Inflammatory bowel diseases, chronic liver diseases and the lung.

This review is devoted to the distinct associations of inflammatory bowel diseases (IBD) and chronic liver disorders with chronic airway diseases, namely chronic obstructive pulmonary disease and bronchial asthma, and other chronic respiratory disorders in the adult population. While there is strong evidence for the association of chronic airway diseases with IBD, the data are much weaker for the interplay between lung and liver multimorbidities. The association of IBD, encompassing Crohn's disease and ulcerative colitis, with pulmonary disorders is underlined by their heterogeneous respiratory manifestations and impact on chronic airway diseases. The potential relationship between the two most prevalent liver-induced pulmonary vascular entities, i.e. portopulmonary hypertension and hepatopulmonary syndrome, and also between liver disease and other chronic respiratory diseases is also approached. Abnormal lung function tests in liver diseases are described and the role of increased serum bilirubin levels on chronic respiratory problems are considered.

Early postoperative prophylactic noninvasive ventilation after major lung resection in COPD patients: a randomized controlled trial.

OBJECTIVES: To investigate whether prophylactic postoperative NIV prevents respiratory complications following lung resection surgery in COPD patients. METHODS: In seven thoracic surgery departments, 360 COPD patients undergoing lung resection surgery were randomly assigned to two groups: conventional postoperative treatment without (n = 179) or with (n = 181) prophylactic NIV, applied intermittently during 6 h per day for 48 h following surgery. The primary endpoint was the rate of acute respiratory events (ARE) at 30 days postoperatively (ITT analysis). Secondary endpoints were acute respiratory failure (ARF), intubation rate, mortality rate, infectious and non-infectious complications, and duration of ICU and hospital stay. MEASUREMENTS AND MAIN RESULTS: ARE rates did not differ between the prophylactic NIV and control groups (57/181, 31.5 vs. 55/179, 30.7%, p = 0.93). ARF rate was 18.8% in the prophylactic NIV group and 24.5% in controls (p = 0.20). Re-intubation rates were similar in the prophylactic NIV and control group [10/181 (5.5%) and 13/179 (7.2%), respectively, p = 0.53]. Mortality rates were 5 and 2.2% in the control and prophylactic NIV groups, respectively (p = 0.16). Infectious and non-infectious complication rates, and duration of ICU and hospital stays were similar between groups. CONCLUSIONS: Prophylactic postoperative NIV did not reduce the rate of ARE in COPD patients undergoing lung resection surgery and did not influence other postoperative complications rates, mortality rates, and duration of ICU and hospital stay.

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.

[Treatment of COPD]. / Traitement de la BPCO.

COPD treatment begins with smoking cessation and influenza and pneumococcal vaccines. Bronchodilators are indicated when dyspnea on exertion is reported (usually, FEV1 < 80% predicted). On-demand short-acting agents are chosen when dyspnea is intermittent, daily long-acting agents are administered once dyspnea occurs in daily life activities. In all cases, anticholinergics and beta2 agonists can be associated when one class is not sufficiently effective. In patients with FEV1 < 50% predicted (budesonide-formoterol) or 60% predicted (fluticasone-salmeterol), repeated exacerbations and symptoms despite maintenance bronchodilators, fixed associations are indicated. When a handicap persists on pharmacological treatment, respiratory rehabilitation centered on education and exercise training has to be proposed. Care for COPD has to integrate treatment of comorbidities such as cardio-vascular diseases, anxiety-depression, malnutrition, muscle dysfunction, osteoporosis, anemia ... Ongoing research aims at identifying new therapeutic targets, focusing on inflammation, remodeling, protease-antiprotease balance, oxidative stress, lung regeneration/repair and mucus production.

[Difficulties in the assessment of dyspnea and respiratory function in general practice]. / Difficultés de l'évaluation de la dyspnée et de la fonction respiratoire en médecine générale.

