Inhaled corticosteroids and adverse outcomes among chronic obstructive pulmonary disease patients with community-acquired pneumonia: a population-based cohort study

IntroductionWhile inhaled corticosteroids (ICS) may increase pneumonia risk in patients with chronic obstructive pulmonary disease (COPD), the impact of ICS on pneumonia outcomes is debated. We examined whether ICS use is associated with adverse outcomes among COPD patients with community-acquired pneumonia (CAP).Materials and methodsPopulation-based cohort study of all COPD patients with an incident hospitalization for CAP between 1997 and 2013 in Northern Denmark. Information on medications, COPD severity, comorbidities, complications, and death was obtained from medical databases. Adjusted risk ratios (aRRs) for pleuropulmonary complications, intensive care unit (ICU) admissions, and 30-day mortality in current and former ICS users were compared with those in non-users, using regression analyzes to handle confounding.ResultsOf 11,368 COPD patients with CAP, 6,073 (53.4%) were current ICS users and 1,733 (15.2%) were former users. Current users had a non-significantly decreased risk of pleuropulmonary complications [2.6%; aRR = 0.82 (0.59–1.12)] compared to non-users (3.2%). This was also observed among former users [2.5%; aRR = 0.77 (0.53–1.12)]. Similarly, decreased risks of ICU admission were observed among current users [aRR = 0.77 (0.57–1.04)] and among former users [aRR = 0.81 (0.58–1.13)]. Current ICS users had significantly decreased 30-day mortality [9.1%; aRR = 0.72 (0.62–0.85)] compared to non-users (12.6%), with a stronger association observed among patients with frequent exacerbations [0.58 (0.39–0.86)]. No significant association was observed among former ICS users [0.89 (0.75–1.05)].ConclusionOur results suggest a decreased risk of death with ICS use among COPD patients admitted for CAP

Pleuroparenchymal complications of community-acquired pneumonia : risk factors, diagnosis and treatment

Les complications pleuropulmonaires (pleurésies infectieuses et abcès pulmonaires) des pneumopathies aiguës communautaires (PAC) sont associées à une morbidité importante mais leurs facteurs de risque et leur prise en charge sont toujours source de débat. Nous avons observé dans 2 études de cohorte (CAPAINS et CAPAINS-2) que l'utilisation d'anti-inflammatoires non stéroïdiens était associée à un risque accru de complications pleuropulmonaires, en particulier chez les patients jeunes et sans comorbidité. Dans une 3ème cohorte de patients BPCO hospitalisés pour une PAC, nous avons trouvé que l'utilisation de corticostéroïdes inhalés n'était pas associée à une modification du risque de complication pleuropulmonaire mais à une diminution de la mortalité, principalement chez les patients exacerbateurs fréquents ou avec un diagnostic de BPCO ancien (> 1 an). Finalement, nous avons mis en place une 4ème étude de cohorte pour évaluer l'impact du diabète et du contrôle glycémique sur l'évolution des PAC. Nous avons conduit une étude prospective évaluant la détection des pleurésies parapneumoniques par la réalisation d'une échographie thoracique quotidienne. Dans une analyse préliminaire, nous avons observé que près des 2/3 des patients présentaient une pleurésie parapneumonique et que l'échographie pleurale était plus sensible que la radiographie de thorax. Cette stratégie de détection précoce des épanchements pleuraux semblait associée à une réduction du nombre d'échecs des traitements médicaux. Les résultats définitifs sont attendus.Nous avons débuté une étude prospective évaluant la pharmacocinétique de l'amoxicilline et de l'acide clavulanique dans les épanchements parapneumoniques compliqués. Nous avons proposé la réalisation d'une étude multicentrique randomisée comparant l'efficacité respective d'un traitement fibrinolytique (altéplase + DNase) et des lavages intrapleuraux au sérum salé dans la prise en charge des pleurésies infectieuses compliquées. Ce projet a été soumis à l'appel d'offre PHRC-N 2020. En conclusion, ce travail fournit quelques réponses aux nombreuses interrogations concernant l'épidémiologie, le diagnostic et le traitement des complications pleuroparenchymateuses des PACPleuroparenchymal complications (pleural infection and lung abscess) of community acquired pneumonia are associated with a high morbidity but their risk factors and management are still debated.In two cohort study (CAPAINS, CAPAINS-2) we observed that non-steroidal anti-inflammatory drugs were associated with an increased risk of pleuroparenchymal complication especially in young and healthy subjects. In a third cohort of COPD patients with pneumonia we found that inhaled corticosteroid use was not associated with pleuroparenchymal outcome but with reduced case fatality. This reduced case fatality was mainly observed among frequent exacerbator and previously diagnosed COPD. Finally, we set up a fourth cohort study to look at the impact of diabetes and glycemic control on the outcomes of community acquired pneumonia.We built a prospective cohort study to evaluate detection of parapneumonic pleural effusion with daily thoracic ultrasound. In a preliminary analysis, we observed pleural effusion in up to 2/3 of the patients and pleural ultrasound was much more sensitive compared to chest X-ray. Early detection of pleural effusion seemed to be associated with decreased failure of medical treatment. Definitive results are awaited.We started a prospective study evaluating the pharmacokinetics of amoxicillin and clavulanic acid in parapneumonic complicated pleural effusion.We planned a multicentric prospective randomized control trial to compare the efficacy of fibrinolysis (alteplase and DNase) and pleural lavage with saline in the treatment of complicated pleural effusion. This project has been submitted to the call for project PHRC-N-2020.In conclusion, this work gives some answers to the numerous questions about epidemiology, diagnosis, and treatment of pleuroparenchymal complications of community acquired pneumonia

