S. Kammoun

Vieillissement de l’appareil respiratoire : modifications anatomiques et conséquences physiologiques

The respiratory system undergoes progressive involution with age, resulting in anatomical and functional changes that are exerted on all levels. The rib cage stiffens and respiratory muscles weaken. Distal bronchioles have reduced diameter and tend to be collapsed. Mobilized lung volumes decrease with age while residual volume increases. Gas exchanges are modified with a linear decrease of PaO(2) up to the age of 70 years and a decreased diffusing capacity of carbon monoxide. Ventilatory responses to hypercapnia, hypoxia and exercise decrease in the elderly. Knowledge of changes in the respiratory system related to advancing age is a medical issue of great importance in order to distinguish the effects of aging from those of diseases.

Influence of Ramadan Observance on Sleep Pattern and Wakefulness at Workamong Medical Trainer in Tunisia

Introduction: Muslims practice intermittent Islamic fasting all over the globe each year during Ramadan. This practice induces several changes that may affect work performance. The aim of this study is to evaluate the impact of fast during Ramadan on eating behaviors, sleep habits, daytime sleepiness, and professional life. Methods: Target population was medical trainees who were working since at least 4 months at the beginning of the study. They were invited to complete an anonymous self-administered questionnaire during and apart from Ramadan. Results: Two hundred forty-three subjects (243) had correctly completed the questionnaire (mean age = 26.81 ± 2.17 years and sex-ratio = 0.69). During Ramadan, all Alcohol drinkers had stopped drinking (p<0.001), and daily tobacco consumption had significantly dropped from 14.82 ± 8.26 to 11.67 ± 8.64 cigarettes during Ramadan (0.002). Consumption of both coffee and tea was significantly reduced from 2.44 ± 1.3 to 1.03 ± 0.71 and from 1.06 ± 0.59 to 0.77 ± 0.66 cups a day, respectively (p<0.0001). The average number of meals per day dropped from 2.92 ± 0.49 before Ramadan to 1.79 ± 0.58 during Ramadan (p = 0.032). The average bedtime was significantly delayed until to 3.80 ± 5.37 am, while it was at 9.7 ± 10.93 pm during the previous month (p<0.0001). The percentage of subjects who went to bed after midnight also had significantly increased from 57.1% to 93.1% (p<0.001). The degree of dissatisfaction about sleep quality had substantially increased from 18.9% at baseline to 54.7% during Ramadan (p<0.0001). Fasted Trainees found more difficult getting up in the mornings (74.1% versus 79% respectively, p<0.0001). The percentage of trainees who often arrived late for work or missed it increased significantly, from 3.7% at baseline to 11.9% during Ramadan (p<0.0001). The majority (81.1%) reported feeling extra sleepy during the daytime of Ramadan month as compared to 60.1% during the previous month (p<0.0001). It was also noted a higher frequency of digestive disorders (46.9% versus 29.6%, <0.001), morning headaches (15.2% versus 6.6%), excessive nervousness (65% versus 57.6%, p<0.001) and concentration and memory disturbances (88.9% versus 77%, p<0.001). Both daily and weekly working hours had significantly decreased during the month of Ramadan (p<0.001). Trainees started their daily work 15 minutes later and left 20 minutes earlier, which results in 35 less minutes worked per day, and around 3 and half hours less per week. Most of participants (88.1%) thought that Ramadan had a negative effect on their sleeping pattern and affected their daytime functioning. Although, the percentage of those who took sedative-hypnotics for sleep disorders had significantly dropped from 7% at baseline to 3.3% during this month (p = 0.0001). Conclusion: The present study showed that Ramadan is associated with several changes in eating behaviors and sleep habits. These changes resulted in sleep pattern impairment, increased daytime sleepiness and reduced work performance. Healthy sleep and eating habits with a suitable work rhythm should be recommended to Fasted medical trainees to minimize the impact of Ramadan on their wellbeing and professional life.

