Long-term survival comparison between the first and second waves among 265 critical COVID-19 patients admitted to the ICU: A retrospective cohort study

BACKGROUD

Management of severe COVID-19 patients admitted to ICU considerably evolved during the first months of the pandemic. It is unclear, however, whether these changes improved long-term survival of these critically ill patients.

METHODS

We conducted a retrospective cohort study in adults with COVID-19 pneumonia admitted to a French ICU between February 2020 and January 2021, a timeframe that covered the first two waves of the pandemic. Primary outcome was to compare long-term survival between the first and second waves. Survival predictor were identified using a Cox proportional-hazards model.

RESULTS

We included 265 patients in the cohort: 140 (52.8 %) and 125 (47.2 %) belonging to the first and second waves, respectively. Baseline characteristics of the patients were similar between the two waves. During W2, use of early corticotherapy increased (86.4% vs. 17.8 %; p <0.001), as well as high-flow oxygen therapy use (68.5% vs. 37.4 %; p<0.001). Need for invasive mechanical ventilation decreased (49.6% vs. 72.9 %; p <0.001) and ICU length of stay was shorter (11 [6-22] vs 19 [8-32]days; p = 0.008). ICU mortality was 32.8 % without significant difference between waves. Survival analysis revealed that 3 variables were independently associated with a worse long-term prognosis: a higher SAPS II score (1.05 [1.04-1.06]; p<0.001), a higher age (1.05 [1.01-1.08]; p = 0.005) and admission during W2 (2.22 [1.15-4.28]; p = 0.017).

DISCUSSION

Despite substantial changes on management of severe COVID-19 patients, we observed a decreased long-term survival among patients admitted during the second wave. We also noted a shorter ICU length of stay.

Clinical standards for diagnosis, treatment and prevention of post-COVID-19 lung disease

BACKGROUND: The aim of these clinical standards is to provide guidance on 'best practice' care for the diagnosis, treatment and prevention of post-COVID-19 lung disease.METHODS: A panel of international experts representing scientific societies, associations and groups active in post-COVID-19 lung disease was identified; 45 completed a Delphi process. A 5-point Likert scale indicated level of agreement with the draft standards. The final version was approved by consensus (with 100% agreement).RESULTS: Four clinical standards were agreed for patients with a previous history of COVID-19: Standard 1, Patients with sequelae not explained by an alternative diagnosis should be evaluated for possible post-COVID-19 lung disease; Standard 2, Patients with lung function impairment, reduced exercise tolerance, reduced quality of life (QoL) or other relevant signs or ongoing symptoms ≥4 weeks after the onset of first symptoms should be evaluated for treatment and pulmonary rehabilitation (PR); Standard 3, The PR programme should be based on feasibility, effectiveness and cost-effectiveness criteria, organised according to local health services and tailored to an individual patient's needs; and Standard 4, Each patient undergoing and completing PR should be evaluated to determine its effectiveness and have access to a counselling/health education session.CONCLUSION: This is the first consensus-based set of clinical standards for the diagnosis, treatment and prevention of post-COVID-19 lung disease. Our aim is to improve patient care and QoL by guiding clinicians, programme managers and public health officers in planning and implementing a PR programme to manage post-COVID-19 lung disease.

Cardiovascular and Venous Thromboembolic Events After Hospital Discharge for COVID-19: A Prospective Single Center Study

Coronavirus disease 2019 (COVID-19) is associated with an increase in venous thrombotic and cardiovascular (CV) events has been reported during hospitalization. No systematic ultrasound follow-up to evaluate sequelae was ever that took place carried out prospectively associated with the evaluation of CV morbidity-mortality at 3 months post-discharge. Consecutive patients hospitalized for COVID-19 in the Amiens-Picardie University Hospital between 1st February and 31st August 2020 were included. The primary objective was the thrombosis incidence at 3 months after hospital discharge. Thrombosis was defined as either venous thromboembolism (VTE) or a CV event (CVE: myocardial infarction (MI), stroke or peripheral arterial disease). A secondary objective was to determine the risk factors for thrombotic events. We included 498 patients (279 men; 56%) of median age 66 (55-76) years. The primary composite outcome occurred in 27 patients (5.4%); 19 patients (3.8%) presented a CVE (stroke, n = 5; MI, n = 9; and peripheral arterial disease, n = 5). Two patients (0.8%) presented VTE. Six patients (1.2%) died. In multivariate analysis, a previous CVE was associated with thrombosis (OR 3.11; 95% CI 1.17-8.24). COVID-19 was significantly associated with thrombotic events post hospital discharge. Special attention should be given to CVE in the follow-up of patients with a previous thrombotic event.

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

INTRODUCTION

While 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 METHODS

Population-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.

RESULTS

Of 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)].

CONCLUSION

Our results suggest a decreased risk of death with ICS use among COPD patients admitted for CAP.

Management of pharmacovigilance during the COVID-19 pandemic crisis by the safety department of an academic sponsor: Lessons learnt and challenges from the EU DisCoVeRy clinical trial