Short-Term Assessment of Obstructive Sleep Apnea Syndrome Remission Rate after Sleeve Gastrectomy: a Cohort Study

International audienceBackgroundSevere obesity is associated with a high prevalence of moderate-to-severe obstructive sleep apnea syndrome (OSA). Bariatric surgery has been shown to effectively reduce excess weight and comorbidities.MethodsWe evaluated the remission rate of moderate-to-severe OSA (apnea-hypopnea index (AHI)>= 15) following sleeve gastrectomy. We performed a single-center retrospective chart review of all patients who underwent preoperative polysomnography (PSG) or polygraphy before primary sleeve gastrectomy. Patients with moderate-to-severe OSA treated by continuous positive airway pressure (CPAP) also underwent postoperative PSG. Bivariate analysis was performed to evaluate the criteria associated with remission of moderate-to-severe OSA.ResultsFrom 2013 to 2018, 39 of 162 patients (24.1%) scheduled for sleeve gastrectomy (SG) presented moderate-to-severe OSA requiring CPAP. Postoperative PSG was performed in 36 patients a mean of 9.96.1 months after SG. Mean BMI decreased from 47.4 +/- 8.4 to 36.3 +/- 7.1 kg/m(2) (p<0.001), and all patients reported clinical improvement of OSA symptoms. A remission of moderate-to-severe OSA was observed in 72.2% of patients with a mean decrease of AHI from 45.8 events/h to 11.3 events/h (p<0.001). Postoperative neck circumference was the only factor associated with OSA remission.Conclusion SG is associated with a rapid improvement of moderate-to-severe OSA partially as a result of a reduction of neck circumference. However, the absence of correlation with excess weight loss suggests that other weight-independent factors may also be involved

Carbon monoxide rebreathing method is a reliable test to evaluate the red cell mass in polycythaemia

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Dissociation between the clinical course and chest imaging in severe COVID-19 pneumonia: A series of five cases.

Although an RT-PCR test is the "gold standard" tool for diagnosing an infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), chest imaging can be used to support a diagnosis of coronavirus disease 2019 (COVID-19) - albeit with fairly low specificity. However, if the chest imaging findings do not faithfully reflect the patient's clinical course, one can question the rationale for relying on these imaging data in the diagnosis of COVID-19. To compare clinical courses with changes over time in chest imaging findings among patients admitted to an ICU for severe COVID-19 pneumonia. We retrospectively reviewed the medical charts of all adult patients admitted to our intensive care unit (ICU) between March 1, 2020, and April 15, 2020, for a severe COVID-19 lung infection and who had a positive RT-PCR test. Changes in clinical, laboratory and radiological variables were compared, and patients with discordant changes over time (e.g. a clinical improvement with stable or worse radiological findings) were analyzed further. Of the 46 included patients, 5 showed an improvement in their clinical status but not in their chest imaging findings. On admission to the ICU, three of the five were mechanically ventilated and the two others received high-flow oxygen therapy or a non-rebreather mask. Even though the five patients' radiological findings worsened or remained stable, the mean ± standard deviation partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO:FiO) ratio increased significantly in all cases (from 113.2 ± 59.7 mmHg at admission to 259.8 ± 59.7 mmHg at a follow-up evaluation; p=0.043). Our results suggest that in cases of clinical improvement with worsened or stable chest imaging variables, the PaO2:FiO2 ratio might be a good marker of the resolution of COVID-19-specific pulmonary vascular insult

Pure SARS-CoV-2 related AVDS (Acute Vascular Distress Syndrome).

BACKGROUND: SARS-CoV-2 virus which targets the pulmonary vasculature is supposed to induce an intrapulmonary right to left shunt with an increased pulmonary blood flow. Such vascular injury is difficult to observe because it is hidden by the concomitant lung injury. We report here what may be, to the best of our knowledge, the first case of a pure Covid-19 related Acute Vascular Distress Syndrome (AVDS). CASE PRESENTATION: A 43-year-old physician, tested positive for Covid-19, was addressed to the emergency unit for severe dyspnoea and dizziness. Explorations were non informative with only a doubt regarding a sub-segmental pulmonary embolism (no ground-glass lesions or consolidations related to Covid-19 disease). Dyspnoea persisted despite anticoagulation therapy and normal pulmonary function tests. Contrast-enhanced transthoracic echocardiography was performed which revealed a moderate late right-to-left shunt. CONCLUSIONS: This case report highlights the crucial importance of the vascular component of the viral disease. The intrapulmonary shunt induced by Covid-19 which remains unrecognized because generally hidden by the concomitant lung injury, can persist for a long time. Contrast-enhanced transthoracic echocardiography is the most appropriate test to propose in case of persistent dyspnoea in Covid-19 patients

No Impact of Corticosteroid Use During the Acute Phase on Persistent Symptoms Post-COVID-19

International audiencePersistent COVID-19 symptoms may be related to residual inflammation, but no preventive treatment has been evaluated. This study aimed to analyze, in a prospective cohort, whether corticosteroid use in the acute phase of COVID-19 in hospitalized patients may reduce the risk of persistent COVID-19 symptoms. A total of 306 discharged patients, including 112 (36.6%) from the ICU, completed a structured face-to-face assessment 4 months after admission. Of these, 193 patients (63.1%) had at least one persistent symptom, mostly dyspnea (38.9%) and asthenia (37.6%). One-hundred and four patients have received corticosteroids. In multivariable adjusted regression analysis, corticosteroid use was not associated with the presence of at least one symptom (OR=1.00, 95% CI: 0.58-1.71, p=0.99) or with the number of persistent symptoms (p=0.74). Corticosteroid use remained ineffective when analyzing the ICU subpopulation separately. Our study suggests that corticosteroid use had no impact on persistent symptoms after COVID-19 in discharged patients