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International audience; IntroductionThe reference technique to measure the diffusing capacity of the lung for carbon monoxide (DLco) is the single-breath method (sb). For patients unable to perform this method, the rebreathing method (rb) can be used. However, the clinical relevance of DLCOrb has not been evaluated. The aim of this study was to assess the feasibility of the rb method in children seen in a clinical setting and its relationships with sb method.Subjects and methodWe prospectively included children referred for 1) a suspected or confirmed interstitial lung disease (ILD group) (DLCOsb and DLCOrb measurements) ; 2) controlled asthma with normal lung function (DLCOrb measurements to derive DLCOrb/KCOrb expected values). DLCOrb was computed from the decrease in CO and Helium concentrations during tidal breathing in a rebreathing bag.ResultsData on DLCOrb measurements were available for 53 (91%) children in the ILD group and 48 (91%) control children (mean (range) 11.5 (4.3-18.2) and 9.5 (4-17) years ; respectively). In the ILD group, high or moderate correlations were found between raw DLCOrb and DLCOsb values (rhô = 0.82 ; P < 0.0001) and between KCOrb and KCOsb (rhô = 0.62 ; P < 0.0001), respectively. Results expressed as percentage predicted were moderately correlated (rhô = 0.55 ; P = 0.0003 for DLCO ; rhô = 0.51 ; P = 0.001 for KCO).ConclusionDLCOrb is easy to perform in children and gives values that are highly correlated to DCLOsb. Our preliminary results are in favour of a possible clinical use after further validation.; IntroductionLa capacité de transfert du monoxyde de carbone (DLCO) est mesurée par la méthode de référence durant une apnée (DLCOap) ou, en cas d’impossibilité d’obtenir une DCLOap, en respiration spontanée avec d’autres méthodes dont celle de la réinspiration (rebreathing ; rb). L’objectif était d’évaluer la faisabilité en clinique de la mesure en réinspiration et sa corrélation avec la mesure en apnée.Population et méthodeÉtude prospective sur une cohorte d’enfants explorés pour 1) pathologie interstitielle diffuse (PID) suspectée ou confirmée ; 2) asthme contrôlé avec fonction respiratoire normale (mesures rb pour en déduire les valeurs attendues de DLCOrb/KCOrb). DLCOrb était calculée à partir de la décroissance des concentrations en CO et en Hélium dans un ballon de réinspiration.RésultatsDLCOrb a été obtenue chez 53 (91 %) enfants PID (11,5 (de 4,3 à 18,2) ans) et 48 (91 %) contrôles (9,5 (de 4 à 17) ans). Dans le groupe PID, les valeurs de DLCOap, DLCOrb et KCOap, KCOrb étaient respectivement fortement ou modérément corrélées en valeurs absolues (rhô = 0,82 ; p < 0,0001 et rhô = 0,62 ; p < 0,0001), et modérément corrélées en pourcentages (rhô = 0,55 ; p = 0,0003 et rhô = 0,51 ; p = 0,001, respectivement).ConclusionDLCOrb est facile à réaliser et fortement corrélée à DLCOap, en faveur de son utilisation possible après validation clinique.

In childhood and adolescence overweight is defined as a body mass index (BMI) above the 97th percentile for age and sex, according to the curves established by the International Obesity Task Force (IOTF). In France, it is estimated that 25 % of children under 18 years old are overweight. Overweight and obesity in this population are multifactorial, with an important influence of genetic factors, modulated by pre and post-natal (maternal smoking), societal and psychological determinants. The impact of obesity on respiratory function in children is mostly characterized by a decreased FEV1/FCV. Moreover, several studies have shown an association between asthma and overweight/obesity, with a pejorative impact of BMI on asthma control. However, asthma is still poorly characterized in this population, and the determinants of bronchial obstruction seem to differ from non-obese children, with less eosinophilic inflammation. Obstructive sleep apnea syndrome (OSAS) is a frequent complication of obesity, affecting up to 80% of obese children and adolescents. It has a specific polysomnographic definition in children. Symptoms are similar to adult OSAS, but with cognitive and neurobehavioral alterations often more important in adolescents. The treatment consists in ENT surgery when indicated (with systematic post-operative polysomnography), and nocturnal continuous positive airway pressure (CPAP). The obesity-hypoventilation syndrome (OHS) has the same definition in children as in adults and affects up to 20% of obese patients. Treatment consists in nocturnal ventilation using bilevel positive airway pressure (BiPAP). Finally, in some extreme cases, bariatric surgery can be performed. The indication should be discussed in a specialised paediatric reference centre.