The current COVID-19 pandemic was an exceptional health situation, including for drug use. As there was no known effective drug for COVID-19 at the beginning of the pandemic, different drug candidates were proposed. In this article, we present the challenges for an academic Safety Department to manage the global safety of a European trial during the pandemic. The National Institute for Health and Medical Research (Inserm) conducted a European multicenter, open-label, randomized, controlled trial involving three repurposed and one-in development drugs (lopinavir/ritonavir, IFN-β1a, hydroxychloroquine, and remdesivir) in adults hospitalized with COVID-19. From 25 March 2020 to 29 May 2020, the Inserm Safety Department had to manage 585 Serious Adverse Events (SAEs) initial notification and 396 follow-up reports. The Inserm Safety Department's staff was mobilized to manage these SAEs and to report Expedited safety reports to the competent authorities within the legal timeframes. More than 500 queries were sent to the investigators due to a lack of or incoherent information on SAE forms. At the same time, the investigators were overwhelmed by the management of patients suffering from COVID-19 infection. These particular conditions of missing data and lack of accurate description of adverse events made evaluation of the SAEs very difficult, particularly the assessment of the causal role of each investigational medicinal product. In parallel, working difficulties were accentuated by the national lockdown, frequent IT tool dysfunctions, delayed implementation of monitoring and the absence of automatic alerts for SAE form modification. Although COVID-19 is a confounding factor per se, the delay in and quality of SAE form completion and the real-time medical analysis by the Inserm Safety Department were major issues in the quick identification of potential safety signals. To conduct a high-quality clinical trial and ensure patient safety, all stakeholders must take their roles and responsibilities.

French recommendations for the diagnosis and management of lymphangioleiomyomatosis

BACKGROUND

The present article is an English-language version of the French National Diagnostic and Care Protocol, a pragmatic tool to optimize and harmonize the diagnosis, care pathway, management and follow-up of lymphangioleiomyomatosis in France.

METHODS

Practical recommendations were developed in accordance with the method for developing a National Diagnosis and Care Protocol for rare diseases of the Haute Autorité de Santé and following international guidelines and literature on lymphangioleiomyomatosis. It was developed by a multidisciplinary group, with the help of patient representatives and of RespiFIL, the rare disease network on respiratory diseases.

RESULTS

Lymphangioleiomyomatosis is a rare lung disease characterised by a proliferation of smooth muscle cells that leads to the formation of multiple lung cysts. It occurs sporadically or as part of a genetic disease called tuberous sclerosis complex (TSC). The document addresses multiple aspects of the disease, to guide the clinicians regarding when to suspect a diagnosis of lymphangioleiomyomatosis, what to do in case of recurrent pneumothorax or angiomyolipomas, what investigations are needed to make the diagnosis of lymphangioleiomyomatosis, what the diagnostic criteria are for lymphangioleiomyomatosis, what the principles of management are, and how follow-up can be organised. Recommendations are made regarding the use of pharmaceutical specialties and treatment other than medications.

CONCLUSION

These recommendations are intended to guide the diagnosis and practical management of pulmonary lymphangioleiomyomatosis.

Respiratory recovery trajectories after severe-to-critical COVID-19: a 1-year prospective multicentre study

BACKGROUND

Survivors of severe-to-critical COVID-19 may have functional impairment, radiological sequelae and persistent symptoms requiring prolonged follow-up. This pragmatic study aimed to describe their clinical follow-up and determine their respiratory recovery trajectories, and factors that could influence them and their health-related quality of life.

METHODS

Adults hospitalised for severe-to-critical COVID-19 were evaluated at 3 months and up to 12 months post-hospital discharge in this prospective, multicentre, cohort study.

RESULTS

Among 485 enrolled participants, 293 (60%) were reassessed at 6 months and 163 (35%) at 12 months; 89 (51%) and 47 (27%) of the 173 ones initially managed with standard oxygen were reassessed at 6 and 12 months, respectively. At 3 months, 34%, 70% and 56% of the participants had a restrictive lung defect, impaired DL_CO and significant radiological sequelae, respectively. During extended follow-up, DL_CO and FVC (% of predicted value) increased by means of +4 points at 6 months, and +6 points at 12 months. Sex, body mass index, chronic respiratory disease, immunosuppression, pneumonia extent or corticosteroid use during acute COVID-19 and prolonged invasive mechanical ventilation (IMV) were associated with DL_CO at month 3, but not its trajectory thereafter. Among 475 (98%) patients with at least one chest computed-tomography scan during follow-up, 196 (41%) had significant sequelae on their last images.

CONCLUSION

Although pulmonary function and radiological abnormalities improved up to 1 year post-acute-COVID-19, high percentages of severe-to-critical disease survivors, including a notable proportion of those managed with standard oxygen, had significant lung sequelae and residual symptoms justifying prolonged follow-up.

Thyrotropin Levels in Patients with Coronavirus Disease 2019: Assessment during Hospitalization and in the Medium Term after Discharge

BACKGROUND

The objectives of this study were (1) to compare TSH levels between inpatients with critical versus non-critical coronavirus disease 19 (COVID-19), and (2) to describe the status of TSH levels three months after hospitalization.

METHODS

We collected data on adult patients hospitalized with COVID-19 at Amiens University Hospital. We compared TSH levels between inpatients with critical (intensive care unit admission and/or death) versus non-critical COVID-19. Thereafter, survivors were invited to return for a three-month post-discharge visit where thyroid function tests were performed, regardless of the availability of TSH measurement during hospitalization.

RESULTS

Among 448 inpatients with COVID-19, TSH assay data during hospitalization were available for 139 patients without prior thyroid disease. Patients with critical and non-critical forms of COVID-19 did not differ significantly with regard to the median (interquartile range) TSH level (0.96 (0.68-1.71) vs. 1.27 mIU/L (0.75-1.79), p = 0.40). Abnormal TSH level was encountered in 17 patients (12.2%); most of them had subclinical thyroid disease. TSH assay data at the three-month post-discharge visit were available for 151 patients without prior thyroid disease. Only seven of them (4.6%) had abnormal TSH levels. Median TSH level at the post-discharge visit was significantly higher than median TSH level during hospitalization.

CONCLUSIONS

Our findings suggest that COVID-19 is associated with a transient suppression of TSH in a minority of patients regardless of the clinical form. The higher TSH levels three months after COVID-19 might suggest recovery from non-thyroidal illness syndrome.

