[Telemonitoring of severe COPD patients]. / Expérience liégeoise dans le télé-monitoring de patients BPCO sévères.

Following a solicitation of INAMI in 2016, a team of the CHU Liège pneumology department has proposed a telemonitoring pilot project in severe chronic obstructive pulmonary disease (COPD) patients. The main objective of the study was to reduce the number of hospitalizations for COPD exacerbation. The patients included in the study had been at least hospitalized once in 12 months before the beginning of the telemonitoring. A close collaboration with the general practitioner was required. Patients were educated in the manipulation of the application and connected objects. The numerous technical difficulties encountered limited the number of patients studied within the short time allowed by INAMI. However, some interesting observations could be made and a first experience in the field acquired. A project on a large scale seems necessary.

Suite à un appel lancé par l'INAMI en 2016, une équipe de soins du Service de Pneumologie du CHU de Liège a proposé un projet pilote de télé-monitoring de patients souffrant de bronchopneumopathie chronique obstructive (BPCO) sévère dont l'objectif principal était de réduire le nombre de ré-hospitalisations pour exacerbation de BPCO. Les patients sélectionnés étaient des patients sévèrement atteints et ayant été au moins hospitalisés une fois dans les 12 mois précédant la mise en place de la surveillance à distance. Une collaboration étroite avec le médecin généraliste était requise. Les patients ont été éduqués à la manipulation de l'application et des objets connectés proposés. Les nombreuses difficultés techniques rencontrées ont limité le nombre de patients étudiés dans les délais courts autorisés par l'INAMI. Cependant, quelques observations intéressantes ont pu être faites et une première expérience dans le domaine a été acquise. Un projet à plus grande échelle paraît nécessaire.

[Long-term oxygen therapy: mortality rate, short-term predictive mortality factors]. / Oxygénothérapie de longue durée : survie à 1 an, facteurs prédictifs de mortalité.

OBJECTIVES: The aims of this study were to assess the survival rate at one year of patients receiving long-term oxygen therapy (LTOT) as prescribed by the National Institute for Health and Disability Insurance's imposed criteria based on international recommendations, to search for short-term predictive factors for mortality and to measure the impact of LTOT on the frequency of hospitalization due to COPD exacerbations. METHODS: We conducted a retrospective analysis of 416 patients suffering from chronic respiratory insufficiency and started on long-term oxygen therapy between 2012 and 2014. The survival curves were estimated by the Kaplan-Meier method. Cox regression models were used to estimate the impact of the variables on survival. The evolution of patients hospitalized for COPD exacerbation was analysed by the McNemar test. RESULTS: The average age of our cohort was 70±10 years. It included 57% women and 78% patients with COPD. The one-year survival rate (n=416) under LTOT was 75%. Identified predictive mortality factors were coronary insufficiency [HR (95% CI): 1.8 (1.2-2.8); P=0.0083], reduction of the left ventricular ejection fraction [HR (95% CI): 2.5 (1.3-4.9); P=0.0080], the presence of osteoporosis [HR (95% CI): 1.7 (1.0-2.9); P=0.040]. There was a 28% reduction in the frequency of hospitalization for exacerbations of COPD during the year after starting LTOT. CONCLUSIONS: Mortality at one year with LTOT was about 25%. Factors predictive of mortality at one year included coronary insufficiency, reduction of the left ventricular ejection fraction and osteoporosis. LTOT seems to reduce hospitalizations due to exacerbations of COPD.

[Sarcoid-like granulomatosis in patients treated with anti-TNFα]. / LE CAS CLINIQUE DU MOIS. Granulomatose sarcoïdose-like chez les patients traités par anti-TNFα.

Over recent years, anti-TNFα have been used to treat rheumatoid arthritis. The principal secondary effect of anti-TNFα is tuberculosis infections. Another paradoxical effect, previously less well understood, is the development of sarcoid-like granulomatous reactions. We report the case of a 36 year old woman who had been treated for 9 years with anti-TNF alpha. She developed a pulmonary sarcoid-like gra-nulomatosis, complication that is rare but not exceptional in patients treated with TNF-blockers. Discontinuation of anti TNF usually led to recovery. It has been suggested that these reactions mainly occur with etanercept, but this requires further confirmation.

[Asthma-COPD overlap syndrome among patients with stable COPD]. / Étude du phénotype mixte BPCO-asthme dans une série de patients BPCO en état stable.

