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Rationale: Ventilator-associated pneumonia (VAP) causes substantial morbidity and mortality. The influence of subglottic secretion drainage (SSD) in preventing VAP remains controversial. Objectives: To determine whether SSD reduces the overall incidence of microbiologically confirmed VAP. Methods: Randomized controlled clinical trial conducted at four French centers. A total of 333 adult patients intubated with a tracheal tube allowing drainage of subglottic secretions and expected to require mechanical ventilation for >=48 hours was included. Patients were randomly assigned to undergo intermittent SSD (n = 169) or not (n = 164). Measurements and Main Results: Primary outcome was the overall incidence of VAP based on quantitative culture of distal pulmonary samplings performed after each clinical suspicion. Other outcomes included incidence of early- and late-onset VAP, duration of mechanical ventilation, and hospital mortality. Microbiologically confirmed VAP occurred in 67 patients, 25 of 169 (14.8%) in the SSD group and 42 of 164 (25.6%) in the control group (P = 0.02), yielding a relative risk reduction of 42.2% (95% confidential interval, 10.4-63.1%). Using the Day 5 threshold, the beneficial effect of SSD in reducing VAP was observed in both early-onset VAP (2 of 169 [1.2%] patients undergoing SSD vs. 10 of 164 [6.1%] control patients; P = 0.02) and late-onset VAP (23 of 126 [18.6%] patients undergoing SSD vs. 32 of 97 [33.0%] control patients; P = 0.01). VAP was clinically suspected at least once in 51 of 169 (30.2%) patients undergoing SSD and 60 of 164 (36.6%) control patients (P = 0.25). No significant between-group differences were observed in duration of mechanical ventilation and hospital mortality. Conclusions: Subglottic secretion drainage during mechanical ventilation results in a significant reduction in VAP, including late-onset VAP. Clinical trial registered with www.clinicaltrials.gov (NCT00219661). [ABSTRACT FROM AUTHOR]

Background: A written action plan (WAP) for managing asthma exacerbations is recommended., Objective: We aimed to compare the effect on unscheduled medical contacts (UMCs) of a digital action plan (DAP) accessed via a smartphone web app combined with a WAP on paper versus that of the same WAP alone., Methods: This randomized, unblinded, multicenter (offline recruitment in private offices and public hospitals), and parallel-group trial included children (aged 6-12 years) or adults (aged 18-60 years) with asthma who had experienced at least 1 severe exacerbation in the previous year. They were randomized to a WAP or DAP+WAP group in a 1:1 ratio. The DAP (fully automated) provided treatment advice according to the severity and previous pharmacotherapy of the exacerbation. The DAP was an algorithm that recorded 3 to 9 clinical descriptors. In the app, the participant first assessed the severity of their current symptoms on a 10-point scale and then entered the symptom descriptors. Before the trial, the wordings and ordering of these descriptors were validated by 50 parents of children with asthma and 50 adults with asthma; the app was not modified during the trial. Participants were interviewed at 3, 6, 9, and 12 months to record exacerbations, UMCs, and WAP and DAP use, including the subjective evaluation (availability and usefulness) of the action plans, by a research nurse., Results: Overall, 280 participants were randomized, of whom 33 (11.8%) were excluded because of the absence of follow-up data after randomization, leaving 247 (88.2%) participants (children: n=93, 37.7%; adults: n=154, 62.3%). The WAP group had 49.8% (123/247) of participants (children: n=45, 36.6%; mean age 8.3, SD 2.0 years; adults: n=78, 63.4%; mean age 36.3, SD 12.7 years), and the DAP+WAP group had 50.2% (124/247) of participants (children: n=48, 38.7%; mean age 9.0, SD 1.9 years; adults: n=76, 61.3%; mean age 34.5, SD 11.3 years). Overall, the annual severe exacerbation rate was 0.53 and not different between the 2 groups of participants. The mean number of UMCs per year was 0.31 (SD 0.62) in the WAP group and 0.37 (SD 0.82) in the DAP+WAP group (mean difference 0.06, 95% CI -0.12 to 0.24; P=.82). Use per patient with at least 1 moderate or severe exacerbation was higher for the WAP (33/65, 51% vs 15/63, 24% for the DAP; P=.002). Thus, participants were more likely to use the WAP than the DAP despite the nonsignificant difference between the action plans in the subjective evaluation. Median symptom severity of the self-evaluated exacerbation was 4 out of 10 and not significantly different from the symptom severity assessed by the app., Conclusions: The DAP was used less often than the WAP and did not decrease the number of UMCs compared with the WAP alone., Trial Registration: ClinicalTrials.gov NCT02869958; https://clinicaltrials.gov/ct2/show/NCT02869958., (©Nicole Beydon, Camille Taillé, Harriet Corvol, Judith Valcke, Jean-Jacques Portal, Laurent Plantier, Gilles Mangiapan, Caroline Perisson, Guillaume Aubertin, Alice Hadchouel, Guillaume Briend, Laurent Guilleminault, Catherine Neukirch, Pierrick Cros, Corinne Appere de Vecchi, Bruno Mahut, Eric Vicaut, Christophe Delclaux. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 29.06.2023.)

