Publication year: 2012
Source:Revue des Maladies Respiratoires

J.-C. Guerin, N. Roche, É. Vicaut, D. Piperno, G. Granet, M. Jannin, F. Deschamps, P. Godard

Introduction Le diagnostic précoce de la BPCO n’est pas satisfaisant en médecine générale. Objectif Évaluer différents outils d’aide au diagnostic (Piko-6, Logiciel, les deux) chez le médecin généraliste (MG). Méthodes Étude randomisée multicentrique contrôlée chez le MG, évaluant l’effet des stratégies testées sur le taux d’adressage de patients à risque de BPCO pour spirométrie et le taux de diagnostics de BPCO. Résultats Deux cent quarante-huit MG ont inclus 1103 patients (55ans, 60 % d’hommes, 31ans de tabagisme). Les taux d’adressage dans les groupes Logiciel (50 % des patients) et Piko/Logiciel (47 %) ont été significativement plus élevés par rapport aux groupes témoin (22 %) et Piko (28 %). Une grande partie (44 %) des EFR demandées par les MG n’a pas été effectuée, souvent à cause du refus des patients. Le taux de confirmation était globalement inférieur dans les groupes Logiciel (47 %) et Piko/Logiciel (43 %) par rapport au groupe Piko (68 %) ou témoin (79 %). La concordance entre les mesures du VEMS de l’EFR et du Piko-6 était faible, de l’ordre de 50 %. Conclusions Le logiciel associé ou non au Piko-6 favorise l’adressage pour EFR par les MG sans augmenter le taux de syndromes obstructifs diagnostiqués, en raison d’une réticence des patients à aller effectuer les EFR. Cependant, l’utilisation d’un outil (Logiciel et/ou mini-spiromètre) semble permettre une détection précoce de la BPCO. Introduction The early diagnosis of COPD in general practice is not satisfactory. Objectives To evaluate the impact of different diagnostic tools (Piko-6, Software) in general practice (GP). Methods A multicentre, randomised, controlled study in GP assessing the effect of the tested strategies on the rate of referrals for spirometry and the rate of detection of airflow obstruction. Results One thousand one hundred and three patients (55years old, 60% males, 31years of smoking habits) were included by 248 GP. The rates of referal to a pneumologist were significantly higher in the Software (50% of patients), and Piko/Software (47%) groups than in the Control (22%) and Piko groups (28%). A high proportion (44%) of lung function tests recommended by the GP were not performed, often because of patient refusal. The confirmation rates were lower in the Software and Piko/Software groups (47% and 43%, respectively) compared with the Piko and Control groups (68% and 79%, respectively). Concordance between PFT and Piko-6 for the diagnosis of airflow obstruction was poor (about 50%). Conclusions The use of software in association or not with the Piko-6 was useful for GPs to identify patients to refer for further lung function testing, but did not improve the confirmation of the obstructive syndrome, mainly due to reluctance of patients to go on to have further lung function tests. The use of a diagnostic tool (software and/or mini-spirometry) does however seem to improve early COPD detection.

BackgroundOral food challenge (FC) protocols are discussed with reference to starting doses, dose increments, safety, and predictability of results. The aim of this study was to evaluate the relation of eliciting allergen doses, specific IgE levels and predictive factors to the outcome of FCs in children.MethodsIn 869 children (median age 1.2 years), FCs were performed with cow's milk (n = 633), hen's egg (n = 456), wheat (n = 265) and/or soy (n = 317) starting at 3–5 mg of protein. Each of the seven doses was administered every 30 min using semi-log increases. Severity of symptoms was graded from I to V. IgE was determined prior to challenges.ResultsOf the children allergic to egg or milk, 9% and 10%, respectively, experienced reactions already at the first dose. Of these, 14% (egg) and 4% (milk) experienced grade IV reactions. In contrast, few children reacted to the first doses of wheat or soy, and most reactions occurred after the maximum dose. For all allergens, grade V reactions did not occur. However, grade IV reactions were seen at all eliciting doses. Elevated specific IgE level, young age and a history of atopic dermatitis were associated with a positive challenge outcome for milk or egg, and also IgE levels were associated with lower eliciting allergen doses and more severe symptoms.ConclusionOral FCs bear a risk of severe reactions at all dose levels. Doses of 3–5 mg protein induced symptoms in up to 10% of children allergic to milk or egg. However, food-specific IgE levels are of limited clinical value for the estimation of FC reactions.

BackgroundMast cells are important in the pathophysiology of airway inflammation and evidence suggests their sub-localisation within the airway is altered in asthma. Little is known about the effect of corticosteroids on mast cell localisation within the bronchi.MethodsWe therefore performed an immunohistochemical analysis of mast cell numbers within the smooth muscle, epithelium and submucosa of healthy subjects (n = 10) and well-characterised asthmatic patients, using either β2-agonists alone (n = 10) or β2-agonists and inhaled corticosteroids (n = 10).ResultsPatients using inhaled corticosteroids displayed significantly lower numbers of mast cells within their epithelium and smooth muscle compared to those not treated with inhaled corticosteroids. Submucosal mast cells were not affected by corticosteroid treatment. Numbers of smooth muscle mast cells correlated with bronchial responsiveness and epithelial mast cells with exhaled NO.ConclusionWe demonstrate that glucocorticosteroids differentially affect mast cell numbers within specific airway sub-locations highlighting the importance of mast cell and smooth muscle/epithelial interactions in asthma pathogenesis.