Durée de lʼexposition avec symptômes, séquelles et coûts de lʼasthme professionnel en relation avec le statut psychologique et socioéconomique

Le facteur le plus important de pronostic de l'asthme professionnel (AP) est la durée des symptômes avant le retrait de lʼexposition à lʼagent causant lʼAP. La qualité de vie réduite, la détresse psychologique et les maladies psychiatriques sont des conditions souvent associées à l'AP. Notre objectif était d'identifier les facteurs, incluant le statut socioéconomique, qui ont une influence sur lʼintervalle de temps nécessaire pour présenter une requête à une agence médicolégale à la suite de lʼapparition de symptômes dʼasthme et de confirmer qu'un tel délai est associé à un moins bon pronostic respiratoire et à des coûts directs plus élevés. En outre, nous avons examiné la relation entre les variables cliniques et socio-économiques dʼune part et leur influence sur les facteurs psychologiques et économiques dʼautre part chez des travailleurs atteints d'AP. Ensuite, nous avons voulu évaluer si les individus souffrant de détresse psychologique (DP) et de morbidité psychiatrique pourraient être identifiés en utilisant un instrument mesurant la qualité de vie (QV). Lʼétude a été effectuée auprès dʼindividus ayant déposé des demandes d'indemnisation pourʼAP auprès du Commission de la sécurité et de la santé du travail du Québec (CSST). Les données ont été recueillies au moment de la réévaluation, soit environ deux ans et demi après le diagnostic. Outre la collecte des marqueurs cliniques de l'asthme, les individus ont été soumis à une évaluation générale de leur histoire sociodémographique et médicale, à une brève entrevue psychiatrique (évaluation des soins primaires des troubles mentaux, PRIME-MD) et à un ensemble de questionnaires, incluant le Questionnaire sur la qualité de vie - AQLQ(S), le Questionnaire respiratoire de St. George (SGRQ) et le Psychiatric Symptom Index (PSI).Soixante personnes ont été incluses dans l'étude. Etre plus âgé, avoir un revenu supérieur à 30 000$CA etêtre atteint dʼAP dû à un allergène de haut poids moléculaire ont une association positive avec le nombre dʼannées dʼexposition avec symptômes avant le retrait. Au cours de la période de suivi, le nombre dʼannées dʼexposition avec symptômes était plus grand chez les individus ayant une hyperréactivité bronchique persistante. Par ailleurs, la présence de symptômes au poste de travail pendant moins d'un an est associée à une réduction des coûts directs. Les paramètres de QV et de DP avaient des corrélations modérées avec les marqueurs cliniques de lʼAP. Les plus fortes associations avec ces variables ont pu être observées dans les cas de la sévérité de l'asthme, des statuts dʼemploi et matrimonial, du revenu et de la durée de la période de travail avec l'employeur. Un seuil de 5,1 au niveau de la sous-échelle de la fonction émotionnelle de lʼAQLQ(S) sʼest avéré avoir la meilleure valeur discriminante pour distinguer les individus avec ou sans détresse psychiatrique cliniquement significative selon le PSI. Nous avons été en mesure d'identifier les variables socio-économiques associées à un intervalle plus long dʼexposition professionnelle en présence de symptômes dʼasthme. De même, une plus longue période d'exposition a été associée à un moins bon pronostic de la maladie et à des coûts de compensation plus élevés. Ces résultats s'avèrent utiles pour la surveillance de lʼAP qui pourrait cibler ces sous-groupes d'individus. La QV et la PS sont fréquemment réduites chez les individus atteints d'AP qui perçoivent une compensation. Elles sont associées à des marqueurs cliniques de lʼasthme et à des facteurs socio-économiques. En outre, nos résultats suggèrent que le questionnaire de lʼAQLQ(S) peut être utilisé pour identifier les individus avec un niveau de détresse psychologique potentiellement significatif.The most important factor in the prognosis of occupational asthma (OA) is the length of exposure with symptoms prior to removal from exposure. Impaired quality of life, psychological distress and psychiatric disease are conditions frequently associated with OA. Our goal was to identify factors, including socio-economic status, that can influence the delay in submitting a claim to a medicolegal agency after the onset of asthmatic symptoms, and to confirm that such a delay is associated with a worse respiratory prognosis and higher direct costs. Further, we examined the association between clinical and socio-economic variables and their influence on psychological and cost outcomes in individuals with OA. Next, we wanted to evaluate whether individuals with clinically significant psychological distress (PD) and psychiatric morbidity could be identified by using a quality of life (QOL) measurement instrument. This is a study of individuals who filed claims for compensation for occupational asthma from the Workersʼ Compensation Board of Quebec (the CSST). Data were collected at re-evaluation, approximately two and a half years after diagnosis. Besides collecting clinical markers of asthma, individuals underwent a general socio-demographic and medical history evaluation, a brief psychiatric interview (Primary Care Evaluation of Mental Disorders, PRIME-MD) and completed a battery of questionnaires, including the Asthma Quality of Life Questionnaire - AQLQ(S), the St. Georgeʼs Respiratory Questionnaire (SGRQ), and the Psychiatric Symptoms Index (PSI). Sixty individuals were included in the study. Being older, having a revenue of >$30,000 Can. (CAD$) and having OA due to high- molecular- weight agents were all positively associated with the number of years of exposure with symptoms before removal from exposure. Individuals with persistent airway hyperresponsiveness at follow-up had a higher number of years with symptoms. Experiencing symptoms in the workplace for less than one year generated lower direct costs. QOL and PD parameters had moderate correlations with clinical markers of OA. Asthma severity, employment and marital status, income and length of employment with the employer showed the strongest associations with QOL and PD. More impaired QOL was associated with higher direct costs for compensation. A cut-off of 5.1 on the AQLQ(S) emotional function subscale had the best discriminative value to distinguish individuals with or without clinically significant psychological distress according to the PSI. We were able to identify socio-economic variables that were associated with a longer interval during which individuals remained symptomatic in the workplace before being removed from exposure. This longer exposure time was associated with worse disease outcomes and higher compensation costs. These findings could prove to be useful in surveillance programs that could be preferentially targeted for these subgroups of individuals. Impaired QOL and PD are frequent among individuals with OA receiving compensation and are associated with clinical markers of OA and socio-economic factors. Further, our findings suggest that the AQLQ(S) questionnaire could be used to identify individuals with potentially clinically significant levels of psychological distress