Personalized medicine, or P4 medicine for "Personalized", "Predictive", "Preventive" and "Participatory", is currently booming for cystic fibrosis, with the development of therapies targeting specific CFTR mutations. The various challenges of personalized medicine applied to cystic fibrosis issues are discussed in this paper.

International audience; To evaluate whether fine air particles could be involved in the occurrence of atopy and allergic diseases, we performed a cross-sectional epidemiological survey involving primary schoolchildren living in six French towns with contrasted air pollution levels. Air pollution was measured during a week in the school yards and by standard air monitoring networks. Children get an examination in school looking for atopic dermatitis and bronchial hyperresponsiveness assessed by a standardized run test. Besides, parents or guardians provided past medical history and environmental data, especially on passive smoking. Overall, 5,338 children, aged 10.4 (+/-0.7) years, coming from 108 different schools and 401 different classes were included in the survey. Taking into account potential confounders, high exposure to proximity PM(2.5) was linked to a higher point prevalence of atopic dermatitis and hyperresponsiveness, to a higher cumulative prevalence of allergic asthma and a higher sensitization rate to common indoor allergens. Thus, these data suggest that chronic exposure to urban fine particles could be a risk factor for atopy, hyperresponsiveness and asthma.

Macrolides are well-known antibiotics exerting antimicrobial as well as anti-inflammatory and immunomodulatory effects. Since the observation of a dramatic improvement in lung disease and survival in patients with diffuse panbronchiolitis, macrolides have been used over the long term in several chronic respiratory diseases. This review describes the results of trials that have evaluated long-term macrolides in the treatment of cystic fibrosis, non-cystic fibrosis bronchiectasis, and asthma, particularly focusing on the impact on children. It also provides new insights on the potential effects of macrolides on diffuse parenchymal lung diseases.

Mayotte is a French territory island, part of the Comoros Archipelago in the Indian Ocean with 200,000 inhabitants. The tuberculosis control program started in 1976, although available epidemiological data remains incomplete. We conducted a retrospective hospital-based survey in 202 outpatients and hospital medical records from the Hospital Centre of the main city to contribute to the epidemiological evaluation of tuberculosis patterns. The tuberculosis frequency remains unchanged since 2000. It affects a young population partly coming from the other neighbouring Comoro Islands (69%) with illegal immigrate status (53% in 2004). The systematic diagnostic screening efficiency of the condition appears marginal. Pulmonary involvement is the most frequent clinical manifestation (78%), although severe extrapulmonary manifestations are not exceptional. Co-infection with HIV and multi resistance to antituberculosis agents are not frequent. Up to 60% of cases have been proven to be bacteriologically linked. The notification rate remains critically low with an estimate of 39% of notifications to the local sanitary authorities in charge of secondary cases screening. The case coverage seems limited both by low socio-economical status and poor health facility accessibility The loss of follow up is dramatically high, 41% on the overall period, and up to 51% in 2004. Our results make mandatory the reinforcement of a tuberculosis survey and control involvement within the context of this French territory. Screening, care and follow up are to be implemented particularly for vulnerable and precarious groups and for patients.

Renal complications of sarcoidosis are rare but they may lead to renal failure. The two most common mechanisms are interstitial nephritis and acute hypercalcaemic renal failure. We report the case of a woman who presented both of these complications.

Chronic respiratory failure (CRF) has an impact on quality of life because of respiratory handicap.The purpose of this study was to analyse the daily life and social activities of patients with CRF. A questionnaire was addressed to over 9000 patients being cared for in the ANTADIR homecare network, with over a 60% response rate.The data showed that patients were old, and frequently had comorbidity. The predominant diagnosis was chronic obstructive airways disease (COPD) and the number of women in this population continues to increase. Respiratory handicap led to a loss of autonomy, a reduction in social activity and mobility of patients, but the impact differed markedly according to the cause of the respiratory failure, as well as age and social class. A typological study of behavioural characteristics revealed three groups of patients with contrasting profiles.These results lead to recommendation for better management of social aspects of patient care in the ANTADIR network.

