Factors influencing therapeutic adherence in Tunisian adults with asthma.

INTRODUCTION: Despite current recommendations, most asthmatics remain insufficiently controlled. This is largely due to non-adherence to medications. Looking for factors associated with lack of therapeutic adherence is mandatory in order to improve the management of these patients. AIM: To assess the degree of compliance in a population of Tunisian asthmatic patients and to identify the factors associated with poor compliance. METHODS: It was a cross-sectional study over a period of six months. Asthma control was assessed using the Asthma Control Test. Treatment compliance was specified using the Morisky questionnaire. Associations between adherence to treatment and certain patient characteristics were sought. RESULTS: During the study period, 165 adult patients were included (average age: 46.8 years±15.3 years; 114 women). The median duration of asthma evolution was 10.5 years [1-60 years]. Asthma was uncontrolled in 50% of the cases. Lack of treatment adherence was observed in 45% of patients. Compliance was better in women (p <0.05) and in patients with better socioeconomic status (p= 0.04). Patients with gastroesophageal reflux disease were also more observant (p=0.03); however, those with obesity were less (p> 0.05). In multivariate analysis, patients with good socioeconomic conditions (OR=4,516; IC95% [1.433-14.232]; p=0,01) and those with a previous a history of coronary artery disease (OR=15,37 ; IC95% [1.25-188.857] ; p=0.03) were more likely to have good adherence. CONCLUSION: Although it is a key element in the management of asthma, treatment compliance remains insufficient in Tunisian patients with asthma. Patient education is essential in order to correct the factors incriminated in uncontrolled asthma. The challenge remains to overcome the socioeconomic difficulties and the lack of access to treatment in our context.

Contribution of mobile applications to learning and medical practice.

INTRODUCTION: Medical mobile applications are increasing, accessible and easy leading to a considerable increase use by physicians. AIM: To assess the contribution of mobile applications to medical learning and practice among medical residents. METHODS: This was a descriptive cross-sectional study carried out during May and June 2021, via an anonymous questionnaire, published online focusing on the contribution of medical applications in the learning and the daily life of medical interns. RESULTS: We collected 134 responses completed by interns in all specialties. The mean age was 28 ± 2.04 years with a predominance of women (gender ratio = 0.39). The average number of years of experience was 4.52 ± 2.5 semesters. All interns had smartphones and 56.7%. Only 3% had no applications on their smartphones and 62.7% had between two and four applications. The most used applications were communication and scoring applications.  several advantages of these applications were noted, mainly assistance in therapeutic management (85.1%), diagnosis (76.9%) and communication (69.4%). However, limitations were mainly the lack of 3G / 4G coverage. For scientific research, the most used search engine were Google, Google Scholar and Pub Med. One hundred and six residents (79.1%) were satisfied with the contribution of applications to learning and 61 wished to have training in the specific use of the smartphone. CONCLUSION: Communication, diagnostic or management help mobile applications have become unavailable in daily practice but also in learning. However, this new mode of instruction must be associated to the classical education.

Breathing pattern during sequential swallowing in healthy adult humans.

Sequential liquid swallowing is a common daily occurrence during which coordination of deglutition and breathing are highly regulated to avoid pulmonary aspiration and to maintain hematosis. We studied the effects of sequential water swallowing (SWS) at fixed swallowing rates and with regular succession of swallows on respiration in healthy subjects. Thirty-one normal adults (19 men, 12 women) with a mean age of 27.96 ± 3.68 yr were explored at rest and during SWS (at 12 and 24 swallows/min). Respiration was recorded by intranasal air pressure changes and timing of deglutition by an acoustic method. Oxygen saturation [arterial O2 saturation from pulse oximetry ( SpO2 )] was monitored with a finger probe. During SWS, we determined the respiratory phase (inspiration or expiration) before and after each ingestion cycle (IC; period of sustained apnea including 1 or more swallows). We also measured inspiratory time (TI), expiratory time (TE), respiratory cycle duration (TT), respiratory rate (RR) and SpO2 at rest and during SWS. We showed that respiration was interrupted by sequential swallows determining a succession of ICs that were often preceded and followed by expiration. During SWS, TI decreased and TE increased compared with rest ( P < 0.01). However, TT, RR, and SpO2 did not change. It seems that the preferential coupling of swallowing with expiration during SWS is favored by an increase in TE to ensure airway protection, although the repetitive swallows, RR, and SpO2 were not altered during SWS. These data may be useful to study the effects of aging and pathological conditions on swallowing and breathing coordination during SWS. NEW & NOTEWORTHY Sequential water swallowing induces ingestion cycles that are often preceded and followed by expiration. Moreover, inspiratory time decreases and expiratory time increases during sequential swallowing compared with rest without changes in ventilatory cycle duration, respiratory rate, and oxygen saturation.