Identification of clinically significant psychological distress and psychiatric morbidity by examining quality of life in subjects with occupational asthma

<p>Abstract</p> <p>Background</p> <p>The Juniper Asthma Specific Quality of Life Questionnaire (AQLQ(S)) is a questionnaire that allows measurement of disease specific quality of life. We wanted to examine correlations between the (AQLQ(S)) general and different subscale scores and both psychiatric morbidity and levels of psychological distress in individuals with occupational asthma (OA) and to determine if results in the emotional function subscale allow identification of individuals with clinically significant psychological distress or current psychiatric disorders.</p> <p>Methods</p> <p>This was a cross-sectional study of individuals with OA who were assessed during a re-evaluation for permanent disability, after they were no longer exposed to the sensitizing agent. Patients underwent a general sociodemographic and medical history evaluation, a brief psychiatric interview (Primary Care Evaluation of Mental Disorders, PRIME-MD) and completed a battery of questionnaires including the AQLQ(S), the St-Georges Respiratory Questionnaire (SGRQ), and the Psychiatric Symptom Index (PSI).</p> <p>Results</p> <p>There was good internal consistency (Cronbach alpha = 0.936 for the AQLQ(S) total score) and construct validity for the AQLQ(S) (Spearman rho = -0.693 for the SGRQ symptom score and rho = -0.650 for the asthma severity score). There were medium to large correlations between the total score of the AQLQ(S) and the SGRQ symptom score (r = -.693), and PSI total (r = -.619) and subscale scores (including depression, r = -.419; anxiety, r = -.664; anger, r = -.367; cognitive disturbances, r = -.419). A cut-off of 5.1 on the AQLQ(S) emotional function subscale (where 0 = high impairment and 7 = no impairment) had the best discriminative value to distinguish individuals with or without clinically significant psychiatric distress according to the PSI, and a cut-off of 4.7 best distinguished individuals with or without a current psychiatric disorder according to the PRIME-MD.</p> <p>Conclusions</p> <p>Impaired quality of life is associated with psychological distress and psychiatric disorders in individuals with OA. Findings suggest that the AQLQ(S) questionnaire may be used to identify patients with potentially clinically significant levels of psychological distress.</p

Adherence to the GOLD Guidelines in Primary Care: Data from the Swiss COPD Cohort.

