Pollution de l’air et asthme de l’enfant

The prevalence of asthma and allergic diseases doubled during the last quarter of the 20th century, particularly among children and adolescents. Given this fact, we cannot attribute this increase exclusively to genetic factors. Environmental factors to which it has been attributed include exposure to allergens and to airborne physicochemical pollutants, and changes in the characteristics of respiratory infections in young infants. In this review, we will point out the role of exposure to air pollutants and their interaction with other environmental factors. Whereas concentrations of the ‘classical’ air quality indicators (SO₂, CO) have more or less decreased steadily in developed countries, asthma prevalence has increased during the same period. However, the relation between the increase incidence of asthma and atmospheric pollution should be examined with the knwoledge that there has been an increase in new forms of pollution, in particular, ultrafine particles. There are at present many experimental studies which show that urban pollution (especially that associated with diesel exhaust particles) elicits chronic oxidative stress, bronchial hyperreactivity and allergic inflammation. Several epidemiological studies suggest that there is an association between the density of automobile traffic and the prevalence of respiratory symptoms, especially asthma and allergic rhinitis. Exposure to automobile traffic-related pollutants during early infancy may accelerate or even provoke, among genetically susceptible subjects, bronchial inflammatory processes which could contribute to the increase in the incidence of asthma in industrialized countries.     

Purpura rhumatoïde de l’adulte

Henoch-Schönlein purpura is a systemic vasculitis of the small vessels characterized by perivascular leucocyte infiltrates. It is an immunoglobulin A-related immune complex-mediated disease involving the skin, the joints and the gastrointestinal system. Renal disease may sometimes be associated to these clinical manifestations. Prevalence of the nephritis is highly variable, depending on the series. More rarely, other organs such as the lungs, the heart or the nervous system may be involved. The clinical diagnosis is confirmed by histopathology of the skin (leukocytoclastic vasculitis) and kidney (endo-capillary proliferative glomerulonephritis), showing IgA deposits in these tissues. Short-term prognosis depends on the severity of digestive involvement, but long-term prognosis depends on the renal disease. Recent publications of pediatric and adult series show that the chronic renal failure may progress, sometimes more than ten years after the initial flare. Treatment is usually supportive. The benefit of more specific treatments (corticosteroids or immunosuppressive drugs) in severe visceral forms (usually abdominal or kidney) has not yet been established.     

Place de l’Anaforcal dans l’enseignement post-universitaire de la rhinite allergique

The National Association of Continuing Medical Education in Allergy (Anaforcal) proposes, for the year 2008, a teaching module on the theme of allergic rhinitis aimed at general practitioners in 50 French cities. The choice of this theme is based on the frequency and the impact of this condition on public health. This teaching module will include three simple, didactic clinical cases. In addition, it contains the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA) report on allergic rhinitis, with various documents on its diagnosis and therapy. The document strongly emphasizes the originality of this training in terms of its organization, conception and interactive teaching method.     

Maladie de Kawasaki de l’adulte

Kawasaki disease (KD) is a multisystemic vasculitis affecting mainly the skin, mucosa, and lymph nodes. Coronary artery aneurysms occur in 25% of patients but their prevalence is reduced to 4% in those patients treated with intravenous immunoglobulin (IVIg) within 10 days of illness onset. Interesting data recently published relate to physiopathology and diagnosis of the disease. Investigations identified an antigen-driven IgA oligoclonal response directed against cytoplasmic inclusions in KD tissues. An algorithm using laboratory tests and echocardiography has been recently proposed to improve early detection of incomplete KD. Although KD predominantly affects children, it may be also of interest for adult physicians. First, patients may develop long-term cardiovascular event. Coronary artery aneurysms may lead to the development of coronary stenosis or thrombosis. Despite the absence of coronary lesions during the acute phase of the disease, patients may present morphological and functional sequelae of coronary and peripheral arteries at convalescent phase. These potential arterial sequelae require long-term follow-up and treatment of associated cardiovascular risk factors. Although the level of injury seems to be correlated with the severity of initial coronary lesions, long-term course of vascular injuries is poorly known. Second, KD may occur in adults with 91 cases reported in the literature. Twenty-one cases have been reported in HIV infected patients. Intravenous immunoglobulins appear to shorten the disease course. Recent studies highlight the existence of incomplete KD and symptomatic coronary aneurysms in adults. Overall, these data suggest that adult patients with biological or echocardiographic features suggestive of incomplete KD should receive prompt IVIg to prevent coronary artery sequelae.     

Maladie de Behçet de l’enfant

Behçet's disease is a chronic multisystem vasculitis of unknown etiology. The disease is commonly described in young adults but can occur in childhood. Diagnosis is based on clinical manifestations since there are no pathognomonic laboratory findings. Early diagnosis in children is challenging due to the insidious nature of the disease and the low sensitivity of adult criteria in the pediatric population. The purpose of this review is to describe the demographic and clinical features of Behçet's disease in childhood, its complications and recent advances in therapeutics highlighting differences with the adult onset disease.     

Indicateurs prédictifs dans l’asthme de l’enfant

Asthma is a chronic condition which is seen frequently in pediatrics. Development of predictors of occurrence, eventual worsening and of the evolution of the condition could improve the overall prognosis. This literature review covers recent advances on this subject. Among the risk factors, perinatal conditions such as prematurity play an important role. The occurrence of respiratory infections in the infant constitutes a key step in the initiation of the bronchial inflammatory process. The social milieu and the environment are clearly contributing factors. Atopy is an essential element in the development of chronic asthma. It worsens the prognosis in certain cases and can be responsible for fatal outcomes. Progress in genetics, especially concerning single nucleotide polymorphisms, which is to say localized amino acid mutations, sheds light on the major role of a genetic factor in certain special cases.     

Anesthésie de l’asthmatique

The asthmatic patient is at risk of bronchospasm during anaesthesia. The risk increases in severe asthma. Uncontrolled asthma is the main risk factor. The preoperative evaluation of asthma control is therefore necessary and if possible the patient will be prepared with bronchodilators and steroids. Locoregional anaesthesia will always be preferred to a general anaesthesia during which endotracheal intubation can induce bronchospasm. Inhaled anaesthetics are well tolerated, in being bronchodilators. Ketamin and benzodiazepines can be used. Propofol and opioids are usually well tolerated in asthmatics. Among myorelaxants, these without histamine release effect will be preferred. During local anaesthesia, lidocain can be used. Its bronchodilator effects are considered. The preventive and a fortiori curative use of beta-2 agonists agents are the treatment of choice of perioperative bronchospasm, associated to steroids.