Frédéric Gormand

Persistent asthma: disease control, resource utilisation and direct costs

Despite evidence that adverse outcomes are less frequent when asthma management is optimised, the link between the level of control, disease severity and medical resource utilisation (MRU) is poorly documented. This relationship was investigated in a group of patients suffering from persistent asthma (Global Initiative for Asthma (GINA) ≥2) in France. In 1998 a computerised family practice database was used to identify asthma patients aged 17–50 yrs. Information from the database was complemented by a patient survey to retrospectively assess the level of asthma control and hospital contacts. Costs of MRU over a 12month study period were related to demographics, medical history, asthma control, and doses of inhaled corticosteroids prescribed during the prestudy period. A review of the computerised medical database identified 1,038 adult patients with persistent asthma, who completed the survey questionnaire. Over a 12month period, the mean cost of MRU was 549.8 E for wellcontrolled patients, 746.3 E per patient with moderate control, and 1,451.3 E per patient with poor control. Costs also increased significantly with age, access to free asthma care, comorbid conditions, asthma symptoms in the past year and whether inhaled corticosteroids had been prescribed before the study period. In patients with persistent asthma, large differences were observed in the use of medical resources according to control and severity. Therefore, if patients appropriately use prescribed control therapy, their use of medical resources may be reduced.

Phenotypic determinants of uncontrolled asthma

BACKGROUND Although uncontrolled asthma remains frequent, determinants of asthma control are poorly studied. OBJECTIVES The aim was to estimate the distribution and the phenotypic characteristics of asthma control in 2 groups of subjects defined by the use of inhaled corticosteroids (ICS) in the past 12 months, in the Epidemiological study on the Genetics and Environment of Asthma, bronchial hyperresponsiveness and atopy (EGEA). METHODS Five hundred one adult current patients with asthma who participated in the follow-up of the EGEA study were included. Asthma control was assessed from survey questions reflecting asthma control, as defined in the 2006 Global Initiative for Asthma guidelines. The factors analyzed were age, sex, educational level, body mass index, active and passive smoking, sensitization to aeroallergens, total IgE, rhinitis, chronic cough/phlegm, and age at asthma onset. Analyses were stratified according to ICS use. RESULTS Uncontrolled asthma was more frequent in ICS users (27.6%, 35.0%, and 37.4% with controlled, partly-controlled, and uncontrolled asthma respectively) compared with non-ICS users (60.0%, 23.9%, and 16.1%, respectively). In ICS users, chronic cough or phlegm and female sex were independently and significantly related to uncontrolled asthma. In non-ICS users, high total IgE and sensitization to molds were associated with uncontrolled asthma. Smoking and rhinitis were not associated with asthma control. CONCLUSION Optimal asthma control remained unachieved in the majority of patients with asthma in this study. Factors associated with uncontrolled asthma were different in ICS users (chronic cough/phlegm, female sex) and non-ICS users (high total IgE and sensitization to molds).

Level of Control and Hospital Contacts in Persistent Asthma

The purpose of this study was to estimate relationships between asthma control and hospital contacts (visits to emergency rooms and hospitalizations) in a group of patients suffering from persistent asthma, after adjustment for prior use of inhaled corticosteroids. A computerized family practice database was used to identify patients (aged 6–50 years) with persistent asthma who received asthma therapy from January 1995. The database provided information on patient demographics and drug therapy. Asthma control was estimated by a survey of patients at the end of a 12-month study period. Frequency of hospital contacts during the study period was related to demographics, asthma control, and prescribed doses of inhaled corticosteroids during a prestudy period. Review of computerized medical files of 497 family practice physicians identified 1966 patients with persistent asthma who met the study criteria. Of these patients, 1251 completed the survey (63.6%). Asthma control was assessed in 1130 patients; it was moderate or poor in 42% of the cases. During the 12-month study period, 14.8% of patients reported at least one hospital contact. The level of asthma control was significantly p < 0.001) associated with hospital contacts. The odds ratio (OR) for hospital contact for good and poor asthma control was 0.5 (95% confidence interval [CI] 0.2–0.7) and 2.2 (95% CI 1.2–4.4), respectively. Asthma control was related to hospital contacts independently of use of inhaled corticosteroids before the study period. Overall, control of asthma was not optimal in this population. The occurrence of hospital contacts was closely related with the level of control. This association was independent of the dose of inhaled corticosteroids prescribed before the study, suggesting that in asthma, hospital contacts are primarily related to the level of control experienced by the patients.