The level of a patient's knowledge about his disease and its treatment is an essential part of an educational assessment. It is useful therefore to make use of a rapid, easy and valid method to collect the information necessary to develop an educational programme adapted to the needs of the patient. The aim of this study is to validate, in a structured way, a knowledge questionnaire on chronic obstructive pulmonary disease (COPD).Following a revue of the literature an initial questionnaire was constructed. It included of four domaines: biomedical aspects; symptoms and signs of severity; general knowledge and treatments. The questionnaire was tested on 35 subjects with COPD in order to assess its clarity and comprehensibility. It was reviewed and modified in both content and format by 11: French experts. The reproducibility was studied by repeat testing.The first version of the questionnaire developed by the working party consisted of 50 items. It was reduced to 41 items after interviews with 35 COPD patients and evaluation by 11 experts. The questionnaire appeared to be reproducible: mean concordance 79.5%; minimum 53.3%; maximum 100% and intra-class correlation coefficient 0.53.This study lead to the development of a French language COPD knowledge questionnaire.

Education in COPD is clearly recommended. The general practitioner (GP) plays a key role in COPD management, and his view on education in medicine is crucial for him to implement it. This work aims at exploring what is the GP's representation of education in COPD.Twenty-seven GP were enrolled in this qualitative research focused on three points: "COPD patient", "COPD patient's education", "tools in COPD patient education". The interviews processing has been carried out by an ALCESTE software (Analysis of Co-occurrent Lexemes in the Simple Terms of a Text) that extracts the key significant structures of a text.Actually, the GPs do not really speak about therapeutic education, they have a rather fuzzy representation of it. They face, in their daily practice, a lack of patients' awareness of the disease, they call to mind an educational model group close to the Alcoholics Anonymous (AA), and the most adequate location for this education looks to be, for them, the hospital. The emotional dimension is noticed, targeted atthe patient and his family circle. In their relationship with their patients, the GPs describe their part as more prescriptive than educative.The GPs' speech analysis shows that education is not a part of their COPD management; the results of our study enable us to foresee the actions to carry out to develop the concept of COPD education in general practice.

Asthma education is a subject of topical interest and is included in the current guidelines. Everyone agrees on the importance of the concepts of the disease in determining the patient's therapeutic behaviour but there have been few studies of the patient's views on asthma education.42 asthmatics replied to an interview bearing on the following themes: asthma in daily life, therapeutic education and methods of education. The interviews were analysed by the ALCESTE software programme (analysis of co-occurrent lexemes in the simple wording of a text) that extracts the major significant components of a text.The first theme was dominated by thoughts about treatment, long term rather than acute, and by problems of everyday life and relationships with others; the second by the organisation, presentation and form of education and the third by thoughts about the information required, its relevance and implications.Asthmatic patients' concepts of therapeutic education are poorly defined. There expectations are implicit but they are not fully aware of them. Clarifying these factors will be a way of creating a better basis for an educational programme.

A patient's knowledge of his disease and its treatment is an essential part of the evaluation of an educational process. It is useful therefore to use a rapid, easy and valid means of collecting the information necessary to produce an educational programme adapted to the needs of the patient.Following a review of the literature an initial questionnaire was constructed. It included four domains: biomedical, signs and symptoms of severity, general knowledge and treatment. The questionnaire was administered to 73 asthmatics in order to assess its clarity and comprehensibility. It was then reviewed and modified in both format and content by 10 French experts. The revised questionnaire was completed by 108 asthmatics distributed throughout 10 French respiratory centres, a group of 83 non-asthmatic subjects and 203 sixth year medical students at the Bordeaux University School of Medicine.The mean scores were: 19 for the non-asthmatics (range 2-36), 25.7 for the asthmatics (range 4-38) and 32.9 for the students (range 17-40), p 0.0001. The questionnaire was shown to be discriminating with good reliability and reproducibility: alpha Cronbach coefficient=0.82; intra-class correlation coefficient=0.70.This study has validated a French language asthma knowledge questionnaire.

A 43-year-old woman presented with a recent history of intermittent dyspnea with wheezing. The chest x-ray evidenced mediastinal nodes. A CT scan showed vascular embolism. Mediastinoscopy was performed and pathology examination of the node confirmed the diagnosis of sarcoidosis. The patient responded to corticosteroid and anticoagulation therapy. Is this a fortuitous association? A vascular localization of sarcoidosis? Thrombosis by compression?

