Prise en charge de l'asthme en médecine de premier recours [Management of asthma in primary care medicine].

The international recommendations issued by GINA (Global Initiative for Asthma) have undergone considerable adaptations over the last years. This article proposes the local adaptation of those guidelines bearing on the practical aspects of the treatment for the general practitioner's use. One of the fundamental changes in these new guidelines on good practice relates to the permanent adaptation of the treatment on the basis of symptom control rather than on the severity of the asthma. Another change from the old recommendations concerns the manner in which the asthma is categorised into different phases.

Role of Tyk-2 in Th9 and Th17 cells in allergic asthma.

In a murine model of allergic asthma, we found that Tyk-2((-/-)) asthmatic mice have induced peribronchial collagen deposition, mucosal type mast cells in the lung, IRF4 and hyperproliferative lung Th2 CD4(+) effector T cells over-expressing IL-3, IL-4, IL-5, IL-10 and IL-13. We also observed increased Th9 cells expressing IL-9 and IL-10 as well as T helper cells expressing IL-6, IL-10 and IL-21 with a defect in IL-17A and IL-17F production. This T helper phenotype was accompanied by increased SOCS3 in the lung of Tyk-2 deficient asthmatic mice. Finally, in vivo treatment with rIL-17A inhibited local CD4(+)CD25(+)Foxp3(+) T regulatory cells as well as Th2 cytokines without affecting IL-9 in the lung. These results suggest a role of Tyk-2 in different subsets of T helper cells mediated by SOCS3 regulation that is relevant for the treatment of asthma, cancer and autoimmune diseases.

NLRP3 inflammasome is required in murine asthma in the absence of aluminum adjuvant.

Background: Inflammasome activation with the production of IL-1 beta received substantial attention recently in inflammatory diseases. However, the role of inflammasome in the pathogenesis of asthma is not clear. Using an adjuvant-free model of allergic lung inflammation induced by ovalbumin (OVA), we investigated the role of NLRP3 inflammasome and related it to IL-1R1 signaling pathway.Methods: Allergic lung inflammation induced by OVA was evaluated in vivo in mice deficient in NLRP3 inflammasome, IL-1R1, IL-1 beta or IL-1 alpha. Eosinophil recruitment, Th2 cytokine, and chemokine levels were determined in bronchoalveolar lavage fluid, lung homogenates, and mediastinal lymph node cells ex vivo.Results: Allergic airway inflammation depends on NLRP3 inflammasome activation. Dendritic cell recruitment into lymph nodes, Th2 lymphocyte activation in the lung and secretion of Th2 cytokines and chemokines are reduced in the absence of NLRP3. Absence of NLRP3 and IL-1 beta is associated with reduced expression of other proinflammatory cytokines such as IL-5, IL-13, IL-33, and thymic stromal lymphopoietin. Furthermore, the critical role of IL-1R1 signaling in allergic inflammation is confirmed in IL-1R1-, IL-1 beta-, and IL-1 alpha-deficient mice.Conclusion: NLRP3 inflammasome activation leading to IL-1 production is critical for the induction of a Th2 inflammatory allergic response.

Devenir à long terme des patients intubés pour état de mal asthmatique [Late outcome after life-threatening asthma]

Pour connaître le devenir à long terme des patients intubés pour état de mal asthmatique, nous avons recontacté en 1990 les 34 patients qui avaient présenté, entre 1978 et 1988, quarante épisodes de détresse respiratoire aiguë. Deux patients sont vivants mais ont été perdus de vue, 3 sont morts dont un seul d'état de mal asthmatique 6 mois après l'épisode initial. Des 29 patients restants (7 hommes et 22 femmes, âge moyen de 48,5 ans) représentant un suivi moyen de 9,6 ans, quinze n'ont jamais été réhospitalisés; des 14 autres, seuls 5 ont requis une intubation et une ventilation mécanique lors d'un épiode ultérieur. La majorité des hospitalisations ultérieures (81%) sont survenues dans les 6 ans suivant l'épiode initial

Occupational exposure to beryllium in Switzerland : exposed workers and occupations at risk