Amikacin Liposomal Inhalation Suspension (ALIS) in the treatment of Mycobacterium abscessus lung infection: a French observational experience

Background

Mycobacterium abscessus infections remain difficult to manage in both cystic fibrosis (CF) and non-CF patients and reported clinical outcomes are largely unsatisfactory. Clinical trial data are limited and no approved therapies are currently available for the management of M abscessus lung diseases. As an alternative, cohort studies may provide insightful information into the management of M abscessus pulmonary disease.

Methods

Based on a retrospective observational cohort study, we investigated the safety and efficacy of amikacin liposome inhaled suspension (ALIS) as an adjunct to a standard antibiotic regimen for M abscessus lung infection in both CF and non-CF patients. We also assessed the association of patient drug compliance with culture conversion and clinical outcomes.

Results

Twenty-six patients had long-term follow-up data available. Culture conversion was achieved in 54% (14/26) of the patients with no difference between CF and non-CF patients after an average treatment duration of 10 months. Patient treatment compliance was significantly better in the converter group compared to nonconverters with an odds ratio of 44.78 associated with good compared to poor patient compliance. Overall, 9 patients (35%) experienced an adverse event that led to treatment discontinuation.

Conclusions

ALIS appears beneficial in both CF and non-CF populations with M abscessus lung disease.

Epidemiology of infection by pulmonary non-tuberculous mycobacteria in French Guiana 2008–2018

Introduction

Unlike diseases caused by Mycobacterium tuberculosis, M. leprae and M. ulcerans, the epidemiology of pulmonary non-tuberculous mycobacteria (PNTM) has not received due attention in French Guiana. The main objective of the current study was to define the incidence of these PNTM infections: NTM pulmonary diseases (NTM-PD) and casual PNTM isolation (responsible of latent infection or simple colonization). The secondary objectives were to determine species diversity and geographic distribution of these atypical mycobacteria.

Methods

A retrospective observational study (2008–2018) of French Guiana patients with at least one PNTM positive respiratory sample in culture was conducted. Patients were then classified into two groups: casual PNTM isolation or pulmonary disease (NTM-PD), according to clinical, radiological and microbiological criteria defined by the American Thoracic Society / Infectious Disease Society of America (ATS / IDSA) in 2007.

Results

178 patients were included, out of which 147 had casual PNTM isolation and 31 had NTM-PD. Estimated annual incidence rate of respiratory isolates was 6.17 / 100,000 inhabitants per year while that of NTM-PD was 1.07 / 100,000 inhabitants per year. Among the 178 patients, M. avium complex (MAC) was the most frequently isolated pathogen (38%), followed by M. fortuitum then M. abscessus (19% and 6% of cases respectively), the latter two mycobacteria being mainly found in the coastal center region. Concerning NTM-PD, two species were mainly involved: MAC (81%) and M. abscessus (16%).

Discussion/Conclusion

This is the first study on the epidemiology of PNTM infections in French Guiana. PNTM’s incidence looks similar to other contries and metropolitan France and NTM-PD is mostly due to MAC and M.abscessus. Although French Guiana is the French territory with the highest tuberculosis incidence, NTM should not be overlooked.

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

Persistent 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.

Clinical and Imaging Determinants of Neurocognitive Disorders in Post-Acute COVID-19 Patients with Cognitive Complaints

Background: Neurocognitive disorders (NCDs) are a part of the post-acute coronavirus disease (COVID-19) syndrome. No study has specifically evaluated NCDs in post-acute COVID-19 patients with cognitive complaints or their MRI determinants. Objective: To characterize NCDs in post-acute COVID-19 patients with cognitive complaints. The secondary objectives were to assess their clinical and MRI determinants. Methods: We included 46 patients with a post-acute COVID-19 cognitive complaint referred to the Amiens University Hospital Memory Center. They underwent a neuropsychological assessment and 36 had cerebral MRI. The G3 overall summary score was the sum of the mean z scores for the executive function, language, and action speed domains. Neuropsychological profiles were compared in a general linear model. Clinical determinants were analyzed by stepwise linear regression. White matter hyperintensities (WMH) masks were analyzed using parcel-based WMH symptom mapping to identify the locations of WMHs associated with cognitive performance. Results: Repeated ANOVA showed a group effect (p = 0.0001) due to overall lower performance for patients and a domain effect (p = 0.0001) due to a lower (p = 0.007) action speed score. The G3 overall summary score was significantly associated with solely the requirement for oxygen (R2 = 0.319, p = 0.031). WHMs were associated with the G3 overall summary score in the following structures, all right-sided (p < 0.01): superior frontal region, postcentral region, cingulum, cortico-spinal tract, inferior longitudinal fasciculus, internal capsule, and posterior segment of the arcuate fasciculus. Conclusion: Post-acute COVID-19 patients with cognitive complaints had NCD, with prominent action slowing, significantly associated with the acute phase oxygen requirement and a right-sided WMH structure pattern.

European Respiratory Society Statement on Long COVID-19 Follow-Up

Patients diagnosed with coronavirus disease 2019 (COVID-19) associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection frequently experience symptom burden post-acute infection or post-hospitalisation. We aimed to identify optimal strategies for follow-up care that may positively impact the patient's quality of life (QoL). A European Respiratory Society (ERS) Task Force convened and prioritised eight clinical questions. A targeted search of the literature defined the timeline of “long COVID” as 1–6 months post-infection and identified clinical evidence in the follow-up of patients. Studies meeting the inclusion criteria report an association of characteristics of acute infection with persistent symptoms, thromboembolic events in the follow-up period, and evaluations of pulmonary physiology and imaging. Importantly, this statement reviews QoL consequences, symptom burden, disability and home care follow-up. Overall, the evidence for follow-up care for patients with long COVID is limited.