(1) Introduction: Chronic obstructive pulmonary disease (COPD) and its associated morbidity and mortality are a global burden on both affected patients and healthcare systems. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) issues guidelines with the aim of improving COPD management. Previous studies reported significant variability in adherence to these recommendations. The objective of this study was to evaluate Swiss primary practitioners' adherence to the GOLD guidelines for the pharmacological treatment of stable COPD. (2) Methods: We studied patients who were included in the Swiss COPD cohort study, an ongoing prospective study in a primary care setting, between 2015 and 2022. The key inclusion criteria are age ≥ 40 years, FEV1/FVC ratio < 70%, and a smoking history of at least 20 pack-years. Adherence to the GOLD guidelines was assessed per visit and over time. (3) Results: The data of 225 COPD patients (mean age 67 ± 9 years, 64% male) and their respective 1163 visits were analyzed. In 65% of visits (726/1121), treatment was prescribed according to the GOLD guidelines. Non-adherence was most common in GOLD groups A and B (64% and 33%) and mainly consisted of over-treatment (two long-acting bronchodilators in group A (98/195, 50%) and ICS in groups A (21/195, 11%) and B (198/808, 25%)). In group D, the prescriptions conformed with the guidelines in 99% of cases (109/108). Guideline adherence was associated with high symptom load (COPD Assessment Test) (OR 1.04, p = 0.002), high number of exacerbations (OR = 2.07, p < 0.001), asthma overlap (OR 3.36, p = 0.049), and diabetes mellitus (OR 2.82, p = 0.045). (4) Conclusion: These results confirm a conflict between the GOLD recommendations and primary practice, mainly concerning over-treatment in GOLD groups A and B. Patients with high symptom load, high exacerbation risk, asthma overlap, and diabetes mellitus are more likely to be treated in conformity with the guidelines. Further research is needed to uncover the reasons for the discrepancies and to design strategies for improvement

Subclinical sleep apnoea and plasma levels of endothelin-1 among young and healthy adults.

OBJECTIVE Obstructive sleep apnoea (OSA) is a risk factor for vascular disease and other adverse outcomes. These associations may be at least partly due to early endothelin-1 (ET-1)-mediated endothelial dysfunction (ED). Therefore, we assessed the relationships between subclinical sleep apnoea and plasma levels of ET-1. METHODS We performed a population-based study among 1255 young and healthy adults aged 25-41 years. Cardiovascular disease, diabetes or a body mass index >35 kg/mwere exclusion criteria. Plasma levels of ET-1 were measured using a high-sensitivity, single-molecule counting technology. The relationships between subclinical sleep apnoea (OSA indices: respiratory event index (REI), oxygen desaturation index (ODI), mean night-time blood oxygen saturation (SpO)) and ET-1 levels were assessed by multivariable linear regression analysis. RESULTS Median age of the cohort was 35 years. Median ET-1 levels were 2.9 (IQR 2.4-3.6) and 2.5 pg/mL (IQR 2.1-3.0) among patients with (n=105; 8%) and without subclinical sleep apnoea (REI 5-14), respectively. After multivariable adjustment, subclinical sleep apnoea remained significantly associated with plasma levels of ET-1 (β=0.13 (95% CI 0.06 to 0.20) p=0.0002 for a REI 5-14; β=0.10 (95% CI 0.03 to 0.16) p=0.003 for an ODI≥5). Every 1% decrease in mean night-time SpOincreased ET-1 levels by 0.1 pg/mL, an association that remained significant after multivariable adjustment (β=0.02 (95% CI 0.003 to 0.033) p=0.02). CONCLUSIONS In this study of young and healthy adults, we found that participants with subclinical sleep apnoea had elevated plasma ET-1 levels, an association that was due to night-time hypoxaemia. Our results suggest that ED may already be an important consequence of subclinical sleep apnoea

Adherence to the GOLD Guidelines in Primary Care: Data from the Swiss COPD Cohort

