[The Incidence of occupational asthma in Alsace from 2001 to 2002. Results of intensification of the ONAP project in Alsace (2001-2002). Regional specificities]. / L'asthme professionnel en Alsace: quelques particularités régionales. Résultats de l'intensification locale de l'ONAP en 2001-2002.

INTRODUCTION: A national surveillance programme (ONAP project) was created in France in 1996 by two professional societies to estimate the incidence and identity the characteristics of occupational asthma. MATERIALS AND METHODS: In 2001 and 2002 chest physicians and occupational physicians in Alsace were intensively solicited for better voluntary reporting of cases of occupational asthma. The objective of this study was to evaluate the consequences of such a procedure on the number of cases reported, with a view to collecting comprehensive data. RESULTS: The mean annual incidence of occupational asthma was estimated at 126 cases per million workers with a female predominance (52.4%). Flours and isocyanates represented 40% of the suspected agents. Isocyanate asthma (21% of the total) was reported mainly in workers in the car supply industry, and seems to be a specific feature of the region. Persulfates represented 5.3% of the cases; latex and aldehydes 2.6%. The study also points to emergent aetiologies and work risks, i.e. quaternary ammonium compounds in disinfecting detergent products used by cleaners and healthcare workers. CONCLUSION: This study, which allowed better assessment of the real incidence of OA in Alsace and better detection of substances and occupations at risk, is an incentive to continue our Surveillance programme.

[The diagnosis and management of occupational asthma]. / Diagnostic et prise en charge de l'asthme professionnel.

INTRODUCTION: Occupational asthma (OA), with a latency period induced by multiple exposures, is characterized by immunological sensitization to the responsible agent, based on both an IgE mediated mechanisms and non specific bronchial hyper responsiveness. DIAGNOSTIC METHODS: In the diagnosis of OA, the medical history is obviously the starting-point. Onset of respiratory symptoms at work and resolution on vacation are indications of the diagnosis. After analysis of several publications, this element appears to have the best level of proof (grade 2+) according to the criteria of evidence-based medicine. A visit of the workplace, with the cooperation of the industrial physician, is essential to characterize the nature of the exposure. Positive immunological tests (skin tests and/or specific IgE) associated with objective criteria of symptoms related to work (modification of PEFR, lung function and/or nonspecific bronchial hyper responsiveness) will confirm the aetiological diagnosis of OA. Specific bronchial provocation tests performed in the laboratory allow the identification of new agents involved in OA and are necessary when other investigations are discordant or unavailable. OA needs a stepwise approach including induced sputum eosinophilic counts and measurements of exhaled nitric oxide. MANAGEMENT OF OA: OA requires removal from the workplace because persistence of exposure to respiratory sensitisers may lead to an increase and prolongation of asthma symptoms. However, removal from the workplace can have tremendous professional, financial and social consequences, and sometimes a compromise must be found with reduction of exposure by various methods combined with adequate treatment. The pharmacological treatment of patients with OA should be the same as for patients with non OA, the use of bronchodilators and corticoids depending on the severity of asthma. Concerning the medico-legal aspects, OA can be recognised as an occupational disease. In France OA is included in several tables of work-related diseases.

Reported incidence of occupational asthma in France, 1996-99: the ONAP programme.

AIMS: To estimate the general and specific incidence of occupational asthma in France in 1996-99; and to describe the distribution of cases by age, sex, suspected causal agents, and occupation. METHODS: New cases of occupational asthma were collected by a national surveillance programme, based on voluntary reporting, named Observatoire National des Asthmes Professionnels (ONAP), involving a network of occupational and chest physicians. For each case, the reporting form included information on age, sex, location of workplace, occupation, suspected causal agent, and methods of diagnosis. Estimates of the working population, used to calculate incidence rates by age, sex, region, and occupation, were obtained from the Institut National de la Statistique et des Etudes Economiques (INSEE) and from the French Securite Sociale statistics. RESULTS: In 1996-99, 2178 cases of occupational asthma were reported to the ONAP, giving a mean annual rate of 24/million. Rates in men were higher than rates in women (27/million versus 19/million). The highest rate was observed in the 15-29 years age group (30/million). The most frequently incriminated agents were flour (20.3%), isocyanates (14.1%), latex (7.2%), aldehyde (5.9%), persulphate salts (5.8%), and wood dusts (3.7%). The highest risks of occupational asthma were found in bakers and pastry makers (683/million), car painters (326/million), hairdressers (308/million), and wood workers (218/million). CONCLUSION: Despite likely underreporting, the number of cases of occupational asthma reported to the ONAP was approximately twice the number of compensated cases over the same period. The relevance of the programme is confirmed by the reproducibility of the results year after year, and its consistency with other surveillance programmes. The ONAP programme is useful for the identification of targets for primary prevention.

[Asthma from tropical abachi wood]. / L'asthme au bois d'abachi.