Follow-up care of patients infected with SARS-CoV-2 is crucial and may improve their quality of life. More evidence and research is emerging to understand the causes, mechanisms and risks of long COVID consequences.https://bit.ly/3J1WMWy

Infection grave à SARS-CoV-2 : évolution du profil des patients admis en réanimation entre les deux premières vagues

Introduction

Méthodes

Résultats

Conclusion

Impact de la corticothérapie systémique sur les séquelles respiratoires des infections à SARS-CoV-2

Introduction

Depuis 2019, l’épidémie de COVID-19 (infection à SARS-CoV-2) est responsable de 4 millions de décès dans le monde. Il n’existe, à ce jour, aucun traitement spécifique. La corticothérapie fait partie, depuis octobre 2020, du standard of care, suite à la publication de plusieurs études (dont la cohorte RECOVERY, NEJM 2020) montrant une amélioration significative de la survie lorsqu’elle est utilisée à la phase aiguë des pneumopathies hypoxémiantes. Cependant, peu de données sont disponibles concernant son impact sur l’atteinte résiduelle. Notre étude a donc cherché à savoir si le recours aux corticoïdes à la phase aiguë des infections à SARS-CoV-2 réduit la survenue de séquelles respiratoires à 3 mois, 6 mois et 1 an.

Méthodes

Il s’agit d’une étude observationnelle, rétrospective, réalisée au CHU d’Amiens entre mars et octobre 2020 concernant les patients ayant été hospitalisés dans une unité COVID. Ces patients étaient convoqués à 3 mois pour la réalisation d’un examen clinique, d’un scanner thoracique, d’explorations fonctionnelles respiratoires et d’un test de marche de 6 minutes. L’évaluation à 6 mois et 12 mois étaient optionnelles.

Résultats

Trois cent neuf patients ont été inclus. Parmi eux, 74 patients (23,9 %) avaient reçu une corticothérapie. À 3 mois, les patients ayant reçu une corticothérapie présentaient significativement plus de lésions en verre dépoli et une atteinte radiologique plus étendue ; ce qui n’était plus le cas à 6 mois et à 1 an. Il n’y avait pas de différence significative concernant les séquelles fonctionnelles à 3 mois comme sur le plus long terme.

Conclusion

Les patients ayant reçu une corticothérapie étaient peu nombreux et les plus graves, issus de la « première vague », ce qui peut expliquer les différences retrouvées lors de l’évaluation à 3 mois. Les séquelles respiratoires à 6 mois et 1 an semblent moins importantes dans le groupe ayant reçu une corticothérapie, mais le nombre de patients est insuffisant pour conclure. Cette étude n’a pas permis de mettre en évidence de différence significative à long terme entre les patients ayant reçu ou non une corticothérapie. Il semble nécessaire de poursuivre cette étude en appariant les patients sur la gravité initiale.

Case Reports: Bronchial Mucosal Vasculature Is Also Involved in the Acute Vascular Distress Syndrome of COVID-19

Background: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which targets the pulmonary vasculature is supposed to induce an intrapulmonary right to left shunt with an increased pulmonary blood flow. We report here what may be, to the best of our knowledge, the first videoendoscopic descriptions of an hypervascularization of the bronchial mucosa in two patients hospitalized for coronavirus disease 2019 (COVID-19) pneumonia.

Cases Presentation: Two patients, 27- and 37-year-old, were addressed to our Pneumology department for suspicion of COVID-19 pneumonia. Their symptoms (fever, dry cough, and dyspnoea), associated to pulmonary ground glass opacities on thoracic CT, were highly suggestive of a COVID-19 disease despite repeated negative pharyngeal swabs RT-PCR. In both patients, bronchoscopy examination using white light was unremarkable but NBI bronchoscopy revealed a diffuse hypervascularization of the mucosa from the trachea to the sub-segmental bronchi, associated with dilated submucosal vessels. RT-PCR performed in bronchoalveolar lavage (BAL) confirmed the presence of Sars-CoV-2.

Conclusions: These two case reports highlight the crucial importance of the vascular component of the viral disease. We suggest that such bronchial hypervascularization with dilated vessels contributes, at least in part, to the intrapulmonary right to left shunt that characterizes the COVID-19 related Acute Vascular Distress Syndrome (AVDS). The presence of diffuse bronchial hypervascularization in the context of COVID-19 pandemic should prompt the search for Sars-CoV-2 in BAL samples.

Évaluation à 3 mois du retentissement de l’infection par le SARS CoV-2 sur la fonction thyroïdienne

Les infections virales peuvent induire des thyroïdites subaiguës ou un syndrome de “basse T3” central ou périphérique pour les formes sévères.

Objectifs

Évaluer la fonction thyroïdienne 3 mois après une hospitalisation pour COVID-19 au CHU d’Amiens. Comparer -les taux de TSH, T4L, T3L à 3 mois chez les patients de réanimation vs unités COVID -les taux à 3 mois (M3) aux taux initiaux disponibles (M0)

Méthodes

Dosage prospectif lors de la consultation de suivi de l’étude “SARS-COv-2SeqCov” proposée aux 467 patients hospitalises entre février et juin 2020.

Résultats

Le bilan a été réalisé chez 141 patients ; ont été exclus ceux aux antécédents thyroïdiens. La TSH médiane était de 1,80 mUI/L [1,33–2,37], la T4L et la T3L médiane de 13,6[12,38–15,20] et 4,23 [4–4,88]pmol/l. 5 patients (4,1 %) avaient une hypothyroïdie fruste. Il n’y avait pas de différence significative entre les patients survivants de réanimation (1,66 mUI/L [1,29–2,08] ; n = 44) vs unités COVID (1,79 mUI/L [1,33–2,37] ;n = 70). Le seul facteur intercurrent M0–M3 (produits de contraste, corticoïdes, amiodarone) influençant significativement la TSH était l’amiodarone : 2,1 [2,05–5,92] vs 1,7 mUI/L [1,33–2,29], (p = 0,038).