Introduction: Beryllium (Be) is increasingly used in various industrial applications. Occupational exposure to Be may lead to chronic beryllium disease (CBD), a pulmonary granulomatous disorder closely similar to sarcoidosis, which develop in 1 to 15% of exposed workers. Although Switzerland is one of the major Be importers worldwide, little information is available about occurrence of exposure and the number of workers exposed in this country. Objectives: 1) evaluate the number of workers potentially exposed to Be in Switzerland; 2) construct a screening tool to allow potential Be exposure detection in a clinical setting. Methods: After identification of industrial sectors involving beryllium exposure based on expert reports and scientific literature, an estimation of the number of workers employed in these relevant industries was made using data from the Swiss federal population census and registries of economic activities. A second analysis was performed to estimate the fraction of workers really exposed to Be in each industrial sector. This adjustment was made according to the results of a French survey (INRS, Institut National de Recherche et de Sécurité) conducted by questionnaire addressed to 4500 companies in relevant industries on their use of beryllium and other issues such as percentage of employees really exposed. These realistic data were used to develop a self-administrated screening questionnaire allowed to identify patients with possible Be exposure. Results: In Switzerland, the number of workers employed in industries using Be was nearly 150 000. The estimated number of workers exposed to beryllium in these industries ranged from 2000 to 4000. Relevant sectors were: microengineering, precision turning, watchmaking and metal waste treatment and recycling. The validation of the self-administrated questionnaire containing a list of jobs and leisure activities associated with potential Be exposure is in progress within the framework of a national study. Conclusions: The number of workers potentially exposed to Be in Switzerland is rather high compared to estimations for other industrialized countries and might constitute an underestimated occupational health problem. Undetected Be exposure in patients with sarcoidosis may occur and result in misdiagnosis. Once validated, the self-administrated questionnaire could be used by clinicians to screen for Be exposure in patients with granulomatous lung disorders.

Traitement de l'asthme et de la rhinite durant la grossesse et l'allaitement [Treatment of asthma and rhinitis during pregnancy and breast feeding]

Inhaled therapies are preferred to systemic ones during pregnancy and breast feeding. A real paradox exists however between the necessity to ensure an optimal treatment for pregnant women with asthma, in order to prevent fetal hypoxia, and the precaution linked to any drug prescription during pregnancy. Thus, the use of topical corticosteroids remains the first choice for asthma as well as rhinitis. Inhaled beta2-agonists are also recommended. Systemic corticosteroids may however be prescribed without hesitation when their use is required for asthma treatment. It is also interesting to note that oral second-generation antihistamines are currently allowed during pregnancy and breast feeding. This type of antihistamines is indeed to be preferred to first-generation ones that generate more side-effects and generally are thus not to be prescribed during breast feeding.

A road map toward a globally harmonized approach for occupational health surveillance and epidemiology in nanomaterial workers

OBJECTIVE: Few epidemiological studies have addressed the health of workers exposed to novel manufactured nanomaterials. The small current workforce will necessitate pooling international cohorts. METHOD: A road map was defined for a globally harmonized framework for the careful choice of materials, exposure characterization, identification of study populations, definition of health endpoints, evaluation of appropriateness of study designs, data collection and analysis, and interpretation of the results. RESULTS: We propose a road map to reach global consensus on these issues. The proposed strategy should ensure that the costs of action are not disproportionate to the potential benefits and that the approach is pragmatic and practical. CONCLUSIONS: We should aim to go beyond the collection of health complaints, illness statistics, or even counts of deaths; the manifestation of such clear endpoints would indicate a failure of preventive measures.

Occupational exposure to solar ultraviolet radiation of outdoor workers in France

