[Improving diagnosis of chronic obstructive pulmonary disease in the general population].
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Diagnosis, Differential↗
Biomedical subjects
Nicolas Roche
Publications and source records attributed to Nicolas Roche.
[Chronic obstructive pulmonary disease].
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Bronchodilator Agents↗
Predictors of an appropriate admission to an ICU after a major pulmonary resection.
BACKGROUND: There are no recommendations about admission to an ICU after a major lung resection and there are considerable differences among institutions in this respect. OBJECTIVES: To audit the practice of admission to an ICU after a major lung resection and evaluate factors predicting the need for intensive care. METHODS: Clinicalrecords of all patients who underwent major pulmonary resections in a 14-month period were reviewed retrospectively. The criteria for postoperative admission to the ICU were: (1) standard pneumonectomy if comorbidity index (CI) >0 and/or ASA score >1, and/or abnormal spirometry or arterial gas analysis; (2) extended pneumonectomy; (3) lobectomy if CI >or=4 and/or ASA >or=3; (4) lobectomy if FEV(1) <60% of predicted; (5) lobectomy if FEV(1) is between 60 and 80% and hypercapnia. RESULTS: Among the 49 patients postoperatively admitted to the surgical ward, only 1 needed late intensive care. Among the 55 patients admitted to the ICU, 25 did not require specific intensive care and were discharged 24 h postoperatively, whereas the remaining 30 patients required specific intensive care. Multivariate analysis identified ASA score, predictive postoperative DL(CO), and predictive postoperative product (PPP) as independent predictors of a need for admission to an ICU. CONCLUSION: This empirical protocol was useful in identifying patients not likely to need admission to the ICU. ASA score, predictive postoperative DL(CO), and PPP are independent predictors of a need for admission to an ICU.
Adolescent↗
Prognosis of cocaine body-packers.
OBJECTIVE: To study the prognosis and complications of cocaine body-packing (concealment of cocaine in the body for transportation between countries). DESIGN: We retrospectively reviewed the files of all cocaine body-packers hospitalized during a 4-year period in a medico-judiciary emergency unit. Subjects included in the survey were identified from the hospital databases using ICD-10 codes. SETTING: The Medico-Judiciary Emergency Unit of Hôtel-Dieu university hospital in Paris is a unique medical and surgical emergency unit receiving all patients in legal custody arrested at the two Paris international airports and suspected of body-packing. PATIENTS: All the cases of cocaine body-packers (n=581) hospitalized between January 1999 and December 2002 were studied. They had been arrested at Paris airports while arriving from drug-producing countries. RESULTS: The mean number of carried packets was 70.0+/-20.4 (range 18-150). The mean duration of hospitalization was 5.0+/-1.6 days (range 1-18). No complication occurred in 573 body-packers cases. Eight subjects developed a complication requiring admission to an intensive care unit: six acute cocaine intoxications due to packet rupture and two intestinal occlusions. No one died. Surgical treatment was necessary in six cases. CONCLUSIONS: Good prognosis observed in these body-packers cases is due to the careful monitoring of asymptomatic patients, allowing early detection and treatment of complications. Surgical removal of the packets when complication occurs is warranted.
Adult↗
Clinical practice guidelines: medical follow-up of patients with asthma--adults and adolescents.
The follow-up of patients with asthma should focus on asthma control (disease course over a number of weeks).
Adolescent↗
Prognosis of patients with acute myeloid leukaemia admitted to intensive care.
This retrospective study assessed the prognostic factors associated with early and long-term outcome in consecutive patients with acute myeloid leukaemia (AML) admitted to the intensive care unit (ICU) over a 9-year period. A total of 83 patients were studied (age 48 +/- 16 years), among whom 60% were neutropenic on admission. For 68%, admission occurred within the first month following diagnosis of AML. The main reason for ICU admission was an acute respiratory disease in 82% of cases. Mechanical ventilation (MV) was required in 57% of patients. In-ICU mortality was 34%. Among patients discharged alive from ICU, 49% died within a year after discharge. Factors significantly associated with in-ICU death in multivariate analysis were simplified acute physiology score II and need for invasive MV (IMV). Age, performance status, AML3 subtype and complete remission were significantly associated with 1-year survival. Patients with acute respiratory failure initially supported with non-invasive MV had significantly better ICU outcome than patients initially supported with IMV. In conclusion, ICU admission is justified for selected patients with AML. The ICU mortality rate is highly predictable by the acute illness severity score. A 1-year survival is predicted by haematological prognostic factors.