Evidence for linkage of a new region (11p14) to eczema and allergic diseases

Asthma, allergic rhinitis (AR) and atopic dermatitis also called eczema are allergic co-morbidites, which are likely to depend on pleiotropic genetic effects as well as on specific genetic factors. After a previous genome-wide linkage screen conducted for asthma and AR in a sample of 295 French EGEA families ascertained through asthmatic subjects, the aim here was to search for genetic factors involved in eczema and more particularly the ones shared by the three allergic diseases using the same EGEA data. In this sake, eczema and phenotypes of “allergic disease” accounting for the joint information on the presence/absence of the three diseases were examined by linkage analyses using the maximum likelihood binomial method. A fine mapping was carried out in regions detected for potential linkage, followed by association studies using the family-based association test (FBAT). Evidence for linkage to 11p14 region was shown for “allergic disease” and eczema. Linkage was also indicated between eczema and 5q13 and between “allergic disease” and both 5p15 and 17q21 regions. Fine mapping supported the evidence of linkage to 11p14 and FBAT analyses showed the association between “allergic disease” and a marker located at the linkage peak on 11p14. Further investigations in this region will allow identifying genetic factor(s) which could have pleiotropic effect in the three allergic diseases.

Uptake of 12-HETE by human bronchial epithelial cells (HBEC): effects on HBEC cytokine production.

12-HETE, the major lipoxygenase end-product of platelets and macrophages, may be released in contact of bronchial epithelium in inflammatory diseases of the lung. We have studied the outcome of 12-HETE in presence of human bronchial epithelial cells (HBEC). When HBEC were incubated with [3H]12-HETE for 30 minutes, 27.5% of total radioactivity was found in HBEC and 72.5% in supernatants. Unesterified 12-HETE accounted for 22.4% of total radioactivity, 4.5% being recovered in phospholipids, preferentially in phosphatidylcholine and phosphatidylethanolamine. No incorporation in neutral lipids was detected. 72.9% of the incubated radioactivity was recovered in un identified metabolites. As 12-HETE has been shown to modulate the expression and production of various proteins, the consequence of the 12-HETE uptake on the release of GM-CSF and IL8 by HBEC was assessed. HBEC from control subjects were cultured for 24 hours with 12-HETE (10(-9) to 10(-7)M) in the presence or absence of TNF alpha. Detectable amounts of both cytokines were released in the supernatant in basal conditions at 24hr, and TNF alpha increased significantly the release of GM-CSF. 12-HETE at 10(-7)M weakly but significantly decreased the TNF-induced release of GM-CSF from HBEC. Thus the uptake of 12-HETE could affect the epithelial cell function in some situations.

Combined Lung Transfer of NO and CO in Patients Receiving Methotrexate or Bleomycin Therapy Compared to Normal Subjects

The first aim of the study is to determine whether combined lung diffusing capacities of nitric oxide (TLNO) and of carbon monoxide (TLCO) are accurate in the followup of patients receiving either methotrexate (MTX) or bleomycin (BLM). The second objective is to determine whether TLCO, TLNO, KCO, and TLCO/VI% (inspiratory volume expressed as percentage of predicted value) correlate better with the diffusing capacity of the membrane (Dm) and/or capillary lung volume (Vc). TLNO and TLCO were measured in three groups: 22 “normal” subjects (N group), 17 patients receiving MTX, and 12 patients treated with BLM. TLCO, TLNO, Dm, and Vc were much lower in the MTX and BLM groups compared to those of the N one. The ratio TLNO/TLCO was higher in the BLM group compared to that of the N group and compared to that of the MTX group. KCO correlated neither with Dc nor with Vc, whereas TLCO/VI% correlated significantly with both Dm and Vc. Combined measurement of TLCO and TLNO seems to be useful in the followup of patients receiving agents inducing lung toxicity and gives a good idea of the alveolar membrane and the capillary volume.

Alteration of membrane phospholipid methylation by adenosine analogs does not affect T lymphocyte activation

Membrane phospholipid methylation has been described during activation of various immune cells. Moreover recent data indicated modulation of immune cells functions by adenosine. As S-Adenosyl-methionine and S-Adenosyl-homocysteine are adenosine analogs and modulators of transmethylation reactions, the effects of SAH and SAM were investigated on membrane phospholipid methylation and lymphocyte activation. SAM (10(-5) M) was shown to induce the membrane phospholipid methylation as assessed by the 3H-methyl-incorporation in membrane extract. This effect was inhibited by SAH. In contrast SAM and SAH did not affect the phytohemagglutinin-induced proliferative response of peripheral blood mononuclear cells. SAH neither modified the early internalization of membrane CD3 antigens nor did it prevent the late expression of HLA-DR antigens on lymphocytes activated by phytohemagglutinin. These results indicate that in vitro alteration of phospholipid methylation does not affect subsequent steps of human T lymphocyte activation and proliferation.