Treatment compliance, passive smoking, and asthma control: a three year cohort study.

AIMS: To study the role of treatment compliance and parents' smoking on asthma control in children with recently diagnosed mild or moderate persistent asthma who were prescribed inhaled anti-inflammatory treatment. METHODS: Prospective cohort study of 167 children aged 6-12 years (64% boys). Patients were examined at inclusion and followed up for three years with a visit every four months. Peak expiratory flow (PEF) was measured twice a day during the week before each visit. Two control criteria were monitored: (1) symptom control = having diurnal or nocturnal exacerbations less than once a week and no symptoms between exacerbations, at all visits; and (2) PEF control = daily PEF variability <20% on each of the seven days before each visit. RESULTS: Symptom control was achieved by 25.1% of children and PEF control by 53.3%. Symptom control was positively related to having understood the way in which the medication worked and taking the prescribed doses (odds ratios (OR) = 3.38 and 4.82 respectively). It was inversely related to smoking within the home (OR = 0.34). PEF control was positively related to taking the prescribed doses (OR = 3.58). It was less frequently achieved if the mother smoked within the home (OR = 0.34). CONCLUSIONS: Results suggest that, to maximise the benefits of available asthma medication and to improve health outcomes, further efforts should be made to convince the parents of asthmatic children not to smoke in the house, and to improve compliance by increasing the patients' understanding of the disease and its treatment.

[Construction and validation of a respiratory epidemiological questionnaire]. / Construction et validation d'un questionnaire en épidémiologie respiratoire.

This paper illustrates the principles of construction and validation of an epidemiological questionnaire by using various aspects of the questionnaire prepared for the Epidemiological Study of the Genetic and Environmental Factors in Asthma, Bronchial Hyper-responsiveness and Atopy (EGEA). Standardised international questionnaires (for adults and children) were adapted and augmented for the requirements of the study. New areas in relation to international epidemiological studies are described (detailed descriptions of asthma and allergic rhinitis, trigger factors exposure tovarious environmental factors and family history). Various aspects of validation are discussed: the acceptibility by the study of missing data in the description of asthmatic symptoms, the construct validity for a score for allergic rhinitis, the reliability of a new self-administered questionnaire for perceived hyper responsiveness to various stimuli and the validity of reported family history using information obtained from family members. Some of these elements could be used in the context of other clinical and epidemiological studies. The complete questionnaire, together with the source of the questions, instructions for interviewers and the method of coding are presented in an appendix available on the internet (http://www.splf.org/bbo/revues-articles/RMR/depotElectronique/2001-110_Kauffmann/Kauffmann2002.htm) which supplements the printed paper.

[Development over 3 years of asthma recently diagnosed in a cohort of children (ASMA study). Factors related to improvement in clinical status]. / Evolution sur 3 ans de l'asthme récemment diagnostiqué dans une cohorte d'enfants (étude ASMA). Facteurs liés à l'amélioration de l'état clinique.

OBJECTIVE: The objective of the ASMA study was to describe the evolution of light to moderate asthma, newly or recently (12 Pounds months) diagnosed in private pneumology centers, and to search for the predictive factors. METHODS: In 1995, 251 private pneumologists, throughout Metropolitan France, recruited 396 asthmatic children, 6 to 12 years old (64% boys). The 334 patients eligible for the study were examined every 4 months during 3 years (a mean of 6 controls were conducted out of the expected 9). The data were collected on standardized questionnaires completed by the physicians and notebooks filled-in by the patients the week before each control. This questionnaire comprised two asthma 'control' criteria: "control" of the clinical state, defined as asthma attacks < 1 per week AND nocturnal awakening < 1 per week AND absence of asthma symptoms between attacks on every control visit; "control" of the need for b2 mimetics on request, defined as the non-use throughout the week preceding the control visit. RESULTS: The global clinical state of the cohort rapidly improved once care was initiated: the proportion of children exhibiting at least one attack of asthma per week rapidly dropped to 43% on inclusion and to 13% on the first control visit (4 months), 10% on the second control visit, and then fluctuated at around 8% up until the last control visit. A similar evolution was noted regarding nocturnal asthma attacks. The proportion of patients with prescriptions for inhaled corticosteroids and long-lasting b2-mimetics increased over the three years of follow-up. Analysis of the factors related to the individual 'control' of the clinical state showed a negative effect in family histories of asthma (father) and the presence of smokers in the home, but above all a positive effect of compliance to treatment and particularly its understanding (OR = 2.5; p = 0.03) and respect of the doses (OR = 2.7; p < 0.01). The positive effect of compliance was confirmed by analysis of the factors related to the use of b2 mimetics on request. CONCLUSION: Smoking should be avoided in the home. Compliance to treatment could be improved by making sure that the patients and their parents fully understand the disease and its treatment, and by persuading them to strictly follow the treatments prescribed.

