An attempt at modeling COPD epidemiological trends in France.

BACKGROUND: Anticipating the future burden of chronic obstructive pulmonary disease (COPD) is required to develop adequate public health policies. METHODS: A dynamic population model was built to estimate COPD prevalence by 2025 using data collected during the most recent large general population study on COPD prevalence in France (2005) as baseline values. Sensitivity analyses were performed to test the effect of variations in key input variables. RESULTS: The model predicted a steady increase in crude COPD prevalence among subjects aged≥45 years from 2005 (prevalence estimate: 84.51‰) to 2025 (projected prevalence: 95.76‰, + 0.56‰/yr). There was a 4-fold increase in the prevalence of GOLD grade 3-4 cases, a 23% relative increase in women and a 21% relative increase in subjects ≥75 years. In sensitivity analyses, these temporal trends were robust. Factors associated with > 5% relative variations in projected 2025 prevalence estimates were baseline prevalence and severity distribution, incidence in women and severity of incident cases, transition rates between severity grades, and mortality. CONCLUSIONS: Projections of future COPD epidemiology consistently predict an increase in the prevalence of moderate-to-very severe COPD, especially due to increases among women and subjects aged ≥75 years. Developing robust prediction models requires collecting reliable data on current COPD epidemiology.

Time trends in pulmonary embolism mortality in France, 2000-2010.

BACKGROUND: Pulmonary Embolism (PE) is a potentially fatal complication of venous thrombosis. Recent and comprehensive estimates of PE incidence and mortality are scarce. Moreover, while contemporary mortality trends of PE would enable the evaluation of prevention and quality of care, such data are lacking. The aim of this study was to provide nationwide estimations of PE mortality and time trends in France between 2000 and 2010. METHODS: Mortality data were obtained from the French Epidemiology Center on medical causes of death. Mortality rates were calculated with PE as an underlying or one of multiple causes of death. The annual percentage changes were assessed using a Poisson regression model. Age-standardized PE mortality rates were also assessed. RESULTS: In 2010, the overall age-adjusted PE mortality rate was 21.0 per 100000. This rate was 30% higher in men than in women and decreased by 3% per year between 2000 and 2010. Over this period, PE mortality declined in men and women over 55 years but only slightly decreased in patients younger than 55. Cancer, obesity, osteopathies and complications of surgery were often coded as the underlying causes of death when PE was an associated cause of death recorded on certificate. DISCUSSION: This study is the first to provide a contemporary and exhaustive nationwide estimation of PE mortality and time trends in France. The observed decrease in PE mortality between 2000 and 2010 is encouraging, but further efforts in prevention are needed to ensure that this reduction is widespread in all age groups.

Symptoms of sleep apnea syndrome: high prevalence and underdiagnosis in the French population.

OBJECTIVE: To determine the prevalence of symptoms evocative of obstructive sleep apnea (SE-OSA) and the magnitude of obstructive sleep apnea (OSA) underdiagnosis. METHODS: We used data from a cross-sectional survey conducted in 2008 in a representative sample of the French general population. Data were collected through interviews and self-administrated questionnaires and were complete for 12,203 adults (≥16 years old). SE-OSA was defined by snoring almost every night plus witnessed apneas or excessive daytime sleepiness (Epworth sleepiness scale score>10). RESULTS: The prevalence of SE-OSA was 4.9% (95% CI: 4.5-5.3), and that of self-reported OSA diagnosis was 2.4% (2.1-2.7). The prevalence of SE-OSA was 8% among people with hypertension and 11% among obese people. A previous sleep monitoring session was reported by 2.7% (2.4-3.0) of the participants and by 15.1% of people with SE-OSA. This latter proportion increased with age (24% in people with SE-OSA aged 60 years or over) and was higher in obese people (26%) and in those with chronic diseases (27% among people with hypertension). CONCLUSION: The prevalence of SE-OSA is high in France and OSA remains underdiagnosed, even in people with obesity or hypertension. Further efforts are needed to improve the diagnosis of OSA.

Chronic bronchitis in the general population: influence of age, gender and socio-economic conditions.

