[School health municipal service and health promotion in Villeurbanne]. / Service municipal de santé scolaire et promotion de la santé à Villeurbanne.

A school health municipal service has been in existence in Villeurbanne since its creation in 1935. It works throughout the city's schools, and in particularly in places which provide the last year of nursery school and all primary-level schools as well. In 1998 it was integrated into the office of the Directorate for Hygiene and Public Health, which provided an opportunity to reconsider its mission and reflect upon the priorities. The balance between screening and prevention was examined. Furthermore, its approach to thematic issues was put into question given the lack of a strategic overall programming methodology. The new health policy aimed at students was executed through a reorganization of evaluations, leading to the creation and implementation of a new programme called "I take care of myself" specifically targeting all first grade children. The results of this programme, which focuses on the development of a more comprehensive approach, are encouraging. Thanks to the programme, health has been reinstalled in its proper place in the schools, and it has become a matter of great importance for the children, their parents and the teachers. Furthermore, the school health service has consolidated and strengthened its role in this manner.

[Suicide mortality in Rhône-Alpes psychiatric sectors. Or the difficulties in a study]. / La mortalité par suicide selon les secteurs psychiatriques en Rhône-Alpes. Ou les difficultés d'une étude.

Mandated by the Social Welfare and Health Regional Office, the Regional Health Observatory realized a study on mortality by suicide in the psychiatric sectors. This work is based mainly on the definitions of a new map of the psychiatry, set on June 1994. Its objective was to give to each sector team a set of quantitative data on deaths due to suicide, happened on their area, both in term of progress (1982-1989) and of comparison (respective level of each sector compared to the "département" mean). This descriptive study is based on the regional cumulated mortality data from 1981-1983 and 1988-1990, given by the National Institute of Health and Medical Research (INSERM) and on the data of General population census in 1990. Epidemiological studies on suicide generally get as reference a delimitated geographical basis, accordingly to most of the important statistical databanks (nation wide, region wide...). The general psychiatric sectors are quite different, as the repartition is complex and their number is important (more than 80 for Rhône-Alpes Region) as well as the diversity of local needs and the organization in psychiatry. This repartition, responding to the needs of a medical and preventive practice, causes a great number of difficulties when one tries to approach this reality with statistics: the frontiers between sectors are determined with a degree of precision overtaking the one of demographical and epidemiological data sources. Taking into account the small size of the sectors, the number of deaths by suicide (mean of 10 to 20 by sector) does'nt enable to estimate the significance of the results. Despite the difficulty of different limitations, the data show inter-sectorial particularities, which could justify a regular epidemiologic survey (i.e.g., a growth in number of death by suicide in the "département" of Rhône between 1982 and 1989 is to be noticed more in urban areas). Such monitoring suggests a better acknowledgment of the feasibility of statistical surveys based on the sectors, and its use in the map of psychiatric services as well as the implementation of means, allowing data to be release quickly at the local level.

[Respiratory function test, a key in the etiologic diagnosis of dyspnea or a simple quantitative test?]. / Exploration fonctionnelle respiratoire (EFR), clef du diagnostic étiologique de la dyspnée ou simple épreuve chiffrée?

When confronted with a case of dyspnoea, three questions must be asked: is the dyspnoea due to a pulmonary organic disease? How severe is it? What is its nature or its origin? In the majority of cases these questions are answered by elementary lung function tests (spirometry and measurement of the residual volume), but for these answers to be valid it must be borne in mind that respiratory function test (RFT) is primarily a physical exercise: no measurement is valid unless the operator is fully involved and the subject explored participates to the best of his possibilities. RFT also is a mental exercise: the data obtained can be well understood only if the operator is conversant with the data described in this article. RFT has multiple applications, and yet this examination is notoriously underestimated and underused by the medical profession. Good practice is its best publicity.

Different bronchoconstrictor effects of carbachol boluses inhaled near residual volume or total lung capacity.

