[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.

From randomized trials to the clinic: is it time to implement individual lung-cancer screening in clinical practice? A multidisciplinary statement from French experts on behalf of the French intergroup (IFCT) and the groupe d'Oncologie de langue francaise (GOLF)

Background

Despite advances in cancer therapy, mortality is still high except in early-stage tumors, and screening remains a challenge. The randomized National Lung Screening Trial (NLST), comparing annual low-dose computed tomography (LDCT) and chest X-rays, revealed a 20% decrease in lung-cancer-specific mortality. These results raised numerous questions. The French intergroup for thoracic oncology and the French-speaking oncology group convened an expert group to provide a coherent outlook on screening modalities in France.

Methods

A literature review was carried out and transmitted to the expert group, which was divided into three workshops to tackle specific questions, with responses presented in a plenary session. A writing committee drafted this article.

Results

The multidisciplinary group favored individual screening in France, when carried out as outlined in this article and after informing subjects of the benefits and risks. The target population involves subjects aged 55–74 years, who are smokers or have a 30 pack-year smoking history. Subjects should be informed about the benefits of quitting. Screening should involve LDCT scanning with specific modalities. Criteria for CT positivity and management algorithms for positive examinations are given.

Conclusions

Individual screening requires rigorous assessment and precise research in order to potentially develop a lung-cancer screening policy.

[Interstitial lung disease due to domestic moulds]

Identifying the role of fungi present in the domestic environment in the development of interstitial pneumonia can be a difficult clinical problem. We report a case of interstitial lung disease case occurring in a 53-year-old patient. He presented with profound hypoxemia (PaO(2) 54mmHg). Chest CT showed diffuse ground glass opacities. Initial blood tests for allergy and autoimmune disease were negative. Faced with a worsening of his clinical status after returning home he was hospitalized several times. At fibreoptic bronchoscopy, multiple white deposits were observed. Bronchoalveolar lavage with differential cell count was performed, revealing a 23% lymphocytosis. Serology for specific household molds showed moderate reaction to various molds found in homes, especially Stachybotrys chartarum. Pulmonary function tests revealed a moderate restrictive pattern with impaired diffusion of carbon monoxide and a bronchiolocentric interstitial pneumonia was found at lung biopsy. After a permanent move to a new residence, clinical parameters, radiological, biological and functional normalized. The final diagnosis was interstitial lung disease related to mycotoxins of S. Chartarum. The diagnosis of hypersensitivity pneumonitis to domestic mold or interstitial lung disease secondary to mycotoxins should be considered in patients presenting with interstitial pneumonia and requires specific investigations to ensure that an environmental cause with an allergic or toxic role is not missed.

A phase II study evaluating the cisplatin and epirubicin combination in patients with unresectable malignant pleural mesothelioma

Few chemotherapeutic agents have demonstrated their efficacy in malignant mesothelioma. The cisplatin plus doxorubicin combination has one of the highest response rates. Epirubicin is an anthracyclin, analogous to doxorubicin, with a different toxicologic pattern. As there are no data on the activity of the combination cisplatin plus epirubicin in malignant mesothelioma, the European Lung Cancer Working Party (ELCWP) designed a phase II study with response rate as primary objective. Sixty-nine eligible patients with malignant pleural mesothelioma were centrally registered. The majority of the patients were male (n=59), had a Karnofsky performance status of 80 or more (n=62) and presented with an epithelial histologic subtype (n=43). Median age was 62 years. In nine patients, metastases were documented at the initial work-up, mainly in bone, lung and skin. Three hundred and twenty-four cycles of chemotherapy were administered. The main toxicities were nausea and vomiting, neutropenia and alopecia. Among 63 assessable patients, response rate was 19.0% (95% confidence interval [CI] 9-29%). Median survival was 13.3 months. In multivariate analysis, poor prognostic factors for survival were neutrophil count and CALGB groups 4-6. In conclusion, cisplatin plus epirubicin appears as an effective regimen in malignant mesothelioma, with a favourable toxicity profile. However, it does not demonstrate superior activity to other active regimens in this disease.

The prevalence of anti-thyroid peroxidase antibodies and autoimmune thyroiditis in children and adolescents in an iodine replete area

BACKGROUND

The iodine supply of the population in Berlin has normalized during the last 5 Years. Therefore autoimmune thyroiditis has become the most important differential diagnosis in children and adolescents with goiter.

