Management of acute exacerbations of chronic obstructive pulmonary disease (COPD). Guidelines from the Société de pneumologie de langue française (summary).

Chronic obstructive pulmonary disease (COPD) is the chronic respiratory disease with the most important burden on public health in terms of morbidity, mortality and health costs. For patients, COPD is a major source of disability because of dyspnea, restriction in daily activities, exacerbation, risk of chronic respiratory failure and extra-respiratory systemic organ disorders. The previous French Language Respiratory Society (SPLF) guidelines on COPD exacerbations were published in 2003. Using the GRADE methodology, the present document reviews the current knowledge on COPD exacerbation through 4 specific outlines: (1) epidemiology, (2) clinical evaluation, (3) therapeutic management and (4) prevention. Specific aspects of outpatients and inpatients care are discussed, especially regarding assessment of exacerbation severity and pharmacological approach.

Disclosure of prognosis to terminally ill patients: attitudes and practices among French physicians.

BACKGROUND: Disclosure of the prognosis to terminally ill patients is a strong prerequisite for integrating the physical, psychological, spiritual, and social aspects of end-of-life care. OBJECTIVE: This study aimed to assess French physicians' general attitudes and effective practices (with patients followed up to death recently) toward such disclosure. DESIGN/SUBJECTS: We used data from a cross-sectional survey conducted among a national sample of 917 French general practitioners, oncologists, and neurologists. RESULTS: A majority of respondents opted for prognosis disclosure only at patients' request, very few opted for systematic disclosure without patient's request, and a significant minority opted for systematic concealment. Concerning deceased patients described by respondents, 44.5% of competent patients were informed of prognosis by their physician, 27.3% were informed by someone else, 9.0% refused to be informed, and 19.2% were simply not informed. Concealment was more frequent for older patients, and physicians involved in a nongovernmental organization (NGO) for patients' support were more likely to disclose the prognosis, even without patient's request. CONCLUSIONS: Disclosure of the prognosis to terminally ill patients is still far from systematic in France. Further research is needed to better understand the motivations of French physicians' disclosure practices, which are probably culturally shaped.

[Doctors' opinions on palliative care: results from a French survey on physicians attitudes and practices]. / Deux points de vue des médecins sur les soins palliatifs.

OBJECTIVE: To examine practitioners' opinions on palliative care. METHOD: Statistical analyses were carried out on data collected from 1000 physicians recruited to participate in a study on knowledge, attitudes and practices with respect to palliative care ("Palliative Care 2002"). A cluster analysis (CAH) was conducted based on responses to nine questions in order to identify homogeneous and contrasting profiles of opinions on palliative care. RESULTS: Two distinctly different categories of profiles emerged. The first one had a restrictive approach to palliative care (n = 387; 38.7%), while the second one supported its expansion (n = 613; 61.3%). CONCLUSION: A newly revised communication campaign which favoured and recognised palliative care could assist in the dissemination of related practices among physicians.

[Terminal care of patients by the general practitioner and the specialist. Results of a French survey "Attitudes and practices in palliative treatment--2002"]. / Prise en charge des malades en fin de vie en médecine générale et spécialisée. Résultats de l'enquête française "Attitudes et pratiques face aux soins palliatifs-2002".

OBJECTIVE: Assess the attitude of the practitioners with regard to the management of patients at the end of their lives, depending on the physician/patient communication and treatment of pain. Method Statistical analysis of the data collected among 1,000 practitioners recruited for a survey on knowledge, attitudes and practices regarding palliative care in 2002. RESULTS: The practitioners who felt "ill at ease" in the management of patients at the end of their life often had a poor opinion regarding morphine and did not systematically their patients of the therapeutic aims. CONCLUSION: Greater awareness by the practitioners of palliative care would help to improve the quality of care supplied to terminally ill patients.

[Management of COPD according to severity by respiratory specialists in France]. / Prise en charge de la BPCO en pneumologie selon le stade de sévérité.