Implication of the vagus nerve in breathing pattern during sequential swallowing in rats.

The ventilatory pattern during sequential swallowing is influenced by the vagal activity. As the vagus nerve is paired and mixed, we aimed (1) to determine if vagal implication in swallowing and breathing coordination is symmetric. (2) to study the importance of vagal afferences in swallowing and breathing coordination. Sixty two Wistar rats (7-11weeks, 260-400g) were studied by barometric plethysmography. In the first part of the study, we determined the effects of a right cervical vagotomy and the effects of a left cervical vagotomy on ventilatory pattern at rest and during sequential swallowing (14 rats with right vagotomy, 14 rats with left vagotomy and 14 rats with sham surgery). Comparisons of ventilatory variables were made between right and left vagotomized animals. Thereafter, we determined the effects of electrical vagus nerve stimulation (VNS) on ventilatory pattern at rest and during sequential swallowing (10 rats with electrical VNS and 10 rats with sham VNS). We showed that a right or a left cervical vagotomy does not alter ventilation at rest, but induces during sequential swallowing a decrease in respiratory rate (RR) (p<0.001) and mean inspiratory flow (VT/TI) (p<0.01) compared to baseline. These modifications were not observed following sham surgery and there were no differences in ventilatory variables at rest and during sequential swallowing between right vagotomized rats and left vagotomized rats (p>0.05). Electrical VNS had no effect on ventilation at rest, but it minimized during sequential swallowing a decrease in RR related to a local alteration of the vagus nerve after placement of the electrodes as shown following sham VNS. In conclusion, the implication of vagus nerve in breathing pattern during sequential swallowing seems symmetric and influenced by activation of the vagal afferent pathway. These data can be useful when testing electrical VNS in swallowing disorders.

The Z-score: A new tool in the interpretation of spirometric data.

Spirometry is an important tool in the diagnosis and management of patients with respiratory pathology. An appropriate interpretation of the spirometric data requires the use of a population-specific reference equation. However, the most widely used equations were established in European populations with limited age groups. The extrapolation of these equations, based on a specific population, and their uses for a different population led to measurement and interpretation biases. In 2012, an international working group conducted a multicenter study and published new reference equations called The Global Lung Initiative (GLI). These enabled the modeling of spirometric parameters from a very large sample collected in several ethnic groups using modern statistical techniques to establish continuous equations for all ages and in many countries. The GLI also recommends the use of a new statistical tool for the expression of results: The Z-score. This tool allows to express, in a simple way: how many standard deviations a subject is deviated from its reference value. The Z-score is calculated by the ratio of the difference between the measured value and that predicted with the residual standard deviation. This simple approach has reduced the false positive results found by the use of the conventional limits of 80% compared to a predicted value or 0.70 in absolute value for the definition of bronchial obstruction that remain still used.

Preoperative assessment in pulmonary resection surgery.

Pulmonary resection can be associated with a significant risk of morbidity and mortality, which depends on the nature and extent of pulmonary resection but also on the patient himself. This risk can be apprehended by a preoperative assessment which estimates the immediate operative risk as well as the physiological state and the post-operative quality of life which can require more conservative therapies. Currently, preoperative exploration of a patient is based on various technological tools, which can range from simple electrocardiogram or simple spirometry to a complex exploration such as a cardiorespiratory effort test. These multiple evaluation tools require the rationalization of good practice processes according to international recommendations, taking into account the patient's specificity and the country context. This approach makes it possible to prioritize examinations according to their availability and accessibility in order to identify patients with high operative risk and to offer them an appropriate therapeutic choice.

Role of metalloproteinases MMP-2 in asthma.

Background - Many metalloproteinases (MMPs) play a role in the pathogenesis and modulation of the severity of asthma. MMP-9 is the predominant in asthma but other MMPs are involved such as the MMP-2. Aim - To determine the role of single nucleotide polymorphism of the gene MMP2 in susceptibility to asthma and its severity. Methods - Study case-control with prospectively enrolled patients with asthma and healthy subjects. We determined within two groups genotypes corresponding to the MMP2 polymorphism in -735C / T position, using a polymerase chain amplification technique associated with a polymorphism in the length of restriction fragments. Results - We included 150 patients with asthma and 150 healthy controls. Comparison of allele and genotype frequencies of the studied polymorphisms between patients and controls showed that there was no association between the SNP-735C / T and susceptibility to asthma and its severity. Conclusion - The role of MMP 2 in asthma remains unclear and no study has been conducted till date, to determine the role of MMP-2 -735C/T gene polymorphism in asthma. This study does not disprove such association. Further studies are needed to clarify the exact role the pathogenesis of asthma.