OBJECTIVE

The aim of the present study was to define the prevalence of anti-thyroid peroxidase (TPO) antibodies and autoimmune thyroiditis in children and adolescents with a normalized iodine intake.

DESIGN

To enable the measurement of antibodies to thyroid peroxidase (anti-TPO-Ab) in a large cohort, a method to determine anti-TPO-Ab in dried filter paper blood spots was established. In co-operation with pediatricians the antibody prevalence was assessed and data regarding thyroid size, echostructure and the medical history concerning iodine intake and familial thyroid diseases were collected.

METHODS

660 children and adolescents participated in the study; urinary iodine, TSH and TPO-Ab were measured and an ultrasound of the thyroid gland was performed.

RESULTS

The sensitivity of the newly established filter paper assay was 91.8% and specificity was 100%. The results confirmed the improved iodine supply, with a median urinary iodine concentration of 139 microg iodine/g creatinine. The prevalence of anti-TPO-Ab was 3.4% with a female to male ratio of 2.7:1.

CONCLUSION

The prevalence of anti-TPO-Ab is lower or equal to data reported from other iodine sufficient areas. Data from a moderate iodine deficiency in schoolchildren range from 0.0 to 7.3%. Using the new filter paper method field studies can be implemented to monitor the effect of changes in iodine nutrition on thyroid autoimmunity. Furthermore, this study on the prevalence of anti-TPO-Ab in a cohort of healthy children and adolescents in an iodine replete area can serve as reference data for future investigations and for the comparison with other groups of patients with increased risks for thyroid autoimmunity.

The treadmill exhausting test is not suitable for screening of growth hormone deficiency!

BACKGROUND/METHOD

We compared the growth hormone response to a modified exercise test--the treadmill exhausting test--to pharmacological stimulation tests in 77 children with short stature. Each child underwent the treadmill test to individual exhaustion and at least one pharmacological test for GH stimulation. To determine the point of individual exhaustion, the heart rate, workload and oxygen consumption were measured.

RESULTS

The mean +/- SEM peak GH concentration (ng/ml) in 47 small, normally growing children (group 1) was 16.1 +/- 1.3 in the pharmacological tests vs. 5.0 +/- 0.6 after a treadmill exhausting test. Thirty children with GH deficiency (group 2) had mean +/- SEM peak GH concentrations (ng/ml) of 5.5 +/- 0.5 in the pharmacological tests and 4.1 +/- 0.7 after physical exercise. The groups differed significantly in the pharmacological tests (p < 0.001) but not in the exhausting test. We found a 90% sensitivity but only a 11% specificity for the treadmill exhausting test compared to the diagnosis obtained by pharmacological testing.

CONCLUSION

We do not recommend the treadmill exhausting test in clinical practice of pediatric endocrinology at all.

[Evaluation and symptomatic treatment of surinfectious exacerbations of COPD: preliminary study of antibiotic treatment combined with fenspiride (Pneumorel 80mg) versus placebo]

Exacerbations of chronic obstructive pulmonary disease (COPD) have an inflammatory component in addition to the possible infectious component. The antiinflammatory properties of fenspiride (Pneumorel(R) 80 mg) should be evaluated in this frequent clinical situation.

OBJECTIVES

Assess the supplementary therapeutic benefit provided by fenspiride administered in combination with antibiotics in COPD patients presenting an episode of bronchial infection.

PATIENTS AND METHODS

A preliminary randomized placebo-controlled double-blind study was conduced in 7 centers. Patients under 80 years of age of both sexes were included. All patients had COPD and presented a bronchial infection defined as the presence of at least 2 of the 3 criteria defined by Anthonisen. Patients were randomly assigned to group F or group P. Group F received an antibiotic therapy from day 1 to day 11 plus fenspiride (3 x 80mg/d from day 0 to day 30). Group P received the same antibiotic therapy plus placebo. Amoxicillin 500mg plus clavulanic acid 125, 3 tablets/day, was administered in both groups.

RESULTS

Thirty-nine patients were included (group F 19 patients, group P 20 patients; 6 women and 33 men; mean age 61.1 +/- 9.8 years). The 3 Anthonisen criteria were present in 79% and 75% of the patients in group F and P respectively (NS). On day 11, expectoration resolved in 39% and 32% (NS) and cough in 44% and 16% (NS) of the patients in groups F and P respectively. Lung auscultation returned to normal in 83% of the patients in group F compared with 47% in group P (p=0.05). A composite clinical score including expectoration cough and auscultation findings showed that 28% of the patients in group F were symptom-free on day 11 compared with 0% in group P (p=0.04). On day 30, the two groups were comparable.