(1) Introduction: Chronic obstructive pulmonary disease (COPD) and its associated morbidity and mortality are a global burden on both affected patients and healthcare systems. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) issues guidelines with the aim of improving COPD management. Previous studies reported significant variability in adherence to these recommendations. The objective of this study was to evaluate Swiss primary practitioners’ adherence to the GOLD guidelines for the pharmacological treatment of stable COPD. (2) Methods: We studied patients who were included in the Swiss COPD cohort study, an ongoing prospective study in a primary care setting, between 2015 and 2022. The key inclusion criteria are age ≥ 40 years, FEV1/FVC ratio < 70%, and a smoking history of at least 20 pack-years. Adherence to the GOLD guidelines was assessed per visit and over time. (3) Results: The data of 225 COPD patients (mean age 67 ± 9 years, 64% male) and their respective 1163 visits were analyzed. In 65% of visits (726/1121), treatment was prescribed according to the GOLD guidelines. Non-adherence was most common in GOLD groups A and B (64% and 33%) and mainly consisted of over-treatment (two long-acting bronchodilators in group A (98/195, 50%) and ICS in groups A (21/195, 11%) and B (198/808, 25%)). In group D, the prescriptions conformed with the guidelines in 99% of cases (109/108). Guideline adherence was associated with high symptom load (COPD Assessment Test) (OR 1.04, p = 0.002), high number of exacerbations (OR = 2.07, p < 0.001), asthma overlap (OR 3.36, p = 0.049), and diabetes mellitus (OR 2.82, p = 0.045). (4) Conclusion: These results confirm a conflict between the GOLD recommendations and primary practice, mainly concerning over-treatment in GOLD groups A and B. Patients with high symptom load, high exacerbation risk, asthma overlap, and diabetes mellitus are more likely to be treated in conformity with the guidelines. Further research is needed to uncover the reasons for the discrepancies and to design strategies for improvement

Risk Factors for Recurrent Exacerbations in the General-Practitioner-Based Swiss Chronic Obstructive Pulmonary Disease (COPD) Cohort.

BACKGROUND Patients with chronic obstructive pulmonary disease (COPD) often suffer from acute exacerbations. Our objective was to describe recurrent exacerbations in a GP-based Swiss COPD cohort and develop a statistical model for predicting exacerbation. METHODS COPD cohort demographic and medical data were recorded for 24 months, by means of a questionnaire-based COPD cohort. The data were split into training (75%) and validation (25%) datasets. A negative binomial regression model was developed using the training dataset to predict the exacerbation rate within 1 year. An exacerbation prediction model was developed, and its overall performance was validated. A nomogram was created to facilitate the clinical use of the model. RESULTS Of the 229 COPD patients analyzed, 77% of the patients did not experience exacerbation during the follow-up. The best subset in the training dataset revealed that lower forced expiratory volume, high scores on the MRC dyspnea scale, exacerbation history, and being on a combination therapy of LABA + ICS (long-acting beta-agonists + Inhaled Corticosteroids) or LAMA + LABA (Long-acting muscarinic receptor antagonists + long-acting beta-agonists) at baseline were associated with a higher rate of exacerbation. When validated, the area-under-curve (AUC) value was 0.75 for one or more exacerbations. The calibration was accurate (0.34 predicted exacerbations vs 0.28 observed exacerbations). CONCLUSION Nomograms built from these models can assist clinicians in the decision-making process of COPD care

Clinical characteristics governing treatment adjustment in COPD patients: results from the Swiss COPD cohort study

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a widespread chronic disease characterised by irreversible airway obstruction [1]. Features of clinical practice and healthcare systems for COPD patients can vary widely, even within similar healthcare structures. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy is considered the most reliable guidance for the management of COPD and aims to provide treating physicians with appropriate insight into the disease. COPD treatment adaptation typically mirrors the suggestions within the GOLD guidelines, depending on how the patient has been categorised. However, the present study posits that the reasons for adjusting COPD-related treatment are hugely varied. OBJECTIVES: The objective of this study was to assess the clinical symptoms that govern both pharmacological and non-pharmacological treatment changes in COPD patients. Using this insight, the study offers suggestions for optimising COPD management through the implementation of GOLD guidelines. METHODS: In this observational cohort study, 24 general practitioners screened 260 COPD patients for eligibility from 2015–2019. General practitioners were asked to collect general information from patients using a standardised questionnaire to document symptoms. During a follow-up visit, the patient’s symptoms and changes in therapy were assessed and entered into a central electronic database. Sixty-five patients were removed from the analysis due to exclusion criteria, and 195 patients with at least one additional visit within one year of the baseline visit were included in the analysis. A change in therapy was defined as a change in either medication or non-medical treatment, such as pulmonary rehabilitation. Multivariable mixed models were used to identify associations between given symptoms and a step up in therapy, a step down, or a step up and a step down at the same time. RESULTS: For the 195 patients included in analyses, a treatment adjustment was made during 28% of visits. In 49% of these adjustments, the change in therapy was a step up, in 33% a step down and in 18% a step up (an increase) of certain treatment factors and a step down (a reduction) of other prescribed treatments at the same time. In the multivariable analysis, we found that the severity of disease was linked to the probability of therapy adjustment: patients in GOLD Group C were more likely to experience an increase in therapy compared to patients in GOLD Group A (odds ratio [OR] 3.43 [95% confidence interval {CI}: 1.02–11.55; p = 0.135]). In addition, compared to patients with mild obstruction, patients with severe (OR 4.24 [95% CI: 1.88–9.56]) to very severe (OR 5.48 [95% CI: 1.31–22.96]) obstruction were more likely to experience a therapy increase (p 999; p = 0.109]). CONCLUSIONS: This cohort study provides insight into the management of patients with COPD in a primary care setting. COPD Group C and airflow limitation GOLD 3–4 were both associated with an increase in COPD treatment. In patients with comorbidities, there were often no treatment changes. Exacerbations did not make therapy increases more probable. The presence of neither cough/sputum nor high CAT scores was associated with a step up in treatment