La TSH M3 était plus élevée qu’à M0 (n = 34) : 1,49 [1,22–1,81] mUI/L vs 1,03 [0,66–1,81], p = 0,041.

Conclusion

Aucune thyroïdite subaiguë clinique n’a été observée mais les 5 hypothyroïdies frustes peuvent suggérer une thyroïdite paucisymptomatique initiale. La TSH médiane plus élevée à 3 mois laisse suggérer la récupération d’un syndrome de basse T3 central en phase infectieuse aiguë.

Management of Drug Toxicity in Mycobacterium avium Complex Pulmonary Disease: An Expert Panel Survey

Adverse events are frequent in nontuberculous mycobacteria pulmonary disease treatment, but evidence to support their management is scarce. An expert panel survey on management of adverse events shows consistent opinions on management of hepatoxicity, ocular toxicity, ototoxicity, tinnitus, and gastrointestinal upset. These opinions can provide assistance in individual patient management decisions.

Randomised trial of first-line bronchial artery embolisation for non-severe haemoptysis of mild abundance

Background

Whereas first-line bronchial artery embolisation (BAE) is considered standard of care for the management of severe haemoptysis, it is unknown whether this approach is warranted for non-severe haemoptysis.

Research question

To assess the efficacy on bleeding control and the safety of first-line BAE in non-severe haemoptysis of mild abundance.

Study design and methods

This multicentre, randomised controlled open-label trial enrolled adult patients without major comorbid condition and having mild haemoptysis (onset <72 hours, 100–200 mL estimated bleeding amount), related to a systemic arterial mechanism. Patients were randomly assigned (1:1) to BAE associated with medical therapy or to medical therapy alone.

Results

Bleeding recurrence at day 30 after randomisation (primary outcome) occurred in 4 (11.8%) of 34 patients in the BAE strategy and 17 (44.7%) of 38 patients in the medical strategy (difference −33%; 95% CI −13.8% to −52.1%, p=0.002). The 90-day bleeding recurrence-free survival rates were 91.2% (95% CI 75.1% to 97.1%) and 60.2% (95% CI 42.9% to 73.8%), respectively (HR=0.19, 95% CI 0.05 to 0.67, p=0.01). No death occurred during follow-up and no bleeding recurrence needed surgery.

Four adverse events (one major with systemic emboli) occurred during hospitalisation, all in the BAE strategy (11.8% vs 0%; difference 11.8%, 95% CI 0.9 to 22.6, p=0.045); all eventually resolved.

Conclusion

In non-severe haemoptysis of mild abundance, BAE associated with medical therapy had a superior efficacy for preventing bleeding recurrences at 30 and 90 days, as compared with medical therapy alone. However, it was associated with a higher rate of adverse events.

Trial registration number

NCT01278199

[SARS-CoV-2 infection: Available data on 15th April 2021]

INTRODUCTION

Since January 2020, when the first cases of SARS-CoV-2 infection were diagnosed in France, pulmonologists have been at the heart of the crisis and should be responsible for the management of acute COVID-19 (and any possible sequelae) BACKGROUND: Many drugs have been evaluated or are currently under evaluation as possible specific treatment for SARS-CoV-2. Nevertheless, as of April 15, 2021, the only recommended treatment in current practice is the "standard of care", i.e. the symptomatic management of infection with SARS-CoV-2. This review presents the state of knowledge on COVID-19 in the acute phase (virological, immunological, epidemiological and therapeutic data) available on 15th April, 2021.

OUTLOOK

A large number of clinical trials are currently ongoing. It is important to propose to patients the opportunity to participate in clinical trials and to structure the research in order to complete the studies.

CONCLUSION

Current management is based on oxygen therapy, thromboprophylaxis and in some cases corticosteroids. No antiviral therapy is currently recommended. These data are constantly evolving.

An open-label randomized controlled trial of the effect of lopinavir/ritonavir, lopinavir/ritonavir plus IFN-β-1a and hydroxychloroquine in hospitalized patients with COVID-19

Objectives

We evaluated the clinical, virological and safety outcomes of lopinavir/ritonavir, lopinavir/ritonavir–interferon (IFN)-β-1a, hydroxychloroquine or remdesivir in comparison to standard of care (control) in coronavirus 2019 disease (COVID-19) inpatients requiring oxygen and/or ventilatory support.

Methods

We conducted a phase III multicentre, open-label, randomized 1:1:1:1:1, adaptive, controlled trial (DisCoVeRy), an add-on to the Solidarity trial (NCT04315948, EudraCT2020-000936-23). The primary outcome was the clinical status at day 15, measured by the WHO seven-point ordinal scale. Secondary outcomes included quantification of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in respiratory specimens and pharmacokinetic and safety analyses. We report the results for the lopinavir/ritonavir-containing arms and for the hydroxychloroquine arm, trials of which were stopped prematurely.

