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Imagerie des pneumopathies infiltratives diffuses chroniques en tomodensitométrie : du diagnostic à la quantification automatisée

La tomodensitométrie a une place essentielle dans le diagnostic et le suivi des pneumopathies infiltratives diffuses chroniques (PID). L’amélioration de la qualité des images, d’une génération de machine à la suivante, permet une meilleure caractérisation lésionnelle, voire tissulaire (lésion inflammatoire potentiellement réversible, lésion fibreuse fixée). Le raisonnement diagnostique en imagerie a évolué avec les progrès technologiques.

On est passé d’un raisonnement basé sur la lésion élémentaire prédominante (notion depatternde type nodulaire, condensation alvéolaire, verre dépoli…), à un diagnostic basé sur l’association de plusieurs lésions élémentaires définissant un motif lésionnel (typiquement pour le diagnostic de fibrose pulmonaire idiopathique), puis aujourd’hui sur l’association de plusieurs motifs définissant un modèle lésionnel (par exemple pour l’analyse des images en verre dépoli).

L’analyse des images tomodensitométriques, permet également une quantification de la sévérité de l’atteinte pulmonaire. Les résultats obtenus sont corrélés au pronostic de la maladie et permettent d’en suivre la progression. Cette quantification est le plus souvent basée sur des critères visuels. Le développement de logiciels de quantification automatisée pourrait être, dans un avenir proche, une aide pour le radiologue.

English Abstract : Computed tomography is important for the diagnosis and follow-up of chronic diffuse interstitial lung diseases. Image quality has improved from each generation of scanner to the next and this continues to allow a better characterization of extent of pathology, or even the nature of the pathological process (potentially reversible inflammatory lesions compared to fibrotic lesions).

The diagnostic imaging approach has evolved at the same time as technological developments. We initially thought in terms of the predominant lesions (nodular, alveolar consolidation, ground-glass opacity), and then moved to reasoning based on patterns, which are a combination of several elementary lesions (typically for the diagnosis of idiopathic pulmonary fibrosis).

Nowadays, studies are focused on building models characterizing a specific disease and which combine several distinct patterns (typically for ground-glass opacity analysis). CT also allows a quantification of the extent of lung disease, which is linked to the prognosis of the disease and helps to monitor its progression. This quantification is usually based on visual criteria, the principles of which are summarized here. The development of automated quantification software could in the near future, be a support for the radiologist.

Exacerbations asthmatiques : spécificités pédiatriques (en dehors du traitement)

L’asthme aurait déjà concerné plus de 10 % des enfants âgés de dix ans. Ce constat mérite une discussion pneumopédiatrique à part entière. Malgré des similitudes entre l’asthme de l’adulte et celui de l’enfant, la population pédiatrique présente certaines spécificités notamment concernant les exacerbations.

L’asthme du nourrisson est une entité particulière dont la définition a bénéficié récemment d’une mise à jour officielle.

Les étiologies d’exacerbations asthmatiques restent les infections, avec en tête les virus dont le typage joue un rôle pronostique. L’environnement intérieur et extérieur peut aggraver l’asthme, notamment par de fortes concentrations de polluants atmosphériques. Les nutriments semblent jouer un rôle pronostique par le biais de la vitamine D ou de la présence d’allergie alimentaire. La recherche de facteurs prédictifs ou de marqueurs inflammatoires de l’asthme est la clé de voûte pour la maîtrise de ces exacerbations, mais les techniques actuelles ne sont pas encore totalement performantes comme la mesure de l’oxyde nitrique exhalé (eNO), l’étude des crachats/exhalas ou encore de simples questionnaires. La prise en charge précoce et continue avec l’éducation thérapeutique des enfants et de leur famille demeure un outil efficace en termes de prévention de rechute des exacerbations.

English Abstract : Asthma concerns more than 10% of 10-year-old children. Despite the similarities between adult and childhood asthma, the pediatric population presents some specific characteristics, notably in relation to exacerbations.

Asthma in the newborn infant is a specific entity, the definition of which has recently been officially recognized. In exacerbations, the most important trigger factors are respiratory virus infections, the strain having prognostic importance. The indoor and outdoor environments are risk factors, particularly high levels of atmospheric pollution. Nutrients seem to play a prognostic role through vitamin D or food allergy. Measurement of exhaled nitric oxide and examination of induced sputum may help in diagnosis and adjustment of treatment but these tools are not yet effective as predictive factors in asthma exacerbations.

Prevention, early management and continued education of children and their families remain the best methods to improve asthma control.

Comparison of tiotropium plus fluticasone propionate/salmeterol with tiotropium in COPD: A randomized controlled study

The combination of tiotropium and fluticasone propionate/salmeterol (FSC) is commonly used to treat chronic obstructive pulmonary disease (COPD), but no study had evaluated the effectiveness of tiotropium plus FSC with 250 μg of fluticasone propionate.