Therapeutic education is part of the recommendations for management of asthmatics. The general practitioner (GP) is an essential link in the management and his/her presentation of education plays an important role in how it is received. This study examines the presentation of therapeutic education by GP's.21 GP's took part in a qualitative enquiry bearing on the following themes: "the asthmatic" and "education of the asthmatic patient". The interviews were analysed by the ALCESTE software programme (Analysis of co- occurrent leximes in the wording of a text) which allows the extraction of the major significant structures of a text.It was found that GP's associate therapeutic education with education in general. They evoke self-teaching tools while they retain the group as the most relevant structure. The notions of time and background treatment were separated. The idea of patient autonomy did not appear spontaneously in the discussion even though it is the foundation of the concept. Analysis of the discussion illustrates the gap that exists between the concepts upon which the recommendations are based and presentation of therapeutic education to asthmatics by GP's.Training of GP's appears to be an essential condition for the development of therapeutic education.

Recent epidemiological studies have shown an increase in the prevalence of asthma and allergic diseases. Among aetiological factors, the domestic environment and, in particular, pet ownership may be a part of it. The relationship between severity of asthma and pets is still unclear. The aim of this study was to evaluate the relationship of asthma and rhinitis prevalence in teenagers with pet ownership.ISAAC I studied 3,303 teenagers (13-14 years old) in Bordeaux in 1994. They completed a written questionnaire about asthma, rhinitis, eczema and their domestic environment. Four groups (asthmatics, asthmatics with rhinitis, teenagers with only rhinitis and a control group without asthma and rhinitis) were studied.4.6% had only asthma. 43.2% had only rhinitis. 10.3% had asthma and rhinitis, 41.7% had no allergic disease. 34.9% kept a cat and 79.4% allowed the cat to go inside. No difference was found between the four groups with regard cat, dog, bird or other pet ownership irrespective if the pet was kept in-doors or out doors. The prevalence of previous asthma was 45.8% and 50.3% for current asthma. No difference was found between the severity of asthma and pet ownership.This is an epidemiological study based on a written questionnaire. Furthermore there is no data on the presence of pets during the first year of life. However, our results suggest that pet ownership amongst asthma and rhinitis sufferers is not different to that in the group without allergic disease.

The impact of asthma on every day life is an important consideration in asthma management. Tobacco use often starts during adolescence, but little is known about its effect on the asthmatic process. The aim of this study is to describe the impact of smoking habits on the every day life of adolescents with asthma. A survey of respiratory symptoms in children aged 13-14 years was conducted in Bordeaux France as part of the International Study of Asthma and Allergies in Childhood (ISAAC). 494 out of the 3.302 adolescents surveyed had a diagnosis of asthma. They filled in a further questionnaire on smoking habits and on the impact asthma had on their every day life. Respiratory symptoms were more frequent among current smoking asthmatic adolescents than non-smoking asthmatic adolescents. The impact of asthma on daily life, with implications for performance at school, family life, psychological status and future job prospects were different for smokers and non-smokers, with problems more prevalent for active smoking asthmatic adolescents. In a multiple regression analysis with confounding factors adjustment, school absence was reported more often in active smokers. Active smoking has an important impact on the every day life of asthmatic adolescents.

We conducted a descriptive epidemiology study to examine the conditions of management of infectious lung disease in institutionalized elderly populations (population profile, diagnostic and therapeutic modalities) and to analyze the general and mental consequences in terms of independence (impact of the infectious event on the subject's life style).A pragmatic survey was conducted by a multicentric observatory composed of 573 general practitioners, practicing in nursing homes. The series included 1790 patients aged over 70 years and residing in nursing homes who developed infectious lung disease over a 10-month period. The MMSE score was used to assess mental status and the Barthel index to assess functional handicap. Each patient was evaluated at the time of the final diagnosis (prescription of an antibiotic or decision for hospitalization) and at most 3 days after the end of this treatment or at discharge from hospital.The elderly population (84 +/- 7 years) was predominantly composed of women. The patients were treated for an acute respiratory infection considered in 30% of the cases to be acute lobar pneumonia. Subgroups of patients were identified for analysis: death (3.7%), x-ray confirmation of the diagnosis (11.5%), hospitalized patients (10.2%). In addition to major deterioration of the general health status, a consequence of the infection more than of the severity of the respiratory symptoms, the development of an acute episode coincided with reduced intellectual functions and onset of a state of confusion. In 70% of the cases, this resulted in a loss of independence of variable importance--simple difficulty for moving around to major functional handicap. The infectious episode was cured or improved (persistence of minor signs not requiring specific treatment) in 94.3% of the cases with appropriate antibiotics: single-drug regimen in 93.7% give per os (75%) or intravenously (25%) using aminopenicillin (with or without a beta lactamase inhibitor) in 80% of the cases. Antibiotic treatment was associated with physical therapy in more than half the cases, and with general conticosteroids in 40%. The treatment scheme was modified in 9.4% of the cases (change of antibiotic in 6%).This survey confirms the high risk related to general conditions in elderly institutionalized patients who develop respiratory infection. More than the infection itself, the rapid degradation of the general health status, or decompensation of comorbid states can create life-threatening situations or favor the development of irreversible handicaps.