Results

The intention-to-treat population included 583 participants—lopinavir/ritonavir (n = 145), lopinavir/ritonavir–IFN–β-1a (n = 145), hydroxychloroquine (n = 145), control (n = 148)—among whom 418 (71.7%) were male, the median age was 63 years (IQR 54–71), and 211 (36.2%) had a severe disease. The day-15 clinical status was not improved with the investigational treatments: lopinavir/ritonavir versus control, adjusted odds ratio (aOR) 0.83, (95% confidence interval (CI) 0.55–1.26, p 0.39), lopinavir/ritonavir–IFN–β-1a versus control, aOR 0.69 (95%CI 0.45–1.04, p 0.08), and hydroxychloroquine versus control, aOR 0.93 (95%CI 0.62–1.41, p 0.75). No significant effect of investigational treatment was observed on SARS-CoV-2 clearance. Trough plasma concentrations of lopinavir and ritonavir were higher than those expected, while those of hydroxychloroquine were those expected with the dosing regimen. The occurrence of serious adverse events was significantly higher in participants allocated to the lopinavir/ritonavir-containing arms.

Conclusion

In adults hospitalized for COVID-19, lopinavir/ritonavir, lopinavir/ritonavir–IFN–β-1a and hydroxychloroquine improved neither the clinical status at day 15 nor SARS-CoV-2 clearance in respiratory tract specimens.

Treatment of Nontuberculous Mycobacterial Pulmonary Disease: An Official ATS/ERS/ESCMID/IDSA Clinical Practice Guideline

Nontuberculous mycobacteria (NTM) represent over 190 species and subspecies, some of which can produce disease in humans of all ages and can affect both pulmonary and extrapulmonary sites. This guideline focuses on pulmonary disease in adults (without cystic fibrosis or human immunodeficiency virus infection) caused by the most common NTM pathogens such as Mycobacterium avium complex, Mycobacterium kansasii, and Mycobacterium xenopi among the slowly growing NTM and Mycobacterium abscessus among the rapidly growing NTM. A panel of experts was carefully selected by leading international respiratory medicine and infectious diseases societies (ATS, ERS, ESCMID, IDSA) and included specialists in pulmonary medicine, infectious diseases and clinical microbiology, laboratory medicine, and patient advocacy. Systematic reviews were conducted around each of 22 PICO (Population, Intervention, Comparator, Outcome) questions and the recommendations were formulated, written, and graded using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. Thirty-one evidence-based recommendations about treatment of NTM pulmonary disease are provided. This guideline is intended for use by healthcare professionals who care for patients with NTM pulmonary disease, including specialists in infectious diseases and pulmonary diseases.

Characteristics and outcomes of COVID-19 in hospitalized patients with and without diabetes

BACKGROUND

Coronavirus disease 2019 (COVID-19) is a rapidly progressing pandemic, with four million confirmed cases and 280 000 deaths at the time of writing. Some studies have suggested that diabetes is associated with a greater risk of developing severe forms of COVID-19. The primary objective of the present study was to compare the clinical features and outcomes in hospitalized COVID-19 patients with vs without diabetes.

METHODS

All consecutive adult patients admitted to Amiens University Hospital (Amiens, France) with confirmed COVID-19 up until April 21st, 2020, were included. The composite primary endpoint comprised admission to the intensive care unit (ICU) and death. Both components were also analysed separately in a logistic regression analysis and a Cox proportional hazards model.

RESULTS

A total of 433 patients (median age: 72; 238 (55%) men; diabetes: 115 (26.6%)) were included. Most of the deaths occurred in non-ICU units and among older adults. Multivariate analyses showed that diabetes was associated neither with the primary endpoint (odds ratio (OR): 1.12; 95% confidence interval (CI): 0.66-1.90) nor with mortality (hazard ratio: 0.73; 95%CI: 0.40-1.34) but was associated with ICU admission (OR: 2.06; 95%CI 1.09-3.92, P = .027) and a longer length of hospital stay. Age was negatively associated with ICU admission and positively associated with death.

CONCLUSIONS

Diabetes was prevalent in a quarter of the patients hospitalized with COVID-19; it was associated with a greater risk of ICU admission but not with a significant elevation in mortality. Further investigation of the relationship between COVID-19 severity and diabetes is warranted.

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.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-05805-5.

[Guide for management of patients with possible respiratory sequelae after a SARS-CoV-2 pneumonia. Support proposals developed by the French-speaking Respiratory Medicine Society. Version of 10 November 2020]

La Société de Pneumologie de Langue Française (SPLF) propose un guide pour la prise en charge thérapeutique des patients ayant d’éventuelles séquelles respiratoires après avoir présenté une pneumonie à SARS-CoV-2 (COVID-19). Les propositions s’appuient sur les données connues des précédentes épidémies, les données préliminaires publiées sur le suivi après COVID-19 et les avis d’experts. Les propositions ont été élaborées par un groupe d’experts puis soumises selon la méthode Delphi à un panel composé de 22 pneumologues. Dix-sept propositions ont été validées, qui vont des examens complémentaires à réaliser après le bilan minimal proposé dans le guide de suivi de la SPLF à la place de la corticothérapie inhalée ou systémique et des médicaments antifibrosants. Ces propositions pourront évoluer dans le temps au fil des connaissances sur le sujet. Ce guide insiste sur l’importance de la discussion multidisciplinaire.

The association between body mass index class and coronavirus disease 2019 outcomes

BACKGROUND/OBJECTIVES

A growing body of data suggests that obesity influences coronavirus disease 2019 (COVID-19). Our study's primary objective was to assess the association between body mass index (BMI) categories and critical forms of COVID-19.

SUBJECTS/METHODS

Data on consecutive adult patients hospitalized with laboratory-confirmed COVID-19 at Amiens University Hospital (Amiens, France) were extracted retrospectively. The association between BMI categories and the composite primary endpoint (admission to the intensive care unit or death) was probed in a logistic regression analysis.