We report the case of a 28-year old man suffering from rhinitis and asthma which appeared 8 years after exposure to different woods, especially abachi wood. Serial PEFR monitoring at work and away from work were consistent with occupational asthma. Spirometry showed an airway obstruction, and metacholine inhalation test was positive. Skin prick-tests performed with different woods were only positive to abachi wood extract. The search for specific IgE was positive to abachi wood (4, 98 KU/l, class 3). The diagnosis of occupational asthma caused by exposure to abachi wood was established, the mechanism underlying this asthma was IgE mediated. Despite respiratory protection measures, the patient had persisting symptoms and was laid off. The German service for social cover asked for an expert evaluation: specific nasal and inhalation provocation tests performed by exposure to fine abachi wood dust were positive. This is an observation with a double significance: first, although the mechanisms underlying wood occupational asthma remain largely unknown, an IgE mechanism for abachi wood was demonstrated; second, legislation is different in France and Germany where occupational asthma will only be acknowledged if inhalation tests are positive.

Occupational asthma in France: a 1-yr report of the observatoire National de Asthmes Professionnels project.

Observatoire National des Asthmes Professionnels (ONAP) was created in 1996 by two French professional societies to estimate the incidence of occupational asthma and to promote preventive measures against it. Occupational and chest physicians were asked to report newly diagnosed cases of work-related asthma and reactive airway dysfunction syndrome (RADS), the information collected included age, sex, occupation, suspected causal agents and diagnostic methods. In 1997, 82.3% of 559 cases reported (64% males, mean age 36 +/- 13 yrs) involved occupational asthma, 4.7% RADS and 12.7% atypical asthma syndromes. Incidence rates (expressed as number of cases per million workers) showed a regional variation that ranged from 4 to 73 (national mean: 25.7). The most frequently suspected agents were flour (23.3%), followed by isocyanates (16.6%), latex (7.5%), aldehydes (5.5%), and persulphates (4.1%). Occupations at risk were bakers (23.9%), healthcare workers (12%), painters (9.1%), hairdressers (5.2%), wood industry workers (4.8%) and cleaners (3.5%). These results are compared to those of other systems set up in Europe and North America. Because of the considerable bias inherent in a surveillance system based on voluntary, reporting, the number of occupational asthma cases reported is probably lower than the real incidence. Nevertheless, the French National Observatory for Occupational Asthma encourages physician awareness of occupational asthma and provides an estimate of its incidence and aetiologies in France.

Quaternary ammonium compounds and occupational asthma.

OBJECTIVE: Quaternary ammonium compounds, among which benzalkonium chloride is one of the best-known, are commonly used as antiseptics, disinfectants, detergents and preservatives. They can cause occupational asthma, which however, has been rarely reported so far, despite wide use of these products. We report three such cases. Possible mechanisms causing asthma are discussed, taking into account their characteristics. METHODS AND RESULTS: Our patients, all female nurses, manifested asthma symptoms upon handling disinfectant solutions containing benzalkonium chloride. Work-related fall in PEFR was observed in all of them. The diagnosis was confirmed by challenge tests where the patients were exposed, in a closed chamber, to suspected disinfectant contained in a tray. All of the women developed early or delayed symptoms upon exposure. Similar challenge tests to placebo or other disinfectants devoid of quaternary ammonium compound were negative. CONCLUSION: These three cases, in addition to others reported in the literature, point out an as yet poorly known etiology of occupational asthma to quaternary ammonium compounds in hospital employees. The exact mechanism of the action remains unexplained.

Migratory pulmonary infiltrates in a patient treated with sotalol.

Beta-blockers may induce several types of adverse respiratory reaction such as asthma, interstitial lung disease with or without pleural effusion, systemic lupus erythematosus or hypersensitivity pneumonitis. More recently, bronchiolitis obliterans with organizing pneumonia (BOOP) has been described. We report here on pulmonary migratory infiltrates with combined histopathological features of both BOOP and eosinophilic pneumonia in a woman treated with sotalol long-term. The patient improved only partially with steroids. Tapering off corticosteroid dosage resulted in relapse, and complete recovery was only obtained after sotalol was stopped.

[Retentional jaundice and hypoxemic pneumopathy]. / Ictère rétentionnel et pneumopathie hypoxémiante.

The authors report the case of a patient with a pancreatic carcinoma who developed lung metastases mimicking a diffuse bronchiolo-alveolar carcinoma. Such features have already been described mostly with carcinomas of the digestive tract but also with breast, and head and neck carcinoma. Macroscopically and microscopically there is no difference between these lung metastases and a primitive bronchiolo-alveolar carcinoma. Identification of a surfactant protein might identify a primitive bronchiolo-alveolar carcinoma.

Can we predict very short term survival in small cell lung cancer?

