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STUDY OBJECTIVES: Asthma and obesity are risk factors for obstructive sleep apnea (OSA) in children but their link to OSA severity is uncertain. We aimed at determining whether asthma or obesity was associated with an increased risk of moderate/severe OSA. METHODS: Children undergoing a one-night polysomnography for suspicion of OSA were retrospectively included. Univariate and multivariate analyses were conducted to assess the clinical and demographic characteristics linked to moderate/severe OSA (obstructive apnea-hypopnea index ≥ 5 events/h of sleep) with odds ratio and 95% confidence interval reported. RESULTS: Four hundred ninety children (311 [64%] boys) were included with a median [25th; 75th percentile] age of 8.7 [5.4; 12.9] years, 164 (33%) nonasthmatics nonobese, 122 (25%) obese nonasthmatics, 125 (26%) asthmatics nonobese, 79 (16%) asthmatics and obese. Moderate/severe OSA was present in 157 (32%) children (75/157 [48%] obese and 52/157 [33%] asthmatics). Independent factors associated with increased or decreased risk of moderate/severe OSA were obesity and male sex (odds ratio 1.82 [1.16; 2.87], P = .01, and 1.55 [1.02; 2.36], P = .04, respectively), and current asthma, age > 6 years, or behavioral disorders (odds ratio 0.45 [0.29; 0.70], P < .001; 0.44 [0.27; 0.73], P < .001; and 0.55 [0.33; 0.92], P = .02, respectively). Abnormal resistance of the respiratory system (measured in 241 children), but not abnormal spirometry (measured in 213 children), increased the risk of moderate/severe OSA (odds ratio 2.95 [1.46–5.96], P = .003). CONCLUSIONS: In our cohort enriched in obese and asthmatic children, obesity was associated with higher risk of moderate/severe OSA whereas current asthma was not. CITATION: Ioan I, Mulier G, Taytard J, Césaire A, Beydon N. Evaluation of obesity and asthma as risk factors for moderate to severe obstructive sleep apnea in children. J Clin Sleep Med. 2022;18(6):1639–1648.

Aims This study addressed two questions: first, does surgical correction of an idiopathic scoliosis increase the volume of the rib cage, and second, is it possible to evaluate the change in lung function after corrective surgery for adolescent idiopathic scoliosis (AIS) using biplanar radiographs of the ribcage with 3D reconstruction? Methods A total of 45 patients with a thoracic AIS which needed surgical correction and fusion were included in a prospective study. All patients underwent pulmonary function testing (PFT) and low-dose biplanar radiographs both preoperatively and one year after surgery. The following measurements were recorded: forced vital capacity (FVC), slow vital capacity (SVC), and total lung capacity (TLC). Rib cage volume (RCV), maximum rib hump, main thoracic curve Cobb angle (MCCA), medial-lateral and anteroposterior diameter, and T4-T12 kyphosis were calculated from 3D reconstructions of the biplanar radiographs. Results All spinal and thoracic measurements improved significantly after surgery (p < 0.001). RCV increased from 4.9 l (SD 1) preoperatively to 5.3 l (SD 0.9) (p < 0.001) while TLC increased from 4.1 l (SD 0.9) preoperatively to 4.3 l (SD 0.8) (p < 0.001). RCV was correlated with all functional indexes before and after correction of the deformity. Improvement in RCV was weakly correlated with correction of the mean thoracic Cobb angle (p = 0.006). The difference in TLC was significantly correlated with changes in RCV (p = 0.041). It was possible to predict postoperative TLC from the postoperative RCV. Conclusion 3D rib cage assessment from biplanar radiographs could be a minimally invasive method of estimating pulmonary function before and after spinal fusion in patients with an AIS. The 3D RCV reflects virtual chest capacity and hence pulmonary function in this group of patients. Cite this article: Bone Joint J 2022;104-B(1):112–119.

International audience; Background: There is a high prevalence of obstructive sleep apnea (OSA) in children with Down syndrome (DS), sometimes associated with alveolar hypoventilation.Objective: To compare transcutaneous partial pressure of carbon dioxide (PtcCO2 ) and pulse oximetry (SpO2 ) in children with DS and in control children with OSA.Patients and methods: This retrospective case-control study involved children followed in Trousseau Hospital (Paris) Sleep Center. Polysomnography (PSG) recordings and clinical files of children with DS were reviewed to identify clinical signs of OSA and comorbidities associated with DS. Controls were children who presented with OSA of ENT origin without other comorbidities (exceptions: two overweight, one obese, and three with well-controlled asthma). DS subjects and controls were matched for age and apnea hypopnea index.Results: There were 28 children in each group. Mean PtcCO2 during sleep was significantly higher in patients with DS compared to controls (44 mm Hg vs 42 mm Hg, P = .001). Five (21%) patients with DS met the American Academy of Sleep medicine criteria for hypoventilation, compared to one (4%) in the control group. The mean PtcO2 during sleep was significantly lower in patients with DS (77 mm Hg vs 82 mm Hg, P = .003).Conclusions: This is the first study to compare nocturnal gas exchange in children with DS to a control group of children with similar OSA. Our data demonstrate that children with DS have increased PtcCO2 regardless of the presence of OSA and its severity. This may be due to respiratory muscle hypotonia and/or ventilatory control alteration in patients with DS.

International audience; Introduction: The recent development of disease-modifying treatments in spinal muscular atrophy (SMA) type 1 shifted these patients' management from palliative to proactive. The aim of this study was to assess patients' nocturnal gas exchanges before noninvasive ventilation (NIV) initiation and their clinical evolution to determine if capnia is a good criterion to decide when to introduce respiratory support.Patients and methods: This multicentric retrospective study reports the respiratory management and evolution of 17 SMA type 1 children (10 females) for whom treatment with Nusinersen was initiated between 2016 and 2018.Results: Median [interquartile range-IQR] age at diagnosis and at first Nusinersen injection was of 4 [3;8] and 4 [3;9] months, respectively. Patients were followed during 38 [24;44] months. Thirteen (76%) patients were started on NIV at a median [IQR] age of 12 [9;18] months. Repeated hospitalizations and intensive care unit admissions were needed for 11 of them. Blood gas and nocturnal gas exchange recordings performed before NIV initiation were always normal. 9/13 X-ray performed before NIV showed atelectasis and/or acute lower respiratory tract infections. There was a significant decrease in the total number of hospital admissions between the first and second year of treatment (p = 0.04).Conclusion: This study shows that patients do not present with nocturnal hypoventilation before respiratory decompensations and NIV initiation, and suggests that a delay in NIV initiation might result in respiratory complications. There is a need for disease-centered guidelines for the respiratory management of these patients, including NIV indications.