Contribution of fixed-dose combinations in the treatment of tuberculosis.

Background - The introduction of fixed-dose combinations (FDCs) of TB treatment in Tunisia is recent (July 2009). WHO and the National Tuberculosis Programme recommend the use of fixed-dose combination (FDC) tablets for the treatment of tuberculosis (TB). The effectiveness of ADF has been demonstrated, however the risk of relapse and tolerance were controversial. Objective - Through a retrospective study, we evaluate, the contribution of FDCs compared with dissociated treatment (TD) (efficacy, tolerance and the occurrence of relapses). Patients and methods - This is a retrospective study conducted in the Department of Pneumology la Rabta. Are included patients with pulmonary tuberculosis (TB) first attack. Two groups were studied: Group I (TC) treated between July 2009 and June 2011 who received ADF. Group II (TD) treated between July 2008 and June 2009 who received TB dissociated treatment. Results - One hundred and seventy one patients were included: 122 in the TC group with an average age of 39.2 years and 49 patients in the TD group with an average age of 38.2 years. Male predominance was observed in the two groups (82/75.5%). The period of apyrexia was below 7 days at more than 80% of patients in the two groups. Sputum smears conversion were obtained between one and two months (median 52,8 vs 55,8 days) in both groups with no significant difference (p = 0.06). The rate of smears conversion at 2 months was 74% in TC group versus 65.3 % (p = 0.12). Eighty patients (65%) of the TC group and 29 patients (59%) of the TD group had one or more adverse effects to treatment without significant difference (p = 0.270). The most common adverse effects were those related to digestive system (17.2% vs 6.1%), liver toxicity (7.4% vs 4.1 %) and urticaria (9.8% vs 8.1%). The treatment successful rate was: 73.7 % in TC group and 77.5 % in TD group. There was no significant difference in treatment compliance, neither in relapse rate nor in the death rate. Conclusion - This study demonstrated non-inferiority of the effectiveness of ADF with a comparable safety. Its effects in the prevention of relapse and resistance BK remain unproven.

Drug Rash with Eosinophilia and Systemic Symptoms to antituberculosis treatment.

Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) syndrome reflects a serious hypersensitivity reaction to drugs. This syndrome is an uncommon adverse reaction due to antituberculosis drugs and is sometimes difficult to identify the culprit agent. We report a case of a 45-year-old woman who received combined antituberculosis drugs (RHZE) for lymph node tuberculosis. Clinical manifestations included fever, dyspnea, rash, hypereosinophilia and visceral involvement (liver involvment). After symptom resolution and biology normalization, anti-tuberculosis drugs were reintroduced successively one after another. Systemic symptoms reappeared with the four anti-tuberculosis drugs. The clinical outcome was favorable with second line antituberculosis treatment.

Effects of chronic aspirations on breathing pattern and ventilatory drive in vagatomized rats.

The aim of this study was to test the hypothesis that aspirations induced by unilateral vagotomy destabilise ventilatory pattern during swallowing. The study was carried out on 15 Wistar rats (2-3 months, 290-350 g) using whole-body plethysmography and video recordings, before and after unilateral vagotomy. The rats were given water ad libitum via a baby bottle fitted with a nipple. The experiment was continued until rest ventilation and swallowing periods were identified on the video recordings. Following the sectioning of the right vagus nerve, all the rats presented bronchial aspirations and unilateral vocal cord paralysis in the aperture position. After the vagotomy there were no changes at rest of the ventilatory variables compared to healthy controls. In healthy animals during swallowing, we observed a decrease in total ventilatory time (TTOT), a decrease in inspiratory time (TI) (p < 0.001), a decrease in expiratory time (TE) (p < 0.001), no change in tidal volume (VT) and an increase in mean inspiratory time (VT/TI) (p < 0.001) compared to the rest period. Animals with chronic aspiration presented during swallowing an increase in TTOT (p < 0.001), TI (p < 0.01), and TE (p < 0.001), no change in VT and a decrease of VT/TI (p < 0.001) and a modification of ventilatory pattern. In conclusion, our results confirmed that swallowing modifies ventilation in healthy animals and that chronic aspiration decreases ventilatory drive and modifies ventilatory pattern during swallowing.