CONCLUSION

In this preliminary study of patients with COPD presenting a bronchial superinfection, there was a significant improvement in lung auscultation and in the composite clinical score in patients given fenspiride. Fenspiride was thus found to provide an early clinical benefit.

[Neurological examination and brain computed tomography in the initial staging of non-small-cell lung cancer: a prospective study]

Brain metastases occur in 17 to 40% of lung carcinoma and 30 to 60% of brain metastases originate from a lung carcinoma. Brain metastasis directly influences prognosis and treatment of lung cancer. The aim of this study was to prospectively compare the findings of the neurological examination performed by a neurologist and results of double dose delayed computed tomography (CT DDD). The neurologist and radiologist were blinded to each other's results. Patients included had non-small-cell lung cancer (NSCLC) and were neurologically asymptomatic with no other cancer. From November 1993 to May 1996, 135 patients were included (126 men and 9 women). Ninety neurological examinations were normal, 34 suggested brain metastasis and 11 were abnormal but did not suggest brain metastasis. One hundred thirteen CTs were normal, 1 showed a brain metastasis and 11 were abnormal but did not evidence brain metastasis. The sensitivity, specificity, positive predictive value and negative predictive value of the neurological examination were 73, 79, 23 and 97% respectively. The presence of brain metastasis was directly related to tumor stage but not to age or histology. We suggest that brain CT DDD should be performed in stage IIIA, IIIB, IV whereas in stage I or II, the neurological examination is sufficient. However, a larger number of patients would be required to confirm these findings.

The status of iodine nutrition in newborn infants, schoolchildren, adolescents and adults in former East Germany

In the former East Germany (GDR) like in the former West Germany (FRG) iodine deficiency and endemic goiter have been described since more than 2 decades. After a program of salt iodization which was started in East Germany in 1985 the urinary iodine excretion of the population increased significantly. The thyroid gland of the newborn is much more sensible to changes of the iodine supply than the thyroid of older children. A total of 1732 subjects was enrolled in the study. After the implementation of the mandatory salt iodization the goiter prevalence in newborns decreased markedly to less than 1%. After the reunification of Germany in 1990 the mandatory prophylaxis was stopped and the urinary iodine excretion in newborns, school-children, adolescents and adults diminished markedly. So in newborns the renal iodine excretion decreased to 2.82 micrograms I/dl in 1992. Since 1994 a reasonable improvement of the iodine supply is observed in the region of Leipzig. In school-children, adolescents and adults the mean value of the urinary iodine excretion is now above 10.0 micrograms I/dl. This value may be considered as an indicator for a normal iodine supply. In a small cohort (n = 28) of newborns infants we found a renal iodine excretion of 18.74 micrograms/dl in 1997. That value also means a significant increase since 1992 and a normal iodine supply in the fetal period. The present results from the region of Leipzig/Saxonia are not representative for the whole of East Germany. To provide an optimal iodine nutrition the use of iodized salt for food manufacturing must be significantly increased.

Small thyroid volumes and normal iodine excretion in Berlin schoolchildren indicate full normalization of iodine supply

Iodine deficiency is the major cause of an increase in thyroid gland volume in infants and children. In this field study we monitored the iodine supply and its effect on the thyroid gland volume in prepubertal and pubertal children in the eastern and western parts of the city of Berlin, so far considered as an area with borderline iodine deficiency. The thyroid gland volume was determined by ultrasound in 1080 (f = 552, m = 528) children aged 3-15 years, and was correlated to age, body-surface area and iodine excretion, which was measured in a first-morning spot urine. The mean iodine concentration was 115.8 micrograms iodine/g creatinine (12.2 micrograms iodine/dl urine), with no significant differences between eastern parts with 114.5 micrograms iodine/g creatinine (12.3 micrograms iodine/dl urine) vs 116.7 micrograms iodine/g creatinine (12.0 micrograms iodine/dl urine) in the western parts of the city. This good iodine supply of the children was surprising compared to former studies in children and adults. Moreover this normalization of the iodine excretion was reflected by smaller thyroid gland volumes in the children. The volume was found to increase with age and was 2.4 +/- 1.1 ml in prepubertal (Prader and Largo: f < or = 10.9 ys, m < or = 11.5 ys) children, compared to 4.3 +/- 1.7 ml in pubertal children. The goiter prevalence, calculated on this data was below 5%. Among all children there were only 11 (aged 8-13 ys) with abnormal findings of the thyroid gland on ultrasound: 6 with small nodules, 1 girl with a thyroid-cyst, 2 girls had an inhomogenous echo structure and 2 girls presented with a hemithyroidea. This study shows that the iodine supply of the children in Berlin has improved, resulting in smaller sized thyroid glands, compared to those which have been previously published for Germany (Müller-Leisse 1988; Klingmüller, 1991; Menken, 1992), but they correspond well to volumes described in countries with sufficient iodine supply.

