subjects carrying the common alpha-1 antitrypsin deficiency mutations PIS and PIZ. However, there are few data on COPD due to rarer deficient variants. In this study, we aimed to explore the features of COPD in subjects carrying the PIMMmalton mutation, which is the most prevalent alpha-1 antitrypsin variant in Tunisia. MATERIAL AND METHODS: Five individuals, heterozygous for PIMMmalton were analyzed and compared to 97 non-deficient COPD patients. Demographic data as well as clinical and functional outcomes from subjects were collected. Blood gases and plasma alpha-1 antitrypsin levels were recorded. RESULTS: PIMMmalton subjects did not show any significant difference in terms of predicted FEV1 (35±13.2%), predicted forced vital capacity (34.2±9.6%) and FEV1 decline (148.6±114mL/year) compared to usual COPD patients (respectively 41.7±17.2%, P=0.500; 43.8±18.8%, P=0.300; 197.9±191mL/year, P=0.800). However, PaO2 was significantly reduced in PIMMmalton subjects (58.8±4.0mmHg) compared to usual COPD (69.9±10.6mmHg; P=0.029) and those patients with chronic bronchitis and centrolobular emphysema (71.0±10.9mmHg; P=0.038). CONCLUSION: PIMMmalton subjects were significantly hypoxic, similar to that observed in PiZZ homozygous rather than observed in heterozygous individuals.

[Obesity and the severity of asthma crisis]. / Obésité et sévérité de la crise d'asthme.

INTRODUCTION: Obesity is associated with inflammatory processes, which could influence the airway inflammation that is found in patients with asthma. Obesity may thus have a role in the development of asthma. However, the role of obesity in the severity of acute asthma has not been well described. PATIENTS AND METHODS: We performed a retrospective study, which included 77 patients hospitalized for acute asthma. Two groups of patients were formed according to their body mass index (BMI): group 1 consisting of 59 patients with a BMI inferior to 30 kg/m(2) and group 2 consisting of 18 patients with a BMI superior or equal to 30 kg/m(2). These two groups were compared according to demographic factors, clinical features and the spirometric severity of asthma. RESULTS: The mean age was 43 ± 17.4 years with a sex-ratio 0.57 (28 men/49 women). Thirty-one percent of these patients had a severe asthma attack requiring hospitalization in intensive care in four patients with the use of mechanical ventilation in two patients. The comparison between obese and non-obese patients did not show a significant difference in the severity of asthma. CONCLUSION: Although a contribution of obesity to the manifestation and severity of asthma is commonly recognized, the present data to not confirm the impact of obesity on the severity of acute attacks.

[Anxiety-depressive disorders and bronchiectasis]. / Troubles anxiodépressifs et dilatation des bronches.

INTRODUCTION: Bronchiectasis is a chronic lung disease that may be associated with anxiety-depressive disorders affecting the quality of life of patients. Detecting these anxiety-depressive disorders may be necessary in the support and overall management of a patient with bronchiectasis. AIMS: To evaluate the prevalence of anxiety and depression in patients with bronchiectasis and to investigate the possible correlation between the severity of the disease and the importance of these psychological disorders. PATIENTS AND METHODS: This was a prospective study that included 53 patients with stable bronchiectasis and without other comorbidities. All the patients underwent a complete clinical examination, spirometry and chest computed tomography. All the 53 patients responded to the Hospital Anxiety and Depression Scale (HAD) questionnaire. RESULTS: Anxiety was present in 22.7% of patients and depression in 20.8%. Subjects who had an anxiety disorder had symptoms primarily of dyspnoea (P=0.001), a low FEV (P=0.04) and respiratory failure at a stage requiring home oxygen therapy (P=0.009). A similar comparison of patients with and without depressive disorder again found a high prevalence of dyspnea (P=0.003), a low FEV (P=0.04), and chronic respiratory failure in the depressive patients. CONCLUSION: Symptoms of depression and anxiety are common in patients with bronchiectasis and appear to be associated with dyspnoea. Early detection is necessary in the context of the overall management of these patients.

[Right upper lobe pulmonary agenesis]. / Agénésie pulmonaire lobaire supérieure droite.

INTRODUCTION: Pulmonary agenesis is a rare congenital anomaly. Other cardiovascular, gastrointestinal, musculoskeletal, and urogenital system anomalies can be observed in association with it. CASE REPORT: A 24-year-old female patient presented to our clinic with a history of cough and chest pain with an abnormal chest X-ray. Physical examination was normal. Chest X-ray, CT-Scan and endoscopy led to the diagnosis of right upper lobe pulmonary agenesis. CONCLUSION: The diagnosis of pulmonary malformations like agenesis or hypoplasia can be delayed and may not occur until adulthood. Once the diagnosis has been established medical follow up is mandatory.