The purpose of this research was to describe the frequency and characteristics of the overlap syndrome among stable COPD patients (stage 2 to 4 according to GOLD). Material and method: We studied 46 patients with stable COPD recruited from the outpatient clinic of the CHU of Liege from May 2013 to April 2014. Definition of the overlap syndrome was based on the coexistence of post-bronchodilation FEV1/FVC < 70% and, either, an asthmatic history before the age of 40, or, at least, two functional and immune-inflammatory asthmatic traits : 1) significant FEV1 reversibility to inhaled bronchodilator (FEVI change >/= 200 ml and >/= 12% after bronchodilation), 2) eosinophilic inflammation : sputum eosinophils ≥ 3%,blood eosinophils ≥ 400/µl, or FENO ≥ 45 ppb, 3) clinical history of airway allergy, or total serum IgE ≥ 113 KU/l, or RAST ≥ 0,35 KU/l against major aeroallergens. 37% patients had the COPD-asthma overlap syndrome and this group had a higher CAT score reflecting more severe symptoms (24,6 ± 8,1 vs 19,4 ± 8, p < 0,05) despite similar level of airway obstruction. The transfer coefficient DLCO/VA was preserved in the overlap group (97 ± 24%), but altered in the pure COPD group (80 ± 20%), p < 0,05. Approximately one third of COPD patients present with the overlap syndrome and they are more symptomatic without any evidence of more severe airway obstruction.

[Pulmonary rehabilitation in chronic obstructive pulmonary disease]. / La réhabilitation pulmonaire dans la bronchopneumopathie chronique obstructive.

The current treatment of chronic obstructive pulmonary disease (COPD) patients must comprise, in addition to an optimal pharmacological treatment, a pulmonary rehabilitation, if possible multidisciplinary, and a program of post-rehabilitation in order to maintain the outcomes. Today pulmonary rehabilitation has proved to be effective in improving dyspnoea, exercise capacity and quality of life in COPD patients, and reducing the use of health services and thus the cost. In this article we want to present pulmonary rehabilitation, its indications and results, and the way by which it is held in the CHU of Liege.

[Exacerbations in COPD: a burden to curtail]. / Les exacerbations dans la BPCO: un fardeau à réduire.

Exacerbations of chronic obstructive pulmonary disease (COPD) play a very important role. Unfortunately they were neglected a long time in the therapeutic tests. However exacerbations influence the decline of the respiratory function over time, cause important deterioration of the quality of life of the patients, increase morbidity and mortality of COPD, and finally represent a burden for health care. Reducing the number of exacerbations could potentially slow down the progression of the disease. Thus the prevention of exacerbations should be the "corner stone" of the maintenance treatment of the COPD. In this review we propose to recall the importance of exacerbations in COPD and to present the treatment which have been shown to reduce exacerbation rate in COPD.

[Is celioscopic approach of pheochromocytoma acceptable? Reflections apropos of a prospective study of 6 personal cases]. / L'abord coelioscopique des phéochromocytomes est-il acceptable? Réflexions à propos d'une ètude prospective de 6 cas personnels.

Today, laparoscopy is for us the technique of choice for approaching presumed benign adrenal tumors. With regards to pheochromocytoma however, two major questions must be addressed. First, is it acceptable to resect potentially multifocal tumors with such a targeted approach? Second, can peroperative hemodynamic changes be anticipated and controlled by the anesthetist, taking into account the additional effects of pneumoperitoneum and catecholamine release on the cardiovascular system? The present prospective study attempts to answer these two questions. From November 1993 to November 1995 we operated on four women and two men, with ages ranging from 33 to 71 years (mean of 47) and a mean Body Mass Index of 25 kg/m2 (range 17-35). Four patients were assigned ASA (American Society of Anesthesiologists) physical status 2, one grade 1 and one grade 3. Comprehensive preoperative work-up, including a CT scan and an I131 MIBG Scan in all, a C11 Hydroxyephedrine PET Scan in 4 and a MRI in one patient, showed a solitary lesion in each case. There were four right-sided and two left-sided tumors, ranging from 30 to 60 mm in diameter. Laparoscopy was always performed transperitoneally. Systemic and pulmonary hemodynamics were thoroughly assessed. Epinephrin and norepinephrin concentrations were measured at the 10 key-time of surgery. Use of continuous intravenous infusion of nicardipine allowed tight control of hemodynamics despite impressive increases in circulating catecholamines. The mean operative time was 76 minutes (range 59-130). Blood loss was minimal. We observed neither mortality nor morbidity. Mean hospital stay ranged from 3 to 13 days (median = 3). All patients are normotensive without drug after a follow-up of 9 to 33 months. In conclusion, we think that laparoscopic removal of selected cases of pheochromocytoma may be performed safely from both the hemodynamical and oncological standpoints.