Earliest prevention of endemic goiter by iodine supplementation during pregnancy

During pregnancy complex changes of maternal thyroid function occur and they are influenced by the maternal iodine supply. It has been demonstrated that with decreasing iodine supply maternal goiter and hypothyroxinemia as well as fetal and neonatal hypothyroidism become more prevalent. Therefore iodine supplementation during pregnancy is now strongly recommended also in areas of moderate iodine deficiency. To monitor the success of iodine supplementation and its theoretical risk of increasing the frequency of thyroid autoantibodies, we have investigated the thyroid volume, thyroid function, urinary iodine excretion and antibodies to thyroid peroxidase at 10-12 weeks of gestation and postpartum in 38 mothers receiving 300 micrograms potassium iodide/day and in 70 mothers without iodine supplementation. In all of their newborns thyroid volume was determined by ultrasound. The thyrotropin (TSH) levels and antibodies to thyroid peroxidase (TPO-ab) in the neonates were measured in dried blood spots on filter paper from their newborn screening. Urinary iodine excretion was increased significantly after iodine supplementation in mothers (p < 0.001) and their newborns (< 0.05). No hypo- or hyperthyroidism was observed in the mothers or newborns. Interestingly, no difference of maternal thyroid volumes was observed between the two groups after pregnancy, but the volumes of the thyroid glands in newborns of mothers who received iodine were significantly (p < 0.004) lower (0.7 +/- 0.4 ml) than in the control group (1.5 +/- 1.1 ml). There was no change in the frequency of TPO-ab in either group after pregnancy. In four mothers transplacental passage of these antibodies was documented by positive measurement in the blood sample of the newborn. This study documents that iodine supplementation during pregnancy in an area of moderate iodine deficiency results in a lower size of neonatal thyroid volume and that this supplementation was not accompanied by an increase in the frequency of TPO-ab.

Inspiratory muscle strength and endurance in steroid-dependent asthma

The adverse effect of long-term steroid treatment on respiratory muscle function remains controversial. We evaluated inspiratory muscle strength and endurance in steroid-dependent asthmatics in comparison with other asthmatics or with patients with chronic obstructive pulmonary disease exhibiting a comparable level of lung hyperinflation. Inspiratory muscle function was assessed by maximal inspiratory pressure (Pimax) and by an incremental inspiratory threshold loading test in 19 patients who had had steroid-dependent asthma (SDA) requiring a mean daily dose of 20.7 +/- 0.8 mg prednisone for 5 +/- 1.4 yr. They were compared with 16 healthy control subjects, 30 patients with COPD, and 16 patients with non-steroid-dependent asthma (NSDA). Pimax as percentage of predicted values (%Pimax) was not significantly different in patients with SDA (77 +/- 5%) or NSDA (83 +/- 6%) than in control subjects (93 +/- 4%). In contrast, %Pimax was lower in patients with COPD (59 +/- 4.4%) than in those with SDA or NSDA (p < 0.05) or the control subjects (p < 0.0001). A significant correlation was found between %Pimax and hyperinflation assessed by the FRC/TLC ratio (r = 0.42; p < 0.001). Inspiratory endurance, defined as the ratio of maximal peak inspiratory pressure sustained for 2 min to individual Pimax (Plim2/Pimax), was significantly lower in the SDA (43 +/- 3%; p < 0.0001), NSDA (65 +/- 4%; p = 0.01), and COPD (55 +/- 3%; p < 0.0001) groups than in the control group (76 +/- 2%). Plim2/Pimax was also lower in patients with SDA than in those with COPD (p = 0.0073) or NSDA (p < 0.0001). Hyperinflation plays a major role in inspiratory muscle dysfunction associated with obstructive lung disorders, but the finding of a significantly decreased endurance in patients with SDA when compared with patients with COPD, despite a lower level of hyperinflation in the former group, points to a deleterious effect of long-term corticosteroid treatment on inspiratory muscle function in asthmatics.