International audience; Rationale: Elexacaftor-tezacaftor-ivacaftor is a CFTR (cystic fibrosis [CF] transmembrane conductance regulator) modulator combination, developed for patients with CF with at least one Phe508del mutation. Objectives: To evaluate the effects of elexacaftor-tezacaftor- ivacaftor in patients with CF and advanced respiratory disease. Methods: A prospective observational study, including all patients aged ⩾12 years and with a percent-predicted FEV1 (ppFEV1)

International audience; Nemaline myopathies are clinically and genetically heterogeneous muscle diseases characterized by the presence of nemaline bodies (rods) in muscle fibers. Mutations in the KLHL40 (kelch-like family member 40) gene (NEM 8) are common cause of severe/lethal nemaline myopathy. We report an 8-year-old girl born to consanguineous Moroccan parents, who presented with hypotonia and poor sucking at birth, delayed motor development, and further mild difficulties in walking and fatigability. A muscle biopsy revealed the presence of nemaline bodies. KLHL40 gene Sanger sequencing disclosed a never before reported pathogenic homozygous mutation which resulted in absent KLHL40 protein expression in the muscle. This further expands the phenotypical spectrum of KLHL40 related nemaline myopathy.

Asthmatic children free of exacerbation with airway obstruction may have low partial pressure of oxygen (PaO2) which can be a marker for future risk, but PaO2 is scarcely measured during pulmonary function testing. We prospectively included asthmatic children with airway obstruction referred for pulmonary function testing, including blood gas analysis (n = 51). Hypoxaemia, defined as a value lower than − 2 z-score, was present in 15 (29%) children, and 37 (72%) children had a significant reversibility after bronchodilator administration. The multivariable model showed a positive influence of baseline forced expiratory volume in 1 s (FEV1) on PaO2 (β coefficient 0.69, [95% CI: 0.07; 1.30]; P = 0.03), whereas uncontrolled asthma and FEV1 reversibility negatively influenced it (β coefficient − 1.59 [95% CI: − 2.74; − 0.44]; P = 0.01; and − 0.07 [95% CI: − 0.13; − 0.02]; P = 0.01, respectively). As a consequence, children with uncontrolled symptoms of asthma and FEV1 reversibility ≥ 12% were significantly more at risk of having hypoxaemia compared to children with well/partly controlled asthma or no significant reversibility of FEV1. Conclusion: Among obstructive asthmatic children without current exacerbation, hypoxaemia is more likely to be seen in children with uncontrolled asthma and a significant post-bronchodilator FEV1 reversibility, in favour of different pathophysiology and treatment requirements of their airway obstruction.

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.

International audience; Objective: To describe the characteristics of children treated with long term continuous positive airway pressure (CPAP) or noninvasive ventilation (NIV) in France.Design: Cross-sectional national survey.Setting: Paediatric CPAP/NIV teams of 28 tertiary university hospitals in France.Patients: Children aged

ObjectiveTo evaluate the safety and clinical efficacy of nusinersen in patients older than 7 months with spinal muscular atrophy type 1 (SMA1).MethodsPatients with SMA1 were treated with nusinersen by intrathecal injections as a part of the Expanded Access Program (EAP; NCT02865109). We evaluated patients before treatment initiation (M0) and at 2 months (M2) and 6 months (M6) after treatment initiation. Survival, respiratory, and nutritional data were collected. Motor function was assessed with the modified Hammersmith Infant Neurologic Examination Part 2 (HINE-2) and physiotherapist scales adjusted to patient age (Children's Hospital of Philadelphia Infant Test of Neuromuscular Disorders and the Motor Function Measure 20 or 32).ResultsWe treated 33 children ranging in age from 8.3 to 113.1 months between December 2016 and May 2017. All patients were alive and were continuing treatment at M6. Median progress on the modified HINE-2 score was 1.5 points after 6 months of treatment (p < 0.001). The need for respiratory support significantly increased over time. There were no statistically significant differences between patients presenting with 2 and those presenting with 3 copies of the survival motor neuron 2 (SMN2) gene.ConclusionsOur results are in line with the phase 3 study for nusinersen in patients with SMA1 treated before 7 months of age and indicate that patients benefit from nusinersen even at a later stage of the disease.ClinicalTrials.gov identifier:NCT02865109.Classification of evidenceThis study provides Class IV evidence that for patients with SMA1 who are older than 7 months, nusinersen is beneficial.

International audience; Background: While the prevalence of Stenotrophomonas maltophilia lung infection in cystic fibrosis (CF) patients has increased in the last decades, its pathogenicity remains controversial. The aim of this study was to investigate the effects of S. maltophilia initial infection on the progression of lung disease in CF children.Methods: This case‐control retrospective study took place in a pediatric CF center. A total of 23 cases defined by at least one sputum culture positive for S. maltophilia, were matched for age, sex, and CFTR mutations to 23 never infected CF controls. The clinical data were collected for 2 years before and after S. maltophilia initial infection and comprised lung function analyses, rates of exacerbations and of antibiotic courses.Results: Compared with controls, cases had lower lung function (P = 0.05), more frequent pulmonary exacerbations (P = 0.01), hospitalizations (P = 0.02), and intravenous antibiotic courses (P = 0.04) before S. maltophilia acquisition. In the year following S. maltophilia initial infection, lung function decline was similar in cases and controls but cases remained more severe, with more frequent pulmonary exacerbations (P = 0.01), hospitalizations (P = 0.02) and intravenous antibiotic courses (P = 0.02).Conclusions: S. maltophilia seems to be a marker of CF lung disease severity and international recommendations to reduce lung infection by this pathogen should rapidly emerge.

