Clinical, biological and radiological features, 4-week outcomes and prognostic factors in COVID-19 elderly inpatients.

OBJECTIVE: To describe clinical, biological, radiological presentation and W4 status in COVID-19 elderly patients. PATIENTS AND METHODS: All patients ≥ 70 years with confirmed SARS-CoV-2 infection and hospitalized in the Infectious Diseases department of the Pitié-Salpêtrière hospital, Paris, France, from March 1st to April 15th 2020 were included. The primary outcome was death four weeks after hospital admission. Data on demographics, clinical features, laboratory tests, CT-scan findings, therapeutic management and complications were collected. RESULTS: All in all, 100 patients were analyzed, including 49 patients ≥ 80 years. Seventy percent had ≥2 comorbidities. Respiratory features were often severe as 48% needed oxygen support upon admission. Twenty-eight out of 43 patients (65%) with a CT-scan had mild to severe parenchymal impairment, and 38/43 (88%) had bilateral impairment. Thirty-two patients presented respiratory distress requiring oxygen support ≥ 6 liters/minute. Twenty-four deaths occurred, including 21 during hospitalization in our unit, 2 among the 8 patients transferred to ICU, and one at home after discharge from hospital, leading to a global mortality rate of 24% at W4. Age, acute renal failure and respiratory distress were associated with mortality at W4. CONCLUSION: A substantial proportion of elderly COVID-19 patients with several comorbidities and severe clinical features survived, a finding that could provide arguments against transferring the most fragile patients to ICU.

Interest of positron-emission tomography and magnetic resonance imaging for radiotherapy planning and control.

Computed tomography (CT) in the treatment position is currently indispensable for planning radiation therapy. Other imaging modalities, such as magnetic resonance imaging (MRI) and positron emission-tomography (PET), can be used to improve the definition of the tumour and/or healthy tissue but also to provide functional data of the target volume. Accurate image registration is essential for treatment planning, so MRI and PET scans should be registered at the planning CT scan. Hybrid PET/MRI scans with a hard plane can be used but pose the problem of the absence of CT scans. Finally, techniques for moving the patient on a rigid air-cushioned table allow PET/CT/MRI scans to be performed in the treatment position while limiting the patient's movements exist. At the same time, the advent of MRI-linear accelerator systems allows to redefine image-guided radiotherapy and to propose treatments with daily recalculation of the dose. The place of PET during treatment remains more confidential and currently only in research and prototype status. The same development of imaging during radiotherapy is underway in proton therapy.

Evaluation of FDG PET combined with cardiac MRI for the diagnosis and therapeutic monitoring of cardiac sarcoidosis.

AIM: To compare combined 2-[18F]-fluoro-2-deoxy-d-glucose (FDG)-positron-emission tomography (PET) and cardiac magnetic resonance imaging (CMR) for the diagnosis and therapy monitoring of cardiac sarcoidosis (CS). MATERIALS AND METHODS: Eighty patients with sarcoidosis and a suspicion of CS who underwent PET and CMR were included retrospectively. PET was undertaken after a low-carbohydrate-high-fat diet in all patients using a combined 16-section PET/computed tomography (CT) camera. PET was considered positive (PET+) in cases of focal or multifocal FDG uptake. CMR was considered positive (CMR+) in cases of subepicardial late gadolinium enhancement (LGE). A subgroup of 50 patients (50/80) was monitored during therapy and classified as responders or non-responders. RESULTS: Eighty-two percent of patients with PET+ (9/11) also had CMR+ imaging, with good spatial agreement (kappa=0,79; 95% confidence interval [CI]: 0.65-0.94). Twenty-seven percent (22/80) had residual physiological FDG uptake, with a standardised uptake value (SUV) not significantly different compared to the SUV from pathological uptake (6.4 versus 6 respectively, p=0,92). The clinical response was more frequent in patients with baseline PET+ compared to baseline PET- (80% versus 45%, p=0.07). PET findings improved in all cases under treatment (7/7), whereas LGE improved in only 33% of patients (3/9). CONCLUSION: Due to high risk of false-positive or undetermined findings, PET might be performed as a second-line study in cases of LGE, to assess inflammatory load. In addition, PET seems suitable to predict and assess response under therapy.