Acute Disease↗
[Epidemiology of chronic obstructive pulmonary disease].
Prevalence of COPD is 4 to 10% in developed countries according to spirometric studies. COPD is markedly under-diagnosed, only 1/3 of patients being recognised. COPD is the only disease whose rank among causes of death increases, placing it at the third place in 2020. In France, COPD-related annual mortality rate is 25 per 100 000, which corresponds to 15 000 deaths. Between 1990 and 2020, it will rise from the 12th to the 5th rank among causes of handicap in the world. The main risk factor is tobacco smoking. Other factors with proven responsibility in the occurrence of COPD include some occupational exposures and inherited alpha 1-antitrypsine deficiency. Other genetic factors, prematurity, bronchial hyper-responsiveness and respiratory infections may also be involved.
France↗
Nociceptin inhibits vanilloid TRPV-1-mediated neurosensitization induced by fenoterol in human isolated bronchi.
Chronic exposure to beta(2)-adrenoceptor agonists, especially fenoterol, has been shown to increase smooth muscle contraction to endothelin-1 in human bronchi partly through tachykinin-mediated pathways. The purpose of this work was to further investigate the role of sensory nerves in fenoterol-induced sensitization of human airways and the effect of nociceptin, a nociceptin/orphanin FQ (NOP) receptor agonist, on the increase in contraction after fenoterol exposure. Human bronchi from 62 patients were sensitized to endothelin-1 by prolonged incubation with fenoterol (0.1 microM, 15 h). The sensitizing effect of fenoterol was inhibited by high concentration of capsaicin (10 microM, 30 min before fenoterol sensitization), which induces depletion of mediators from sensory nerves, or co-incubation of fenoterol and capsazepine (1 microM), a vanilloid TRPV-1 receptor antagonist. Moreover, short pretreatment of bronchi with capsaicin (10 microM) or capsazepine (1 microM) after sensitization by fenoterol decreased the rise in smooth muscle contraction to endothelin-1. Nociceptin (1 microM) also inhibited the increased contraction in fenoterol-sensitized bronchi. Tertiapin (10 microM), an inhibitor of the inward-rectifier K(+) channels, but not naloxone (0.1 microM), a DOP/KOP/MOP receptor antagonist, prevented the inhibitory effect of nociceptin. In conclusion, fenoterol induces sensitization of human isolated bronchi to endothelin-1 in part through the stimulation of the vanilloid TRPV-1 receptor on tachykininergic sensory nerves. Nociceptin inhibits airway hyperresponsiveness via NOP receptor activation. This effect involves inward-rectifier K(+) channels.
Adrenergic beta-Agonists↗
Protease-activated receptor 2 in regulation of bronchomotor tone: effect of tobacco smoking.
Protease-activated receptors are G protein-coupled receptors activated by serine-proteases. Protease-activated receptor 2 is involved in the regulation of airway smooth muscle tone but its effects vary according to species and experimental conditions. We determined the effects of protease-activated receptor 2 activation on smooth muscle tone and airway reactivity to histamine in guinea pigs and smoking or non-smoking humans. The effects of trypsin and protease-activated receptor activating peptide on the isometric tension and response to histamine of guinea pig tracheal and human bronchial rings were studied. Human tissues were obtained from 6 smokers and 4 non-smokers. We assessed the effects of epithelial removal, inhibitors of cyclooxygenases, nitric oxide synthases, neutral endopeptidase and antagonists of acetylcholine, histamine, bradykinin and tachykinin receptors. Bronchomotor responses to protease-activated receptor 2 activation were variable in guinea pig, in half of animals PAR2 activation induced smooth muscle relaxation through the epithelial release of prostanoids but not of nitric oxide. In human airways, protease-activated receptor 2 activation reduced responsiveness to histamine in bronchial rings from smokers but increased responsiveness in bronchi from non-smokers. This study demonstrates an influence of tobacco smoking on the effect of protease-activated receptor 2 activation on airway responsiveness in humans, with an increased protection against histamine-induced contractions, probably through an increased epithelial release of prostanoids. The role of airway protease-activated receptor 2 may be to maintain smooth muscle tone homeostasis.
