Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial.

Importance: Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. Objective: To determine whether hydrocortisone improves outcome for patients with severe COVID-19. Design, Setting, and Participants: An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. Interventions: The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). Main Outcomes and Measures: The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). Results: After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. Conclusions and Relevance: Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. Trial Registration: ClinicalTrials.gov Identifier: NCT02735707

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Une méthode de réduction de modèle basée sur l'échantillonnage pour le calcul d'une réponse vibro-acoustique aléatoire en basse fréquence

International audienceLa caractérisation de la signature acoustique et vibratoire de structures en mer en présence d'incertitudes est considérée avec intérêt dans l'industrie marine. La dimension stochastique de tels problèmes pouvant être grande, nous proposons une méthode basée sur le mariage efficace de techniques de réduction de modèle et d'approche par échantillonnage pour le calcul de la réponse vibroacoustique aléatoire en basses fréquences

Wetlands management and risk for West Nile virus circulation in Camargue, Southern France

International audienc

Wetlands management and risk for West Nile virus circulation in Camargue, Southern France

International audienc

Wetlands management and risk for West Nile virus circulation in Camargue, Southern France

International audienc

Complément à l'analyse de l’impact des Engins de peche sur les Habitats et especes listés dans les directives "Habitats" et "Oiseaux" (Natura 2000)

Après une description des méthodes adoptées en réponse à la demande, les résultats présentent : -Une cartographie générale de l’emprise des zones Natura 2000, -L’ensemble de la flotte des sous divisions concernées par les zones Natura 2000, -Les méta-métiers sélectionnés dans la demande complémentaire (chalut à perche, chalut de fond, dragues, tamis à civelle et senne tournante). Cette description est réalisée par façade et sous division CIEM pour l’Atlantique et par région en Méditerranée. Elle précise le nombre de navires, le nombre de mois d’activité, ainsi que les productions en tonnage et valeur par espèce. Le document est complété en annexe par des fiches de synthèse par façade (Mer du Nord/ Manche /Atlantique et Méditerranée) et des représentations cartographiques de la distribution spatiale des flottille

Wetlands management and West Nile Virus circulation, Southern France

International audienc

Taxonomic and functional diversity of Streptomyces in a forest soil

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Importance of Wetlands Management for West Nile Virus Circulation Risk, Camargue, Southern France

To assess environmental and horse-level risk factors associated with West Nile Virus (WNV) circulation in Camargue, Southern France, a serosurvey was conducted on non-vaccinated horses (n = 1159 from 134 stables) in 2007 and 2008. Fifteen Landsat images were examined to quantify areas with open water and flooded vegetation around sampled horses. Mean percentages of areas of open water and flooded vegetation, as well as variations in these percentages between 3 periods (November to February = NOT, March to July = END and August to October = EPI), were calculated for buffers of 2 km radius around the stables. Results of the final logistic regression showed that the risk of WNV seropositivity in horses decreased with their date of acquisition and age. Results also demonstrated the significant role of environmental variables. Horse serological status was associated with variations of open water areas between the NOT (November to February) and END (March to July) periods, as well as between END and EPI (August to October). WNV spillover was found more intense in areas where water level decreased strongly from winter to spring and from spring to summer