[Cardiac sarcoidosis: Diagnosis and therapeutic challenges]. / Sarcoïdose cardiaque : avancées diagnostiques et thérapeutiques.

Sarcoidosis is a granulomatous disorder of unknown cause characterized by non-caseating granuloma in young adults. Cardiac involvement is rare and range from 2 to 75% depending on diagnostic criteria. Cardiac involvement in sarcoidosis may be asymptomatic or may manifest as rhythm/conduction troubles or congestive heart failure. The diagnosis and treatment of cardiac sarcoidosis may be challenging. However, advances have come in recent years from the use of cardiac MRI and 18FDG-TEP scanner, as well as from the stratification of the risk of ventricular tachycardia/fibrillation. Due to the rarity of the disease, there is no reliable prospective large study to guide therapeutic strategy for cardiac sarcoidosis. Corticosteroids are probably efficacious, in particular in case of atrio-ventricular block or moderate heart failure. Immunosuppressive drugs have not been largely studied but methotrexate could be helpful. In refractory forms, TNF-α antagonists have been used with success.

[Limitations of active therapeutic and palliative care in chronic respiratory disease]. / Intensité des soins lors des exacerbations et des complications des pathologies respiratoires chroniques.

The issue of intensive and palliative care in patients with chronic disease frequently arises. This review aims to describe the prognostic factors of chronic respiratory diseases in stable and in acute situations in order to improve the management of these complex situations. The various laws on patients' rights provide a legal framework and define the concept of unreasonable obstinacy. For patients with chronic obstructive pulmonary disease, the most robust decision factors are good knowledge of the respiratory disease, the comorbidities, the history of previous exacerbations and patient preferences. In the case of idiopathic pulmonary fibrosis, it is necessary to know if there is a prospect of transplantation and to assess the reversibility of the respiratory distress. In the case of amyotrophic lateral sclerosis, treatment decisions depend on the presence of advance directives about the use of intubation and tracheostomy. For lung cancer patients, general condition, cancer history and the tumor treatment plan are important factors. A multidisciplinary discussion that takes into account the patient's medical history, wishes and the current state of knowledge permits the taking of a coherent decision.

FDG-PET/CT in the prediction of pulmonary function improvement in nonspecific interstitial pneumonia. A Pilot Study.

PURPOSE: Our study aimed to analyse the characteristics of nonspecific interstitial pneumonia (NSIP) using FDG-PET/CT (PET) and to evaluate its ability to predict the therapeutic response. PROCEDURES: Eighteen NSIP patients were included. Maximum standardized uptake value (SUVmax), FDG uptake extent (in percentage of lung volume), high resolution CT scan (HRCT) elementary lesions, and HRCT fibrosis score were recorded. The predictive value of the parameters for lung function improvement was evaluated using logistic regression and Receiver Operating Characteristic (ROC) curve analysis (n=13/18). RESULTS: All patients had an increased pulmonary FDG uptake (median SUVmax=3.1 [2-7.6]), with a median extent of 19% [6-67]. Consolidations, ground-glass opacities, honeycombing and reticulations showed uptake in 90%, 89%, 85% and 76%, respectively. FDG uptake extent was associated with improvement of pulmonary function under treatment (increase in forced vital capacity>10%, p=0.03), whereas SUVmax and HRCT fibrosis score were not (p>0.5). For FDG uptake extent, ROC analysis showed an area under the curve at 0.85±0.11 and sensitivity/specificity was 88%/80% for a threshold fixed at 21%. CONCLUSIONS: Increased FDG uptake was observed in all NSIP patients, both in inflammatory and fibrotic HRCT lesions. The quantification of FDG uptake extent might be useful to predict functional improvement under treatment.

[Usefulness of imaging in large vessel vasculitis]. / Place de l'imagerie dans l'évaluation des vascularites de gros vaisseaux.