The purpose of this study was to describe the diagnostic and therapeutic strategies used by general practitioners (GPs) in patients with lower respiratory tract infections (LRTI).Four hundred fifty GPs practicing in France participated in the study; they included 804 patients. The GP recorded social and demographic data and their prescription on a data sheet and responded to a phone questionnaire about their strategy.Most of the LRTI were acute bronchitis (72%); pneumonia and acute exacerbations of chronic bronchitis were observed respectively in 11% of the patients recruited. Diagnostic criteria used by the GPs were generally auscultation signs in patients with fever, cough and expectoration. Specialized advice (always a chest physician) and hospitalization were exceptional. Prescription of complementary exams was strongly related to the diagnosis of pneumonia (OR = 33.3; CI0.95: 15.48-70.4). Sick leaves were related to general symptoms (fever, asthenia). Antibiotics were prescribed in 95.7% of the patients, mainly aminopenicillin (40.4%) and macrolides (33.2%). Nonsteroidal or steroidal antiinflammatory drugs were prescribed in 72.5% of the patients irrespective of the LRTI diagnosis.The fact that GPs do not often refer patients to specialists or order hospitalization confirms their important role in setting up recommendations. It would also be necessary to develop an education program on better use of antibiotics targeted to GPs and patients.

Asthma patients, in their daily life, may experience 3 different situations needing 3 types of management: attack (which is an emergency issue); post-attack period (very often under-diagnosed and under-treated, what is one of the major relapse factors); stable state (which should be the "natural" state of any chronic patient). Despite the availability of very active treatments, asthma still represents an handicap for many patients, and mortality rates go unchanged. All this has lead to issue asthma severity scales and consensus therapeutic management guidelines. Promoting and implementing these guidelines is the only way for improving asthma management.

Respiratory allergic diseases include seasonal allergic rhinitis or hay fever, perennial allergic rhinitis and allergic asthma. Prevalence of asthma is difficult to assess through epidemiological questionnaires. In France hay fever roughly affects 6% of children and 18% of teenagers and nasal allergies, more than one fourth of young adults. Prevalence of asthma is equal to 10 to 15% in teenagers and 7 to 9% in young adults. Risk factors include genetic as well as environmental factors. The role of the former have been exemplified in family studies, especially twin studies, and surveys of inbred populations. Environmental factors can be allergic or non-allergic. The influence of allergenic exposure on sensitization, occurrence and severity of respiratory allergic disease is well documented. The triggering influence of non-allergenic factors on established allergic diseases is also clear. In contrast, their implication in allergic sensitization and occurrence of allergic diseases need to be clarified.

The purpose is to determine the response to, and toxicity of docetaxel (Taxotère) in patients with inoperable non small cell lung cancer (NSCLC), previously untreated. Seventy patients with stage IIIB or IV NSCLC were treated by 100 mg/m2/ 3 weeks of docetaxel until tumor progression or severe toxicity. Premedication with diosmine and prednisolone was given in all patients: 66/70 were eligible and 55/70 were assessable for antitumoral activity. Median age: 63 years, WHO performans status 0-1: 83%, stage IV: 96%. For eligible patients, 17/66 (26%) achieved an objective response: 1 complete response and 16 partial response (IC 95% = 15-36). With a median follow-up of 23.4 months (range 14.9-28.7), for evaluable patients, the median response duration was 8 months, the median time to progression 4 months, and the median survival time 10 months. The median number of administered cycles is 5 (range 1-12). The estimate one year survival rate was 47%. Seventy-six patients presented neutropenia (grade 3-4); febrile neutropenia was observed in 7% of cycles. Non haematological toxicities are: fluid retention related to docetaxel (2.9%), diarrhea (6%), nausea-vomiting (4%), asthenia (3%), nail changes (6%). Docetaxel (Taxotère) administered at 100 mg/m2/3 weeks has relevant clinical activity in previously untreated NSCLC with a acceptable toxicity.

