Self-reported sleepiness and not the apnoea hypopnoea index is the best predictor of sleepiness-related accidents in obstructive sleep apnoea.

To evaluate the value of apnoea + hypopnoea index versus self-reported sleepiness at the wheel in anticipating the risk of sleepiness-related accidents in patients referred for obstructive sleep apnoea. A cross-sectional analysis of the French national obstructive sleep apnoea registry. 58,815 subjects referred for a suspicion of obstructive sleep apnoea were investigated by specific items addressing sleepiness at the wheel and sleepiness-related accidents. Apnoea + hypopnoea index was evaluated with a respiratory polygraphy or full polysomnography. Subjects had a median age of 55.6 years [45.3; 64.6], 65% were men, with a median apnoea + hypopnoea index of 22 [8; 39] events/h. Median Epworth sleepiness scale score was 9 [6; 13], 35% of the patients reported sleepiness at the wheel (n = 20,310), 8% (n = 4,588) reported a near-miss accident and 2% (n = 1,313) reported a sleepiness-related accident. Patients reporting sleepiness at the wheel whatever their obstructive sleep apnoea status and severity exhibited a tenfold higher risk of sleepiness-related accidents. In multivariate analysis, other predictors for sleepiness-related accidents were: male gender, ESS, history of previous near-miss accidents, restless leg syndrome/periodic leg movements, complaints of memory dysfunction and nocturnal sweating. Sleep apnoea per se was not an independent contributor. Self-reported sleepiness at the wheel is a better predictor of sleepiness-related traffic accidents than apnoea + hypopnoea index.

Prevalence of residual excessive sleepiness in CPAP-treated sleep apnoea patients: the French multicentre study.

The percentage of compliant continuous positive airway pressure (CPAP)-treated apnoeic patients that continue to experience residual excessive sleepiness (RES) is unknown. RES was defined by an Epworth Sleepiness Scale (ESS) score of >or=11. In total, 502 patients from 37 French sleep centres using CPAP >3 h night(-1) attending their 1-yr follow-up visit were eligible. ESS and polysomnographic data as well as symptoms, quality of life, depression scores and objective CPAP compliance at 1 yr were collected. Overall, 60 patients remained sleepy on CPAP (ESS 14.3+/-2.5) leading to a prevalence rate of RES of 12.0% (95% confidence interval (CI) 9.1-14.8). After having excluded associated restless leg syndrome, major depressive disorder and narcolepsy as confounding causes, the final prevalence rate of RES was 6.0% (95% CI 3.9-8.01). Patients with RES were younger and more sleepy at diagnosis. The relative risk of having RES was 5.3 (95% CI 1.6-22.1), when ESS before treatment was >or=11. Scores of emotional and energy Nottingham Health Profile domains were two times worse in patients with RES. As 230,000 obstructive sleep apnoea patients are currently treated in France by continuous positive airway pressure, more than 13,800 of them might suffer from residual excessive sleepiness.

[Educational diagnosis in asthma. Descriptive results of a questionnaire survey]. / Diagnostic éducatif de l'asthme. Résultats descriptifs d'une enquête par questionnaire.

The object of this work was to carry out an audit on an asthmatic's knowledge of their disease and of the risk factors, their usual therapy and of therapy for acute exacerbations as well as their need for information and education. The study was carried out by a survey of 327 adult asthmatics who were in consultation with specialist physicians in thoracic medicine. The information was gathered using an anonymous questionnaire completed by a nurse. The doctors looking after these patients had given their opinion on the severity of their asthma and the educational needs of their patients. The population studied had an average of 47 +/- 17 years. Forty seven per cent of the subjects were masculine. The general level of education was high. Seventy five per cent of the patients were from an urban environment. The duration of the asthma was on an average of 19 years. Half of these patients had already been in hospital for a serious attack. One third of the patients were considered by their doctors as having severe asthma. The patients were good at distinguishing the level of severity of their acute exacerbations and adapted their therapy on their own initiative in appropriate fashion based on the degree of severity of their disease. The enquiry revealed that patients take some liberties around the basic treatment that they had been prescribed. It also showed some defects or errors in their knowledge of the disease and the appropriate approach vis-à-vis the disease. One noted for example that one third of the asthmatics had already stopped the treatment before the date fixed by their doctor. In a general, patients who were surveyed were interested in their health problems with their health and hoped to be better informed both on asthma and its treatment. This study was biased towards an interest in the understanding of the education in order to manage the asthmatic population better.

Treatment of bronchial asthma with terfenadine; a randomized controlled trial.

1. Terfenadine, a histamine H1-receptor antagonist, was studied in 52 patients with stable mild perennial asthma with an allergic basis. 2. After a placebo run-in period, patients were randomly allocated to either terfenadine 120 mg twice daily or placebo. After 2 weeks they were crossed over to the other treatment. Forty-six patients completed the study. 3. Terfenadine was significantly more effective than placebo as measured by peak expiratory flows and by symptom scores. 4. These results suggest that histamine may play a more significant role in asthmatic bronchoconstriction than is currently recognised.

[Asthma and synthetic antihistaminics]. / L'asthme et les antihistaminiques de synthèse.