Background Pulmonary hemosiderosis is a rare and complex disease in children. A previous study from the French RespiRare® network led to two important findings: 20% of the children presented with both pulmonary hemosiderosis and Down syndrome (DS), and at least one tested autoantibody was found positive in 50%. This study investigates the relationships between pulmonary hemosiderosis and DS. Methods Patients younger than 20 years old and followed for pulmonary hemosiderosis were retrieved from the RespiRare® database. Clinical, biological, functional, and radiological findings were collected, and DS and non-DS patients’ data were compared. Results A total of 34 patients (22 girls and 12 boys) were included, among whom nine (26%) presented with DS. The mean age at diagnosis was 4.1 ± 3.27 years old for non-DS and 2.9 ± 3.45 years old for DS patients. DS patients tended to present a more severe form of the disease with an earlier onset, more dyspnoea at diagnosis, more frequent secondary pulmonary hypertension, and an increased risk of fatal evolution. Conclusions DS patients have a higher risk of developing pulmonary hemosiderosis, and the disease seems to be more severe in this population. This could be due to the combination of an abnormal lung capillary bed with fragile vessels, a higher susceptibility to autoimmune lesions, and a higher risk of evolution toward pulmonary hypertension. A better screening for pulmonary hemosiderosis and a better prevention of hypoxia in DS paediatric patients may prevent a severe evolution of the disease. Electronic supplementary material The online version of this article (10.1186/s13023-018-0806-6) contains supplementary material, which is available to authorized users.

International audience; Primary ciliary dyskinesia (PCD) and cystic fibrosis (CF) both entail bronchiectasis and pulmonary impairment as measured using spirometry, during childhood. We aimed at looking whether blood gas exchanges progressed differently between CF and PCD children in a retrospective study of repeated measurements. Comparisons between groups (Wilcoxon-Mann-Whitney and Chi-squared tests) and a mixed linear model, adjusted for age, evaluated associations between diseases and PaO2, PaCO2, or PaO2-PaCO2 ratio.Among 42 PCD and 73 CF children, 62% and 59% had respectively bronchiectasis (P = 0.75). Spirometry and blood gases were similar at inclusion (PaO2 median [IQR] PCD −1.80 [−3.40; −0.40]; CF −1.80 [−4.20; 0.60] z-scores; P = 0.72). PaO2 and PaO2-PaCO2 ratio similarly and significantly decreased with age in both groups (P

Objectives Osteogenesis imperfecta (OI) is the most common genetic skeletal disorder. Extraskeletal findings are common but an association with sleep-disordered breathing (SDB) has never been described. The aim of this study was to investigate clinical features of children with OI and suspected SDB. Methods A retrospective study of clinical records, signs of SDB and polysomnographic recordings of children with OI was performed. We paid particular attention to symptoms that could be associated with SDB in this population – scoliosis, kyphosis, vertebral arthrodesis, chest wall deformities, basilar impression, autonomy – as well as data already known to be associated with obstructive sleep apnea such as body mass index and upper-airway impairment. Results We reviewed the clinical charts of 188 patients referred to our genetic skeletal disorders reference center for OI. Among the 15 patients (8%) with polysomnographic recordings, 12 (6.4%) had sleep-disordered breathing. We found a negative correlation between the Brief Assessment of Motor Function score and Apnea Hypopnea Index (r = −0.68; p = 0.01) and Desaturation Index (r = −0.62; p = 0.02). The Apnea Hypopnea Index was higher for non-walkers than walkers (mean [SD]: 6.5 [3.6] vs. 2.4 [1.5]; p = 0.02) and with type III versus IV OI. Two patients were started on continuous positive airway pressure ventilation, with clinical improvement. Conclusion For OI children, symptoms suggesting obstructive sleep disorders should be searched for systematically, especially in children with compromised autonomy, high body mass index, trunk deformations, and severe OI type.

Background: Spinal muscular atrophy is an autosomal recessive neuromuscular disorder that is caused by an insufficient level of survival motor neuron (SMN) protein. Nusinersen is an antisense oligonucleotide drug that modifies pre–messenger RNA splicing of the SMN2 gene and thus promotes increased production of full-length SMN protein. Methods: We conducted a randomized, double-blind, sham-controlled, phase 3 efficacy and safety trial of nusinersen in infants with spinal muscular atrophy. The primary end points were a motor-milestone response (defined according to results on the Hammersmith Infant Neurological Examination) and event-free survival (time to death or the use of permanent assisted ventilation). Secondary end points included overall survival and subgroup analyses of event-free survival according to disease duration at screening. Only the first primary end point was tested in a prespecified interim analysis. To control the overall type I error rate at 0.05, a hierarchical testing strategy was used for the second primary end point and the secondary end points in the final analysis. Results: In the interim analysis, a significantly higher percentage of infants in the nusinersen group than in the control group had a motor-milestone response (21 of 51 infants [41%] vs. 0 of 27 [0%], P Conclusions: Among infants with spinal muscular atrophy, those who received nusinersen were more likely to be alive and have improvements in motor function than those in the control group. Early treatment may be necessary to maximize the benefit of the drug.

International audience; BACKGROUND: Although the negative impact of environmental tobacco smoke (ETS) on airway diseases in children is well known, the effect of ETS on allergic sensitization is still debated. OBJECTIVE: To evaluate how maternal allergies modulate the effect of tobacco exposure on allergic sensitization in childhood. METHODS: Of 9000 children in grades 4 and 5 selected in 6 cities in France, 7798 participated in a survey that consisted of an epidemiologic questionnaire, skin prick testing to common allergens, and skin examination for eczema. Tobacco exposure was obtained from parent questionnaires. RESULTS: Twenty-five percent of the children had allergic sensitization, 25.2% had eczema, 11.6% had allergic rhinitis, 9.9% had asthma, and 8.3% had exercise-induced asthma. Twenty percent of the children were exposed to tobacco in utero. Maternal exposure had a greater impact than paternal exposure on children's allergic sensitization. Prenatal exposure was more associated with sensitization than postnatal exposure. Children with maternal allergies and exposure to maternal ETS during pregnancy were at higher risk for sensitization to house dust mite (25.7% vs. 14.0%; odds ratio, 1.95; 95% confidence interval, 1.19-3.18; P = .006). In contrast, sensitization to food allergens was not associated with tobacco exposure. CONCLUSIONS: Children exposed to maternal smoking had a higher risk of sensitization to house dust mite, especially when the mothers were allergic.