[Smoking habits and severity of obstructive sleep apnea hypopnea syndrome]. / Tabagisme et sévérité du syndrome d'apnées hypopnées obstructives du sommeil.

INTRODUCTION: Smoking habits have many adverse health effects. The effect of tobacco on obstructive sleep apnea hypopnea syndrome is well-documented but the effect on the severity of this syndrome has not been completely established. AIM OF THIS STUDY: Evaluate the effect of tobacco on the severity of sleep apnea hypopnea syndrome. PATIENTS AND METHODS: During 4 years 307, patients were referred to our department for a suspicion of obstructive sleep apnea hypopnea syndrome. Among these patients, only 151 patients had an obstructive sleep apnea syndrome confirmed by nocturnal polygraph. Smoking status, clinical and spirometric data were determined in these 151 patients. RESULTS: Among these 151 patients, 101 were non-smokers and 50 current smokers. The apnea and hypopnea index (AHI) were higher among current smokers than non-smokers (42.96/h versus 28.77/h; P<0.0001). The percent of patients who had a not severe obstructive sleep apnea syndrome were higher among non-smokers than current smokers patients (P=0.009). Current smokers were 3.7 times more likely having severe obstructive sleep apnea hypopnea syndrome than non-smokers (OR=3.7; P=0.001). CONCLUSION: Smoking habits seems to be associated with the severity of obstructive sleep apnea syndrome that's why smoking cessation is very important in the treatment of obstructive sleep apnea hypopnea syndrome.

[Unusual alveolar proteinosis]. / Protéinose alvéolaire atypique.

Pulmonary alveolar proteinosis (PAP), a rare infiltrative disease of unknown aetiology, is characterized by an accumulation of abnormal lung surfactant in the alveoli. The diagnosis is based on the results of the bronchoalveolar lavage (BAL) and sometimes on the lung biopsy. The authors report the case of a 49-year-old woman who was hospitalized for chronic expectoration of the membranes. The chest X-ray revealed alveolar opacities in the lowest part of the right lung. The chest CT scan detected alveolar ground glass opacities with interlobular thickening involving the middle lobe. The BAL was opaque with periodic acid-Schiff stain-positive acellular material. The anatomopathology analysis of the membranes concludes as to the presence of granular eosinophilic material and the absence of neoplasic cells or hydatidous membranes. The diagnosis of PAP was established. Since functional deterioration was not detected, therapy was based on physiotherapy alone. The evolution was favourable, with the disappearance of the symptomatology and the normalisation of the chest X-ray. This observation shows an unusual presentation of PAP based on membrane expectoration and unusual localized lesions.

[An unusual association: tracheobronchomegaly with a normal pulmonary function test]. / Trachéobronchomégalie avec exploration fonctionnelle respiratoire normale: une association rare.

Tracheobronchomegaly is a rare condition characterised by marked dilation of the trachea and the main bronchi. The clinical presentation of this disease is nonspecific and the diagnosis is based on the radiological features, especially computed tomography of chest. Pulmonary function tests are often abnormal showing airflow limitation with increased residual volume. The authors report a rare case of a 31-year-old man presenting tracheobronchomegaly is normal pulmonary function test.

[Submaximal exercise capacity and quality of life in exclusive water-pipe smokers]. / Aptitude aérobie sous-maximale et qualité de vie des fumeurs exclusifs de narguilé

BACKGROUND: It is well known that oxidative stress is increased significantly by regular water-pipe smoking (WPS). This could lead to muscle dysfunction and thus to impairments of exercise and quality of life (QOL). Considering the impressive number of WP smokers, we intend to investigate the potential effect of WPS on submaximal exercise capacity and QOL. AIMS: (1). To evaluate the submaximal exercise capacity by the 6-minutes walking test (6-MWT). (2). To compare the deficiency, incapacity and QOL data of exclusive WPS with those of two control groups (never smokers and exclusive cigarette smokers). (3). To determine the factors influencing the 6-minutes walk distance (6-MWD) of WPS subjects. METHODS: A multicentre study including 180 exclusive WPS [> or =5 WP-year] men aged > or =40 years. Cigar or cigarette smoking, contraindications to the 6-MWT or cortico-steroid therapy will be exclusion criteria. QOL evaluation, spirometry, electrocardiogram and two 6-MWT will be performed. Signs of exercise impairment will be: 6-MWD< or =lower limit of normal, end of walk dyspnoea > or =5/10, haemoglobin saturation fall > or =5 points. Data from WPS subjects will be compared with those from 90 never smoking subjects and 90 exclusives cigarettes smokers. EXPECTED RESULTS: (1). WPS will affect significantly the submaximal exercise capacity. (2). Resting spirometric, 6-MWT and QOL data of exclusive WPS subjects will be significantly reduced compared to never smoking subjects. (3). The 6-MWD's of exclusive WPS subjects will be significantly influenced by cumulative WP consumption, by resting spirometric data, by obesity and by physical activity score.