Anti-histamines are considered weakly effective in the treatment of asthma whether in acute exacerbations or as basic therapy. However, there are numerous arguments which plead in their favour, and not only the recognised role of histamines as an important mediator of the immediate response. Besides, since 1948 when it was shown that the first anti-histamines (classical anti-histamines) possessed undeniable anti-histamine like actions, which showed them to have both broncho-dilator activity and a protective effect on bronchospasm induced by inhalation of histamine or allergens. Unfortunately, this efficacy in asthma is only achieved with high doses which are responsible for troublesome side-effects. This is why with the arrival of new anti-histamines specific for H1 receptors, without anti-cholinergic or sedative effects, one can envisage the day when high dose anti-histamines are evaluated in the treatment of asthma. Pharmacological studies in animals have clearly shown their bronchomotor action. Similarly, the first work carried out in men, confirms the anti-asthmatic potential by showing a protective action in the bronchial response, to isocapnic hyperventilation, to exercise and to allergens. As for anti-H2, their impact on asthmatic broncho-constriction is poorly defined: for some they potentiate, for others they inhibit.

Induction of late cutaneous reaction by kallikrein injection: comparison with allergic-like late response to compound 48/80.

Although IgE antibody is able to provoke a late cutaneous allergic response (LCAR), the mechanism of its development is not clear. It seems to involve vasoactive and clotting mediators released from mast cells and basophils. Substances biologically similar to plasma kallikrein (KK), a Hageman factor activator, have been shown to be released by basophils in the course of an IgE-dependent reaction. Because compound 48/80 induces LCAR-like responses in the skin, we compared the ability of tissue KK and compound 48/80 to induce late cutaneous reactions (LCRs). All 40 test subjects showed an immediate wheal and flare reaction (WF) after both KK and 48/80. The WF was followed by an LCR characterized by diffuse edema, pain, and erythema in 36 of 40 subjects with 48/80 and 26 of 40 with KK. The LCRs evoked by the two agents did not differ in their appearance or in their time of development. These reactions increased until the 5 hr mark, began to decrease at the 10 hr mark, and were gone after 24 hr. Histologic study showed edema and a mixed cell infiltration with fibrin deposition. Challenge of the original injection site and a new site after 1 or 2 wk showed a local refractory state lasting 2 wk. Prednisone almost totally suppressed the LCRs induced by both KK and 48/80.

[Immunological changes following heart surgery under extracorporeal circulation (author's transl)]. / Modifications immunitaires après chirurgie cardiaque faite sous circulation extra-corporelle.

Post-operative immunological changes were studied in 40 patients undergoing heart surgery. Tty-five patients were operated upon under extracorporeal circulation (ECC), and 15 without ECC. Immunological investigations were performed before, immediately after the operation and again 7 days later. The post-operative changes recorded were early decrease in IgG and IgM followed by a rise in IgM, transient lymphocytopenia affecting mainly T lymphocytes and delayed increase in complement (CH50, C2, C3). These changes were comparable in both groups of patients and therefore seemed to relate to the operation itself rather than to the ECC. It may be concluded that ECC does not appear to increase the risk of post-operative infection by depressing immune defence mechanisms.

Gallium-67 in the evaluation of sarcoidosis: correlations with serum angiotensin-converting enzyme and bronchoalveolar lavage.

Gallium-67 (67Ga) scanning was assessed for its usefulness in the evaluation and follow-up of 54 patients with sarcoidosis, both treated and untreated. Scans were repeated in 23 subjects. Serum levels of angiotensin-converting enzyme (ACE) were determined concurrently in all 54 patients and bronchoalveolar lavage was performed in 29 patients. Gallium-67 scan was effective in the detection and assessment of lesions not revealed by traditional methods of investigation, particularly those affecting the mediastinum, spleen, and salivary glands. The scan also enabled fibrotic lesions, which do not show uptake, to be distinguished from granulomatous lesions, which do--an advantage of prognostic interest particularly in patients with pulmonary lesions. Another merit of 67Ga scanning was that it offered a means of following disease progression in each site. In patients showing spontaneous clearing of disease or receiving treatment the scintigraphic method was more sensitive than serum ACE determination. Scan findings showed a rough correlation with serum ACE but not with bronchoalveolar lavage findings. This suggests that the three markers probably reflect different stages of the granulomatous process. On the strength of this study the indications for gallium scanning in sarcoid patients can be defined more clearly than has previously been possible.

[Serum level of angiotensin-converting enzyme in sarcoidosis. Attempted correlation with the clinical activity of the disease (author's transl)]. / Taux sérique de l'enzyme de conversion de l'angiotensine dans la sarcoïdose. Essai de corrélation avec l'activité clinique de la maladie.

Serum levels of angiotensin-converting enzyme (ACE) were measured in 111 healthy subjects and in 117 adult patients with mediastinal and pulmonary sarcoidosis. The patients were followed up for 3 years. Detailed clinical investigations and ACE level measurements were performed every three months. The activity of the disease was assessed in 94 patients without treatment and in 23 patients under corticosteroid therapy. Mean ACE levels were significantly higher (p less than 0,0001) in all patients with sarcoidosis than in controls. They were also high (greater than 35 units/ml) in 32 patients with active forms of the disease. In 19 patients with inactive forms ACE levels were either moderately raised on normal, while considerable variations were observed in those with stable, persistent sarcoidosis. Complete spontaneous or therapeutically induced remission were accompanied by a return of ACE to normal values, but this was not the case for incomplete remission. There was no correlation between ACE levels and the radiological stages of the disease. Measuring ACE levels in patients with sarcoidosis may therefore contribute to diagnosis and surveillance and help to distinguish between complete and incomplete remissions.

[Alveolar proteinosis and acute leucosis. One observation (author's transl)]. / Protéinose alvéolaire et leucose aiguë. A propos d'une observation.

The authors observed a pulmonary alvelolar proteinosis in an 11 years old child with acute leucosis. They underlined the exceptional character of this association in a child, while it is known in the adult and almost always with a bad prognosis. A dysimmunity context linked to a hematological disease and/or its treatment, is favoured among the pathogenic hypotheses.