Determine the response to, and toxicity of docetaxel (Taxotere) in patients (pts) with inoperable non-small-cell lung cancer (NSCLC) previously treated with platinum-containing chemotherapy.Twenty-seven patients with stage IIIB or IV NSCLC, having received one platinum-containing regimen were treated with 100 mg/m2/3 weeks of docetaxel until tumor progression or severe toxicity. Premedication with prednisolone and diosmin was given in all patients. Antitumoral activity was assessable in 21/27 pts. Median age: 52 years; WHO performance status 0-1: 77% pts, stage IV disease: 63% pts.6/21 eligible pts (24%) achieved a partial response to treatment [C.I 95%: 5.6-42]. Median time to progression: 2.9 months, median survival: 8.5 months with a median follow-up of 23.7 months (range: 13.5-27). Hematologic toxicity: grade 3-4 neutropenia: 75% pts, febrile neutropenia: 11% cycles. Non hematologic toxicities: fluid retention, rash, alopecia, sensory neuropathy, asthenia, and nail changes.Docetaxel (Taxotere) administered at 100 mg/m2/3 weeks has relevant clinical activity against platinum treated NSCLC pts. Neutropenia is the main toxicity.

In the Lazarus' transactional model of stress, each individual when facing a stressful situation, set up specific adjustement strategies called coping, including a meaningful pattern of cognitive, behavioral, emotional and somatic responses. Coping strategies used by asthmatic patient are relatively unknown. The objective of this study was to assess the usual coping strategies. We administered the WCC (a shortened version of Lazarus and Folkman's questionnaire) to 116 asthmatic patients and 880 healthy adults French subjects (males and females). A principal component analysis, followed by varimax rotations yielded three factors accounting for about 68.2% of the total variance. They were interpreted as Problem-focused, Emotion-focused and Social-support seeking types of coping. These two first dimensions of coping were closed to those generally described in the literature. Asthmatic patients used more emotion-focused strategy than the control group. These results and their theoretical and practical implications are discussed.

Lower respiratory tract infections (LRTI) are very often managed by General Practitioners (GPs). In France, the 1991 Lille Consensus Conference set out guidelines for the management of respiratory tract infections; in 1994, the Ministry of Health published Official Medical Recommendations (OMR) to be applied to seasonal respiratory infections. The aim of the study is to evaluate the impact of these OMR in 1995 on GPs' attitude when confronted with a community-acquired pneumonia in a previously healthy 40-year-old adult, with no sign of complications. Sixty seven GPs took, part in the same study by questionnaire in 1992 and 1995; we observed an increase in the prescription of aminopenicillin without a beta-lactamase inhibitor (41% in 1992 vs 66% in 1995; p = 0.009), and a reduction in both the use of aminopenicillin with a beta-lactamase inhibitor (35% in 1992 vs 11% in 1995; p = 0.002) and the concomitant prescription of cortico-steroids (43% in 1992 vs 14% vs 14% in 1995; p = 0.0009). Between 1992 and 1995, general practitioners in the Bordeaux region have changed their therapeutic choices in community-acquired pneumonia. In 1995, antibiotic prescriptions followed consensus guidelines more closely.

There is often a discrepancy between doctors' and patients' points of view on asthma. However, few studies have been devoted to the patients' representation of asthma. In this study 27 subjects, with moderate asthma, had to choose from a list of 35 groups of words and expressions, those which look to them to best evoke asthma. The results of this descriptive study show that "allergy" is the most frequently chosen term associated by patients with "suffocate", "attack", "heredity", and "psychic". Asthmatic patients minimise disease severity and refuse to be categorised as ill; they reject terms stigmatising asthmatic subject and the dangerousness of their disease. However, they recognise that asthma has psychological repercussions and prefer self-care. They consider drugs as dangerous and are afraid of their addiction and toxicity. These results have implications on information and education of asthmatic patients. To identify, for each patient, what is his/her representation of his/her disease would be very useful to provide patients with an adapted and personalized help for the management of his/her disease.