INTRODUCTION: The diagnosis and treatment of chronic obstructive pulmonary disease (COPD) is suboptimal in many patients, which may impact on morbidity, mortality, use of healthcare resources and patients' overall quality of life. OBJECTIVES: To describe the management of COPD by respiratory physicians from the French mainland according to severity. METHODS: Observational cross-sectional survey performed in France in 2006-2007. 515 pulmonologists located throughout the national territory were involved and each of them had to recruit 5 patients with stable COPD. RESULTS: The study included 2494 patients (mean age 67 years, 78% males), of whom nearly 50% had severe to very severe COPD (GOLD stage III-IV). At inclusion, 93.2% of patients were receiving pharmacological treatment, most often non-nebulised bronchodilators (91.2%) and/or inhaled corticosteroids (73.7%). Pulmonary rehabilitation was scheduled or had been performed within the last 2 years in 26.9% of patients. Investigations and treatments were more frequent when the disease was more severe, but there was considerable overlap between severity grades. CONCLUSIONS: Differences in decisions about the investigation and treatment of COPD by pulmonologists can not be explained only by the severity of disease. Efforts must be made to identify other patient characteristics associated with these decisions, in order to help developing future recommendations.

Immunotherapy with an aluminum hydroxide-adsorbed Juniperus ashei foreign pollen extract in seasonal indigenous cypress pollen rhinoconjunctivitis. A double-blind, placebo-controlled study.

BACKGROUND: The efficacy of standardized Juniperus ashei extract was assessed in patients with allergic rhinoconjunctivitis due to European cypress pollens. METHODS: Forty adults with European cypress-allergic rhinoconjunctivitis were randomized to receive immunotherapy or a matched placebo. Specific immunotherapy was performed with a standardized, aluminum hydroxide-adsorbed J. ashei extract with a potency of 100 IR (arbitrary index of reactivity) containing 54 microg of Jun a 1/ml (Alustal, Stallergenes, France). Subcutaneous injections started in October 2000. The maintenance dose was 0.30 ml of the 100-IR concentration per month. Rhinitis and conjunctivitis symptoms were rated according to a 4-point score. RESULTS: Seventeen patients from the treated group and 15 patients from the placebo group completed year 2001; 14 in each group completed year 2002. A statistically significant improvement (41%, p < 0.02) in the conjunctivitis symptom score was observed in actively treated patients compared to the placebo group at the peak of the 2001 pollen season. Improvement in rhinitis (17%) was not significant. This significant improvement was greater at the peak of the 2002 pollen season (63%, p < 0.01). CONCLUSIONS: This study therefore indirectly validates the concept of treatment by major allergen because J. ashei is absent from the region in which this study was conducted.

Opinions toward pain management and palliative care: comparison between HIV specialists and oncologists.

Despite the introduction of HAART, pain is still a common symptom in people living with HIV/AIDS. For these persons, pain management supplied by palliative care teams may support standard HIV care. This study compares opinions toward palliative care of 83 HIV specialists and 217 oncologists (French national survey: Palliative Care 2002). Data were collected by phone questionnaire. A cluster analysis was carried out in order to identify contrasted profiles of opinions toward palliative care. A logistic regression was performed to test the relationships between identified clusters and physicians' characteristics. With a two-cluster partition, we observed a profile corresponding to a restrictive conception of palliative care. Within this profile, physicians were more prone to consider that palliative care should be used only for terminally-ill patients, and only after all curative treatments have failed, with a restrained prescriptive power for physicians providing palliative care. This conception was associated with reluctance toward morphine analgesia. Once controlled for other physicians' characteristics, HIV specialists were more likely than oncologists to endorse this restrictive conception (OR=1.9, CI 95% [1.1; 3.3]). Thus French HIV specialists should be more informed about the utility of providing palliative care, even for patients who are not in terminal stage.