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Montelukast versus Budesonide as a First Line Preventive Therapy in Mild Persistent Asthma in 2 to 18 y.

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OBJECTIVES: To compare the efficacy of oral Montelukast and inhaled Budesonide as a first line preventive therapy in mild persistent asthma in age group 2-18 y.

METHODS: This prospective randomized controlled clinical study was conducted for 12 wk. Sixty patients of mild persistent asthma aged 2 to 18 y were randomly allocated to either oral Montelukast (n = 60) or inhaled Budesonide (n = 60) group. Outcomes measured were improvement in peak expiratory flow rate (PEFR), forced expiratory volume 1 s/forced vital capacity (FEV1/FVC), day time and night time symptoms and frequency of exacerbations and need to change medications.

RESULTS: There was significant improvement in PEFR, FEV1/FVC, day time and night time symptoms and frequency of exacerbations in both groups. However, more significant improvement in FEV1/FVC (CI 95 %, p = 0.029) and day time symptoms (CI 95 %, p = 0.002) was seen in Budesonide group compared to Montelukast group.

CONCLUSIONS: The present study suggests that oral Montelukast is not inferior to Budesonide in treatment of mild persistent asthma in 2 to 18 y children in terms of control of symptoms and improvement in pulmonary function tests over a 12 wk period. However, there was more significant improvement in day time symptoms, more significant increase in FEV1/FVC ratio and less exacerbation in patients receiving Budesonide compared to those receiving Montelukast. However, side effects due to long term use of steroids such as growth stunting and bone osteopenia should also be considered before recommending. Trial registered at CTRI no. REF/2012/09/004035.

Wheezing phenotypes in young children: an historical cohort study.

Wheezing phenotypes in young children have usually been described on the basis of questionnaire surveys instead of prospectively doctor-diagnosed episodes, and have never been described in terms of incidence rates.

AIMS: To identify wheezing phenotypes in the first three years and describe their incidence trends, and to investigate their relationship with asthma at six years of age.

METHODS: Doctor-diagnosed wheezing episodes in the first 36 months and active asthma at six years were identified in a historical cohort of 3,739 children followed from birth in 29 primary care health centres in Spain. Wheezing phenotypes were identified by means of latent class analysis. Changes in incidence rates of wheezing were identified through joinpoint regression models and their predictive ability for asthma was analysed.

RESULTS: One never/infrequent wheeze phenotype and three wheezing phenotypes were identified. There were two early phenotypes which started wheezing at a median age of six months, one of which was transient while the other had a heavy recurrence of episodes. A third phenotype exhibited a delayed onset of wheezing, a constant rise in incidence through the first 36 months, and a relationship with allergic asthma. These three phenotypes had a higher prevalence of active asthma at six years than the never/infrequent wheeze phenotype, but the classification had a weak predictive ability for asthma due to low sensitivity.

CONCLUSIONS: The use of incidence rates contributes to the clarification of the natural history of infant wheezing.

Caractéristiques des consultations pour exacerbation d’asthme aux urgences pédiatriques. Évaluation et perspectives pour une amélioration de la gestion pré-hospitalière

Introduction L’asthme est une des pathologies les plus fréquemment rencontrées aux urgences pédiatriques. L’objectif est de caractériser les consultations aux urgences pour exacerbation d’asthme et la gestion de ces exacerbations avant le recours aux soins d’urgence.

Méthodes Étude prospective menée pendant trois mois aux urgences pédiatriques du CHU de Clermont-Ferrand incluant des enfants âgés d’un à 16ans.

Résultats Cent quarante-trois patients ont été inclus. Il s’agissait d’exacerbations modérées à sévères dans 69,2 % des cas (n =99). La gestion pré-hospitalière était appropriée dans 17,5 % des cas (n =25). La plupart des patients asthmatiques connus n’avaient pas de suivi spécialisé (n =56). Un protocole d’action en cas d’exacerbation au domicile avait été mis en place dans 16,5 % des cas (n =20). Les exacerbations étaient plus sévères chez les enfants plus jeunes (p =0,002) et dans les milieux de niveau économique faible (p =0,025).

Conclusions La sensibilisation sur la conduite à tenir en cas d’exacerbation, notamment la possession et l’application d’un plan d’action, paraît insuffisante. La diminution du recours aux soins d’urgences pourrait passer par une amélioration du diagnostic et de l’éducation thérapeutique des patients asthmatiques.

Introduction The frequency of emergency department visits for asthma is a major public health problem in pediatrics. The aim of this study is to establish the characteristics of children visiting pediatric emergency departments for acute asthma and to assess their therapeutic management prior to admission.

Methods A prospective clinical study performed during 3months at the pediatric emergency department of the university teaching hospital of Clermont-Ferrand, of children aged 1 to 16years admitted to the department with a clinical diagnosis of asthma exacerbation.

Results One hundred and forty-three patients were included in the study. Asthma crises were moderate to severe in 69.2% of cases (n =99). Initial therapeutic management prior to the admission to the emergency department was appropriate in 17.5% of cases (n =25). Most of the known asthmatic patients had not been followed up by a pediatric pulmonologist (n =56). A crisis protocol had been set up in 16.5% of cases (n =20). Exacerbations were more severe among younger patients (P =0.002) and economically disadvantaged children (P =0.025).