International audience; BackgroundLow-dose azithromycin has beneficial effects on severity of the lung disease in cystic fibrosis (CF) patients for a period of 6–12 months after initiation of the treatment. Although its impact in the longer term is uncertain, this treatment is frequently used chronically. The aim of this retrospective study was to investigate the effects of low-dose azithromycin treatment on the progression of CF lung disease in patients treated for more than 12 months.MethodsAll of the CF patients followed in our pediatric center and who had been on low-dose azithromycin for more than 12 sequential months were included. The clinical data were collected for one year before and three years after the initiation of the azithromycin treatment. These data comprised lung function analyses, rates of exacerbations and of antibiotic courses, and changes in the airways' bacterial colonization.ResultsA total of 68 patients were included (mean age: 9.95 yrs (3.61)). After 12 months, significant reductions in the numbers of pulmonary exacerbations and antibiotic courses were present. However, this effect was not maintained in the subsequent periods, during which increased rates of both pulmonary exacerbations and antibiotic courses were observed. The lung function decline was not modified during the treatment, and a decreasing time-dependent trend typical of CF was observed for the various parameters. No differences in the airway colonization by pathogens such as P. aeruginosa and methicillin-sensitive and/or -resistant Staphyloccocus aureus were observed during the treatment. However, isolated Staphyloccocus aureus strains became resistant to macrolides after 6 months of azithromycin and remained resistant thereafter.ConclusionsNo clinical benefits of low-doses azithromycin were present after one year of treatment in young CF patients. Selection for macrolide-resistant strains of bacteria occurred, which should lead to a reconsideration of the duration of azithromycin treatment in CF.

International audience; Pulmonary hyalinizing granuloma (PHG) is a rare disease characterized by single or multiple benign lung nodules mimicking lung neoplasma. Histologic analysis reveals homogenous hyaline lamellae, usually surrounded by collection of plasma cells, lymphocytes and histiocytes in a perivascular distribution. The clinical and radiological findings have been described in small series, but the long-term outcomes have rarely been reported. The objectives were to describe the clinical, radiological and outcomes of PHG in new cases and through a literature review. Patients with PHG were found by a multicenter search among French departments of internal medicine, pulmonology and anatomo-pathology. Review of the literature was made through the National Library of Medicine’s MEDLINE database using keywords “hyalinizing granuloma.” Five news cases and 135 cases of the literature were found. There were 82 men and 57 women, mean age at the diagnosis 44.6 years (15–83). Patients were frequently asymptomatic (n = 39, 27.4 %). The nodule was unique in 37 cases (28.9 %) and multiple in 91 cases (71.1 %). 18FDG PET scan revealed hypermetabolism of the nodule in 9/15 cases (60 %). A systemic disease was associated in 65 cases (mainly mediastinal and retroperitoneal fibrosis, autoimmune, tumoral or infectious disease or thromboembolism). The outcomes were evaluated in 73 patients when follow-up was available: 14 patients had a surgical resection of the nodule. Forty-five patients did not receive any immunosuppressive drug. Among these patients, 2 improved, 29 were stable and 14 worsened. Corticosteroids were used as a monotherapy in 19 patients and led to radiological improvement in 8 cases, stabilization in 8 cases and worsening in 3 cases. Five patients were treated with corticosteroids and at least one immunosuppressive drug and 4 patients improved. PHG is a rare benign disease, mimicking lung neoplasma, frequently associated with systemic diseases.

To evaluate the prevalence of nocturnal symptoms in a large sample of asthmatic patients, and to assess the agreement between patients' complaints and general practitioners' (GPs') reports in primary care.Cross-sectional survey involved 3,526 GPs and 751 specialists (pulmonologists and allergists) and included 13,493 patients with persistent asthma. Symptoms, treatment, and social and medical data were collected in real time by the patients and their GPs.France.Prevalence of nocturnal symptoms was 60%. A total of 7,989 patients with nocturnal symptoms had complete data for both patients and GPs; 3,849 (48.1%) had perfect agreement between GP and their complaints for nocturnal symptoms (agreement group; [kappa = 1]); 3,376(42.2%) declared having no symptoms during the night, but these were detected by the GP during the visit (underestimated by patients and detected by GPs); 773(9.6%) declared having nocturnal symptoms, but these were not detected by GPs. Patients with a good agreement with their GP's opinion were significantly more frequently followed-up by a specialist than other patients (p = 0.002).Nocturnal symptoms appear to be underdeclared by patients. GPs should therefore systematically ask their patients about nocturnal symptoms to increase control of asthma and to adequately manage its treatment.

Background: Quality of life (QOL) is an important component of evaluation in oncology. Usually, QOL is used in phase III studies to compare two treatments. The aim of this trial was to evaluate the impact of the disclosure of the diagnosis of cancer on QOL by using the European Organisation for Research and Treatment of Cancer core Quality of Life Questionnaire (EORTC QLQ)-C30 questionnaire and the supplemental lung cancer-specific module QLQ-LC13. Patients and methods: Patients hospitalised for exploration of an abnormal chest X-ray, with no previous history of cancer, a performance status ≤2, and able to fulfil the questionnaire were eligible. The patients answered the questionnaire two times: before (Q1) and after (Q2) the disclosure of the diagnosis. Results: Seventy patients answered at Q1 and Q2. After the disclosure, some scores deteriorated: arm pain ( P =0.009), physical functioning ( P =0.01), role functioning ( P =0.008), emotional functioning ( P =0.0001) and social functioning ( P =0.012), whereas the patients' own assessment of global QOL (item global QOL in functioning scales) did not show the same evolution. Conclusion: Disclosure of the diagnosis had an impact on social and emotional QOL. Patients with lung cancer need psychological support at the beginning of their disease.