High-dose and low-dose systemic corticosteroids are equally efficient in acute severe asthma

The optimal amount of systemic corticosteroids to be used in acute severe asthma remains an unresolved issue. In this double-blind, randomized study we compared two doses of methylprednisolone (1 vs 6 mg.kg-1 q.d.) in asthmatics presenting with an acute severe asthma attack, unresponsive to an intensive beta 2-agonist regimen administered during a run-in period. Concurrent therapy, including oxygen, inhaled and intravenous salbutamol, and aminophylline was strictly standardized. The response was assessed by serial bedside spirometry. The primary outcome measurement was forced expiratory volume in one second (FEV1) (expressed as percentage of predicted values) at 24 and 44 h. The trial was designed in order to achieve a statistical power of 90%. Twenty three patients were included in the low-dose group and 24 in the high-dose group. Both groups were comparable in terms of demographic profiles, history of asthma, and severity of the current attack. Improvement in pulmonary function was similar in both groups. At 44 h, the mean (+/- SD) FEV1 values were 53 +/- 22 and 45 +/- 14% in the low and in the high-dose group respectively (NS). We conclude that high dose systemic corticosteroids offer no further benefit over low-doses in the treatment of severe acute asthma.

Gender affects audiometric shape in presbyacusis

A review of large-scale surveys of hearing over the past 50 years reveals a "gender-reversal" phenomenon in the average audiograms of the elderly. Above 1 kHz males show greater average loss than females, but below 1 kHz females show greater average loss than males. The effect increases with both age and degree of hearing loss. The difference is present whether or not the elderly persons complain of a hearing problem and remains after persons with a history of noise exposure are excluded from the analysis. A possible explanation, based on the greater likelihood of cardiovascular disease in the elderly female, is considered.

Stimulation of nitrogen and whole-body protein metabolism in growth hormone-deficient children by recombinant human growth hormone: relationship to growth

The effect of a mammalian-cell-derived recombinant human growth hormone (rhGH) on nitrogen and whole-body protein metabolism was assessed in 12 children with complete growth hormone (GH) deficiency. All the patients received single oral doses of 15N-glycine (95 atom % 15N), 20 mg/kg body weight, prior to and following 7 days of treatment with rhGH, 1.7 IU/m2 body surface area (BSA) per day, administered subcutaneously. Prior to rhGH, mean urinary 15N-nitrogen excretion was 42.8 +/- 8% of the administered dose, which fell significantly to 22.8 +/- 7% during rhGH administration (p < 0.0001). Stimulation of protein metabolism by rhGH resulted in a protein net gain rate of 1.1 +/- 0.4 g/kg/day, which was significantly higher than the 0.6 +/- 0.5 g/kg/day rate seen prior to rhGH (p < 0.001). In patients subsequently placed on daily subcutaneous injections of rhGH 1.7 IU/m2 BSA, mean height velocity standard deviation score (HV SDS) for chronological age significantly increased from -3.8 +/- 2.6 to +8.5 +/- 3.1 and +3.3 +/- 2.2, during the 1st and 2nd years of treatment, respectively. However, there was no correlation between the long-term response to rhGH treatment and the short-term changes in nitrogen or protein metabolism in GH-deficient children.

[Hemoglobin A1 in hypoglycemias in childhood]

The average HbA1 concentrations of 20 patients with hypoglycaemic diseases were not significantly different from metabolically healthy controls. There was also no correlation between the HbA1 and the blood glucose levels of these patients. Remarkably, two patients which responded to therapy with an increase of blood glucose showed also an increase of HbA1.

Pediatric cancer mortality rates in New Jersey and the United States

The authors studied pediatric mortality rates for four major categories of neoplasms for the years 1950 to 1985. This report indicates differences in trends between the rates of the New Jersey population and of the United States population, for males and females, and whites and nonwhites.

Problems in the clinical measurement of acoustic reflex latency

Two problems in the clinical measurement of acoustic reflex latency are discussed. First, the rise characteristic of the reflex is affected by the frequency of the eliciting signal. Due to the closed ipsilateral feedback loop system the reflex rises more rapidly at low frequencies than at high frequencies. Second, the temporal characteristic of the measurement apparatus may influence the apparent morphology of the reflex at low frequencies.