[Drainage in thyroid surgery. Is it always a must?]. / Le drainage en chirurgie thyroïdienne. Est-ce toujours une nécessité?

Drainage in thyroid surgery has been a routine but empirical practice with no scientific evidence to support its benefit. A retrospective review of a personal series of 1789 thyroidectomies over a 3 1/2-year period was conducted. Except for thyroid cancer surgery with lymphadenectomy and large mediastinal goiters requiring sternotomy, no case selection for non-drainage was employed. Patients were stratified only on a chronological basis, according to whether key were drained (n = 575, 1993-1994) or not drained (n = 1214, 1994-1996). Both series included toxic goiters, large plunging compressive goiters, bilateral and redo procedures. Severe life-threatening hematoma requiring reexploration occurred in 5 drained patients (0.9%) and in 5 undrained patients (0.4%). Minor postoperative wound hematoma were conservatively treated in 17 drained patients (2.9%) and 6 undrained patients (1.3%). In our experience, drainage after thyroid surgery may not mandatory provided that the field is completely dry before closure. We therefore, progressively modified our operative strategy in order to improve a meticulous haemostatic technique, considered to be more important than the use of drains. Meticulous surgical technique and obliteration of dead space led us to observe a dramatic decrease of the incidence of hemorrhagic complications, eliminating the need for systematic drainage after thyroid surgery.

[Endocrine surgery by hypnosis. From fiction to daily clinical application...]. / Chirurgie endocrinienne sous hypnose. De la fiction à l'application clinique quotidienne....

Between April 1994 and March 1996, 108 thyroidectomies (97 partial or unilateral lobectomies and 11 bilateral lobectomies) and 13 cervical explorations for hyperparathyroidism were performed under hypnosedation (HS) technique combining hypnosis and light conscious sedation. Informed consent was obtained from each patient. None of these patients underwent preoperatively standard susceptibility test score or preparatory hypnotic session. Nevertheless, no patient required conversion to general anesthesia. Operative data and postoperative courses were compared to a well-matched population (n = 70) of patients operated on for thyroid diseases under general anesthesia (GA). Under HS, mortality was zero and surgical management was only complicated by unilateral definitive recurrent laryngeal nerve paralysis in one case (0.8%) and the need for neck reexploration for severe hematoma after parathyroidectomy in another case. Hyperparathyroidism was cured in all cases. The surgeons all reported better operating conditions, estimated by visual analog scale (VAS), for cervicotomy using HS (8.9 +/- 0.6 cm vs 8.0 +/- 1.2 cm in the GA group, p < 0.01). This is probably related to reduced bleeding in the operative field. All the patients reported a very pleasant experience and enjoyed having their surgery performed under HS (VAS of satisfaction: 9.35 +/- 0.99 vs 2.88 cm +/- 2.8 cm in the GA group, p < 0.001). Patients having HS had less postoperative pain (VAS of pain: 2.2 +/- 1.6 cm vs 3.2 +/- 2.0 cm in the GA group, p < 0.01), whereas antalgic consumption was significantly reduced in the HS group compared with the GA group (paracetamol on first postoperative day was, 932 +/- 519 mg vs 1437 +/- 622 mg in the GA group, p < 0.001). Hospital stay was also significantly lower (46.3 h +/- 14.6 vs 74.2 +/- 9.5 h in the GA group, p < 0.001), providing a substantial reduction of the costs of medical care. The postoperative fatigue syndrome and surgical convalescence were significantly improved after HS (VAS of fatigue: 2.05 +/- 2.01 cm vs 4.7 +/- 2.4 cm in the GA group, p < 0.001, hand grip test: 95.5% of preoperative muscular maximum force vs 89.9% in the GA group, p < 0.01). Full return to social or professional activity was usually accomplished after 10.3 +/- 10.2 days in the HS group vs 36 +/- 8 days in the GA group, p < 0.001). From this study, we concluded that HS is a very effective technique for providing relief of intra- and postoperative pain in endocrine surgery. This technique results in high patient satisfaction and better surgical convalescence. This technique therefore can be used in most motivated patients and reduces the socio-economic impact of hospitalization.