The purpose of this study was to determine if the lung volume at which aerosol inhalation begins (LVi) influences airway responses to bronchoconstrictor agents. We compared the effects of carbachol boluses (25, 50 and 100 ml), inhaled at high and low LVi (averaging 72.2 and 15.8% of vital capacity, respectively) on specific airway resistance (SRaw). In order to eliminate the possible influence of airway obstruction on aerosol distribution and deposition, we selected 5 asthmatic subjects with normal respiratory function (spirometry, SRaw, nitrogen washout and closing volume); furthermore, non-cumulative dose-response curves were obtained (i.e. the patients inhaled only one dose of carbachol on a given test day). Inhaling carbachol at low LVi yielded a significantly (p less than 0.01) larger degree of bronchoconstriction. Differences in bronchial responses were probably due to differences in the amount of particles deposited in the airways and/or to their distribution. These data suggest that LVi should be controlled for quantified inhalation provocation tests.

[Bronchodilator effects of an atropinic compound: oxitropium pressurized aerosol. Comparison with theophylline in asthma]. / Effets bronchodilatateurs d'un atropinique: l'oxitropium aérosol-doseur. Comparaison avec la théophylline dans l'asthme.

Oxitropium bromide (Tersigat pressurized aerosol) is a new anticholinergic agent. Two puffs of 100 micrograms given in 27 adult patients with asthma produced a 33% mean increase in FEVI, significantly bigger than the 20.9% increase obtained by an intra-muscular injection of theophylline (240 mg) in the same patients.

[Measurement of the effect of a bronchodilator using FEV1: how to express it?]. / Mesure d'un effet bronchodilatateur par le VEMS: comment l'exprimer?

An assessment of the effect of a bronchodilator on VEMS (FEV1) is based on a "before and after" comparison with the chosen drug. Most often the percentage rise in FEV1 compared to the initial value is calculated (I), and a minimum of 20% reversibility is expected for asthma. But the change of FEV1 expressed as a percentage of predicted theoretical value (II) may also be calculated. With the help of 50 cases of asthma selected by the first criteria (I) after an inhalation of an adrenergic stimulant the following changes were shown: That the first method (I) is biased, over estimating for low initial values; That the second method (II) was not inconvenient and furnished all the information derived. It shows in particular that 14/50 subjects have a variation of FEV1 less than 10% of their theoretical value, which has considerable therapeutic interest and merits further discussion.

[Inadequate use of pressurized aerosols by asthmatic patients [author's transl]. / Mauvaise utilisation des aérosol-doseurs par les asthmatiques.

The purpose of this study was to determine in a population of asthmatics, the number of patients who correctly used the pressurized aerosols (bronchodilator drugs or steroids) spontaneously, or after training sessions. 115 asthmatics (in- or outpatients, 14-70 years old) were asked to use their inhaler in the presence of an observer. The inhalation technique was considered correct when (1) the puff release was coordinated with a deep inspiration and (2) when the inspiration was followed by a few seconds' breath-holding. The patients were divided into two groups: a trained group of 46 patients who were observed for 1 month or more after the two above-mentioned maneuvres had been demonstrated to them by a physician and the need for correct use strongly emphasized. The other group (the untrained group) comprised 69 patients who were presumably using their inhalers according to the manufacturer's instructions: (1) expiration; (2) inspiration and actuation, and (3) apnea. In the trained group 52% of the patients were classified by the observer as correct users, as compared to 28% in the untrained group. The results were not influenced by sex. age or occupational differences. These observations suggest that a majority of asthmatics probably derived incomplete benefit from the use of pressurized aerosols. Although training apparently results in a more efficient use of the canisters, this study shows that training sessions must be repeated, and the results checked at regular intervals by a member of the medical staff. In subjects who repeatedly fail to achieve a correct inhalation technique the drug should be given by another route.

Mechanisms of the bronchoconstrictor effects of deep inspiration in asthmatic patients.