Asthma severity and adequacy of management in accident and emergency departments in France: a prospective study.

BACKGROUND: Recent guidelines have enabled doctors to establish accident and emergency department management strategies for acute asthma on the basis of severity of exacerbations at presentation. However, there is no available information on acute asthma patients classified according to severity of disease. Our aim was to describe the severity of such exacerbations at presentation, and the adequacy of treatment and management. METHODS: We did a 12-month multicentre cross-sectional observational cohort study in adult patients with acute asthma who attended one of 37 accident and emergency departments in France. The doctors who examined the patients obtained information using a formatted chart. We classified exacerbations according to severity (life-threatening, severe, or mild to moderate), on the basis of clinical findings and peak expiratory flow value, as defined by currently used guidelines. FINDINGS: Of 3772 patients with acute asthma, 975 (26%) had life-threatening attacks, 1834 (49%) had severe exacerbations without life-threatening features, and 963 (26%) had mild to moderate exacerbations. Initial treatment included nebulised b2 agonists, anticholinergics, and systemic corticosteroids in 3492 (93%), 1841 (49%), and 2252 (60%), respectively. According to severity classification, anticholinergics were used in 494 (51%), 913 (50%), and 434 (45%) of patients in life-threatening, severe, and mild to moderate exacerbations groups, respectively; corticosteroids were given in 666 (68%), 1117 (61%), and 468 (49%), respectively. The overall admission rate was 54.2%, and mean stay was 6.1 (SD 6.0) days. Patients were admitted in 747 (77%), 1018 (55%), and 278 (29%) of cases in life-threatening, severe, and mild to moderate groups, respectively. Three patients died in hospital. INTERPRETATION: Acute asthma exacerbations are often life-threatening in patients who attend accident and emergency departments, and management of patients is not ideal, mainly because of underuse of corticosteroids and inappropriate admission rates according to severity.

Using Global Initiative for Asthma guidelines to assess asthma severity in populations.

The classification of asthmatics into severity categories is a crucial issue for assessing the asthma burden within a community, in which a proportion of patients is currently treated. There is no epidemiological method currently available. The Global Initiative for Asthma (GINA) was used to classify 4,362 patients aged 16-45 yrs (49% males, 42% taking inhaled corticosteroids), enrolled by 545 chest specialists in France with short standardized questionnaires including forced expiratory volume in one second (FEV1) measurements. Two independent GINA classifications were combined, one based only on symptoms and FEVI, and the other based only on current medication, to construct a final "symptom-FEV1 medication" classification. Almost 40% of the patients classed as step 1, 30% of those classed as step 2 and 13% of those classed as step 3 in the initial symptom-FEV1-classification, were allocated to categories of higher severity in the final classification. The approach was validated by showing that the proportions of: 1) patients considered by the physicians as having severe or moderately severe asthma; 2) patients with a history of hospital admission for asthma; and 3) patients with a history of emergency department visits for asthma, increased with severity steps in the final classification, for each step of the two initial independent classifications. The treatment manage plan in the Global Initiative for Asthma was not developed for assessing severity of asthma but rather to describe the recommended therapy for asthma with different severity. This is the first attempt to assess the severity of asthma in a large population of asthmatics mostly taking treatment, based on the Global Initiative for Asthma guidelines. The authors propose this simple and pragmatic procedure for a potential classification which should be put to the test in other studies.

Quality of life in allergic rhinitis and asthma. A population-based study of young adults.