Chronic bronchitis (CB) is an indicator of an increased risk of developing COPD, but its symptoms are often underestimated. Demographic and socio-economic conditions might influence its prevalence, reporting and impact. Data from a large epidemiological survey of the French general population were analyzed to determine the burden of CB, the magnitude of under-diagnosis and the influence of age, gender and socio-economic conditions. Altogether, 9050 participants aged 45 years or more provided complete data. The prevalence of symptoms and diagnosis of CB was 3.5% and 3.4%, respectively. CB was associated with impaired health status and activity and, in women, work loss. Among subjects with symptoms of CB, only 28.6% declared a known diagnosis of respiratory disease. Factors associated with symptoms of CB in multivariate analysis were male gender, active smoking, lower income and occupational category: the highest prevalence was observed in manual workers (5.6%) and self-employed subjects (5.2%). The under-diagnosis of CB was more marked in men and subjects of higher socio-economic categories. These results confirm that CB is markedly under-diagnosed in the general population. Socio-economic conditions influence both its prevalence (higher in low categories) and rate of diagnosis (lower in high categories), which should be considered when elaborating prevention and detection campaigns.

Asthma and major depressive episode in adolescents in France.

RATIONALE: The association between asthma and anxiety disorders in teenagers is well documented, but data about the association with mood disorders are scarce. METHODS: We analyzed data from a cross-sectional study conducted among ninth grade schoolchildren in France in 2003-2004. The teenagers were selected by two-stage sampling and interviewed by school doctors/nurses using a standardized questionnaire including questions about asthma and asthma-like symptoms. They also completed a self-administered questionnaire in which the occurrence of major depressive episodes (MDEs) during the past 12 months was assessed by the Composite International Diagnostic Interview-Short Form. RESULTS: A total of 7000 teenagers (mean age 15.1 years) were included. The prevalence of wheezing in the past 12 months was 10.0% and that of current asthma (wheezing in the past 12 months in children who had already had asthma attacks, or treatment for wheezing or asthma in the past 12 months) was 8.5%. The prevalence of MDE during the past year was 14.2% in teenagers with current asthma versus 9.2% among the others. The association between current asthma and past-year MDE remained significant after adjustment for age, gender, family structure, and the father's employment status. Asthma was uncontrolled (at least four attacks of wheezing, one awakening per week due to wheezing, one severe wheezing, four unplanned medical visits, or one hospitalization for a wheezing attack in the past year) in more than half (58.3%) of asthmatic teenagers with an MDE in the past year versus 35.3% of those without an MDE. CONCLUSION: Asthma is associated with a higher prevalence of MDE. Among adolescents with asthma, MDE is associated with poorer asthma control. These findings highlight the need for a comprehensive care management of asthma in France that takes the psychological dimension into account.

Hospitalizations for asthma in children are linked to undertreatment and insufficient asthma education.

BACKGROUND: Most hospital admissions for asthma exacerbation are avoidable with adequate disease management. OBJECTIVES: The objective of this study was to describe the characteristics of children hospitalized with an asthma exacerbation to identify modifiable factors leading to hospitalization. METHODS: The study was conducted in 14 pediatric units and included children 3-17 years of age who were hospitalized for an asthma exacerbation. The present analysis covers 498 children with known asthma. Staff physicians used a standardized questionnaire to collect data. Asthma history came from a parental interview and included usual asthma care, frequency of symptoms and quick-relief medication use in the previous month, frequency of exacerbations and number of unscheduled healthcare visits during the past year, and prior asthma-related hospitalizations. RESULTS: More than half the children had previously been hospitalized for an exacerbation, 42% used continuous inhaled corticosteroids, and 57% had a regular follow-up for asthma. Asthma had been well controlled over the past year for 11%, 12% had experienced exacerbations during the past year but that had been optimally controlled during the previous month, and 11% had recently become poorly controlled (infrequent exacerbations in the previous year and non-optimal control in the previous month). The remaining 327 children (66%) were consistently poorly controlled (non-optimal asthma control in the previous month and frequent exacerbations over the previous year). Among this group, 69% had at least one of the following preventable risk factors for hospitalization: no regular controller therapy (49%), no asthma action plan (40%), or no follow-up for asthma (35%). CONCLUSIONS: Two-thirds of the children with asthma hospitalized for an exacerbation had been consistently poorly controlled during the previous year. They were frequently undertreated and insufficiently educated about asthma. Further efforts are needed to improve asthma treatment and education in France.