Background: The AIR II study is a prospective multicentre assessing management of lower respiratory tract infections (LRTIs) in adults by general practitioners (GPs). Epidemiological studies generally address the prescriptions of antibiotics. To our knowledge, little is known about the real impact of non-antibiotic therapeutic prescriptions (defined here as co-prescriptions) in LRTI. Therefore, the aim of the study was to evaluate non-antibiotic prescriptions in LRTIs. Methods: Two thousand general practitioners (GPs) were randomly selected and asked to participate in each of 30 predefined areas covering mainland France. The patient's sociomedical record was completed by the GP during the consultation and sent to the data processing centre at the same time as an anonymous copy of his prescription. The GP also had to report the inclusion by telephone and agree to a telephone appointment with an interviewer. Results: GPs (n=3144) reported 5469 evaluable cases. Pneumonia accounted for 9.6% of diagnoses, acute exacerbations of chronic bronchitis 14.9% and acute bronchitis 72.5%. Antibiotics were prescribed to 96.5% of patients. In addition to the 5270 prescriptions of antibiotics, co-prescriptions proved to be twice as numerous as prescriptions of antibiotics (10,027 prescriptions for 5115 patients). Mucomodifiers, steroidal anti-inflammatory drugs and bronchodilators were significantly more prescribed in AECB than others. Non-steroidal anti-inflammatory drugs and antitussives were significantly more prescribed in acute bronchitis than AECB or CAP. Conclusions: Our results suggest that recommendations of management in LRTIs need to take into account co-prescriptions.

International audience; BACKGROUND: Allergic sensitization to Alternaria has been related to asthma in various studies, but its association with allergic rhinitis is still controversial. OBJECTIVES: The aim of this study was to assess at the population level the relationships in childhood between Alternaria sensitization and 'past-year rhinoconjunctivitis' (PYRC), 'ever hay fever' (EHF) and 'ever allergic rhinitis caused by allergens other than pollens' (EAR) according to the presence or the absence of asthma. METHODS: This study is part of the Six Cities Study, the French contribution to the International Study of Asthma and Allergies in Childhood (ISAAC) Phase II. Children underwent skin prick test (SPT) to Alternaria and parents filled a standardized medical questionnaire. RESULTS: Some 6726 children with a mean age of 10 years were examined. The overall prevalence of Alternaria sensitization was 2.8%, 0.8% for monosensitization. Prevalences of symptoms in sensitized children were 27.7% for PYRC, 27.0% for EHF and 30.4% for EAR. Adjusted Odds Ratios (OR) between Alternaria sensitization and allergic rhinitis phenotypes were 2.34 (95% confidence interval: 1.51-3.63) for PYRC, 2.40 (1.65-3.50) for EHF and 2.95 (2.05-4.23) for EAR. The relationship still remained in the case of monosensitization to Alternaria for both PYRC and EAR when excluding the asthmatic children [OR = 3.87 (1.54-9.78) and 2.88 (1.10-7.55) respectively]. CONCLUSION: In our population-based sample of children, we found a link between Alternaria sensitization and allergic rhinitis, independently of asthma, which is compatible with the mechanisms of deposition of Alternaria in the upper airways.

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.

We prospectively considered 65 patients admitted for a spontaneous pneumothorax (SP) to describe the pragmatic management of SP, the first recurrence-free interval after medical therapeutic procedure and to specify the first recurrence risk factors over a 7-year period in these patients treated medically. The treatment options were observation alone (9%), needle aspiration (6%), small calibre chest tube (Pleurocatheter) drainage (28%) or thoracic tube drainage (49%), and pleurodesis with video-assisted thoracic surgery procedure (8%). Duration of the drainage and length of hospital stay were shorter in the Pleurocatheter group than in the thoracic tube group (P < 0.01). Among the 47 patients (72%) with a first SP and treated medically, nine patients (19%) had a first homolateral recurrence (FHR) during a mean follow-up of 84+/-13 months. Recurrence-free intervals ranged from 1 to 24 months (mean +/- SD: 9.3+/-8.4 months). FHR cases were more frequent in the Pleurocatheter group (P < 0 04). Analysis of potential risk factors showed that the patient's height and a previous homolateral SP episode are independent recurrence risk factors.

International audience; BACKGROUND: Fine particulate matter has been linked to allergies by experimental and epidemiological data having used aggregated data or concentrations provided by fixed-site monitoring stations, which may have led to misclassification of individual exposure to air pollution. METHODS: A semi-individual design was employed to relate individual data on asthma and allergy of 5338 school children (10.4 +/- 0.7 years) attending 108 randomly chosen schools in 6 French cities to the concentrations of PM2.5 (fine particles with aerodynamic diameter 2.5 microm) assessed in proximity of their homes. Children underwent a medical visit including skin prick test (SPT) to common allergens, exercise-induced bronchial (EIB) reactivity and skin examination for flexural dermatitis. Their parents filled in a standardised health questionnaire. RESULTS: After adjustment for confounders and NO2 as a potential modifier, the odds of suffering from EIB and flexural dermatitis at the period of the survey, past year atopic asthma and SPT positivity to indoor allergens were significantly increased in residential settings with PM2.5 concentrations exceeding 10 microg/m3 (WHO air quality limit values). The relationships were strengthened in long-term residents (current address for at least 8 years). CONCLUSIONS: Findings support the hypothesis that changes in allergy prevalence observed in recent decades might be partly related to interactions between traffic-related air pollution and allergens. Further longitudinal investigations are needed to corroborate such results.