Background: The decision-making on antiplatelet drug withdrawal or continuation before performing a pleural procedure is based on the balance between the risk of bleeding associated with the antiplatelet therapy and the risk of arterial thrombosis due to its interruption. Knowledge on antiplatelet therapy-associated risk of bleeding after pleural procedures is lacking., Research Question: Is the risk of bleeding associated with antiplatelet drugs increased in patients undergoing pleural procedures?, Study Design and Methods: We conducted a French multicenter cohort study in 19 centers. The main outcome was the occurrence of bleeding, defined as hematoma, hemoptysis, or hemothorax, during the 24 h following a pleural procedure. Serious bleeding events were defined as bleeding requiring blood transfusion, respiratory support, endotracheal intubation, embolization, or surgery, or as death., Results: A total of 1,124 patients was included (men, 66%; median age, 62.6 ± 27.7 years), of whom 182 were receiving antiplatelet therapy and 942 were not. Fifteen patients experienced a bleeding event, including eight serious bleeding events. The 24-h incidence of bleeding was 3.23% (95% CI, 1.08%-5.91%) in the antiplatelet group and 0.96% (95% CI, 0.43%-1.60%) in the control group. The occurrence of bleeding events was significantly associated with antiplatelet therapy in univariate analysis (OR, 3.44; 95% CI, 1.14-9.66; P = .021) and multivariate analysis (OR, 4.13; 95% CI, 1.01-17.03; P = .044) after adjusting for demographic data and the main risk factors for bleeding. Likewise, antiplatelet therapy was significantly associated with serious bleeding in univariate analysis (OR, 8.61; 95% CI, 2.09-42.3; P = .003) and multivariate analysis (OR, 7.27; 95% CI, 1.18-56.1; P = .032) after adjusting for the number of risk factors for bleeding., Interpretation: Antiplatelet therapy was associated with an increased risk of post-pleural procedure bleeding and serious bleeding. Future guidelines should take into account these results for patient safety., (Copyright © 2020 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Ustekinumab (Stelara(®)) is efficacious in severe cutaneous psoriasis. Numerous adverse effects have been reported but treatment withdrawal is rarely required. The present case concerns eosinophilic pneumonia treated with ustekinumab., Patient and Methods: A 71-year-old male patient presented severe plaque psoriasis with an indication for biotherapy. Pre-treatment investigations showed a highly positive interferon gamma test without any anomalies in the CT chest scan. The patient was treated with anti-tuberculosis agents and ustekinumab was then introduced. Seven months later, the patient presented a cough resistant to antibiotics. A CT scan showed frosted-glass-like shadows and mediastinal lymphadenopathy. The bronchoalveolar lavage fluid contained 800elements/mm(3), of which 34% eosinophils. There were 1480G/L eosinophils in peripheral blood. There was nothing evocative of infectious or tumoral causes, and a diagnosis of eosinophilic pneumonia was made. Ustekinumab was stopped and 10weeks later, the patient's condition worsened; after further examination, systemic corticosteroids were given, beginning with prednisone 1mg/kg. Seven months later, the patient was symptom-free, without eosinophilia, and his chest scan was normal. The corticosteroids were stopped., Discussion: Eosinophilic pneumonia includes various disorders characterized by eosinophilic infiltration of lung tissue, with or without the presence of eosinophils in peripheral blood. Eosinophilic pneumonia can be caused by many different drugs. Diagnosis is difficult because clinical and radiological abnormalities may develop at different times after treatment initiation and they are non-specific. A favourable outcome may occur spontaneously on treatment withdrawal or a short course of corticosteroid therapy may be needed. A case of eosinophilic pneumonia under ustekinumab has already been reported, supporting the causal involvement of this drug in our patient. Eosinophils in peripheral blood have also been reported with anti-TNF-alpha. In conclusion, where a patient on biologic treatment for psoriasis presents persistent cough, once infectious disease has been ruled out, eosinophilic pneumonia should be considered., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Introduction: Takotsubo cardiomyopathy can complicate several conditions including neurological emergencies. A few recurrent cases associated with seizures have been reported, but none of the patients had status epilepticus. The pathophysiology of takotsubo syndrome, although debated, may involve stunning of the myocardium by a catecholamine storm triggered by stress. Patients with epilepsy may be at increased risk for takotsubo syndrome, which may occur repeatedly., Methods: We report on a postmenopausal woman with symptomatic epilepsy who experienced recurrent takotsubo cardiomyopathy triggered by convulsive status epilepticus. Brief seizures were not associated with takotsubo syndrome. The relevant literature was reviewed., Results: Over a 1-year period, she experienced two episodes of convulsive status epilepticus with complete neurological recovery after treatment. Echocardiography showed latero-septo-apical hypokinesia and apical ballooning. The cardiac abnormalities resolved fully and she recovered her baseline level of self-sufficiency. During the same period, she experienced several brief seizures, with no cardiac manifestations., Conclusion: The occurrence of takotsubo cardiomyopathy in association with convulsive status epilepticus, but not with brief seizures, supports neurogenically mediated myocardial stunning related to direct toxicity of endogenous catecholamines. Neuro-intensivists must be aware of this potentially fatal but fully reversible cardiac complication, which may be among the causes of death in patients with status epilepticus.