Do inhaled corticosteroids increase the risk of Pneumocystis pneumonia in people with lung cancer

Pneumocystis pneumonia (PCP) is a life-threatening infection in immunocompromised patients. It is relatively uncommon in patients with lung cancer. We report a case of PCP in a 59-year-old man with a past medical history of chronic obstructive pulmonary disease treated with formoterol and a moderate daily dose of inhaled budesonide. He had also advanced stage non-small lung cancer treated with concurrent chemo-radiation with a cisplatin-etoposide containing regimen. The diagnosis of PCP was suspected based on the context of rapidly increasing dyspnea, lymphopenia and the imaging findings. Polymerase chain reaction testing on an induced sputum specimen was positive for Pneumocystis jirovecii. The patient was treated with oral trimethoprim-sulfamethoxazole and systemic corticotherapy and had showed clinical and radiological improvement. Six months after the PCP diagnosis, he developed a malignant pleural effusion and expired on hospice care. Through this case, we remind the importance of screening for PCP in lung cancer patients under chemotherapeutic regimens and with increasing dyspnea. In addition, we alert to the fact that long-term inhaled corticosteroids may be a risk factor for PCP in patients with lung cancer. Despite intensive treatment, the mortality of PCP remains high, hence the importance of chemoprophylaxis should be considered.

Giant cystic schwannoma of the middle mediastinum with cervical extension

Schwannomas (neurilemmomas) are benign tumors arising from the Schwann cells of the neural sheath. They are typically, well-encapsulated lesions which rarely adhere to the adjacent structures. In the chest, schwannomas are often seen within the posterior mediastinum and commonly originating along intercostal nerves. Several operative approaches have previously been described for the resection of these tumors, including thoracoscopic techniques and posterolateral thoracotomy. We report in this case a giant cystic mediastinal schwannoma of the left recurrent laryngeal nerve with cervical extension, unresectable by the usual described approaches, which was completely removed through a cervical approach.

Secondary pleural hydatidosis: Complication of intrapulmonary echinococcosis

Hydatid disease has a wide geographic distribution around the world. In human, the liver is the most commonly affected organ, followed by the lungs. Intrathoracic extrapulmonary locations are generally the mediastinum, pleura, pericardium and chest wall. Pleural involvement usually follows the rupture of a pulmonary or hepatic cyst inside the pleural space causing secondary pleural hydatidosis. We report four cases of patients who were referred to our hospital for management of pleural hydatid disease as a complication of intrapulmonary echinococcosis.

The Impact of Obstructive Sleep Apnea and Daytime Sleepiness on Work Performance: An Observational Cross-Sectional Study in a North African Population

Background: Obstructive sleep apnea hypopnea syndrome (OSAHS) has been shown to be associated with many serious health conditions. The impact on occupational health is still unclear as it was scarcely studied. Purpose: The aim of this study was to assess the association of work performance with OSAHS and daytime sleepiness. Methods: A cross-transversal study was conducted including Tunisian active adult subjects referred for suspected sleep disordered breathing. All subjects completed the Epworth Sleepiness Scale (ESS), the Work Productivity and Activity Impairment Questionnaire (WPAI), and the Patient Health Questionnaire 9 (PHQ9). They all underwent polygraph testing level 3. Result: One hundred thirty-nine subjects completed the survey, including 107 (77%) blue-collar workers, and 32 (23%) white-collar workers. Participants were classified as following: 50 patients with apnea hypopnea index (AHI) ≥ 30 and 89 with AHI <30. Among the four outcomes of the WPAI scale, only presenteeism was associated with AHI (p=0.012). A significant association has been found between daytime sleepiness and three outcomes of WPAI. Sleepy patients with ESS ≥ 11 had lower work performance in terms of presenteeism (42.46 ± 28.40 vs. 24.71 ± 24.77 p=0.0001), absenteeism (12.26 ± 25.51 vs. 6.05 ± 18.32, p=0.101), overall work productivity loss (47.43 ± 31.65 vs. 26.58 ± 28.47, p= 0.0001), and decline in activity (46.67 ± 30.75 vs. 32.14 ± 27.02, p=0.004) in comparison with non-sleepy participants. A strong correlation of presenteeism and overall work productivity loss scores with ESS was demonstrated among white-collar workers (r=0.624, p=0.0001; r=0.602, p=0.0001 respectively). PHQ9 score was significantly higher in sleepy subjects (p=0.0001). Near miss accidents in the workplace and work related accidents were significantly more frequent in those with ESS ≥ 11 (p=0.012, p=0.026; respectively). Conclusion: The most relevant finding of this study was the involvement of daytime sleepiness in performance impairment, while the impact of AHI was less clear.

How does serum brain natriuretic peptide level change under nasal continuous positive airway pressure in obstructive sleep apnea-hypopnea syndrome?