The imaging is essential for the diagnosis of large vessels arteritis, in order to assess the persistent inflammation of arterial lesions, to evaluate the treatment response and search the vascular complications. In patients with giant cell arteritis (GCA), the aortitis could be suspected in 2 situations: in the presence of general constitutional symptoms or systematic screening of aortitis in patient with confirmed GCA. The frequency of aortitis varies according to the imaging method and could be detected in 40 % of patients with computed tomography and MRI, and approximately in 60 % with FDG-PET/CT. The clinical and prognostic value of systematic detection of aortitis during the GCA remains to be determined. In Takayasu arteritis, imaging is performed to diagnose the large vessels vasculitis, to determine the arterial lesions extension to assess the persistent inflammation of arterial lesions. The persistent vascular inflammation should be suspected in the presence of arterial thickness, of arterial enhancement, a parietal edema and increased arterial FDG uptake (>liver). However, the value of these parameters and the threshold remain to be determined. Thus, the value of FDG-PET/CT and MRI and of parameters used to characterize the persistent arterial inflammation should be further studied.

Diagnostic efficacy of ultrasound-guided core-needle biopsy of peripheral lymph nodes in sarcoidosis.

BACKGROUND: Core-needle biopsy guided by ultrasound can be performed for investigating peripheral lymph node (PLN). The aim of this study was to determine the efficacy of this technique in sarcoidosis. METHODS: Retrospective review of files of all patients in the database of the radiology department of Avicenne university hospital who underwent PLN biopsies guided by ultrasound from January 2008 to June 2011 (n=292). Cases with either granulomas at histology with the procedure or with a final diagnosis of sarcoidosis were included in the study. RESULTS: The histological specimens were adequate in 282 out of 292 cases (96%) showing non-caseating granulomas in 22 cases (n=20 patients with a final diagnosis of sarcoidosis and n=2 patients with tuberculosis). After reviewing clinical files of the 282 patient, 22 were confirmed to have sarcoidosis, at initial presentation (n=19) or later during flare-up or relapse (n=3) with only 2 patients having no granuloma on PLN biopsy. PLN were palpable in 18 cases and only detected by (18F)FDG-PET/CT showing increased PLN uptake in 4 cases. The sensitivity and specificity of adequate biopsy were 91 and 99% and the positive and negative predictive values were 91 and 99%, respectively. CONCLUSION: Core-needle biopsy guided by ultrasound has a high efficacy for evidencing granulomas in sarcoidosis patients with PLN involvement either clinically palpable or in the presence of (18F)FDG-PET/CT uptake.

FDG-PET/CT findings in systemic mastocytosis: a French multicentre study.

INTRODUCTION: Mastocytosis is a clonal haematological disease characterized by uncontrolled proliferation and the activation of mast cells. The value of FDG-PET/CT (FDG-PET) in mastocytosis has yet to be determined. METHODS: We retrospectively identified patients with an established diagnosis of systemic mastocytosis (SM), according to the WHO criteria, who underwent PET using the French Reference Centre for Mastocytosis database. Semi-quantitative and visual analysis of FDG-PET was performed and compared to the clinico-biological data. RESULTS: Our cohort included 19 adult patients, median age 65 years [range 58-74], including three with smouldering SM (SSM), three with aggressive SM (ASM), 10 with an associated clonal haematological non-mast-cell lineage disease (SM-AHNMD), and three with mast cell sarcoma (MCS). FDG-PET was performed at the time of the SM diagnosis (15/19), to evaluate lymph node (LN) activity (3/19) or the efficacy of therapy (1/19). FDG uptake was observed in the bone marrow (BM) (9/19, 47%), LN (6/19, 32%), spleen (12/19, 63%), or liver (1/19, 5%). No significant FDG uptake was observed in the SSM and ASM patients. A pathological FDG uptake was observed in the BM of 6/10 patients with SM-AHNMD, appearing as diffuse and homogeneous, and in the LN of 5/10 patients. All 3 MCS patients showed intense and multifocal BM pathological uptake, mimicking metastasis. No correlation was found between the FDG-PET findings and serum tryptase levels, BM mast cell infiltration percentage, and CD30 and CD2 expression by mast cells. CONCLUSIONS: FDG uptake does not appear to be a sensitive marker of mast cell activation or proliferation because no significant FDG uptake was observed in most common forms of mastocytosis (notably purely aggressive SM). However, pathological FDG uptake was observed in the SM-AHNMD and in MCS cases, suggesting a role of FDG-PET in their early identification and as a tool of therapeutic assessment in this subgroup of patients.