Question: Outdoor occupational exposure could be associated with important cumulative and intense exposure to ultraviolet (UV) solar radiation. Such exposure would increase risk of skin cancer. However, little information exists on jobs associated with intense UV exposure. The objective of this study was to characterise occupational UV exposure in a representative sample in France. Methods: A population-based survey was conducted in May-June 2012 through computer-assisted telephonic interviews in population 25 to 69 years of age. Individual UV irradiation was computed with declared time and place of residence matched to UV records from satellite measurement (Eurosun project). We analysed factors influencing exposure to UV (annual average and seasonal peak). Results: A total of 1442 individuals declared having an occupational exposure to UV which represents 18% of population aged 25 to 69 years. Outdoor workers were more frequently men (58%), aged 40-54 (43%), with a phototype III or IV (69%). Occupations associated with highest UV exposure were: construction workers (annual daily average 62.8 Joules/m2), gardeners (62.6), farmers (52.8), culture/art/social sciences workers (52.0) and transport workers/mail carriers (49.5). The maximum of UVA exposure was found for occupation with a strong seasonality of exposure: culture, art or social sciences works (98.1 Joules/m2), construction works (97.2), gardening (96.7) and farming (95.0). Significant factors associated with high occupational UV exposure were gender (men vs. women: 53.6 vs. 42.6), phototype (IV vs. I: 51.9 vs. 45.5) and taking lunch outdoors (always vs. never: 59.8 vs. 48.6). Conclusion: Our study showed that some occupations were associated with particularly intense UV exposure such as farmers, gardeners, construction workers. Other unexpected occupations were also associated with high UV exposure such as transport workers, mail carriers and culture/art/social sciences workers.

Factors associated with healthcare professionals' intent to stay in hospital: a comparison across five occupational categories.

OBJECTIVE: To identify factors associated with intent to stay in hospital among five different categories of healthcare professionals using an adapted version of the conceptual model of intent to stay (CMIS). DESIGN: A cross-sectional survey targeting Lausanne University Hospital employees performed in the fall of 2011. Multigroup structural equation modeling was used to test the adapted CMIS model among professional groups. Measures Satisfaction, self-fulfillment, workload, working conditions, burnout, overall job satisfaction, institutional identification and intent to stay. PARTICIPANTS: Surveys of 3364 respondents: 494 physicians, 1228 nurses, 509 laboratory technicians, 935 administrative staff and 198 psycho-social workers. RESULTS: For all professional categories, self-fulfillment increased intent to stay (all β > 0.14, P < 0.05). Burnout decreased intent to stay by weakening job satisfaction (β < -0.23 and β > 0.22, P < 0.05). Some factors were associated with specific professional categories: workload was associated with nurses' intent to stay (β = -0.15), and physicians' institutional identification mitigated the effect of burnout on intent to stay (β = -0.15 and β = 0.19). CONCLUSION: Respondents' intent to stay in a position depended both on global and profession-specific factors. The identification of these factors may help in mapping interventions and retention plans at both a hospital level and professional groups' level.

Predictors of physiotherapy and occupational therapy use two years after a vocational rehabilitation for orthopaedic trauma

Introduction.- Health care utilization is an important field of our economy. Nevertheless a minority of cases induce the majority of costs. For instance, in the setting of accident insurance, the most expensive 5% of all injured cases involve 80% of the health care costs. Although physiotherapy and occupational therapy consist of only a small proportion of these costs, it is nevertheless important to evaluate the factors that predict its use in order to improve services (i.e. allocation of resources to those who need them and benefit most).Patients and methods.- In this longitudinal prospective study, the cohort consisted of 2156 consecutively included patients with orthopaedic problems attending the clinique Romande de réadaptation (CRR) at Sion for inpatient rehabilitation after a work, traffic or leisure related injury. Two years after discharge, a questionnaire regarding the use of different health cares was send to the patients (1502 patients returned their questionnaires). The aim of this study was to calculate, with a logistic multivariate model, in-patient hospitalized for orthopaedic problems, the variables that mostly predict physiotherapy use 2 years after discharge.Results.- The full multivariate model contains 46 predictors. The use of physiotherapy and occupational therapy was significantly predicted in this multivariate model by the following predictors: Patients with a spinal problem (OR 1.51 versus lower-extremity problem, 95% CI 1.01 to 2.27), a disability pension (OR 1.69, 95% CI 1.09 to 2.60), patients with sports activities (OR 1.56, 95% CI 1.26 to 1.94), patients with longer stay at the rehabilitation clinic (OR 1.22 per week, 95% CI 1.05 to 1.41), women (OR 1.64, 95% CI 1.09 to 2.48) and those consulting a psychiatrist (OR 1.66, 95% CI 1.06 to 2.60).Discussion.- In this prospective study with a 2-year follow-up, different factors predicted the use of physiotherapy and occupational therapy after an injury. Further studies are needed to clarify the impact of these factors for the health care utilization and the strategies, which would allow to improve allocation of available resources.