RESULTS

In total, 433 patients were included, and BMI data were available for 329: 20 were underweight (6.1%), 95 have a normal weight (28.9%), 90 were overweight (27.4%), and 124 were obese (37.7%). The BMI category was associated with the primary endpoint in the fully adjusted model; the odds ratio (OR) [95% confidence interval (CI)] for overweight and obesity were respectively 1.58 [0.77-3.24] and 2.58 [1.28-5.31]. The ORs [95% CI] for ICU admission were similar for overweight (3.16 [1.29-8.06]) and obesity (3.05 [1.25-7.82]) in the fully adjusted model. The unadjusted ORs for death were similar in all BMI categories while obesity only was associated with higher risk after adjustment.

CONCLUSIONS

Our results suggest that overweight (and not only obesity) is associated with ICU admission, but overweight is not associated with death.

Correlation between the Epworth Sleepiness Scale and the Maintenance of Wakefulness Test in Obstructive Sleep Apnea Patients Treated with Positive Airway Pressure

BACKGROUND

The Epworth sleepiness scale (ESS) is often used to evaluate the impact of treatment in patients with obstructive sleep apnea hypopnea syndrome (OSA). We aimed to evaluate the correlation between ESS and the Maintenance of Wakefulness Test (MWT) in a population of OSA patients treated with positive airway pressure (PAP).

METHODS

We retrospectively included all patients during a 2-year period who were diagnosed with OSA in our sleep clinic and required PAP therapy. ESS was evaluated at baseline and after PAP therapy for all patients, and all had a concomitant MWT. Correlation between final ESS, change in ESS, and MWT were evaluated using Spearman's correlation. Given that MWT is considered as the gold standard, the diagnostic performance of ESS was evaluated against MWT.

RESULTS

Hundred thirty-four OSA patients were included. At the time of MWT, 89.6% of the patients were compliant (PAP use ≥4hours/night), and only 9 (6.7%) had persistent sleepiness despite PAP treatment (mean sleep latency at MWT<19.4min). Moderate correlation was observed between final ESS and MWT (Spearman's correlation coefficient=-0.42), but no correlation was found between change in ESS and MWT. Diagnostic performance was as follows for final ESS: sensitivity=55.6%, specificity=84.8%, PPV=20.8%, and NPV=96.4%.

CONCLUSIONS

ESS was moderately correlated with MWT in a population of OSA patients compliant with PAP therapy. In this population, ESS showed poor diagnostic performance in identifying patients with persistent excessive daytime sleepiness. CLINICALTRIALS.

GOV IDENTIFIER

NCT03629834.

Treatment of Nontuberculous Mycobacterial Pulmonary Disease: An Official ATS/ERS/ESCMID/IDSA Clinical Practice Guideline

Nontuberculous mycobacteria (NTM) represent over 190 species and subspecies, some of which can produce disease in humans of all ages and can affect both pulmonary and extrapulmonary sites. This guideline focuses on pulmonary disease in adults (without cystic fibrosis or human immunodeficiency virus infection) caused by the most common NTM pathogens such as Mycobacterium avium complex, Mycobacterium kansasii, and Mycobacterium xenopi among the slowly growing NTM and Mycobacterium abscessus among the rapidly growing NTM. A panel of experts was carefully selected by leading international respiratory medicine and infectious diseases societies (ATS, ERS, ESCMID, IDSA) and included specialists in pulmonary medicine, infectious diseases and clinical microbiology, laboratory medicine, and patient advocacy. Systematic reviews were conducted around each of 22 PICO (Population, Intervention, Comparator, Outcome) questions and the recommendations were formulated, written, and graded using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. Thirty-one evidence-based recommendations about treatment of NTM pulmonary disease are provided. This guideline is intended for use by healthcare professionals who care for patients with NTM pulmonary disease, including specialists in infectious diseases and pulmonary diseases.

Treatment of Bone and Joint Tuberculosis in France: A Multicentre Retrospective Study

Background: Nine percent of all cases of tuberculosis are bone and joint tuberculosis (BJTB). BJTB occurs in two main forms: spinal (STB) and extraspinal (ESTB). The aim of this study was to compare STB with ESTB in terms of diagnosis, treatment and outcomes. Methods: We collected demographic, clinical, microbiological, treatment duration and outcome data for patients with BJTB in a retrospective multicentre study over a 17-year period. Results: Of the 116 patients included in the study, 69 (59.5%) had STB and 47 (40.5%) had ESTB. The median age was higher in the ESTB group. There were significantly more foreign-born patients in the STB group. The median time for diagnosis was longer for ESTB (6 months) than STB (4 months) (p = 0.017). Magnetic resonance imaging was highly reliable for the diagnosis. Direct examination and histology allowed the diagnosis to be made in more than 80% of cases. The median treatment duration of 12 months, regardless of the type of BJTB, was longer than recommended. A favourable outcome was achieved in 91.9% of cases. Conclusion: The management of BJTB remains challenging. An earlier diagnosis should be more effective, reducing the total duration of treatment and leading to better tolerance.

Treatment of nontuberculous mycobacterial pulmonary disease: an official ATS/ERS/ESCMID/IDSA clinical practice guideline

Nontuberculous mycobacteria (NTM) represent over 190 species and subspecies, some of which can produce disease in humans of all ages and can affect both pulmonary and extrapulmonary sites. This guideline focuses on pulmonary disease in adults (without cystic fibrosis or human immunodeficiency virus infection) caused by the most common NTM pathogens such as Mycobacterium avium complex, Mycobacterium kansasii, and Mycobacterium xenopi among the slowly growing NTM and Mycobacterium abscessus among the rapidly growing NTM. A panel of experts was carefully selected by leading international respiratory medicine and infectious diseases societies (ATS, ERS, ESCMID, IDSA) and included specialists in pulmonary medicine, infectious diseases and clinical microbiology, laboratory medicine, and patient advocacy. Systematic reviews were conducted around each of 22 PICO (Population, Intervention, Comparator, Outcome) questions and the recommendations were formulated, written, and graded using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. Thirty-one evidence-based recommendations about treatment of NTM pulmonary disease are provided. This guideline is intended for use by healthcare professionals who care for patients with NTM pulmonary disease, including specialists in infectious diseases and pulmonary diseases.