Background Obstructive sleep apnea-hypopnea syndrome (OSAHS) is associated with cardiovascular morbidity and mortality, which can be improved by using continuous positive airway pressure (CPAP) therapy. However, the pathophysiological links between the two kinds of disease and the mechanism of the CPAP effect remain incompletely understood. We aimed to inquire into the myocardial involvement in this relationship. We suggested that serum brain natriuretic peptide (BNP) is sensitive enough to detect myocardial stress caused by OSAHS. Design and methods Sixty-four subjects without cardiovascular disease (21 controls, 24 normotensive OSAHS patients, and 19 hypertensive OSAHS patients) were analyzed for serum BNP at baseline and serially over 6 months. CPAP was applied to 23 patients with severe OSAHS. Results At baseline, the serum BNP levels were significantly higher (p=0.0001) in the OSAHS group (22.3±14.79 pg/ml) than in the control group (9.2±6.75 pg/ml). Increased serum BNP levels were significantly associated with mean transcutaneous oxygen saturation (SpO2) (p<0.0001), minimal SpO2 (p=0.002), oxygen desaturation index (p=0.001), and total sleep time spent with SpO2 lower than 90% (p=0.002). All patients with elevated BNP levels (≥37 pg/ml) had moderate or severe OSAHS (11/43 OSAHS patients). The more severe the OSAHS, the higher the BNP levels were. However, only the difference between severe and mild OSAHS was statistically significant (p=0.029). Hypertensive OSAHS patients had the highest baseline BNP levels (27.7±16.74 pg/ml). They were significantly higher (p=0.001) than in normotensive OSAHS patients (18±11.72 pg/ml) (p=0.039) and the controls (9.2±6.75 pg/ml). As compared with baseline, treatment with CPAP significantly decreased BNP levels in both hypertensive and normotensive OSAHS patients (respectively, from 36±16.10 to 29.7±14.29 pg/ml, p<0.001, and from 20±10.09 to 16±8.98 pg/ml, p<0.001). In contrast, the BNP levels slightly increased in the controls (from 9.2±6.75 to 9.5±7.02 pg/ml, p=0.029), but there was no statistically significant difference in comparison with the baseline value. The effect of CPAP on BNP levels was more marked in patients with higher baseline BNP levels and those with the most prolonged nocturnal desaturation (p=0.001, r=0.65). It was also more marked in hypertensive OSHAS patients (p=0.015, r=0.72) in comparison with normotensive OSAHS patients (p=0.03, r=0.62). Conclusion BNP seems to be sensitive enough to detect myocardial stress caused by OSAHS. As such, it is a potential marker for screening of preclinical cardiovascular damage in patients with untreated OSAHS. Application of CPAP decreases levels significantly in normotensive and particularly in hypertensive OSAHS. These findings are consistent with previous results suggesting the potential benefits of CPAP on cardiovascular outcome in OSAHS patients.Background Obstructive sleep apnea-hypopnea syndrome (OSAHS) is associated with cardiovascular morbidity and mortality, which can be improved by using continuous positive airway pressure (CPAP) therapy. However, the pathophysiological links between the two kinds of disease and the mechanism of the CPAP effect remain incompletely understood. We aimed to inquire into the myocardial involvement in this relationship. We suggested that serum brain natriuretic peptide (BNP) is sensitive enough to detect myocardial stress caused by OSAHS. Design and methods Sixty-four subjects without cardiovascular disease (21 controls, 24 normotensive OSAHS patients, and 19 hypertensive OSAHS patients) were analyzed for serum BNP at baseline and serially over 6 months. CPAP was applied to 23 patients with severe OSAHS. Results At baseline, the serum BNP levels were significantly higher (p=0.0001) in the OSAHS group (22.3±14.79 pg/ml) than in the control group (9.2±6.75 pg/ml). Increased serum BNP levels were significantly associated with mean transcutaneous oxygen saturation (SpO2) (p<0.0001), minimal SpO2 (p=0.002), oxygen desaturation index (p=0.001), and total sleep time spent with SpO2 lower than 90% (p=0.002). All patients with elevated BNP levels (≥37 pg/ml) had moderate or severe OSAHS (11/43 OSAHS patients). The more severe the OSAHS, the higher the BNP levels were. However, only the difference between severe and mild OSAHS was statistically significant (p=0.029). Hypertensive OSAHS patients had the highest baseline BNP levels (27.7±16.74 pg/ml). They were significantly higher (p=0.001) than in normotensive OSAHS patients (18±11.72 pg/ml) (p=0.039) and the controls (9.2±6.75 pg/ml). As compared with baseline, treatment with CPAP significantly decreased BNP levels in both hypertensive and normotensive OSAHS patients (respectively, from 36±16.10 to 29.7±14.29 pg/ml, p<0.001, and from 20±10.09 to 16±8.98 pg/ml, p<0.001). In contrast, the BNP levels slightly increased in the controls (from 9.2±6.75 to 9.5±7.02 pg/ml, p=0.029), but there was no statistically significant difference in comparison with the baseline value. The effect of CPAP on BNP levels was more marked in patients with higher baseline BNP levels and those with the most prolonged nocturnal desaturation (p=0.001, r=0.65). It was also more marked in hypertensive OSHAS patients (p=0.015, r=0.72) in comparison with normotensive OSAHS patients (p=0.03, r=0.62). Conclusion BNP seems to be sensitive enough to detect myocardial stress caused by OSAHS. As such, it is a potential marker for screening of preclinical cardiovascular damage in patients with untreated OSAHS. Application of CPAP decreases levels significantly in normotensive and particularly in hypertensive OSAHS. These findings are consistent with previous results suggesting the potential benefits of CPAP on cardiovascular outcome in OSAHS patients.