International audience; Among early-life environmental factors, parental smoking (ETS) has been associated with adverse respiratory outcomes in children. The aim of the study was to evaluate whether parental smoking might lead to asthma and allergies taking into account family history of asthma, personal atopy, breast feeding as confounders and owing pets and day-care during the first 6 months of life as modifiers. About 9000 children of fourth and fifth grade were selected in six cities of France. About 7798 answered an epidemiological questionnaire, underwent a medical examination including skin prick test positivity to common allergens, skin examination for eczema, and run test to assess exercise-induced asthma (EIA). Prevalence of allergies was, respectively, 25.2% for eczema, 12.9% for rhinitis, 9.9% for asthma and 25% for atopy. About 8.3% had an EIA. About 21.6% of children were exposed to maternal tobacco smoking during pregnancy. Maternal smoking, in utero and later, was significantly related to lifetime wheezing (odds ratio (OR): 1.24[1.10-1.56]) and asthma (OR: 1.22[1.04-1.66]). There was no association between atopy, rhinitis, eczema and parental smoking, respectively. ETS remains a risk factor of wheezing in childhood. Counselling parents of children to quit smoking still remains a public health policy.

Criteria for the prescription of long-term oxygen therapy (LTOT) have been published by academic societies and regulatory bodies, but many prescriptions for LTOT do not fulfil these criteria. Demographic, functional data and survival were compared in chronic obstructive pulmonary disease (COPD) patients with different levels of oxygenation, i.e. arterial oxygen tension (Pa,O2) < 8 kPa or > or = 8 kPa (60 mmHg), at the time of initial registration in the ANTADIR Observatory. Data were collected between 1984-1995. Selection criteria were a diagnosis of COPD or emphysema with forced expiratory volume in one second (FEV1) < 80% pred, FEV1/vital capacity (VC) < 70% and age between 18-75 yrs. Of 7,700 patients prescribed LTOT 18.5% had stable Pa,O2 > or = 8 kPa. While the FEV1 was the same they differed from the patients with more severe hypoxaemia in having a higher rate of diagnosis of primary emphysema and a lower arterial carbon dioxide tension (Pa,CO2). In this group of patients LTOT was more frequently administered as liquid oxygen than in other patients on LTOT. The survival of these patients was reduced compared to the general population of the same age and sex but comparable to that of patients with a Pa,O2 between 6.7-8 kPa (50-60 mmHg). Patients prescribed long-term oxygen therapy with an arterial oxygen tension > or = 8 kPa (60 mmHg) in the ANTADIR network were shown to have severe chronic obstructive pulmonary disease on the basis of spirometry and their survival was similar to that of more hypoxaemic patients. Randomized controlled trials of the effect of long-term oxygen therapy in patients with arterial oxygen tension > or = 8 kPa are needed.

International audience; BACKGROUND: Whereas effects on allergic and respiratory health have been established for passive tobacco smoking, contradictory results still exist for active tobacco smoking. OBJECTIVE: Whether adolescents with asthma and allied diseases have higher rates of active smoking compared with adolescents without asthma was assessed after controlling for environmental tobacco smoking exposure. METHODS: A population-based sample of 14,578 adolescents was enrolled in an epidemiological survey on allergies in France. RESULTS: After controlling for age, sex, geographic region, familial allergy and passive smoking, current (in the past year) wheezing (12.4%), current asthma (5.6%), lifetime asthma (12.3%), current rhinoconjunctivitis (13.9%), lifetime hayfever (14.4%) and current eczema (9.3%) but not lifetime eczema (22.5%) were all significantly related to active smoking (>1 cigarette/day) (9.3%). A higher risk of current wheezing, current and lifetime asthma or current eczema was seen in smokers exposed to passive smoking compared with smokers not exposed to it using a polychotomous logistic regression model, in which the different modalities of exposure to active and passive smoking constituted the response variable. Passive smoking was significantly associated only with current diseases. Active smoking was also highly related to both severe asthma (OR=4.02; 95% confidence interval: 1.37, 11.79) and severe rhinoconjunctivitis (OR=2.95; 1.58, 5.49). The highest rate of adolescents suffering from the co-morbidity of lifetime asthma and hayfever (3.6%) was also seen in active smokers compared with passive and non-smokers (5.5% vs. 3.6% and 3.1%, respectively; P=0.001). CONCLUSIONS: Being asthmatic or allergic does not seem to act as a deterrent towards starting active smoking or continuing to smoke in adolescence. Results suggest the need for considering individual allergic status in programming health educational activities aimed at reducing smoking among adolescents.

Besides environmental triggers, a family history of asthma is a strong risk factor for the development of asthma in offspring. The pooled data from 13,963 interviews of randomly selected, 20 to 48 yr-old participants from the 30 centers of the European Community Respiratory Health Survey (ECRHS) were analyzed with conventional logistic regression and a Class A regressive model adapted for the segregation of various transmission modes in families. The asthma prevalence in the interviewed index generation was 6.9% (95% confidence interval [CI]: 6.5 to 7.3), and in the parent generation was 6.1% (5.8 to 6.4). As with asthma prevalence, the risk of a subject having asthma if a parent had asthma also had a large geographic variation across the survey centers. The mean risk if a father had asthma was 2.9 (2.4 to 3.5), and If the mother had asthma was 3.2 (2.6 to 3.9). The risk increased to 7.0 (3.9 to 12.7) if both parents were affected. For developing extrinsic asthma, extrinsic asthma in any parent was a greater risk factor (4.9 [3.9 to 6.0]) than intrinsic asthma of the parent (1.5 [0.8 to 2.6]), and the risk for women was slightly higher than that for men (4.3 [3.3 to 5.5] versus 3.6 [2.6 to 5.0]). Applying different segregation models, only a model for a two-allele gene with a codominant inheritance could not be rejected, assuming a major gene with a population frequency of 24.2%. Further results make a multilocus/threshold model likely. In conclusion, a history of asthma in parents is a strong risk factor for asthma in the offspring. Under the assumptions of the applied segregation analysis, at least one major gene exists which could be a gene involved also in allergy. However, asthma is not fully described by a single-gene model. The risk for asthma varies within the European countries, and should be seen in the context of a complex genetic and environmental pathophysiology.