BACKGROUND: Dyspnea is one of the principal signs of chronic respiratory diseases. OBJECTIVE AND METHODS: To determine the appropriate questions and tests for recognizing dyspnea, 295 general practitioners questioned 1991 patients with or at risk of COPD in this cross-sectional study. After a brief training session, the physicians were asked to assess respiratory function with a small electronic spirometer. RESULTS: A questionnaire with a six-point semi-quantitative scale of dyspnea detected more dyspneic patients (78.1%) than the single question "Are you usually short of breath?" (68.6%), which in turn detected this symptom more often than simply listening for spontaneous complaints (33.7%). Even when dyspnea was reported only for substantial exertion, it was associated with impairment of all domains of quality of life. Only half the spirometry results met the minimal criteria of validity and reproducibility. DISCUSSION AND CONCLUSIONS: These results underline the importance of a specific, systematic assessment of dyspnea in patients at risk, and the need for sufficient training and practice before the use of electronic spirometers in general practice.

[Pharmacological treatment of stable chronic obstructive pulmonary disease]. / Traitement médicamenteux de la bronchopneumopathie chronique obstructive en état stable.

The pharmacological treatment of chronic obstructive pulmonary disease (COPD) can significantly improve quality of life by reducing exacerbations, dyspnea and exercise intolerance, thereby limiting the degree of handicap and improving daily activities. Recently, large randomised trials showed that some treatments can alter the decline in FEV1, which was previously only accessible to smoking cessation, and maybe reduce mortality. Bronchodilators are the first-line pharmacological treatment of COPD. Their clinical efficacy cannot be predicted by the inconstant changes in FEV(1.) Their main mechanism of action is the reduction in lung hyperinflation. Theophylline has a lower efficacy/tolerance ratio than inhaled bronchodilators. In symptomatic patients with FEV1 <50/60% predicted and repeated exacerbations despite bronchodilators, inhaled corticosteroids combined with long acting beta-agonists can be used. Several other approaches targeting inflammation and oxidative stress, remodelling and lung regeneration are also being studied. Medications must be associated with non-pharmacological measures (including help towards smoking cessation, education, exercise training...). Systemic manifestations of COPD must also be taken into account.

The effect of an information leaflet upon knowledge and awareness of COPD in potential sufferers. A randomized controlled study.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is markedly under-diagnosed, which may be related to the under-reporting of symptoms and poor awareness of the disease. We hypothesized that written information on COPD may help increase awareness of the disease in people at risk of developing it. OBJECTIVES: To evaluate the impact of an information leaflet sent by postal mail on the level of knowledge of COPD in subjects with or at risk of COPD. METHODS: A total of 860 subjects with or at risk of COPD were selected by using a phone questionnaire. All subjects who reported a known diagnosis of COPD, a chronic cough and sputum production, or a smoking history of at least 15 pack-years were eligible for selection. Their knowledge of COPD was assessed during a telephone interview (baseline). They were randomized into 2 groups, with only 1 group receiving the information leaflet, and were then contacted 3 months later for a second interview. The changes in the knowledge of COPD from baseline were compared between subjects who reported receiving and reading the leaflet (true sensitized group) and subjects to whom the leaflet was not sent (control group). RESULTS: At the follow-up interview, the proportion of patients who spontaneously mentioned 'respiratory difficulties', when asked about the meaning of COPD, significantly increased in the true sensitized group (+11.9%) compared with the control group (+2.6%, p < 0.05). In addition, the frequency of patients who cited lung function test as the primary diagnostic tool for COPD increased by +14.4% in the true sensitized group versus+2.0% in the control group (p < 0.05). However, there was no short-term leaflet-dependent improvement in smoking behaviour or utilization of health-care resources. CONCLUSIONS: This study shows that an information leaflet sent by postal mail to subjects with or at risk of COPD can significantly improve their knowledge of COPD; however, it has no significant impact on their behaviour.

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.

[Epidemiology of chronic obstructive pulmonary disease]. / Epidémiologie de la bronchopneumopathie chronique obstructive.

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.

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.

Short-term and long-term outcomes of moxifloxacin compared to standard antibiotic treatment in acute exacerbations of chronic bronchitis.