Relationship between glutathione S-transferase P1 polymorphisms and chronic obstructive pulmonary disease in a Tunisian population.

Chronic obstructive pulmonary disease (COPD) is a multifactorial disease with possible genetic predisposition and involvement of various environmental factors. Several candidate genes have been reported as potentially associated with this lung disease. The glutathione S-transferase P1 gene (GSTP1) was proposed to be involved in susceptibility to develop COPD. It belongs to the GST family, which is a group of phase II enzymes that catalyze the glutathione conjugation of many endogenous and exogenous electrophilic compounds, such as carcinogens, therapeutic drugs, environmental toxins, and oxidative stress products. We conducted a case-control study to investigate genetic polymorphisms of this enzyme [exon 5 (Ile105Val) and exon 6 (Ala114Val)] in 234 unrelated COPD cases and 182 healthy controls from a Tunisian population. Genotyping was carried out using polymerase chain reaction and restriction fragment length polymorphism methods. GSTP1 Ala114/Val114 and Val114/Val114 genotypes were not found in either patients or healthy controls. However, there were differences in the distribution of various exon 5 GSTP1 genotypes between COPD patients and healthy controls. GSTP1 Val105/Val105 was significantly more common in patients compared to controls (OR = 2.67; 95%CI = 1.45-4.92; P = 0.0013). Multivariate logistic regression analysis confirmed a significant relationship between the mutant genotype and COPD (OR = 2.58; 95%CI = 1.31-5.09; P = 0.026), after adjustment for classic risk factors. Analysis of variance showed no correlation between age, body-mass index, pack-years, percentage of predicted FEV1 values, and any of the GSTP1 genotypes. We conclude that subjects with GSTP1 Val105 allele are at higher risk of COPD.

[Familial idiopathic pulmonary fibrosis associated with autoimmune polyendocrinopathy and epidermodysplasia verruciformis]. / Fibrose pulmonaire idiopathique familiale associée à une polyendocrinopathie auto-immune et à une épidermodysplasie verruciforme.

Familial idiopathic pulmonary fibrosis (IPF) is a very rare and progressively fatal disease. Its pathogenesis is not fully understood and involves damage to alveolar epithelial cells of possibly immunological, microbiological or chemical origin, leading to fibrosing healing. A genetic predisposition has been demonstrated. The authors report the case of a female patient whose brother died at the age of 29 from IPF. She had epidermodysplasia verruciformis since childhood, with the absence of pubertal development. At the age of 31, she presented diffuse interstitial pneumonia. A lung biopsy confirmed the diagnosis of IPF. Endocrine explorations detected hypogonadotropic hypogonadism, primary hypothyroidism and magnetic resonance imaging revealed an empty sella turcica. The association of familial IPF, autoimmune polyendocrinopathy and genetic dermatosis caused by a cellular immune deficiency supports the hypothesis of an immune dysfunction in the pathogenesis of IPF.

[Biochemical and molecular diagnosis of alpha 1 antitrypsin deficiency in a Tunisian family]. / Diagnostic biochimique et moléculaire du déficit en alpha 1 antitrypsine dans une famille tunisienne.

Our study investigated alpha 1 antitrypsin deficiency (AATD) diagnosis in a family originated from central Tunisia and showing a familial history of asthma. Biochemical and genetic diagnosis for AATD was performed according to current diagnostic standards. AAT level quantification in affected individuals showed plasma AAT levels consistent with intermediate AATD (ranged from 0.91 to 1.04 g/L). The molecular analysis was assessed using the genotyping of the most prevalent PI*S and PI*Z SERPINA1 mutations and the sequencing of AAT coding exons for rare AATD variants detection. No PI*S or PI*Z deficient variants were seen in this family. Sequencing results showed the inheritance of the deficient rare variant PI*M(wurzburg) (P369S) at the heterozygous state in the mother and two affected siblings. However, AATD status remains unexplained in the third affected case, with no mutations detected in the AAT coding exons.