Association between renin-angiotensin system inhibitors and COVID-19 complications

Aims

To describe the characteristics of patients hospitalized with COVID-19 (including their long-term at-home medication use), and compare them with regard to the course of the disease. To assess the association between renin–angiotensin system inhibitors (RASIs) and disease progression and critical outcomes.

Methods and results

All consecutive hospitalized patients with laboratory-confirmed COVID-19 in a university hospital in Amiens (France) were included in this study. The primary composite endpoint was admission to an intensive care unit (ICU) or death before ICU admission. Univariable and multivariable logistic regression models were used to identify factors associated with the composite endpoint. Between 28 February 2020 and 30 March 2020, a total of 499 local patients tested positive for SARS-CoV-2. Of these, 231 were not hospitalized {males 33%; median [interquartile range (IQR)] age: 44 (32–54)}, and 268 were hospitalized [males 58%; median (IQR) age: 73 (61–84)]. A total of 116 patients met the primary endpoint: 47 died before ICU admission, and 69 were admitted to the ICU. Patients meeting the primary endpoint were more likely than patients not meeting the primary endpoint to have coronary heart disease and to have been taking RASIs; however, the two subsets of patients did not differ with regard to median age. After adjustment for other associated variables, the risk of meeting the composite endpoint was 1.73 times higher (odds ratio 1.73, 95% confidence interval 1.02–2.93) in patients treated at baseline with a RASI than in patients not treated with this drug class. This association was confirmed when the analysis was restricted to patients treated with antihypertensive agents.

Conclusions

We highlighted a potential safety signal for RASIs, the long-term use of which was independently associated with a higher risk of severe COVID-19 and a poor outcome. Due to the widespread use of this important drug class, formal proof based on clinical trials is needed to better understand the association between RASIs and complications of COVID-19.

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

BACKGROUND

Severe 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.

METHODS

We 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.

RESULTS

From 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 9.9 ± 6.1 months after SG. Mean BMI decreased from 47.4 ± 8.4 to 36.3 ± 7.1 kg/m² (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.

Multidisciplinary advisory teams to manage multidrug-resistant tuberculosis: the example of the French Consilium

SETTING: The World Health Organization (WHO) recommends that multidrug-resistant tuberculosis (MDR-TB) treatment should be managed in collaboration with multidisciplinary advisory committees (consilia). A formal national Consilium has been established in France since 2005 to provide a centralised advisory service for clinicians managing MDR-TB and extensively drug-resistant (XDR-TB) cases.OBJECTIVE: Review the activity of the French TB Consilium since its establishment.DESIGN: Retrospective description and analysis of the activity of the French TB Consilium.RESULTS: Between 2005 and 2016, 786 TB cases or contacts of TB cases were presented at the French TB Consilium, including respectively 42% and 79% of all the MDR-TB and XDR-TB cases notified in France during this period. Treatment regimens including bedaquiline and/or delamanid were recommended for 42% of the cases presented at the French TB Consilium since 2009. Patients were more likely to be presented at the French TB Consilium if they were born in the WHO Europe Region, had XDR-TB, were diagnosed in the Paris region, or had resistance to additional drugs than those defining XDR-TB.CONCLUSION: The French TB Consilium helped supervise appropriate management of MDR/XDR-TB cases and facilitated implementation of new drugs for MDR/XDR-TB treatment.

Pleural transudate: pathophysiology during superior vena cava syndrome

Pathophysiology, diagnosis and treatment of pleural transudates has widely been described in the literature [1–3]. Except for left heart failure, which requires diuretics, thoracoscopic talc pleurodesis appears to be a safe and effective therapeutic option [4–6]. We report the case of a woman who presented with a sudden pleural fluid formation from her parietal pleura during a talc pleurodesis for a recurrent transudative pleural effusion. We discuss the pathophysiology of this phenomenon.

Pleural transudative effusion arises from imbalances between the hydrostatic and/or oncotic pressures. Temperature drop following talc poudrage through a spray may accentuate the pressure changes induced by superior vena cava syndrome.http://ow.ly/EpZm30nwVZj

[Risks associated with the use of non-steroidal anti-inflammatory drugs during pneumonia]

INTRODUCTION

Outpatient treatment of community-acquired pneumonia (CAP) patients with non-steroidal anti-inflammatory drugs (NSAIDs) is frequent, although this is not based on clinical recommendations and there is no scientific evidence supporting better symptom relief in comparison to acetaminophen.

STATE OF THE ART

Experimental data suggest that NSAIDs alter the intrinsic functions of neutrophils, limit their locoregional recruitment, alter bacterial clearance and delay the resolution of inflammatory processes during acute bacterial pulmonary challenge. In hospitalized children and adults with CAP, observational data suggest a strong and independent association between the outpatient exposure to NSAIDs and the occurrence of pleuropulmonary complications (pleural empyema, excavation, and abscess). In the only study taking into account possible protopathic bias, the association still persists. Other markers of morbidity have been described, including delay in hospital management, prolonged antibiotic therapy, and higher transfer rate to an intensive care unit.

PERSPECTIVES

Data describing the role of self-medication and the biological mechanisms involved are needed.

CONCLUSIONS

Intake of NSAIDs during outpatient treatment of CAP is probably the second modifiable factor of morbidity after inadequate antibiotic therapy. In light of existing data in children and adults, health authorities should urgently reassess the risk-benefit ratio of NSAIDS in CAP.