Post-COVID central hypersomnia, a treatable trait in long COVID: 4 case reports.

Introduction: Fatigue is the most commonly reported post-COVID symptom. A minority of patients also report excessive daytime sleepiness, which could be a target for treatment. Methods: Among 530 patients with a post-COVID condition, those with excessive daytime sleepiness were systematically assessed for objective central hypersomnia, with exclusion of all cases not clearly attributable to SARS-CoV-2 infection. Results: Four cases of post-COVID central hypersomnia were identified, three fulfilling the criteria of the 3rd International Classification of Sleep Disorders for idiopathic hypersomnia, and one for type II narcolepsy. We report here their clinical history, sleep examination data and treatment, with a favorable response to methylphenidate in three cases and spontaneous resolution in one case. Conclusion: We highlight the importance of identifying cases of post-COVID central hypersomnia, as it may be a treatable trait of a post-COVID condition.

Dysfunctional breathing symptoms, functional impact and quality of life in patients with long COVID-19: a prospective case series.

BACKGROUND: Dysfunctional breathing is increasingly recognised after SARS-CoV-2 infection, but the associated symptoms, functional impact and quality of life have not been systematically studied. METHODS: This study describes a prospective case series of 48 patients with dysfunctional breathing based on compatible symptoms and an abnormal breathing pattern during cardiopulmonary exercise testing. Patients with underlying disease that could explain these symptoms were excluded. Median time from COVID-19 to evaluation was 212 (IQR 121) days. Self-administered questionnaires, including the Nijmegen questionnaire, Short-Form (36) Health Survey (SF-36), Hospital Anxiety and Depression Scale, modified Medical Research Council scale, post-COVID-19 Functional Scale, and specific long COVID symptoms, were the outcome measures. RESULTS: On average, mean V'O2 was preserved. Pulmonary function tests were within limits of normality. Hyperventilation, periodic deep sighs/erratic breathing and mixed types of dysfunctional breathing were diagnosed in 20.8%, 47.1% and 33.3% of patients, respectively. After dyspnoea, the five most frequent symptoms using the Nijmegen scale with a cut-off of ≥3 were faster/deeper breathing (75.6%), palpitations (63.8%), sighs (48.7%), unable to breathe deeply (46.3%) and yawning (46.2%). Median Nijmegen and Hospital Anxiety and Depression Scale scores were 28 (IQR 20) and 16.5 (IQR 11), respectively. SF-36 scores were lower than the reference value. CONCLUSIONS: Long COVID patients with dysfunctional breathing have a high burden of symptoms, functional impact and a low quality of life, despite no or negligible organic damage.

Underlying lung disease and exposure to terrestrial moderate and high altitude: personalised risk assessment.

Once reserved for the fittest, worldwide altitude travel has become increasingly accessible for ageing and less fit people. As a result, more and more individuals with varying degrees of respiratory conditions wish to travel to altitude destinations. Exposure to a hypobaric hypoxic environment at altitude challenges the human body and leads to a series of physiological adaptive mechanisms. These changes, as well as general altitude related risks have been well described in healthy individuals. However, limited data are available on the risks faced by patients with pre-existing lung disease. A comprehensive literature search was conducted. First, we aimed in this review to evaluate health risks of moderate and high terrestrial altitude travel by patients with pre-existing lung disease, including chronic obstructive pulmonary disease, sleep apnoea syndrome, asthma, bullous or cystic lung disease, pulmonary hypertension and interstitial lung disease. Second, we seek to summarise for each underlying lung disease, a personalized pre-travel assessment as well as measures to prevent, monitor and mitigate worsening of underlying respiratory disease during travel.

Dysfunctional breathing diagnosed by cardiopulmonary exercise testing in 'long COVID' patients with persistent dyspnoea.

BACKGROUND: 'Long COVID'-associated dyspnoea may persist for months after SARS-CoV-2 infection. Among the causes of persistent dyspnoea, dysfunctional breathing (DB), defined as an erratic or inappropriate ventilation at rest or exercise, has been observed, but little is known about its occurrence and pathophysiology among individuals with 'long COVID'. We aimed to describe the occurrence and identify clinical predictors of DB among patients following SARS-CoV-2 infection. METHODS: Cardiopulmonary exercise testing (CPET) was performed in 51 SARS-CoV-2 patients (median age, 64 years (IQR, 15)); male, 66.7%) living with 'long COVID' and persistent dyspnoea. CPET was classified into three dominant patterns: respiratory limitation with gas exchange abnormalities (RL); normal CPET or O2 delivery/utilisation impairment (D); and DB. Non-parametric and χ2 tests were applied to analyse the association between CPET dominant patterns and demographics, pulmonary function tests and SARS-CoV-2 severity. RESULTS: Among 51 patients, DB mostly without hyperventilation was found in 29.4% (n=15), RL in 54.9% (n=28) and D in 15.7% (n=8). When compared with RL individuals, patients with DB were younger, had significantly less severe initial infection, a better transfer capacity for carbon monoxide (median 85% (IQR, 28)), higher oxygen consumption (22.9 mL/min/kg (IQR, 5.5)), a better ventilatory efficiency slope (31.6 (IQR, 12.8)), and a higher SpO2 (95% (IQR, 3)). CONCLUSIONS: Our findings suggest that DB without hyperventilation could be an important pathophysiological mechanism of disabling dyspnoea in younger outpatients following SARS-CoV-2 infection, which appears to be a feature of COVID-19 not described in other viral diseases.