Conclusions This study uncovers poor knowledge of the disease among asthmatic children and their families, and an insufficient awareness among health practitioners of current recommendations for the treatment of asthmatic children. Admissions to the emergency department for asthma could be partly avoided by improving diagnosis and therapeutic education.

Profil clinique des fumeurs à la consultation d’aide au sevrage tabagique (Centre hospitalier universitaire de Sousse, Tunisie)

Introduction La lutte antitabac est l’une des priorités d’action en santé publique en Tunisie. Cette lutte a été marquée par la création, en décembre 2009, d’unités d’aides au sevrage tabagique.

Dans le cadre d’une première évaluation de ces centres, nous avons étudié le profil clinique des fumeurs sollicitant la consultation d’aide au sevrage tabagique de notre hôpital universitaire (hôpital Sahloul, Sousse, Tunisie). Méthodes Une étude transversale descriptive a été menée auprès des fumeurs s’étant présentés à la consultation d’aide au sevrage tabagique depuis la date de sa création jusqu’au mois de juin 2012. Le recueil des données a été fait à partir des dossiers des consultants.

Résultats La population de l’étude, concernant les 279 fumeurs colligés, était à prédominance masculine (92,8 %) avec un âge moyen de 41,7±13,4ans. Les antécédents cardiovasculaires et respiratoires étaient les plus fréquents (31 %). Une anxiété était retrouvée chez 46,2 % des consultants. Plus de la moitié (51,2 %) étaient de gros fumeurs et fortement dépendants à la cigarette (50,5 %). Parmi les consultants 70 % étaient motivés à l’arrêt du tabac et plus de la moitié (53,8 %) ont essayé au moins une fois d’arrêter de fumer.

Conclusion Le profil clinique des consultants de cette étude correspond à celui de « fumeurs difficiles » nécessitant une prise en charge collaborative dans les consultations d’aide au sevrage tabagique.

Background Smoking cessation intervention is among the most vital elements of the prevention of tobacco smoking. Our study aimed to describe the clinical profile of patients attending our smoking cessation unit.

Methods We conducted a cross-sectional study from December 2009 to June 2012. The patients were recruited in the Tobacco cessation unit of Sahloul Hospital (Sousse, Tunisia). The data were collected from the consultants’ records.

Results A total of 279 patients attended. They were mostly men (92.8 %). The mean age was 41.7±13.4 years. Among medical conditions, a history of cardiovascular and respiratory disease was the most frequent (31 %). Anxiety was present in 46.2 % of patients. More than half of the patients (51.2 %) were heavy smokers and 50.5 % were strongly nicotine dependent (Fagerström's score>7). Seventy percent were motivated to stop smoking and 53.8 % had tried to quit at least once.

Conclusion The majority of our patients could be considered as heavy smokers. Therapeutic combinations and medical treatment are suggested to assist practitioners trying to help them.

Résections pulmonaires majeures par vidéothoracoscopie : 20ans après les premières réalisations

La chirurgie mini-invasive pour les exérèses pulmonaires majeures existe maintenant depuis 20ans, mais son développement reste encore controversé en France. Les différentes techniques utilisées ainsi que les définitions multiples ont prêté à confusion chez les médecins et les chirurgiens. Le bénéfice de ces chirurgies « mini-invasives » n’a pas toujours été très clair, avec une sécurité opératoire souvent remise en cause.

Les avancées technologiques récentes (imagerie, colonne vidéo HD, instrumentations) ont apporté une aide essentielle pour assurer la sécurité optimale des patients.

L’objectif principal de cette revue est de préciser la définition actuelle de la chirurgie mini-invasive ou vidéothoracoscopique (VTC), les techniques, les résultats mais aussi les écueils. Cependant cette chirurgie présente des atouts multiples à la fois sur le plan clinique mais aussi universitaire. La chirurgie thoracique mini-invasive s’inscrit dans l’histoire naturelle de la chirurgie mais les différences cliniques entre ces deux grands types de chirurgie d’exérèse sont faibles.

La VTC n’est pas une révolution chirurgicale mais une évolution qu’il faut maîtriser au même titre que les évolutions en radiothérapie et radiologie interventionnelle. Elle s’inscrit en complément des stratégies de dépistage précoce du cancer qui ont fait la preuve récente de leur efficacité.

Major lung resection using minimally invasive techniques – video-assisted thoracoscopic surgery (VATS) – was first described 20years ago. However, its development has been slow in many countries because the value of this approach has been questioned. Different techniques and definitions of VATS are used and this can be confusing for physicians and surgeons.

The benefit of minimally invasive thoracic surgery was not always apparent, while many surgeons pointed to suboptimal operative outcomes. Recently, technological advances (radiology, full HD monitor and new stapler devices) have improved VATS outcomes. The objectives of this review are to emphasize the accepted definition of VATS resection, outline the different techniques developed and their results including morbidity and mortality compared to conventional approaches. Minimally invasive thoracic surgery has not been proven to give superior survival (level one evidence) compared to thoracotomy. A slight advantage has been demonstrated for short-term outcomes. VATS is not a surgical revolution but rather an evolution of surgery. It should be considered together with the new medical environment including stereotactic radiotherapy and radiofrequency.

VATS seems to be more accurate in the treatment of small lung lesions diagnosed with screening CT scan. In the academic field, VATS allows easier teaching and diffusion of techniques.

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