Quality of life has been found to be impaired both in patients with asthma and in patients with allergic rhinitis, but the relative burden of these diseases has not been investigated. We analyzed answers to the SF-36 questionnaire from 850 subjects recruited in two French centers participating in the European Community Respiratory Health Survey, a population-based study of young adults. Both asthma and allergic rhinitis were associated with an impairment in quality of life. However, 78% of asthmatics also had allergic rhinitis. Subjects with allergic rhinitis but not asthma (n = 240) were more likely than subjects with neither asthma nor rhinitis (n = 349) to report problems with social activities, difficulties with daily activities as a result of emotional problems, and poorer mental well-being. Patients with both asthma and allergic rhinitis (n = 76) experienced more physical limitations than patients with allergic rhinitis alone, but no difference was found between these two groups for concepts related to social/mental health. As asthma was not found to further impair the quality of life in subjects with allergic rhinitis for concepts related to mental disability and well-being, and as subjects with asthma often also suffer from allergic rhinitis, further studies on quality of life in asthma should ensure that the impairment in quality of life attributed to asthma could not result from concomitant allergic rhinitis.

Asthma in adults: comparison of adult-onset asthma with childhood-onset asthma relapsing in adulthood.

The prevalence of asthma in children and young adults is rising. Although the general features of asthma are similar in children and adults, there are several differences. Studies of the differences between childhood- and adult-onset asthma may provide new insight into the phenotypic heterogeneity of asthma. The aim of this cross-sectional study was to compare the characteristics of asthmatic adults who reported having (n = 84) or not having (n = 235) asthma in childhood. The participating patients were recruited by chest specialists throughout France and were examined from March to November 1995. The specialists completed a standardized questionnaire, and carried out a clinical examination and spirometric tests. Male sex; greater severity, particularly lower spirometry values related to small airways; greater severity and earlier onset of allergy; and maternal history of atopic dermatitis and perennial rhinitis were found to be associated with reported childhood asthma. This study exhibits highly internally consistent results and indicates that subjects who did have childhood asthma and relapse in adulthood appeared to have a potentially more severe form of asthma.

Use of personal passive samplers for measurement of NO(2), NO, and O(3) levels in panel studies.

We measured personal exposure to nitrogen dioxide (NO(2)), nitrogen monoxide (NO), and ozone (O(3)), using personal passive samplers during three 4-day periods, in a panel study of asthmatics continuing the normal activities of everyday life. Fifty-five adults, mean age 42 years, 53% men, and 39 children, mean age 11 years, 67% boys, wore two Ogawa passive samplers simultaneously: one for O(3), the other for NO(2) and NO. Mean outdoor pollution was measured at a regional monitoring network. Personal exposure levels were scattered; they were (on average) higher than stationary-site levels for NO and lower for NO(2) and O(3). In adults, 41% of the variance of personal exposure to NO(2) was explained by mean stationary-site measurement levels (P<0.0001). Twenty-one percent additional variance was explained by living near a main road, not having an extractor fan over the cooker, older age, and male sex. NO and O(3) personal exposures correlated poorly with stationary-site measurements. In panel studies of the health effects of air pollution, personal exposure to NO(2) and NO can be measured satisfactorily by passive samplers: such measurements are necessary for NO but not for NO(2). For O(3), accurate personal exposure measurement remains a challenge and further technical development is required.

Perennial rhinitis: An independent risk factor for asthma in nonatopic subjects: results from the European Community Respiratory Health Survey.

BACKGROUND: Although clinical and experimental studies suggest that upper respiratory tract dysfunction may affect the lower airways, rhinitis is usually not studied as a potential risk factor for asthma. This is because both diseases share key elements of pathogenesis and are usually considered as different manifestations of the same underlying "atopic" state. OBJECTIVE: We sought to assess whether asthma is associated with rhinitis in the absence of immunologic disorders in a population study. METHODS: Data from 34 centers participating in the European Community Respiratory Health Survey were analyzed. Random samples of 20- to 44-year-old subjects were invited to complete a detailed questionnaire and undergo total and specific IgE measurements, skin prick tests to 9 allergens, and bronchoprovocation challenges with methacholine. RESULTS: Subjects with perennial rhinitis (n = 1412) were more likely than control subjects (n = 5198) to have current asthma. After adjustment for sex, age, smoking habit, family history of asthma, geographic area, and season at the time of examination, asthma was strongly associated with rhinitis among atopic subjects (odds ratio [OR] = 8.1; 95% confidence interval [CI] = 5.4-12.1) but also among nonatopic subjects (OR = 11.6; 95% CI = 6.2-21.9). Moreover, the association remained very strong when the analysis was restricted to nonatopic subjects with IgE levels of 80 kIU/L or less (OR = 13.3; 95% CI = 6. 7-26.5). In nonasthmatic subjects bronchial hyperresponsiveness was also more frequent in subjects with rhinitis than in those without rhinitis (OR = 1.7; 95%CI = 1.2-2.6 in nonatopic subjects with IgE levels of