Characteristics of Severe Asthma Patients and Predictors of Asthma Control in the Swiss Severe Asthma Registry

Background: Asthma is a chronic airway disease, affecting over 300 million people worldwide. 5–10% of patients suffer from severe asthma and account for 50% of asthma-related financial burden. Availability of real-life data about the clinical course of severe asthma is insufficient. Objectives: The aims of this study were to characterize patients with severe asthma in Switzerland, enrolled in the Swiss Severe Asthma Registry (SSAR), and evaluate predictors for asthma control. Method: A descriptive characterisation of 278 patients was performed, who were prospectively enrolled in the registry until January 2022. Socio-demographic variables, comorbidities, diagnostic values, asthma treatment, and healthcare utilisation were evaluated. Groups of controlled and uncontrolled asthma according to the asthma control test were compared. Results: Forty-eight percent of patients were female and the mean age was 55.8 years (range 13–87). The mean body mass index (BMI) was 27.4 kg/m2 (±6). 10.8% of patients were current smokers. Allergic comorbidities occurred in 54.3% of patients, followed by chronic rhinosinusitis (46.4%) and nasal polyps (34.1%). According to the ACT score, 54.7% had well controlled, 16.2% partly controlled and 25.9% uncontrolled asthma. The most common inhalation therapy was combined inhaled corticosteroids/long-acting β2-agonists (78.8%). Biologics were administered to 81.7% of patients and 19.1% received oral steroids. The multivariable analysis indicated that treatment with biologics was positively associated with asthma control whereas higher BMI, oral steroids, exacerbations, and COPD were negative predictors for asthma control. Conclusion: Biologics are associated with improved control in severe asthma. Further studies are required to complete the picture of severe asthma in order to provide improved care for those patients

Resting and Post Bronchial Challenge Testing Carbon Dioxide Partial Pressure in Individuals with and without Asthma

Objective: There is conflicting evidence about resting carbon dioxide levels in asthmatic individuals. We wanted to determine if transcutaneously measured carbon dioxide levels prior and during bronchial provocation testing differ according to asthma status reflecting dysfunctional breathing. Methods: We investigated active firefighters and policemen by means of a validated questionnaire on respiratory symptoms, spirometry, bronchial challenge testing with methacholine (MCT) and measurement of transcutaneous blood carbon dioxide partial pressure (PtcCO 2) at rest prior performing spirometry, one minute and five minutes after termination of MCT. A respiratory physician blinded to the PtcCO2 results assigned a diagnosis of asthma after reviewing the available study data and the files of the workers medical screening program. Results: The study sample consisted of 128 male and 10 female individuals. Fifteen individuals (11%) had physiciandiagnosed asthma. There was no clinically important difference in median PtcCO 2 at rest, one and five minutes after recovery from MCT in asthmatics compared to non-asthmatics (35.6 vs 35.7 mmHg, p = 0.466; 34.7 vs 33.4 mmHg, p = 0.245 and 37.4 vs 36.4 mmHg, p = 0.732). The median drop in PtcCO2 during MCT and the increase after MCT was lower in asthmatics compared to non-asthmatics (0.1 vs 3.2 mmHg, p = 0.014 and 1.9 vs 2.9 mmHg, p = 0.025). Conclusions: PtcCO2 levels at rest prior and during recovery after MCT do not differ in individuals with or without physicia