A young patient presented with a small bowel infarction with pneumatosis intestinalis in the early course of life-threatening severe acute asthma. Low cardiac output with severe congestive right heart failure combined with the use of high doses of epinephrine to reverse the near-fatal bronchospasm probably contributed to this previously unreported complication. The presence of gas collections in the submucosal space was possibly the consequence of diffuse small bowel mucosal disruption. Early recognition of this unusual complication is of major importance to ensure appropriate therapeutic management.

The TNM classification was adopted as a means of evaluating bronchopulmonary cancer and has been used since-1996. It is an international classification and has been recognised since 1986 [5]. After a brief review of the former TNM classification the different features of the newly defined classification are specified concerning particularly the definition of T3 and T4 tumours, some malignant T4 pleural effusions and disease of the lymph nodes (N2, N3) as well as a final classification with 5 stages. Some controversy has appeared over the daily use of this classification and are discussed in the recent literature. They are related to: the re-grouping in Stage 1 of patients with different survivals (T1N0M0 and T2N0M0), the resectability of certain T4 tumours involving the carina, the adverse prognosis of invasion of the visceral pleural and above all the definition of N2 mediastinal node disease which groups together patients with a very heterogeneous prognosis. In 1993, a supplemental was published by the International Union Against Cancer (UICC) entitled "Commentary on the Uniform use of TNM". The commentaries referred to the bronchopulmonary cancers that have been re-grouped and included point by point discussion of the TNM classification. Very recently, Moutain has published some revisions of the TNM classification which will be discussed here.

Background: The objective of this prospective study was to assess in 96 patients with resected nonsmall cell lung carcinoma (NSCLC) the prevalence of both blood and lymphatic vessel invasion (BVI and LVI) according to stage, as well as their prognostic value for disease free and overall survival., Methods: BVI and LVI were evaluated by hematoxylin and eosin stains on surgical specimens after resection. Associations among variables were tested by Fisher's exact test or the chi-square test; prognostic values on time-failure data were analyzed by the log rank test and the multivariate Cox model., Results: BVI was present in 52% of NSCLC cases and LVI in 59%. Venous but not arterial vascular invasion correlated with the T factor and pTNM, whereas LVI correlated with the N factor and pTNM. In univariate analysis, LVI but not BVI was associated with a short disease free interval (P = 0.0007) and poor survival (P = 0.0001). The estimated relative risk of death in patients with LVI was 3.2 compared with patients without LVI. In multivariate analysis, LVI and pTNM were additional predictors for poor disease free and overall survival. In this series, BVI had no prognostic value., Conclusions: The prevalence of BVI and LVI appeared high in patients with NSCLC, especially those with advanced pTNM stages. LVI was predictive of poor outcome, both time to recurrence and death.