Is bronchial hyperresponsiveness more frequent in women than in men? A population-based study.

To test the hypothesis that a greater proportion of women than men react to methacholine challenge and investigate the possible reasons for any differences observed, we recruited 495 subjects 20 to 44 yr of age (50.9% male) in Paris and 304 subjects (51.3% male) in Montpellier (France), as part of the European Community Respiratory Health Survey. The proportion of responders (PD20 < or = 4 mg methacholine) was 33.7% in women and 11.9% in men (odds ratio = 3.8; 95% confidence interval = 2.4-6.0) in Paris and 43.2% in women and 29.5% in men (odds ratio = 1.8; 95% confidence interval = 1.1-2.9) in Montpellier. These differences could not be explained by asthma, respiratory symptoms, atopy, or lung function parameters. In stepwise logistic regressions including sex, asthma, and asthma-like symptoms, nasal allergies, atopy, baseline FEV1, FEV1%pred, FVC, and FEV1%FVC, the odds-ratios for the effect of female sex on PD20 < or = 4 mg methacholine were 5.2 (3.0-9.0) in Paris and 2.2 (1.2-3.8) in Montpellier. Reacting to low doses of methacholine (PD20 < or = 0.5 mg) was associated with asthma and atopy in both men and women. In contrast, reacting to doses between 0.5 and 4 mg was associated with asthma and atopy only in men and with heavy tobacco consumption only in women. We conclude that the excess of hyperresponsiveness in women is not due to their having smaller lung size or airway caliber than men and may be related to a greater susceptibility to smoking.

[Asthma in private pneumology practice]. / Asthme en pneumologie libérale.

We assessed asthma severity in patients attending private practice chest specialists, studied the factors related to classification by physicians, and described medications prescribed. 545 chest specialists scattered throughout France, included the patients examined from 3 to 28 May 1993 (N = 14,865). Besides a classification of asthma severity in four classes (mild, moderate, moderately severe, and severe), questionnaires included 20 questions on the history and characteristics of asthma, lung function level and medications prescribed. The proportion of mild asthmatics was 55% among the 3,620 children (aged 6 to 15 years), 42% among the 6,479 young adults (aged 16 to 45 years), and 18% among the 4,766 older adults (aged 46 to 75 years). Followed-up patients were considered more severe than new patients among adults, but not among children. The factors related to asthma severity were impaired FEV1, history of hospitalization, critical care and emergency visits for asthma, limitation of physical activities, and, to a latter extent, symptoms between exacerbations, frequent asthma attacks and daily use of beta 2-agonists. Anti-inflammatory drugs were prescribed to practically all patients from grade 2 (moderate): steroids increased whereas sodium cromoglycate and nedocromil decreased with increasing severity. This study provides a valuable estimate of the classification and medications prescribed to asthmatic patients examined by 50% of private practice chest specialists in France.

Alcohol consumption, gamma-glutamyl transpeptidase (GGT), and pulmonary function: a cross-sectional and longitudinal study in working men.