[Diagnostic and therapeutic management of medium and long-term sequelae of SARS-CoV-2 infection]. / Prise en charge diagnostique et thérapeutique des séquelles à moyen et long termes liées à l'infection à SARS-CoV-2.

Somatic or psychological sequelae after a SARS-CoV-2 infection are common. Specific organ damage should be investigated to explain persistent symptomatology and propose a treatment. A specialized consultation for the follow-up of patients after a SARS-CoV-2 infection is useful to clinically assess the patient, organized further investigations, offer treatment options and refer the patient to other specialists or to a rehabilitation program. Such a consultation is also intended to reduce the public health burden of long Covid and to collect data that can improve our management in the future.

Les séquelles somatiques ou psychologiques après une infection à SARS-CoV-2 sont fréquentes. Des atteintes d'organes spécifiques doivent être recherchées pour expliquer une symptomatologie persistante et proposer un traitement. Une consultation spécialisée pour le suivi des patients après une infection à SARS-CoV-2 est utile pour évaluer cliniquement le patient, organiser les examens complémentaires, offrir des options de traitements et orienter le patient vers d'autres spécialistes ou un programme de réhabilitation. Une telle consultation a également pour objectif de diminuer le fardeau du Covid long sur la santé publique et de collecter les données qui pourront améliorer notre prise en charge dans le futur.

Utility of Rapid On-Site Cytologic Evaluation during Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in Malignant and Nonmalignant Disease.

BACKGROUND: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an accurate procedure to sample mediastinal tissue. Rapid on-site cytologic evaluation (ROSE) has been advocated to improve the performance of this procedure, but its benefit remains controversial. Our objective is to assess the utility of ROSE for EBUS-TBNA diagnostic accuracy among unselected patients. METHODS: We prospectively collected data from all consecutive EBUS-TBNA procedures performed between 2008 and 2014. ROSE was introduced since 2011 in our daily practice. The accuracy of EBUS-TBNA with and without ROSE was compared in a univariate and multivariate model accounting for confounding factors. The impact of ROSE was then analyzed according to the etiology and size of the lesions. RESULTS: Among 348 EBUS-TBNA procedures analyzed, 213 were performed with ROSE. The overall accuracy tended to be better with ROSE than without (90.6 vs. 84.4%; p = 0.082). After adjustment in a multivariate model, the benefit of ROSE still did not reach statistical significance (adjusted odds ratio 1.86; 95% confidence interval 0.79-4.41). Similar results were obtained in subgroups of patients with malignant disease or sarcoidosis. The size of the lesion did not influence the impact of ROSE on accuracy. CONCLUSIONS: ROSE was associated with a moderate increase in the accuracy of EBUS-TBNA, but the difference was not statistically significant. The same effect of ROSE was observed in malignant and nonmalignant lesions and this effect was not influenced by the lesion's size.

Short-Term Preoperative High-Intensity Interval Training in Patients Awaiting Lung Cancer Surgery: A Randomized Controlled Trial.

INTRODUCTION: Impairment in aerobic fitness is a potential modifiable risk factor for postoperative complications. In this randomized controlled trial, we hypothesized that a high-intensity interval training (HIIT) program enhances cardiorespiratory fitness before lung cancer surgery and therefore reduces the risk of postoperative complications. METHODS: Patients with operable lung cancer were randomly assigned to usual care (UC) (n = 77) or preoperative rehabilitation based on HIIT (Rehab) (n = 74). Maximal cardiopulmonary exercise testing and the 6-minute walk test were performed twice before surgery. The primary outcome measure was a composite of death and in-hospital postoperative complications. RESULTS: The groups were well balanced in terms of patient characteristics. During the preoperative waiting period (median 25 days), the peak oxygen consumption and the 6-minute walking distance increased (median +15%, interquartile range, 25th to 75 percentile [IQR25%-75%, %] = +9% to +22%, p = 0.003 and +15%, IQR25%-75% = +8% to +28%, p < 0.001, respectively) in the Rehab group, whereas peak oxygen consumption declined in the UC group (median -8%, IQR25%-75% = -16% to 0%], p = 0.005). The primary end point did not differ significantly between the two groups: at least one postoperative complication developed in 27 of the 74 patients (35.5%) in the Rehab group and 39 of 77 patients (50.6%) in the UC group (p = 0.080). Notably, the incidence of pulmonary complications was lower in the Rehab compared with in the UC group (23% versus 44%, p = 0.018), owing to a significant reduction in atelectasis (12.2% versus 36.4%, p < 0.001), and this decrease was accompanied by a shorter length of stay in the postanesthesia care unit (median -7 hours, IQR25%-75% = -4 to -10). CONCLUSIONS: In this randomized controlled trial, preoperative HIIT resulted in significant improvement in aerobic performances but failed to reduce early complications after lung cancer resection.