Aged↗
[A disease accessible to treatment].
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Bronchopneumonia↗
[Mode of action of bronchodilators in COPD. Aims of their use and criteria of assessment].
THERAPEUTIC POSSIBILITIES: Chronic obstructive pulmonary disease (COPD) remains under-diagnosed and under-treated despite its growing impact on public health. However several treatments, either pharmacological or not (pulmonary rehabilitation with exercise training), can improve quality of life significantly, even if they can not modify the natural history of the disease, as reflected by the decline in FEV1, which smoking cessation is the only way to alter. THE ACTION OF BRONCHODILATORS: Bronchodilators represent the first-line pharmacological treatment. Their clinical efficacy cannot be predicted by the inconstant changes in FEV1, since their main mechanism of action is the reduction in lung hyperinflation. Besides decreasing dyspnea, they reduce the number of exacerbations and improve quality of life.
Bronchodilator Agents↗
[Bronchodilators in COPD: latest recommendations, recent data and perspectives].
DEMONSTRATED EFFICACY: Inhaled bronchodilators improve the quality of life of COPD patients by reducing dyspnea and exacerbation frequency. There is no data supporting the superiority of one of the families of inhaled bronchodilators (i.e. beta 2 agonists and anticholinergic agents) over the other. Thus, the choice has to be based on the individual symptomatic response. These agents can be combined. OTHER POSSIBILITIES: Long-acting beta 2 agonists are already available and long-acting anticholinergics should be marketed soon. Theophylline has a lower efficacy/tolerance ratio than inhaled bronchodilators but can provide additional benefits when associated with the latter in some patients. Phosphodiesterase inhibitors with both bronchodilating and anti-inflammatory effect are being developed. THE BENEFITS OF CORTICOSTEROIDS: Finally, in symptomatic patients with FEV1<50% predicted and repeated exacerbations despite bronchodilators, inhaled corticosteroids can be added.
Administration, Inhalation↗
[Control of asthma by treatment with inhaled corticosteroids and prolonged action beta 2-agonists in free or fixed combination. Results of the ALISE study].
CONTEXT: The basics of asthma treatment are well defined in the guidelines, however the criteria for the choice between fixed and free combinations of inhaled corticosteroids and long acting beta 2-agonist have not been clearly established. METHOD: A modified Juniper questionnaire (using peak expiratory flow rather than maximal expiratory volume per second) was used by 421 general practitioners to assess asthma control in 861 adult patients (aged 47 +/- 17 years) having received inhaled corticosteroids and long-acting beta 2-agonist in a fixed (n = 413) or free (n = 448) combination for at least 6 weeks. RESULTS: Treatment groups were comparable for demographics, asthma history and severity as assessed by the physician. Despite better compliance to treatment in the fixed combination group and a mean daily dose of corticosteroids around two-fold greater compared with free combination group (913 +/- 450 micrograms/d vs 401 +/- 178 micrograms/d), the mean Juniper score was lower in the free combination group (1.60 +/- 0.94 vs 1.73 +/- 0.96) with a greater percentage of patients controlled (Juniper score < 2): 67.6% vs 60.8%. Other treatments for asthma were significantly less frequent with the free combination (14.2% vs 22.3%), as were local side effects and notably voice changes (3.3% vs 9.5%. COMMENTS: The apparently greater efficacy/safety ratio of the free combination was probably due to the greater severity of asthma in the patients treated with a fixed combination. This highlights the interest of free combinations as first-line therapy for patient with mild to moderate asthma.
Administration, Topical↗
Effect of acute and chronic inflammatory stimuli on expression of protease-activated receptors 1 and 2 in alveolar macrophages.