Hospital admissions related to acute exacerbations of chronic obstructive pulmonary disease in France, 1998-2007.

BACKGROUND: Acute exacerbations of chronic obstructive pulmonary disease (AE-COPD) necessitating hospital admission have a major impact on patient outcome and management costs. We examined temporal trends in AE-COPD-related hospital admissions in France between 1998 and 2007. METHODS: Data were obtained from the French national hospital discharge database for patients aged at least 25 years. AE-COPD was identified with both a "narrow" and a "broad" definition, according to the position (primary or associated) of diagnoses, in order to ensure robustness. RESULTS: In 2007, among adults aged 25 years or more, the crude AE-COPD-related admission rates were 23/10000 in men and 10/10000 in women using the narrow definition. Using the broad definition, these rates were respectively 38 and 16/10000. With the narrow definition, the annual number of AE-COPD-related admissions increased by 38% between 1998 and 2007, while in-hospital lethality decreased from 7.6% to 6.0%. The proportion of male patients decreased from 72% to 68%. Similar trends were found using the broad definition. The age-standardized AE-COPD-related admission rate increased by 4.4% per year in women and by 1.6% per year in men with the narrow definition, and by respectively 3.8% and 1.2% with the broad definition. A strong seasonal pattern of admissions for AE-COPD was found, matching that of general practitioners visits for influenza-like illness. CONCLUSION: Hospitalization rates for AE-COPD have increased in France in recent years, especially among women. By contrast, AE-COPD-related in-hospital lethality has decreased.

Deaths with asthma in France, 2000-2005: a multiple-cause analysis.

Mortality from asthma has decreased in many countries since the 1990s. Mortality statistics are usually based only on the underlying cause of death. The objectives of this study were to describe the characteristics of deaths and the trends in asthma-related mortality using multiple-cause analysis. Data were obtained from the French Centre of Epidemiology on Medical Causes of Death. Because ICD-10 was implemented in 2000, the analysis covers the period 2000-2005. In 2004-2005, asthma was the underlying cause of 42% of deaths with certificates mentioning asthma. The age-standardised rates of death from asthma decreased from 2000 through 2005 (-12% and -11%/year in the 1-44 and 45-64 age groups, respectively). The decline for all deaths with asthma was less pronounced (-9%/year in the 1-44 age group and -8%/year in the 45-64). Among adults aged 65 or older, the decrease in asthma-related mortality was higher in men (-12%/year for underlying cause, -9% for multiple-cause) than women (-5% and -3%, respectively). Since 2002, age-standardised rates of asthma-related mortality have been higher in women than men. In people aged 1-44 years, in-hospital deaths have declined between 2000 and 2005 while the proportion of non-hospital deaths increased from 53% to 67%. Regardless of the definition used, the age-standardised rate of asthma-related deaths decreased from 2000 to 2005, and the faster decline for underlying cause than for multiple-cause mortality argues for a real decline in mortality attributable to asthma. Using multiple cause-of-death analysis provides additional information for asthma mortality surveillance.

Short-term effect of pollen exposure on antiallergic drug consumption.