Inhaled medications are widely used in patients suffering from bronchial diseases. Beside their pharmacological properties, nebulised solutions have physico-chemical characteristics that can alter bronchial reactivity. Non-isotonic solutions can induce a bronchial hyperresponsiveness and/or a severe bronchonconstriction. Nevertheless, multiple drugs are used for nebulisation despite their unknown osmolarity. The aim of this study was to measure the tonicity of drug solutions commonly used for nebulisation in patients suffering from bronchial disease. Drug solutions were prepared either according to manufacturer recommendations or by diluting the stock in 5 ml of NaCl (0.9%) or H2CO3 (0.14%). Although bronchodilatator solutions (i.e. salbutamol, terbulatine, ipratropium bromide) were nearly isotonic, some drugs prepared for nebulisation had either a very high (e.g. mesna, netilmicine) or a very low (e.g. gomenol, sodium cromoglycate) tonicity. These values may be responsible for bronchoconstriction. Some hypertonic solutions, prepared with drugs such as acetylcytein or netilmycin, are not commercialised for nebulisation but are commonly used for aerosol therapy. In addition, solutions initially isotonic could become significantly hypertonic towards the end of nebulisation. Taken together, these results suggest that non-isotonic solutions should be used with caution specially in patients with bronchial hyperresponsiveness, even when aerosol therapy is prescribed for upper airways.

The consensus of the French Society of Infectious Diseases established in 1991 states that Streptococcus pneumoniae and Haemophilus influenzae are the main causal agents of community-acquired lower airway infections and that antibiotics constitute the "prudent" solution in case of acute bronchitis which persists more than one week or in case of pneumonia in "fragile" at-risk adults. The efficacy of these "probabilistic" recommendations depends on the epidemiology of the infectious agents. The objective of this study was to identify the causal germs in lower airway infections and determine their sensitivity to the antibiotics recommended in the consensus statement. The study was conducted from December to March, in 1992 and 1993. Expectoration samples were obtained from 111 cases including 29 patients with chronic bronchitis. Seventy different strains were isolated including 24 strains of H. influenzae (3 betalactamase producers), 15 strains of S. pneumoniae (1 with reduced sensitivity to peni G: MIC = 1 mu/ml), 9 strains of S. aureus (2 methicillin resistant), and 8 strains of Branhamella catarrhalis (6 betalactamase producers). The number of positive serologies was very low: 5 Chlamydiae pneumoniae, 2 Chlamydiae trachomatis and 1 Mycoplasma pneumoniae. In conclusion H. influenzae is the most frequent germ; S. pneumoniae infections with reduced peni-G sensitivity and atypical germs are uncommon. The consensus recommendations appear to be adapted to the bacterial flore causing community-acquired lower airway infection in healthy and at-risk subjects.

Moderate asthma is a frequent disorder in general medicine. In 1990, the British Thoracic Society published their first guidelines on the management of asthma. Three years later, we have studied, using a questionnaire, the diagnosis and therapeutic criteria of moderate asthma used by general physicians, and comparing these to the guideline recommendations. Out of 46 physicians questioned in Bordeaux, 40 (87 per cent) agreed to participate in the study. Thirty two physicians (80 per cent) described as moderate an asthma which was mild according to the guidelines; eight physicians (20 per cent) described a moderate asthma according to the guidelines; twenty five (63 per cent) considered as severe a moderate asthma according to the recommendations, although eleven (28 per cent) considered it as moderate and four (10 per cent) did not give an opinion. In total, four (10 per cent) judged asthma severity according to the guidelines (Group R), twenty one (52 per cent) over-estimated the severity of moderate asthma (Group S), and fifteen (37 per cent) gave an inconsistent assessment (Group 1). Twenty six (65 per cent) prescribed an association of beta-2-agonists and inhaled corticosteroids for moderate asthma. Although most of the questioned physicians gave an appropriate treatment for moderate asthma treatment adapted to the severity of the situation, their therapeutic approach did not seem to be based upon the same criteria than that recommended in the guidelines.