Preoperative Peak Oxygen Uptake in Lung Cancer Subjects With Neoadjuvant Chemotherapy: A Cross-Sectional Study.

BACKGROUND: In non-small-cell lung cancer patients, high peak oxygen uptake (peak V̇O2 ) predicts lower rates of postoperative complications and better long-term survival. Neoadjuvant chemotherapy (NAC) may negatively impact peak V̇O2 . METHODS: Cardiopulmonary exercise testing (CPET) was performed in 34 consecutive stage IIIA/IIIB non-small-cell lung cancer subjects scheduled for elective lung surgery. Using multivariate linear regression adjusted for potential confounders, we compared CPET results in subjects receiving or not receiving NAC (NAC+, n = 19; NAC-, n = 15). RESULTS: Adjusted peak V̇O2 was lower in NAC + compared with NAC- subjects (-5.3 mL/min/kg [95% CI -8.3 to -2.2], P = .01). Likewise, oxygen pulse, maximal work load, and ventilatory threshold were also lower in NAC+ subjects, whereas peak heart rate and breathing reserve were similar. NAC+ subjects presented lower values of diffusion capacity for carbon monoxide (DLCO) (P = .035) and hemoglobin concentrations (P < .001). DLCO was strongly correlated with peak V̇O2 (r(2) = 0.56). Adjustment for DLCO reduced the effect of NAC on peak V̇O2 without suppressing it. CONCLUSIONS: NAC was associated with lower preoperative peak V̇O2 in subjects with non-small-cell lung cancer. This lower aerobic fitness may result from NAC-induced reduction in pulmonary gas exchange or heart toxicity. Since lower fitness is linked to poorer outcome, the decision for NAC may have to be balanced with its possible toxicity.

[Bone tuberculosis: when consider this diagnosis?]. / Tuberculose osseuse: quand faut-il y penser?

The most common presentation of bone tuberculosis (TB) is called spondylodiscitis, or "Pott's disease", which is a difficult diagnosis due to its low prevalence in Switzerland. It should be considered in patients with persistent back pain, who are at high risk, such as migrant population and immunocompromised patients. Diagnosis is based on imaging and the detection of M. tuberculosis in biopsy of affected vertebra orparaspinal abscess, or even if active tuberculosis is proven in any other site. It's essential to initiate appropriate treatment as quickly as possible in order to avoid neurological complications and spinal deformity and to identify cases that will require a surgical therapy.

Risk Assessment of Tuberculosis in Contacts by IFN-γ Release Assays. A Tuberculosis Network European Trials Group Study.

RATIONALE: Latent infection with Mycobacterium tuberculosis is defined by a positive IFN-γ release assay (IGRA) result in the absence of active tuberculosis. Only few, mostly monocentric studies have evaluated the role of IGRAs to predict the development of tuberculosis in recent contacts in low-incidence countries of tuberculosis. OBJECTIVES: To analyze IGRA results and the effect of preventive chemotherapy on tuberculosis progression rates among recent contacts. METHODS: Results from contact investigations at 26 centers in 10 European countries including testing for latent infection with M. tuberculosis by the QuantiFERON-TB Gold In-Tube (QFT) test or the T-SPOT.TB (TSPOT) were prospectively collected and analyzed. MEASUREMENTS AND MAIN RESULTS: Among 5,020 contacts of 1,023 index cases, 25 prevalent secondary cases were identified at screening. Twenty-four incident cases occurred among 4,513 contacts during 12,326 years of cumulative follow-up. In those with a positive IGRA result, tuberculosis incidence was 0.2 (QFT) and 0 (TSPOT) per 100 patient-years when contacts received preventive chemotherapy versus 1.2 (QFT) and 0.8 (TSPOT) per 100 patient-years in those not treated (38 and 37 patients needed to be treated to prevent one case, respectively). Positive and negative predictive values were 1.9% (95% confidence interval [CI], 1.1-3.0) and 99.9% (95% CI, 99.7-100) for the QFT and 0.7% (95% CI, 0.1-2.6) and 99.7% (95% CI, 99.1-99.9) for the TSPOT. CONCLUSIONS: Tuberculosis rarely developed among contacts, and preventive chemotherapy effectively reduced the tuberculosis risk among IGRA-positive contacts. Although the negative predictive value of IGRAs is high, the risk for the development of tuberculosis is poorly predicted by these assays.