Our aim was to assess whether tiotropium (18 μg once daily) plus FSC (250/50 μg twice daily) provides better clinical outcomes compared to tiotropium monotherapy.

Methods : In this 24-week, randomized, open label, multicenter two-arm parallel study, 479 patients received tiotropium plus FSC (n = 237) or tiotropium alone (n = 242).

Results : After 24 weeks of treatment, the triple-inhaled treatment group had a significant improvement in pre-bronchodilator FEV1(L) compared to the tiotropium-only group (0.090 L vs. 0.038 L;P = 0.005). Regarding health-related quality of life, the mean change in total score on the St. George’s Respiratory Questionnaire for COPD patients (SGRQ-C) was −6.6 points in the tiotropium plus FSC group, but −1.5 points in the tiotropium-only group (P = 0.001). In the subgroup of GOLD stage II patients with COPD, treatment with tiotropium plus FSC also improved FEV1compared to tiotropium alone (0.088 L vs. 0.030 L;P = 0.011) and improved the total SGRQ-C score than tiotropium alone (−4.5 points vs. −1.0 points, respectively).

This triple-inhaled treatment approach did not induce more adverse events, such as pneumonia.

Conclusion : Over the course of 24 weeks, FSC (250/50 μg twice daily) added to tiotropium provided greater improvement in lung function and quality of life in patients with COPD (FEV1 ≤ 65%) than tiotropium alone.

Barriers to adherence to COPD guidelines among primary care providers

Despite efforts to disseminate guidelines for managing chronic obstructive pulmonary disease (COPD), adherence to COPD guidelines remains suboptimal. Barriers to adhering to guidelines remain poorly understood.

Methods : Clinicians from two general medicine practices in New York City were surveyed to identify barriers to implementing seven recommendations from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. Barriers assessed included unfamiliarity, disagreement, low perceived benefit, low self-efficacy, and time constraints. Exact conditional regression was used to identify barriers independently associated with non-adherence.

Results : The survey was completed by 154 clinicians. Adherence was lowest to referring patients with a forced expiratory volume in 1 s (FEV1) <80% predicted to pulmonary rehabilitation (5%); using FEV1to guide management (12%); and ordering pulmonary function tests (PFTs) in smokers (17%). Adherence was intermediate to prescribing inhaled corticosteroids when FEV1<50% predicted (41%) and long-acting bronchodilators when FEV1<80% predicted (54%). Adherence was highest for influenza vaccination (90%) and smoking cessation counseling (91%). In unadjusted analyses, low familiarity with the guidelines, low self-efficacy, and time constraints were significantly associated with non-adherence to ≥2 recommendations. In adjusted analyses, low self-efficacy was associated with less adherence to prescribing inhaled corticosteroids (OR: 0.28; 95% CI: 0.10, 0.74) and time constraints were associated with less adherence to ordering PFTs in smokers (OR: 0.31; 95% CI: 0.08, 0.99).

Conclusions : Poor familiarity with recommendations, low self-efficacy, and time constraints are important barriers to adherence to COPD guidelines. This information can be used to develop tailored interventions to improve guideline adherence.

Global alliance against chronic respiratory diseases in Italy (GARD-Italy): Strategy and activities

The steady increase in incidence of chronic respiratory disease (CRD) now constitutes a serious public health problem. CRDs are often underdiagnosed and many patients are not diagnosed until the CRD is too severe to prevent normal daily activities. The prevention of CRDs and reducing their social and individual impacts means modifying environmental and social factors and improving diagnosis and treatment. Prevention of risk factors (tobacco smoke, allergens, occupational agents, indoor/outdoor air pollution) will significantly impact on morbidity and mortality.

The Italian Ministry of Health (MoH) has made respiratory disease prevention a top priority and is implementing a comprehensive strategy with policies against tobacco smoking, indoor/outdoor pollution, obesity, and communicable diseases. Presently these actions are not well coordinated.

The Global Alliance against Chronic Respiratory Diseases (GARD), set up by the World Health Organization, envisages national bodies; the GARD initiative in Italy, launched 11/6/2009, represents a great opportunity for the MoH.Its main objective is to promote the development of a coordinated CRD program in Italy. Effective prevention implies setting up a health policy with the support of healthcare professionals and citizen associations at national, regional, and district levels. What is required is a true inter-institutional synergy: respiratory diseases prevention cannot and should not be the responsibility of doctors alone, but must involve politicians/policymakers, as well as the media, local institutions, and schools, etc.

GARD could be a significant experience and a great opportunity for Italy to share the GARD vision of a world where all people can breathe freely.

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