Epidemiological studies of the relationships between pulmonary function and reported alcohol intake showed inconsistent results. The use of biological markers of alcohol is needed. The objective of this study was to assess the relationships of alcohol consumption, assessed by a standardized questionnaire, and gamma-glutamyl transpeptidase (GGT), to forced expiratory volume in 1 sec (FEV1) level and decline over 10 years, in working men. Three hundred twenty-eight policemen aged 22-55 years were examined in 1980 (first survey) and again in 1990 (second survey). The two cross-sectional analyses used the 1980 data and the 1990 data separately. Longitudinal analysis used 1980 alcohol consumption and GGT values, and 10-year FEV1 decline. In both cross-sectional surveys, elevated alcohol consumption was significantly associated with impaired age-adjusted and height-adjusted FEV1. Further adjustment for smoking habit, education level, and asthmatic status did not alter these results. An increase of 25 g/day of alcohol was associated with 50.0 ml (95% confidence interval: 1.5 to 98.5) and 55.3 ml (95% confidence interval: 7.8 to 102.8) decrease of corresponding multivariate-adjusted FEV1 in 1980 and in 1990, respectively. GGT was also negatively associated with FEV1 in both cross-sectional surveys. Similar patterns of associations were also observed between vital capacity measurements and alcohol variables. In the longitudinal analysis, there was no relationship between either alcohol consumption or GGT and FEV1 decline. Findings suggest that alcohol consumption was associated with impaired lung function, but there was no evidence of accelerated FEV1 decline over 10 years related to alcohol consumption in this "healthy" population of middle-aged men.

Undertreatment in a nonselected population of adult patients with asthma.

BACKGROUND AND AIM: The question of undertreatment has frequently been raised concerning the management of asthma but, to date, very few studies have been carried out. In those studies that have been performed, the methodology was inadequate because they were conducted on a selected population of patients with asthma or by interviewing doctors. As part of the European Community Respiratory Health Survey, nonselected patients with asthma (22 to 44 years old) in two French cities (Paris and Montpellier), were examined to assess possible undertreatment. METHODS: Patients with asthma were recruited according to a positive response to questions on asthma in a questionnaire and a positive methacholine challenge. The severity of asthma was assessed by a cumulative score, which has previously been shown to be significantly correlated with the validated clinical score of Aas. Patients were asked to attend the clinic and bring with them any medications that they regularly received. The optimal treatment of asthma was based on the International Consensus Report on the Management of Asthma. RESULTS: According to the international guidelines, among the patients who required antiinflammatory treatment, 86.4% were undertreated in Paris and 66.7% were undertreated in Montpellier (p < 0.03, chi square test). Moreover, among the patients with severe asthma, 85% and 60%, respectively, were not receiving an antiinflammatory treatment. CONCLUSION: This study is the first to highlight the magnitude of undertreatment of patients with asthma in a nonselected population.

Use of two methods of analysis to estimate the annual rate of tuberculosis infection in Southern Algeria.

SETTING: Analysis of tuberculin skin test surveys. OBJECTIVE: To estimate the annual tuberculous infection rate in Tamanrasset (southern Algeria) by applying on the one hand the classical method of the Tuberculosis Surveillance Research Unit (TSRU) of the International Union Against Tuberculosis, and on the other the study of variations of allergy published by Raj Narain et al. METHODS: 3675 pupils aged 5-18 years were tested in October 1982 or November 1983; 1240 of them were tested on both occasions. The technique of the World Health Organization, with 2 TU PPD RT23 tuberculin was used by trained testers. The TSRU method was applied to the 863 children aged 5-15 years without bacille Calmette-Guerin (BCG) scar, according to three estimates of the prevalence of infection (cut-off points of the distribution of reactions of 10 mm, of 14 mm corrected by dividing by 0.82, and mirror technique with a mode of 17 mm), and to three hypotheses of the decrease in infection risk (1%, 3% and 5%). The study of variations of allergy was used in the 1240 pupils tested twice (BCG-vaccinated or not). RESULTS: The average annual risk of tuberculous infection estimated by the TSRU method was lower than 1% (0.5%-0.6% according to the most stringent criteria). By the method of variations of allergy, the estimated annual infection rate was 0.9%. For the latter, our results are consistent with those obtained by other researchers. CONCLUSIONS: These findings suggest that the study of variations of allergy might be a good alternative approach to estimate the annual infection rate in countries where children are BCG-vaccinated at birth, which is the case for most developing countries.

Bronchial hyperresponsiveness as a predictor of wheezing in a follow-up study of healthy men.