Improvement in the bronchial obstruction is the aim of treatment for patients with chronic bronchitis. In this work, we attempted to identify subjective psychosocial and neurophysiological factors which are essential for understanding the quality of life in these patients. The study included 77 male patients under 80 years of age who were diagnosed as having chronic bronchitis by their family physician. In all cases, the disease state was stable without any other complication or co-morbidity. Each patient responded to a questionnaire and underwent volume-flow tests. The population was divided into 2 groups by VEMS: VEMSor = 50% (n = 48) and VEMS50 (n = 19). Main component analysis followed by varimax rotation was used to analyse data. A Cronbach coefficient was calculated to measure data skewness. The Pearson correlations were calculated for the different factors. Mean intergroup means were compared with the unpaired t test. Data analysis demonstrated two physical factors: dyspnea and bronchial obstruction; 4 psychological factors: anxiety, impotency/hopeless feeling, depression, fatigue: and one psychological trait. Key symptoms of chronic bronchitis developed in patients with affective states contributing to the patient's subjective description of his disease and influencing therapeutic management. A better understanding of these patients is needed to improve treatment of chronic bronchitis.

Because asthma is an episodic disease with intermittent and unpredictable manifestations, the patient must be constantly on the alert to his condition, causing permanent stress for the entire family. The time and effort spent for treatment can be a great burden for the patient and his family and friends, sometimes causing a handicap in school or profession life. Consequently, the way relatives, friends, and society in general perceive asthma can have an effect on their reaction to the disease. Dominant attitudes in a given social setting create a standard, socially accepted definition of the disease which can play an essential role in asthma-induced morbidity. The link between morbidity, mortality, poverty and quality of health care is a constant feature in epidemiological data on asthma. In areas where pollution is low or access to health care unimpaired, survival curves for asthma patients are similar to those for the non-asthmatic population, demonstrating the role of the social context in asthma-induced mortality. One must however be very prudent in analyzing epidemiological data on asthma since most published work has been conducted in a specific cultural and medical context, often with a health care structure which is quite different from the situation in France. In order to improve the situation of the asthma population in France, two essential questions, "which patients suffer from their asthma?" and "which patients die from their asthma?" must be answered. Then in order to reach those patients which do not consult, the general population should then be informed. Important targets include better informing general practitioners, facilitating access to health care, training asthma patients, and improving social aid to compensate for the patient's economic incapacity. No matter what improvements in treatment are acquired, in these factors are not taken into consideration, there can be little hope of improving asthma-induced morbidity and mortality.

In order to compare the clinical efficacy and safety of cefatrizine (Cefaperos) and cefpodoxime proxetil (Orelox) in the treatment of secondarily infected chronic obstructive pulmonary disease (COPD) in adults, a multicentre, randomized, open study was conducted by 60 general practitioners in two parallel groups of patient suffering from COPD complicated by an acute episode of superinfection (Anthoniesen stages 2 and 3). After verification of the eligibility criteria, written consent and randomization, the patients received, for 10 days, either cefatrizine at the dose of 1 g/day or cefpodoxime proxetil at the dose of 400 mg/day. A self-assessment form was given to the patient. A telephone visit was planned for D3. The final visit on D11 +/- 1 evaluated clinical efficacy (success or failure) and safety. The study population was composed of 250 patients with a mean age of 59.9 +/- 15.9 years (sex ratio M/F = 1.5). The principal etiology of COPD was chronic bronchitis in 67.5% of patients, longstanding asthma in 24.5% and emphysema in 6.8%. The mean history of the disease was 13.0 +/- 10.8 years. The Anthoniesen score was equal to 2 in 73.6% of patients, 3 in 8.8% of patients and 1 in 17.6% of patients. No significant difference concerning these criteria was observed between the two study groups. The clinical success rate was equivalent in the two groups. The time to regression of clinical signs tended to be shorter, up until the sixth day (mainly between D4 and D6) for patients treated with cefatrizine (p = 0.09; NS). The clinical safety was considered to be good and was comparable in the two study groups. This study concluded on the equivalent clinical efficacy of cefatrizine and cefpodoxime proxetil in the treatment of superinfections of COPD in general practice (97.5% and 99%, respectively), with a satisfactory and comparable safety, but with a much lower cost of treatment for cefatrizine. This conclusion is particularly important in the context of opposable medical references, as, although the treatment of superinfections of COPD by second and third generation cephalosporins is frequently proposed, the prescription of a less expensive cephalosporin appears to be more relevant.