BACKGROUND: Several studies have investigated the association between pollen exposure and asthma emergency admissions, but only 2 have investigated the effect of airborne allergens on consultations for rhinitis or conjunctivitis and none has used drug consumption as the health indicator. OBJECTIVE: To analyze the short-term association between pollen exposure and antiallergic drug consumption in the urban area of Clermont-Ferrand, France, taking into account the potentially confounding effect of air pollution and meteorological factors. METHODS: We used the French health insurance database to select all individuals from the Clermont-Ferrand urban area having benefited from reimbursement for antiallergic treatment from January 1, 2000, through December 31, 2001, and from January 1, 2003, through December 31, 2004. An episode of treated allergic rhinitis, rhinosinusitus, or conjunctivitis (ARC) was defined as the association of an oral antihistamine and a local antiallergic drug on the same prescription. The relations between daily changes in pollen concentrations and daily changes in the number of treated ARC cases were analyzed using a Poisson regression model with penalized spline functions. RESULTS: The risk of treated ARC associated with an interquartile increase in pollen concentration increased significantly for Poaceae (5%, P < .001), Fraxinus (7%, P < .001), Betula (7%, P < .001), and Corylus (2%, P < .02). This increase was significant in all age groups for Poaceae and Fraxinus pollen and in people younger than 65 years for Betula pollen. The effect was mainly concentrated on the present day, except for Poaceae pollens, for which the risk remained significantly (P < .001) increased until 3 days lag time. CONCLUSIONS: This study showed a significant increase in treated ARC cases related to Poaceae, Fraxinus, and Betula. Specific risks are difficult to evaluate for species that share the same pollination period. Time-series studies based on drug consumption are useful to highlight and to supervise pollen-related diseases requiring ambulatory care.

Prefixed equimolar nitrous oxide and oxygen mixture reduces discomfort during flexible bronchoscopy in adult patients: a randomized, controlled, double-blind trial.

STUDY OBJECTIVES: Flexible bronchoscopy (FB) is an invasive procedure associated with patient discomfort and frequent nose pain. A simple sedation procedure that does not require the intervention of an anesthetist is of interest. The aim of this prospective, randomized, double-blind study was to assess efficiency of nitrous oxide inhalation on the reduction of FB-induced discomfort in adult patients. DESIGN AND SETTINGS: Two hundred six patients were randomized to receive either a prefixed equimolar nitrous oxide/oxygen mixture (N2O) or a prefixed equimolar nitrogen and oxygen mixture (control). The primary outcome was stress as assessed by pulse rate and systemic BP during the procedure. Secondary outcomes were self-assessed pain using a visual analog scale (VAS) and patient satisfaction based on a questionnaire. Adverse events were recorded. RESULTS: A significant increase in BP was observed only in the control group (p = 0.003), while pulse rate values did not differ between the two groups. As assessed by the VAS, pain was lower in the N2O group as compared to placebo (p = 0.02). Nose pain and cough were also significantly reduced by N2O. Adverse events, mostly anxiety, were reported in 10 patients. CONCLUSION: These results indicate that equimolar N2O inhalation is efficient in reducing patient discomfort and may be an alternative to general anesthesia.

Standardized protocol improves asthma management in emergency department.

This study assessed, 30 months after its initiation, the impact of a standardized asthma management program designed to facilitate the implementation of asthma management guidelines in a tertiary teaching hospital adult emergency department. The program was initiated in a stepwise manner: first, a retrospective baseline audit; followed by generation of local guidelines; validation of these guidelines by all staff involved; distribution of the guidelines; a second practice audit; use of these results to further improve the program; feedback to the staff; twice-yearly information meetings; and a new audit 2 years later. The main results were a significant improvement in history taking (p < 0.001), increased use of serial airflow measurements (p < 0.001), increased steroid use (p < 0.001), and better documentation of follow-up arrangements (p < 0.01). Several tests of questionable value were no longer prescribed routinely. The improvements persisted after 2.5 years. In contrast, there was no improvement in the proportion of medical files that contained records of discharge prescriptions for outpatients. Implementation of locally agreed guidelines resulted in a marked improvement in several aspects of asthma management in an emergency department; the program must be pursued to maintain and further improve quality of care.

Polymorphism of the serotonin transporter gene and pulmonary hypertension in chronic obstructive pulmonary disease.