We assessed the relationship between bronchial hyperresponsiveness (BHR) and the onset of wheezing 5 years later, by epidemiological analysis of 194 working men without asthma or wheezing at the first examination. In 1985/ 1986 and 1990/1991, subjects answered a British Medical Research Council questionnaire and performed lung function measurements and methacholine challenge tests (total dose 6 mg). BHR was measured in three ways: (1) FEV1 fall > or = 20% (PD20+); (2) the two-point response slope expressed as percentage decline of FEV1/dose, and (3) a four-parameter model: FEV1 at dose (d)/ prechallenge FEV1 = ONE-k(d-delta)+a, where 'k' is the slope of the relative variation of FEV1 with the dose, 'delta' the threshold dose, and 'alpha' a shape factor. In the 13 new wheezers, the mean values of the two-point slope and of k were significantly increased, and the proportion of reactors was almost threefold (the latter was not statistically significant). Among nonsmokers, delta was significantly lower in new wheezers than in the others, whereas the slope and k had similar mean values. Among smokers, new wheezers had increased mean values for the slope and k, and an increased proportion of reactors, whereas delta was not decreased. Thus, BHR was a significant predictor of wheezing, independent of the method of analysis. Moreover, the model distinguished between two components of bronchial response: wheezing was predicted by sensitivity (delta) in nonsmokers, and by reactivity (k) in smokers.

Prevalence of asthma and asthma-like symptoms in three French cities.

BACKGROUND: This study is part of the European Community Respiratory Health Survey (ECRHS), which uses a common methodology in different areas throughout the world. This paper describes the prevalences of reported asthma, asthma-like symptoms and nasal allergies, their relationships to age group and sex, and the relationships of asthma-like symptoms to current asthma, in the general population aged 20-44 years of three French urban areas. METHODS: The study population of 2804 subjects in Grenoble, 3774 in Montpellier and 3152 in Paris (18th district), randomly selected from electoral rolls, answered a postal questionnaire (stage I of ECRHS). The response rates were 77.8%, 68.6% and 74.4%, respectively. RESULTS: The prevalences were approximately 14% for wheezing, 16% for chest tightness and 4.5% for nocturnal shortness of breath in the three areas. Asthma attacks in the last 12 months were reported by 2.7% of subjects in Grenoble, 3.5% of subjects in Montpellier and 4.0% of subjects in Paris (P = 0.02). For nasal allergies, the prevalences were 28.0%, 34.3% and 30.8%, respectively (P < 0.001). Asthma was inversely correlated to age (higher prevalence in the youngest) but was not related to sex. Neither age distribution nor sex ratio explained the differences between areas. Among the asthma-like symptoms, wheezing and nocturnal shortness of breath correlated strongly with asthma, chest tightness correlated moderately and nocturnal coughing correlated poorly. CONCLUSION: The prevalences observed were higher than expected from previous comparable French studies in young adults. These results are consistent with the hypothesis of a recent increase of asthma and allergies.

Peak expiratory flow rate variability in population surveys. Does the number of assessments matter?

We investigated the effect of reducing the number of daily peak expiratory flow (PEF) measurements on (1) the amplitude of PEF variability and (2) the relationships of this amplitude to bronchial reactivity to methacholine. One hundred seventeen workers (mean age = 38.7 years +/- 9.5; men = 86.3%) recorded their highest of three PEF measurements, every 3 waking hours, ie, 5 times a day, for 7 days, each using a newly purchased peak flowmeter (Vitalograph), and underwent methacholine challenge tests. The variability of PEF of each subject was expressed using the three sets of indices: amp%mean, ie, highest of the daily measurements considered minus the lowest/mean x 100, averaged over 6 days from the second to the seventh, amp%highest (same as amp%mean, but with the highest daily measurements as denominators) and SD%mean (calculated initially as single measures using the data of the 6 days considered, with standard deviation (SD) of each subject's PEF measurements). For each set, we used the indices constructed with the five daily measurements of each day (gold standard), with the first, third, fourth, and fifth, the first, third, and fourth, the first and third, and the first and fourth. The PEF variability was significantly reduced when reducing the number of daily measurements, only when the amp%mean and the amp%highest sets were used. No decrease was observed with the SD%mean set of indices, and SD%mean constructed with the first, third, fourth, and fifth daily measurement was satisfactory. Whatever the sort of index used, three daily measurements were sufficient to identify the group of subjects with excessive variability in relation to methacholine reactivity.