International audience; SETTING: Whether and how cigarette smoking influences asthma are still matters of debate. OBJECTIVE: To identify risk factors associated with asthma according to whether individuals began active smoking before or after asthma onset. DESIGN: A sample of 544 individuals was examined using the protocol of the European Community Respiratory Health Status, Phase 1. RESULTS: Current active smoking (43.6%) was associated with wheezing during the past year (15.2%, OR 3.7; 95% CI 1.7-8.4), but not with asthma (17.6%, OR 0.78; 95% CI 0.48-1.26). However, active smoking modulated risk factors for asthma. Asthma that developed before smoking and asthma without smoking were both significantly related to nasal allergy, parental asthma and atopy (as assessed by skin prick test positivity and increased total and specific IgE levels). Only a lower FEV1 level was significantly associated with asthma that initiated after beginning smoking. CONCLUSIONS: Our data put forward different phenotypes of asthma according to the timing of smoking onset and suggest that asthma either never accompanied by smoking or followed by smoking onset might be characterised by an allergic pattern. Longitudinal studies are warranted to further clarify the relationships among asthma phenotypes according to the sequence of disease onset and smoking.

The authors are indebted to the collaborators in the participating centres and all parents, children, teachers and other school staff who participated in the surveys. There are many field workers and funding agencies who supported data collection and national, regional and international meetings, including the meetings of the ISAAC Steering Committee. Unfortunately, these are too numerous to mention (they are acknowledged elsewhere) but the authors particularly wish to thank the funders who supported the ISAAC International Data Centre including the Health Research Council of New Zealand, the Asthma and Respiratory Foundation of New Zealand, the National Child Health Research Foundation, the Hawke’s Bay Medical Research Foundation, the Waikato Medical Research Foundation, Glaxo Wellcome New Zealand and Astra New Zealand, as well as Glaxo Wellcome International Medical Affairs for finding the regional coordinating centres. The International Data Centre is now supported by a grant from the BUPA Foundation., The International Study of Asthma and Allergies in Childhood (ISAAC) Phase One showed large worldwide variations in the prevalence of symptoms of asthma, rhinoconjunctivitis and eczema, up to 10 to 20 fold between countries. Ecological analyses were undertaken with ISAAC Phase One data to explore factors that may have contributed to these variations, and are summarised and reviewed here. In ISAAC Phase One the prevalence of symptoms in the past 12 months of asthma, rhinoconjunctivitis and eczema were estimated from studies in 463,801 children aged 13 - 14 years in 155 centres in 56 countries, and in 257,800 children aged 6-7 years in 91 centres in 38 countries. Ecological analyses were undertaken between symptom prevalence and the following: Gross National Product per capita (GNP), food intake, immunisation rates, tuberculosis notifications, climatic factors, tobacco consumption, pollen, antibiotic sales, paracetamol sales, and outdoor air pollution. Symptom prevalence of all three conditions was positively associated with GNP, trans fatty acids, paracetamol, and women smoking, and inversely associated with food of plant origin, pollen, immunisations, tuberculosis notifications, air pollution, and men smoking. The magnitude of these associations was small, but consistent in direction between conditions. There were mixed associations of climate and antibiotic sales with symptom prevalence. The potential causality of these associations warrant further investigation. Factors which prevent the development of these conditions, or where there is an absence of a positive correlation at a population level may be as important from the policy viewpoint as a focus on the positive risk factors. Interventions based on small associations may have the potential for a large public health benefit., peer-reviewed

Summary The uptake of the monoamine radiolabelled tracer 125I-meta-iodo-benzyl-guanidine (MIBG) was studied in vitro in platelets from 15 healthy volunteers and five allergic patients whose serum IgE concentration was 37 ± 33 and 650 ± 200 IU/ml, respectively. The MIBG uptake was determined by means of a gamma counter after incubation in a buffer. Binding of IgE to platelets significantly reduced MIBG uptake both in healthy subjects and in allergic patients. This reduction was significantly related to the action of IgE as it did not occur after binding of IgG. Moreover, MIBG uptake plotted versus increasing concentration of IgE (ranging from 10 to 3000 IU/ml) was fitted by a classical sigmoidal curve which was not significantly different between healthy subjects and allergic patients. Lastly, the effect of IgE on MIBG uptake was due to the binding of the sole IgE as it was not modified by subsequent addition of anti-IgE. It is concluded that the binding of the sole IgE to its specific receptor on platelets alters the transport of monoamines.

Pirarubicin (THP) (Roger Bellon Laboratory, France) is a new anthracycline under clinical development. In order to assess the efficacy and toxicity of the drug in small-cell lung carcinoma (SCLC), we have undertaken this trial in front-line therapy in patients with metastatic disease, PS less than 3 and at least one evaluable lesion. Responses were assessed after two cycles of THP (60 mg/m2 i.v. bolus every 3-4 weeks) and a further cross over to VP16 + CDDP (three cycles) was systematic whatever the response to THP. This crossover was performed after only one cycle in case of obvious progression. From June 1988 to April 1990, 32 patients were enrolled: 6 were ineligible (4 non-SCLC, 2 M0), 26 patients were fully evaluable for THP and 18 patients for VP16-CDDP. The characteristics of the patients were as follows: mean age 57.4 years (38-71); T4: 54%; T3: 27%; T2: 19%; N3: 62%; N2: 35%; No: 4%. The efficacy was as follows 1 complete response and 2 partial responses (confirmed by endoscopy); 12 patients received only one cycle because of obvious progression; the overall response rate is 12% (95% confidence interval 0-24%). The patient who had complete response after pirarubicin remained in CR after VP16-CDDP, whereas the 2 patients who had partial response achieved CR for one and PR for the other; among the 15 who did not respond 1 CR and 7 PR were observed. The only significant toxicity of THP was granulopenia without infection. THP seems to be an effective anthracycline in SCLC, and the study is continuing. A response could be reached in 50% of the nonresponders with standard therapy and 10 of 24 patients (42%) finally responded. Therefore, this schedule for testing new drugs in metastatic SCLC appears ethically acceptable.

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.