Continuous versus intermittent nebulization of salbutamol in acute severe asthma: a randomized, controlled trial.

STUDY OBJECTIVE: This study was conducted to compare the clinical and spirometric effects of continuous and intermittent nebulization of salbutamol in acute severe asthma. METHODS: Forty-two consecutive patients presenting to the emergency department for acute severe asthma (peak expiratory flow [PEF] mean+/-SD, 24%+/-12% predicted) were prospectively randomly assigned to receive 27.5 mg of salbutamol by either continuous or intermittent nebulization over a 6-hour period. The continuous nebulization group received 15 mg of salbutamol during the first hour and 12.5 mg over the next 5 hours. The intermittent nebulization group received 5 mg of salbutamol every 20 minutes during the first hour and 2.5 mg hourly over the next 5 hours. All participants received oxygen and intravenous hydrocortisone. Clinical and spirometric assessment was performed at baseline, 40 minutes, 60 minutes, and at 3 and 6 hours after the start of the nebulization. Secondary endpoints were the respective rates of hospitalization and treatment failure. RESULTS: A significant clinical and spirometric improvement was observed in both groups over baseline as soon as the 40th minute and was sustained thereafter (absolute PEF increase at the sixth hour 30%+/-18% and 32%+/-22% in the continuous and intermittent nebulization groups, respectively; P <.01 over baseline). PEF and the clinical score evolved similarly in both groups. There was no difference between the groups regarding the failure rate of the initial bronchodilator treatment to terminate the asthma attack (3 [14%] in the continuous nebulization group and 2 [9.5%] in the intermittent nebulization group, absolute difference 4.5% [95% confidence interval -14% to 23%]). Eight (38%) patients and 9 (43%) patients from the continuous and intermittent nebulization groups, respectively, required hospitalization according to predefined criteria (absolute difference 4.8% [95% confidence interval -24% to 34%]). CONCLUSION: We did not observe an appreciable difference between continuous and intermittent nebulization of salbutamol in acute severe asthma. The decision to use one of these nebulization methods should be based on logistical considerations.

Undertreatment in a nonselected population of adult patients with asthma.

BACKGROUND AND AIM: The question of undertreatment has frequently been raised concerning the management of asthma but, to date, very few studies have been carried out. In those studies that have been performed, the methodology was inadequate because they were conducted on a selected population of patients with asthma or by interviewing doctors. As part of the European Community Respiratory Health Survey, nonselected patients with asthma (22 to 44 years old) in two French cities (Paris and Montpellier), were examined to assess possible undertreatment. METHODS: Patients with asthma were recruited according to a positive response to questions on asthma in a questionnaire and a positive methacholine challenge. The severity of asthma was assessed by a cumulative score, which has previously been shown to be significantly correlated with the validated clinical score of Aas. Patients were asked to attend the clinic and bring with them any medications that they regularly received. The optimal treatment of asthma was based on the International Consensus Report on the Management of Asthma. RESULTS: According to the international guidelines, among the patients who required antiinflammatory treatment, 86.4% were undertreated in Paris and 66.7% were undertreated in Montpellier (p < 0.03, chi square test). Moreover, among the patients with severe asthma, 85% and 60%, respectively, were not receiving an antiinflammatory treatment. CONCLUSION: This study is the first to highlight the magnitude of undertreatment of patients with asthma in a nonselected population.

Immunotherapy with a standardized Dermatophagoides pteronyssinus extract. V. Duration of the efficacy of immunotherapy after its cessation.

Specific immunotherapy (SIT) using a standardized mite extract is effective and safe when administered under optimal conditions. However, the duration of its effectiveness after cessation of treatment remains unknown. Forty asthmatic subjects who had received SIT with a standardized Dermatophagoides pteronyssinus (Der p) extract under the same protocol were studied. All had received SIT for a period of 12-96 months and were not receiving pharmacologic treatment. The FEV1 was within normal range in all patients. After cessation of treatment, patients were followed for up to 3 years at 6-month intervals. The patient was considered to have relapsed when symptoms of asthma and/or rhinitis occurred and/or when pulmonary function tests were impaired. Skin tests with increasing concentrations of Der p were carried out before and at the end of SIT. Forty-five percent of the patients did not relapse. The duration of efficacy of SIT was related to the duration of SIT itself (P < 0.04). Most patients who did not relapse had a decrease in skin test reactivity at the end of SIT, whereas most patients who relapsed did not show any change (P < 0.003). The duration of efficacy of SIT after its cessation depends upon the duration of SIT and may be predicted by the effect of SIT on skin tests.