Impact of CPAP treatment on pro-BNP in obstructive sleep apnea syndrome

Background: Obstructive sleep apnea (OSA) patients have increased cardiovascular morbidity and mortality. The cardiovascular markers associated with OSA are currently not defined. Objective: The aim of this study is to evaluate whether repeated apneas and hypoxia influence the levels of pro-brain natriuretic peptide (BNP) in OSAS patients and if these effects could be reversed by treatment. Patients and Methods: A prospective study in 61 consecutive patients with suspected sleep disordered breathing referred to our sleep laboratory was conducted. OSAS was confirmed by polygraphy (PG). Serum pro-BNP was measured prior to and after 3 months of CPAP therapy. Results: Low or high levels of NT- pro-BNP were not associated with apnea-hypopnea index and other sleep related indices (p=0.6).A statistically significant difference was observed between basal and three-month pro-BNP levels in hypertensive (39 +/-9.9 pg/ml to 28 +/-7.4 pg/ml, p=0.03) and normotensive (25.2+/-6.8 pg/ml to 20 +/-5.3 pg/ml, p=0.025) patients with OSAS. Conclusions: CPAP therapy may improve cardiovascular comorbidity and co-mortality in OSAS and sleep disordered breathing, in general.

Revue généraleVieillissement de l’appareil respiratoire : modifications anatomiques et conséquences physiologiquesAging of the respiratory system: Anatomical changes and physiological consequences

The respiratory system undergoes progressive involution with age, resulting in anatomical and functional changes that are exerted on all levels. The rib cage stiffens and respiratory muscles weaken. Distal bronchioles have reduced diameter and tend to be collapsed. Mobilized lung volumes decrease with age while residual volume increases. Gas exchanges are modified with a linear decrease of PaO(2) up to the age of 70 years and a decreased diffusing capacity of carbon monoxide. Ventilatory responses to hypercapnia, hypoxia and exercise decrease in the elderly. Knowledge of changes in the respiratory system related to advancing age is a medical issue of great importance in order to distinguish the effects of aging from those of diseases.

Localisation médiastinale d’une lymphocèle du canal thoracique : à propos d’un cas opéré

Resume Introduction La lymphocele du canal thoracique est une entite pathologique exceptionnelle ; secondaire a la deterioration et a la dilatation kystique de la paroi de ce vaisseau. Son origine peut-etre congenitale ou degenerative. Observation Nous rapportons l’observation d’un patient âge de 47 ans, opere pour formation kystique symptomatique, localisee au niveau du mediastin postero-inferieur, confirmee au scanner. Une thoracotomie postero laterale a permis la resection totale de cette formation qui s’est revelee etre une lymphocele. L’analyse chimique du liquide et l’etude histopathologique de la poche kystique ont confirme le diagnostic. Les suites operatoires etaient simples. Conclusion L’interet de cette observation est de montrer les particularites cliniques de cette entite et d’insister sur les modalites du diagnostic et de la prise en charge operatoire.