BACKGROUND: The serotonin transporter (5-HTT) is involved in the pulmonary artery smooth muscle hyperplasia that leads to pulmonary hypertension (PH). Because hypoxia and 5-HTT gene polymorphism control 5-HTT expression, we examined 5-HTT gene polymorphism and PH in hypoxemic patients with advanced chronic obstructive pulmonary disease (COPD). METHODS AND RESULTS: In 103 patients with COPD recruited in France (n=67) and the UK (n=36), we determined 5-HTT gene polymorphism and pulmonary artery pressure (PAP) measured during right heart catheterization (France) or Doppler echocardiography (UK). Ninety-eight subjects from the 2 countries served as control subjects. The distribution of 5-HTT gene polymorphism did not differ between patients and control subjects. In patients carrying the LL genotype, which is associated with higher levels of 5-HTT expression in pulmonary artery smooth muscle cells than the LS and SS genotypes, PH was more severe than in LS or SS patients. Mean PAP values in patients from France with the LL, LS, and SS genotypes were 34+/-3, 23+/-1, and 22+/-2 mm Hg (mean+/-SEM), respectively (P<0.01). Corresponding systolic PAP values in the UK were 40+/-3, 28+/-3, and 24+/-3 mm Hg, respectively (P<0.01). Compared with control subjects, platelet 5-HTT protein was increased in COPD patients in proportion to the hypoxemia level, and strong 5-HTT immunostaining was observed in remodeled pulmonary arteries from COPD patients. CONCLUSIONS: 5-HTT gene polymorphism appears to determine the severity of PH in hypoxemic patients with COPD. Because PH is an important prognostic factor in this disease, recognition of patients at risk for PH should be helpful in managing COPD.

Transmission of tuberculosis from adults to children in a Paris suburb.

Tuberculosis in children is often acquired by contact with a family or household member. The aim of our study was to evaluate risk factors for latent infection and active disease in exposed children in a suburb of Paris. We examined medical records for the period 1997-2000 at six departmental centers for medical prevention in Val de Marne. Thirty-nine patients aged 18 years or more with M. tuberculosis-positive sputum samples, and living with children or adolescents, were identified. Ninety-one children, aged 3 months-17 years, were exposed to these index cases. All the children initially underwent a tuberculin skin test and chest radiography, and children with no criteria for latent infection or active disease at time of initial evaluation were asked to attend a second evaluation 3 months later. Overall, 20 of the 91 (22%) children were infected, including 4 children identified only at the second evaluation. Eight (40%) of the 20 infected children had active disease, including 2 of the 4 children identified at the second evaluation. The risk of infection was not influenced by the children's age, but was significantly associated with three characteristics of the adult cases, i.e., age younger than 40 years, presence of cavitary lesions, and smears with more than 100 bacilli per microscopic field. In conclusion, our results call for early examination of all exposed children, in order to prevent infection and progression to active disease, and for a routine second evaluation after the adult contact has ended.

Prediction of obstructive sleep apnea by OxiFlow in overweight patients.

OBJECTIVES: The aim of our study was to assess the diagnostic characteristics of the OxiFlow (OF) device that combines oximetry with recording of thermistor airflow. METHODS: In patients referred to the sleep laboratory of an obesity clinic apnea-hypopnea index (AHI, events h(-1)) was calculated both by a full-night polysomnography (PSG) and OF on a separate night. Fifty-six patients were studied, of whom 49 had OSA defined as an AHI> or =15 events h(-1). RESULTS: There was an underestimation of AHI by OF when assessed by the Bland-Altman plot. Sensitivity (Se), specificity (Sp), positive (PPV) and negative (NPV) predictive values for OF-AHI thresholds (10, 15 and 20 events h(-1)), taking PSG as a gold standard with a fixed PSG-AHI threshold of 15 events h(-1), were evaluated in two groups of patients with intermediate (group A, n=18, OSA prevalence=72.2%) and high (group B, n=38, OSA prevalence=94.7%) clinical probability of OSA. Se and PPV ranged respectively from 0.77 to 0.85 and from 0.73 to 0.77 (group A); from 0.74 to 0.97 and from 0.94 to 0.98 (group B). Sp and NPV ranged respectively from 0.20 to 0.40 and from 0.33 to 0.40 (group A); from 0.50 to 0.83 and from 0.21 to 0.67 (group B). Likelihood ratios (LRs) for a positive OF result ranged from 1.06 to 1.28 (group A) and from 1.83 to 4.42 (group B). CONCLUSIONS: We conclude that in a population with a high OSA prevalence, we have found a low agreement between PSG-AHI and OF-AHI and an underestimation of AHI by OF. The LRs of OF as a diagnostic test were of low significance, precluding its usefulness in generating significant shifts in pretest to posttest probability of OSA.