The most popular way to define asthma based on questionnaires is to use definitions taken from cross-sectional international studies on asthma. These definitions may not, however, be optimal for future studies focusing on risk factors of asthma. The current authors, therefore, compared the performance of different operational definitions of asthma. The European Community Respiratory Health Study I was a cross-sectional study of 21,924 subjects aged between 25-44 yrs in 18 countries. Operational definitions of asthma compared included different combinations of symptoms of asthma and bronchial hyperresponsiveness. A continuous asthma score, ranging from 0-8, was defined as the sum of positive answers to eight main symptom questions. There was no threshold in the associations of asthma symptoms with severity or risk factors of asthma, which would have suggested a dichotomous definition of asthma. Using dichotomous definitions requiring the presence of several asthma symptoms strengthened associations with studied risk factors, and also increased the estimated specificity and positive predictive value. Using a continuous asthma score also improved the power of the analyses. In conclusion, dichotomous definitions of asthma yielding higher odds ratios are achieved by requiring positive responses to several questions on symptoms. However, symptoms of asthma are possibly best analysed as a continuous asthma score.

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.

Summary Background : Smoking is a preventable cause of increased morbidity and mortality. Therefore, interventions have been used to assist smokers in overcoming their addiction. The aim of the study was to describe factors associated with smoking cessation, in patients applied to our smoking cessation (SC) unit in 1999, in a prospective study. Methods : Patients were followed-up during two years. Detailed medical history, Fagerstrom test, Hospital Anxiety and Depression (HAD) scale questionnaire, Motivation scale and replacement therapy were systematically recorded. Results : Three hundred patients (58% men, 42% women) applied to the SC unit from January to December 1999. The mean age was 42yrs old. They smoked in average 24 cig/d. Mean duration of smoking was 20 years. Fagerstrom score was 5.86 (min 0; max: 10). Patients seemed to be more anxious (score 9.6) than depressed (5.09), according to the HAD score. 79% of them received both psychosocial intervention, pharmacotherapy and nicotine replacement therapy. 66% of patients were followed-up ( n = 198 ). Two years later, the smoking cessation rate was 12% ( n = 36 ). Motivation, Fagerstrom and HAD scores were not associated with the quitting rate. Quitting rate was higher (25.9%) in patients who attempted to quit smoking for the first time than in others (19%). By contrast, the quitting rate was significantly associated with age ( P = 0.03 ). Conclusion : Success to quit smoking was positively associated with age, and negatively with alcohol dependence.

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.

Vocal cord dysfunction (VCD) has been frequently discussed as confounding the diagnosis of asthma, and it is recommended to examine vocal cord function in cases of difficult asthma. However, there is also strong evidence that asthma may be associated with VCD, sometimes masquerading as exercise-induced asthma. Gerhardt's syndrome frequently induces severe acute respiratory distress requiring ventilatory support, and this condition might be mistaken for a severe acute asthma attack. Here, a case of bilateral paralysis of the vocal cords, which was associated with asthma, is described.

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.

The Analyse Infections Respiratoires (AIR) II study is a prospective, multicentre survey of the management of lower respiratory tract infections in patients aged 15-65 yrs by general practitioners (GPs) in France. To obtain real-time data recording, practitioners were required to submit an anonymous copy of their drug prescriptions. They were then interviewed over the telephone about the patients' sociodemographic data, signs and symptoms, as well as their presumptive diagnosis and the investigations they had decided upon. GPs (n=3,144) reported 5,469 evaluable cases. Pneumonia accounted for 9.6% of diagnoses, acute exacerbations of chronic bronchitis 14.9% and acute bronchitis 72.5%. The symptomatology covered an extremely wide range of clinical features, which, although statistically different in terms of incidence, overlapped to a large extent across diagnoses. By contrast, hospitalization, investigations or referral to a specialist were much more prevalent in pneumonia, although still very infrequent in general terms (0.5, 1.2 and 10.8%, respectively). Antibiotics were prescribed in 96.5% of patients, with minor differences between diagnoses. However, other medications such as nonsteroid, anti-inflammatory drugs, steroids, nonspecific antitussives and bronchial liquefiers accounted for two-thirds of the prescriptions. This study demonstrates the lower respiratory tract infections encountered by general practitioners are usually mild. However, antibiotic prescription was more systematic than in previous studies and the prescription of nonspecific symptomatic treatments was twice as frequent. General practitioners did not perform additional examinations or refer on a regular basis. There was a high prescription rate for symptomatic treatment.

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.

Primary lung non-Hodgkin's lymphoma is a rare neoplasm mostly represented by low-grade B-cell lymphomas of mucosa-associated lymphoid tissue. Their diagnostic criteria are now well defined on surgical specimens, but pathologists may experience difficulties in distinguishing them on exiguous biopsies from benign lymphoid hyperplasia and other lymphomas. Therefore, we examined a series of 26 lung lymphoid lesions to further define the pathologic features of either lymphoma or lymphoid hyperplasia on small specimens. We observed 16 primary lung non-Hodgkin's lymphomas with a large predominance of low-grade mucosa-associated lymphoid tissue-type lymphomas (87.5%, n = 14). There were no autoimmune disorders, but three patients had a concomitant infectious disease (hepatitis C virus and Helicobacter pylori gastritis). One patient presented with a synchronous pulmonary adenocarcinoma. As well as the classical mucosa-associated lymphoid tissue cellular infiltrate, immunohistochemical characterization of the 14 mucosa-associated lymphoid tissue-type lymphomas revealed the CD20+/CD43+ centrocyte-like cell phenotype in 10 cases (71.5%). Although the lymphoepithelial lesions observed in all lymphomatous cases have been reported in lung lymphoid hyperplasia, the determination of B-cell CD20+/CD43+ phenotype of the intraepithelial lymphocytes highly increased the specificity of lymphoepithelial lesions. A monoclonal immunoglobulin heavy chain gene rearrangement was present in 71.4% of the mucosa-associated lymphoid tissue-type lymphoma specimens. Investigation of H. pylori by polymerase chain reaction detection was negative, even for the two cases associated with H. pylori gastritis.

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.