BACKGROUND: Protease-activated receptors 1 and 2 (PAR-1 and PAR-2) are 7-transmembrane G protein-coupled receptors activated by serine proteases in many cell types, including monocytes-macrophages, leading to the production of pro-inflammatory mediators, cytokines, and growth factors. OBJECTIVE: We determined the influence of chronic smoking and asthma on the expression of PAR-1 and PAR-2 receptors on alveolar macrophages (AMs). METHODS: We used RT-PCR and immunocytochemistry with confocal microscopy to determine mRNA and protein expression of PAR-1 and PAR-2 in AMs obtained from healthy smokers, asthmatic patients, and healthy subjects. In addition, we examined the effect of IL-1beta and LPS. RESULTS: PAR1 mRNA was decreased, whereas PAR2 mRNA was increased in 24-hour cultured AMs from smokers when compared with values in AMs from healthy subjects. Paradoxically, there was a higher degree of PAR-1 protein staining in AMs from smokers, whereas PAR-2 staining was similar in smokers and healthy subjects. PAR-1 and PAR-2 mRNA and protein expression were similar in asthmatic patients and control subjects. IL-1beta and LPS had no effect on PAR1 and PAR2 gene expression by AMs. CONCLUSIONS: There is a dissociation between gene and protein expression of PAR-1 and PAR-2. PAR-1 protein overexpression in AMs from smokers might be important in the pathophysiology of chronic airways disease.
Adult↗
Prospective testing of two models based on clinical and oximetric variables for prediction of obstructive sleep apnea.
STUDY OBJECTIVE: To test the validity of two models for prediction of obstructive sleep apnea syndrome (OSAS) before polysomnography. DESIGN: Prospective study. SETTING: Sleep laboratory in an obesity clinic. PATIENTS: Data from two populations were analyzed: the first (group 1) included 102 consecutive overweight patients referred to our laboratory by an obesity clinic between May 1992 and November 1994, and was used to develop the prediction models. The second (group 2) included 108 consecutive new patients referred to our laboratory by the same obesity clinic between February 1997 and September 1998, and was used to test the prediction models. MEASUREMENTS AND RESULTS: Models were developed using a clinical score, pulmonary function tests, arterial blood gas tensions, and nocturnal pulse oximetry. OSAS was defined by an apnea-hypopnea index (AHI) > 15 events per hour, as measured by full-night polysomnography. Step-by-step multiple linear regression analysis (MLR) was used to provide an equation for calculation of predicted AHI, while logistic regression analysis (LR) provided an equation for calculation of the probability (P') of having OSAS. Characteristics of groups 1 and 2 were similar except for the prevalence of OSAS, which was higher in group 2 (74% vs 39% in group 1). The negative predictive value (NPV) of the MLR model dropped from 82.9% in group 1 to 36.7% in group 2. In parallel, the NPV of a P' < 0.25 according to LR decreased from 78.6% in group 1 to 23.5% in group 2. CONCLUSION: Our results emphasize the need for systematic prospective testing of mathematical predictive models in OSAS, since their diagnostic characteristics may differ markedly between populations, even when the setting and mode of recruitment remain unchanged.
Female↗
[Mucoregulators in acute bronchitis syndromes: focus on use by general practitioners and data from the literature].
Antibiotics have long been used in the initial treatment of acute bronchitis (AB) and acute exacerbations of chronic bronchitis (AECB). However, their lack of value in AB has been clearly demonstrated and antibiotic therapy is justified in only a few cases of AECB. In parallel, although the value of mucoregulators in these diseases is still debated, their prescription remains important in general practice. In this context, our aim was to determine the prescribing behaviour of general practitioners (GPs) with regard to these drugs, as well as the beliefs of GPs concerning the place of mucoregulators in the treatment of AB in children and adult smokers, as well as in patients with non-obstructive AECB. A survey was carried out in 370 GPs, who were presented with three standardised and computerised medical cases: (i) rhinopharyngitis + AB in a child; (ii) AB in an adult smoker without a previous medical history; and (iii) a patient with non-obstructive AECB. The results showed that mucoregulators are frequently prescribed by GPs for children and adults with AB, or in AECB. This high prescribing rate is due to the belief of the GPs that these drugs are effective and well tolerated, which is confirmed by the literature. Their use avoids the frequent and unjustified prescription of antibiotics in situations where they are not recommended but where the patients request drug therapy.
Acute Disease↗