[Should cardiopulmonary rehabilitation be provided to patients with lung cancer?]. / Faut-il proposer un réentrainement cardio-pulmonaire aux patients souffrant d'un cancer du poumon?

The exercise capacity has a specific importance in patients with non small cell lung cancer (NSCLC) at all stages of the disease. In the preoperative period for the early stages of the disease, low exercise capacity can be improved and thus allow curative surgery for unfit patients with NSCLC. The body of current literature suggests a beneficial effect of cardiopulmonary rehabilitation on exercise capacity, quality of life and length of hospital stay or rate of post-operative complications. For patients with advanced disease, exercise capacity, which is a predictor of survival, could be maintained at higher level with adapted cardiopulmonary rehabilitation. Ongoing studies will precise the best programs for patients with NSCLC and help to establish guidelines for clinicians.

Adverse effects and adherence to treatment of rifampicin 4 months vs isoniazid 6 months for latent tuberculosis: a retrospective analysis.

AIM OF STUDY: To compare rates of treatment interruption because of side effects and completion rates between subjects treated for latent tuberculosis infection (LTBI) by isoniazid (INH) for 6 months and subjects treated with rifampicin (RIF) for 4 months. METHODS: Retrospective analysis of all patients treated for LTBI by INH (1993-2002) or RIF (2004-2007) based on a database including age, gender, prior liver diseases, alcohol consumption, completion rates, time and cause of interruption and monthly analysis of ASAT and ALAT. RESULTS: 624 subjects were included, 426 treated by INH and 198 by RIF. Gender, origin, history of prior hepatic disease and alcohol excess did not differ between groups. Treatment interruption because of hepatotoxicity was significantly higher in the INH group than in the RIF group (6.1% vs 2.0%; p = 0.03). Completion of treatment was significantly higher in the RIF group compared to the INH group (83% vs 74%; p = 0.02). CONCLUSION: A 4-month RIF treatment was associated with significantly less interruption of treatment because of hepatotoxicity and higher completion rates compared to a 6-month INH regimen. These results support the RIF regimen as an alternative to the presently recommended 9 months of INH in clinical practice.

Laparoscopic training on Thiel human cadavers: a model to teach advanced laparoscopic procedures.

BACKGROUND: Nowadays, the laparoscopic approach represents the gold standard for a wide range of various basic and advanced procedures. To reduce the learning curve in advanced laparoscopic surgery, the search for new teaching tools is of utmost importance. Our experiences with a new teaching tool to train advanced laparoscopic procedures are reported. METHODS: Hands-on training courses in colon, hernia, bariatric and vascular surgery using Thiel human cadavers (THCs) were organised by the Swiss Association of Laparoscopic and Thoracoscopic Surgery (SALTS). The courses were held by consultant surgeons expert in the field of minimal invasive surgery (MIS). At the end of each course, data was collected using a standardised, anonymous questionnaire using a Likert scale (1 = strongly disagree; 2 = disagree; 3 = neither agree nor disagree; 4 = agree; 5 = strongly agree). Data are presented as mean +/- standard deviation (SD), percentages (%) or total number (n), if indicated. RESULTS: From January 2005 to May 2006, six courses (colon = 2; hernia = 2; bariatric = 1; vascular = 1) were organized with a total of 33 participants (31 consultant surgeons; two senior residents). The authenticity of tissue colour, tissue consistency and operative tactility, respectively, were stated for the courses as follows: colon (mean: 4.4/4.2/4.2), hernia (mean: 4.3/4.2/4.0), bariatric (mean: 4.5/4.8/4.3) and vascular (mean: 2.8/2.8/2.6) courses. A high mean overall satisfaction with the courses (colon: 4.0; hernia: 4.2; bariatric: 5.0 and vascular surgery: 4.1) was also observed. All participants of the colon, bariatric, hernia and vascular courses will recommend the courses to other surgeons. CONCLUSION: Training on THCs might be an excellent additional model to teach advanced bariatric, hernia and colon surgery. However, an important issue that remains to be defined is which training model (THC, anesthetized animals, virtual computer training, etc.) is the most appropriate for the curriculum of the skill or procedure that is being trained.