The ETHICA study (part I): elderly's thoughts about intensive care unit admission for life-sustaining treatments.

PURPOSE: To assess preferences among individuals aged ≥80 years for a future hypothetical critical illness requiring life-sustaining treatments. METHODS: Observational cohort study of consecutive community-dwelling elderly individuals previously hospitalised in medical or surgical wards and of volunteers residing in nursing homes or assisted-living facilities. The participants were interviewed at their place of residence after viewing films of scenarios involving the use of non-invasive mechanical ventilation (NIV), invasive mechanical ventilation (IMV), and renal replacement therapy after a period of invasive mechanical ventilation (RRT after IMV). Demographic, clinical, and quality-of-life data were collected. Participants chose among four responses regarding life-sustaining treatments: consent, refusal, no opinion, and letting the physicians decide. RESULTS: The sample size was 115 and the response rate 87 %. Mean participant age was 84.8 ± 3.5 years, 68 % were female, and 81 % and 71 % were independent for instrumental activities and activities of daily living, respectively. Refusal rates among the elderly were 27 % for NIV, 43 % for IMV, and 63 % for RRT (after IMV). Demographic characteristics associated with refusal were married status for NIV [relative risk (RR), 2.9; 95 % confidence interval (95 %CI), 1.5-5.8; p = 0.002] and female gender for IMV (RR, 2.4; 95 %CI, 1.2-4.5; p = 0.01) and RRT (after IMV) (RR, 2.7; 95 %CI, 1.4-5.2; p = 0.004). Quality of life was associated with choices regarding all three life-sustaining treatments. CONCLUSIONS: Independent elderly individuals were rather reluctant to accept life-sustaining treatments, especially IMV and RRT (after IMV). Their quality of life was among the determinants of their choices.

Detection of asymptomatic aortic involvement in ANCA-associated vasculitis using FDG PET/CT.

Large vessel involvement in ANCA-associated vasculitis is very rare. We report here on the case of two patients with ANCA-associated vasculitis and asymptomatic aortic arch involvement diagnosed using FDG-PET/CT. Because aortic involvement in ANCA-associated vasculitis is a potentially life-threatening condition, its early detection can be crucial. FDG-PET/CT may also provide new insights into large vessel involvement as part of the spectrum of ANCA-associated vasculitis.

[Pulmonary sarcoidosis imaging]. / Imagerie de la sarcoïdose pulmonaire.

Sarcoidosis is a juvenile systemic granulomatosis. Its polymorphic clinical presentation depends on its different localisations, thoracic and extrathoracic. The role of imaging is very important for all localisations; but for mediastinopulmonary involvement, which is the most frequent (>90% of cases), it plays a major role in detecting the disease, diagnosing it, its prognosis, decision-making regarding treatment of it and in the monitoring of its development. Standard radiography, which sometimes detects the disease, forms the basis for its four-stage prognostic classification. CT scanning enables the study of mediastinal and hilar lymphadenopathy and the study of parenchyma, making it possible to identify micronodules of lymphatic distributions, alveolar opacities, septal lines, ground-glass hyperintensities, nodules surrounded by a ring of satellite micronodules, peribronchovascular thickening; all potentially reversible lesions. Elsewhere, it highlights irreversible fibrous lesions: hilar peripheral linear opacities; septal linear opacities; bronchial distortion, honeycomb destruction or even perihilar fibrotic masses. Less frequently we can visualise bronchiolar or cystic involvement. Benign in most cases, the sarcoidosis prognosis becomes bleaker in the event of hemoptysis, Aspergillus colonisation or before the onset of pulmonary hypertension.

Utility of high-resolution chest CT scan in the emergency management of haemoptysis in the intensive care unit: severity, localization and aetiology.