A single deep inspiration (DI) is commonly followed by transient airflow obstruction in asthmatic patients. In some patients, however, DI results in a sustained response which suggests that more than one mechanism may be responsible. We have studied the characteristics of the response to repeated DI, and their modificatiion by various pharmacological agents, by measuring specific airway resistance (sRaw) in ten subjects who showed reproducible and consistent increases in sRaw after DI. Two types of reaction were observed: type A (n = 8) had an immediate maximum and usually short persistence; type B (n = 2) had a delayed maximum with a progressive increase. In type A reactions repetition of DI showed different patterns of response--either a reproducible reaction to each DI or a plateau effect. In type B reactions the response spontaneously increased with repeated DI. Type A responses to DI were inhibited completely by a beta-adrenergic stimulant (BAS), largely by an anticholinergic drug (AC, ipratropium bromide), but in no case by disodium cromoglycate (DSCG). Type B responses were inhibited completely by BAS, largely by DSCG, and partially by AC. These findings suggest that the response to DI is due to bronchoconstriction, which in type A reactions is of reflex origin, vagally mediated, and is due in part or wholly to mediator-release in type B reactions.

Airway response to carbachol in normal and asthmatic subjects: distinction between bronchial sensitivity and reactivity.

By constructing cumulative dose-response curves to inhaled carbachol in 12 normal and 17 asthmatic subjects with comparable baseline specific airway conductance, we have shown that there were wide variations among subjects in the dose of carbachol needed to cause a 25 per cent decrease in specific airway conductance (bronchial sensitivity) and in the slopes of the curves (bronchial reactivity). Furthermore, there was no significant correlation between these 2 characteristics of the bronchial response to carbachol. The mean dose-response curves of the asthmatic and the normal subjects were widely divergent, indicating that the asthmatic subjects differed from normal subjects more in terms of bronchial reactivity than in bronchial sensitivity. This suggests that different mechanisms determine the sensitivity and reactivity of the bronchial tree, and that hyper-reactivity is the main feature of the asthmatic response. Both should be assessed when the bronchial response to bronchoconstrictor agents is measured.

Bronchial response to inhaled prostaglandin F2alpha in patients with common or aspirin-sensitive asthma.

The effect of aerosolized prostaglandin F2alpha (PGF2alpha) on specific airway resistance (SRaw) has been measured in patients with common (n = 10) or aspirin-sensitive asthma (n = 5). In all subjects PGF2alpha caused a dose-related increase in SRaw, but considerable individual differences in sensitivity were observed. The patients with aspirin intolerance did not differ from regular asthmatics in terms of their response to PGF2alpha. Two types of reactions to PGF2alpha could be distinguished from their time-course: immediate and short-lasting (3 cases) or delayed and long-lasting (12 cases). Inhalation of a beta-adrenergic drug rapidly and completely reversed the effect of PGF2alpha, suggesting that the increase in SRaw was due to bronchospasm. In 7 subjects the inhalation of an anticholinergic drug (SCH 1000) prior to PGF2alpha inhibited to a large extent the effect of the latter, suggesting that the cholinergic system played an important role in the bronchial response to PGF2alpha. In 9 subjects no correlation was found between the bronchial sensitivity to carbachol and PGF2alpha.

[Relationship between the initial dimensions of bronchial ring and its contraction after acetylcholine (author's transl)]. / Contraction par l'acétylcholine d'anneaux bronchiques isolés : influence du calibre initial

Contractions produced by comulative doses of acetylcholine were studied in isolated canine bronchical rings from 2 to 10 mm internal diameter. The maximal active tension achieved was directly related to the initial caliber of the ring and to the amount of smooth muscle. The maximal decrease in caliber was relatively greater (--39%) in the smaller than in the larger bronchi (--17%). However the corresponding increase in airway resistance may be predicted to be more important in the larger resistive bronchi.