We retrospectively reviewed the charts of 151 consecutive patients diagnosed as small cell lung cancer in our department and who had at least one course of chemotherapy. Nineteen patients died during the first 2 months, of the probability were reported to construct a receiver operating characteristic curve i.e. 13% of the population. The probability of dying within 2 months was investigated through a stepwise logistic regression. A performance status < or = 70 (Karnofsky index), an age > 60, a platelet count < or = 150,000/mm3, elevated alkaline phosphatase and a sodium < or = 135 mmol/l were independent predictors of a very short term survival and contributed to the equation for the probability of dying within a 2-month period. Sensitivity and specificity for various cutoff points characteristic curve allowing one to determine for a given patient his risk of being a very short term survivor. Such an approach could prevent inclusion of patients with high risk of early death in clinical trials and help to choose appropriate treatments for such poor risk patients.

Inability of serum neuron-specific enolase to predict disease extent in small cell lung cancer.

Serum neuron-specific enolase (NSE) levels were measured before treatment in 112 patients diagnosed as having small cell lung cancer in our department. All these patients underwent exhaustive staging procedures: 53 had limited disease (LD) and 59 extensive disease (ED). Serum NSE was elevated in 83% of the patients (i.e. 71% of the patients with LD and 93% of the patients with ED). Mean values of NSE differed significantly according to disease extent. A receiver-operating characteristic curve was constructed with different cut-off levels of serum NSE in order to determine the accuracy of NSE for identifying ED. There was no level of NSE capable of predicting with sufficient accuracy the presence of ED. The best compromise was given by a threshold of 35 micrograms/l: 60% of the ED patients had a serum NSE above 35 micrograms/l but 30% of the LD patients also had a serum NSE above 35 micrograms/l.

[Pre-therapeutic prognostic factors of survival in small cell bronchial cancer. Retrospective study in a series of 112 patients]. / Facteurs pronostiques préthérapeutiques de la survie dans le cancer bronchique à petites cellules. Etude rétrospective d'une série de 112 patients.

Pretherapeutic prognostic factors were studied retrospectively in 112 consecutive patients diagnosed as small cell lung cancer between January 1st 1986 and December 30th 1990 in our department. Mean age of the population was 59.3, 89.3% were males. Median survival time of the whole population is 11.66 months. It is 15.3 months for the 48 patients with limited disease stage and 9.74 months for 64 patients with extensive disease stage. Among the patients with limited disease stage, those with supraclavicular lymph nodes had a significantly shorter survival (p < 0.001). Univariate analysis of survival identified age, performances status, weight loss, T, N, bone and liver involvement, serum sodium, albumin and sedimentation rate as prognostic factors. The final model in multivariate analysis of survival includes for the patients with performance status < or = 70, extent of disease as an independent prognostic factor and for the patients with performance status < 70, extent of disease, serum sodium and albumin.

[Loop diuretics and the treatment of asthma]. / Diurétiques de l'anse et traitement de l'asthme.

Current data in the literature show a protective effect of loop diuretics in relation to certain types of experimental bronchospasm. This action has sometimes been observed after the administration of diuretics as aerosols in less severe cases of asthma. The initial observations on bronchospasm induced by physical stimuli (exercise, distilled water and hyperventilation), have been extended to bronchospasm provoked by allergens or certain chemical stimuli (metabisulphide, adenosine 5'-monophosphate, and salicylic acid). On the other hand provocation tests using histamine or acetylcholine are modified, either a little or not at all by diuretics. The proposed mechanisms of action are multiple, but are still very hypothetical: an action on ionic fluxes in the epithelial cells, in mastocytes, in nerve cells and in muscle cells inducing the secretion of prostaglandin. Diuretics certainly have opened some interesting patho-physiological approaches, but current data concerning their efficacy in asthmatics are still fragmentary and do not, at the current time, allow them to take a significant place in the therapeutic arsenal of asthma drugs.

[Development of 62 typical carcinoid tumor of the bronchi surgically treated. Prognostic value of histopathological features]. / Evolution de soixante-deux tumeurs carcinoïdes typiques des bronches opérées. Valeur pronostique des caractères histopathologiques.

The pathological and clinical features of 62 carcinoid tumours of the bronchus operated between 1975 and 1987 were reviewed in order to determine the prognostic value of certain parameters: limit of proliferation, vascular invasion, lymph node involvement. This series corresponded to 36 central tumours and 25 peripheral tumours, all treated surgically. One patient was lost to follow-up, 3 developed recurrences, 56 are still alive without recurrence and 3 died from intercurrent causes. The histological appearance of the tumours was homogeneous and typical. Twenty-eight lesions were strictly intrabronchial, 34 invaded the lung with incomplete limits in twenty cases. The tumour showed signs of vascular invasion in ten cases and the adjacent lymph nodes were invaded in eight cases. The local recurrence was undoubtedly related to an excessively conservative primary resection, as the primary tumour did not demonstrate any unusual features. The two tumours which metastasized showed vascular invasion: one metastasized to a hilar node, but these features were observed in other cases which retained a benign course. The standard histological diagnosis of typical carcinoid tumour does not appear to raise any particular difficulties; it is reliable. The course of the disease is sometimes malignant but no histological parameter is able to accurately predict this outcome.