The purpose of this study is to assess the utility of the chest high-resolution computed tomography (HRCT) scan for estimating the severity of haemoptysis, localize the bleeding site and to determine a cause of the bleeding. We reviewed 80 consecutive patients who were admitted to a respiratory intensive care unit (RICU) for haemoptysis and who underwent unenhanced HRCT scanning and fibre-optic bronchoscopy (FOB) within 48 h. The number and type of lobar involvement on the CT scan were correlated to prognostic factors, the amount of bleeding and the bleeding aetiology. We compared HRCT scan observations on localization and bleeding aetiology with FOB results. The number of involved lobes was correlated with the daily (p<0.001) and cumulative (p<0.001) volume of haemoptysis and found to be significantly greater in the group of patients who were mechanically ventilated and/or died (2.7 vs 1.8, p<0.03). FOB and HRCT localized the bleeding site or side, respectively, in 71 (89%) and 64 (80%) patients (p>0.05). Of the nine patients without FOB localization, HRCT localized the bleeding site in six patients (67%). The initial HRCT scan correctly identified 48 aetiologies (60%), whereas FOB identified only 2 proximal bronchogenic carcinomas. The extent of lobar involvement seen by HRCT is a prognostic factor correlated with the daily and cumulative volume of haemoptysis. FOB and HRCT are complementary techniques for bleeding site localization. HRCT-scan is also the best exam to determine the cause of haemoptysis, even while it is occurring.

[Cause of non-pertinent hospital stays: interobserver concordance using the French version of the Appropriateness Evaluation Protocol]. / Etude de la concordance inter-observateurs des raisons de non-pertinence des journées d'hospitalisation identifiée par la version française de l'Appropriateness Evaluation Protocol (2e partie).

BACKGROUND: The modified French version of the Appropriateness Evaluation Protocol (AEPf) has been validated. Inappropriate days according to simple medical and technical criteria are identified with this tool. The aim of this study is to highlight the interest of investigating the reasons for inappropriate days and to assess the inter-observers reliability of the questionnaire developed for this purpose. METHODS: This questionnaire collects on one hand the needs of patients - distinguishing health care and accommodation needs - and on the other hand the reasons for inappropriate hospital days. The data were collected from January to September 1998 in nine voluntary medical and surgical departments. For each day of study randomly selected, each inappropriate hospital day according to AEPf has been included. Data were collected by two health professionals (a nurse and a physician), using a concurrent design. RESULTS: The reliability of the over-ride option of the appropriateness assessment of the 345 hospital days was good (overall Kappa coefficient: 0.66; 95% CI: 0.55-0.78). The comparison of the two expert judgments on health care needs fulfilled during the hospital day was acceptable; the Kappa coefficient was 0.62 (95% CI: 0.52-0.72). The reliability of expert assessment on patient accommodation needs (home, housing facilities or hospital) was good (Kappa coefficient: 0.67; 95% CI: 0.60-0.75). When hospital was not the accommodation the most adapted for patient, the reliability of the reasons for inappropriate days was high (Kappa coefficient: 0.75; 95% CI: 0.61-0.80). Kappa coefficients were different between hospitals, indicating a center effect. CONCLUSION: This instrument has been found to be reliable and should be used in complement of the first part of the AEPf which assess the prevalence of inappropriate days. It might help to detect dysfunctions within or outside the hospital and thus be used for evaluation or planning of health care.

[Aneurysm of the thoracic aorta and spondylodiscitis disclosing brucellosis]. / Anévrysme de l'aorte thoracique et spondylodiscite révélant une brucellose.

Brucellosis, which decreased during the eighties in France, remains a public health problem in many Mediterranean countries. We report the case of a 65-year old patient native of Morocco, of thoracic aorta aneurysm and lumbar spondylodiscitis due to Brucella melitensis, revealed by haemoptysis and lumbar pains, with a favourable outcome after aortic graft resection, spinal plaster immobilization and specific lengthy antibiotic treatment. This case report is characterized by the absence of endocarditis or infectious focus near the aneurysm. Diagnosis of aneurysm and spondilitis due to Brucella melitensis is based on imaging and bacteriological and serological examination. Because of a clinical and biological intolerance for rifampicin and cotrimoxazole, this patient received ofloxacin-doxycyclin-streptomycin. We discuss antibiotic recommendations and stress the interest of the early diagnosis of complicated forms of brucellosis for a better prognosis.