STUDY OBJECTIVES: To compare the effectiveness of oral moxifloxacin with standard antibiotic therapy in acute exacerbation of chronic bronchitis (AECB). DESIGN: Multicenter, multinational, randomized, double-blind study of two parallel treatment arms. PATIENTS: Outpatients >or= 45 years old with stable chronic bronchitis, smoking history of >or= 20 pack-years, two or more AECBs in the previous year, and FEV(1) < 85% of predicted value. Patients were enrolled when in a stable condition, and patients with exacerbations within 12 months of enrollment were randomized. INTERVENTIONS: Randomization (stratified on steroid use) between moxifloxacin (400 mg qd for 5 days) and standard therapy (amoxicillin [500 mg tid for 7 days], clarithromycin [500 mg bid for 7 days], or cefuroxime-axetil [250 mg bid for 7 days]). MEASUREMENTS: Assessment at enrollment, randomization (Anthonisen type 1 exacerbation), 7 to 10 days after treatment, and monthly until next AECB or up to 9 months. The primary efficacy variable was clinical success (sufficient improvement, no alternative antimicrobial therapy required) 7 to 10 days after therapy. Secondary predefined end points were clinical cure (return to pre-exacerbation status), further antimicrobial use, time to next AECB, and bacteriologic success. RESULTS: Three hundred fifty-four patients received moxifloxacin, and 376 patients received standard therapy. At 7 to 10 days after therapy, clinical success rates were similar in intention-to-treat (ITT) patients (95% confidence interval [CI], - 0.7 to 9.5) and per-protocol (PP) patients (95% CI, - 3.0 to 8.5). Moxifloxacin showed superior clinical cure rates over standard therapy in both ITT patients (95% CI, 1.4 to 14.9) and PP patients (95% CI, 0.3 to 15.6), and higher bacteriologic success in microbiologically valid patients (95% CI, 0.4 to 22.1). Fewer ITT patients required antimicrobials after treatment with moxifloxacin than standard therapy (p < 0.01). Time to next exacerbation was longer with moxifloxacin; median and mean times to new AECBs in ITT patients who did not require any further antibiotics were 131.0 days and 132.8 days in moxifloxacin, and 103.5 days and 118.0 days in standard therapy, respectively (p = 0.03). The occurrence of failure, new exacerbation, or any further antibiotic was less frequent in moxifloxacin-treated patients for up to 5 months of follow-up (p = 0.03). CONCLUSIONS: Moxifloxacin was equivalent to standard therapy for clinical success and showed superiority over standard therapy in clinical cure, bacteriologic eradication, and long-term outcomes.

[Chronic obstructive pulmonary disease in France: the patients' perspective. Results of an international survey (Confronting COPD)]. / Bronchopneumopathie chronique obstructive en France: le point de vue des patients Résultats d'une enquête internationale (Confronting COPD).

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) has become a real public health problem throughout the world. In spite of its association with high rates of morbidity and mortality, it is not accorded sufficient attention. In this paper, we present the results of the French part of the international survey "Confronting COPD in North America and Europe" concerning the impact of COPD from the perspective patients'. METHODS: Subjects were randomly recruited by means of telephone questionnaires. Patients included in the survey were to be aged > or =45 years with a cumulative cigarette consumption of > or =10 packets-yrs, and having been diagnosed with COPD, emphysema or chronic bronchitis, or whose symptoms fulfilled a definition of chronic bronchitis. RESULTS: According to this survey, the prevalence of COPD among smokers (mean number of packets per year: 38.2 +/- 26.1) was 3.2%. COPD was undiagnosed in 17% of patients in spite of the presence of characteristic symptoms. Respiratory difficulties had a marked adverse effect on the quality of life although patients tended to play down the severity of their problems. DISCUSSION: This survey reveals that COPD appears to be under-diagnosed and under-treated in France, as shown by the results of the same survey in the other 7 countries taking part. Considerable efforts are thus required to improve the speed and precision of diagnosis and to improve management of these patients.

Bacteremia caused by Acinetobacter ursingii.

Acinetobacter ursingii has not been reported in infectious processes apart from its recent description as a new species. A bacteremia caused by A. ursingii in a patient with a pulmonary adenocarcinoma confirms that this microorganism is an opportunistic human pathogen. The isolate was susceptible to imipenem, aminoglycosides, rifampin, and fluoroquinolones.