To estimate the frequency of initial refusal of inhaled treatment in Algerian pneumology outpatients and to describe the characteristics of patients presenting this refusal. Multicenter cross-sectional study (September 2022 to January 2023) conducted in seven clinics. Attitudes were classified as immediate acceptance, difficult acceptance, or persistent refusal. Initial refusal combined the last two. Three hundred eighty-five (385) patients were included (mean age 40.1±25.0 years; 49.9% male). Initial refusal occurred in 127/385 (33.0%), including 32/385 (8.3%) with persistent refusal; 95/127 (74.8%) accepted after discussion. Patients with initial refusal were younger, more often in a new initiation setting, and more likely to show poor disease acceptance. Immediate acceptance was more frequent when prescriptions included a long-acting beta-2 agonist or a fixed inhaled corticosteroid plus long-acting beta-2 agonist combination, and when the device was a capsule inhaler. It was also more frequent in patients previously exposed to inhaled therapy or with a close relative using an inhaler. Fears (adverse effects, dependence, stigma) and social influences were mainly reported by refusers; 54/127 (42.5%) cited close relatives as the main influence. Time devoted to information and advice was longer in the initial refusal group (6.39±3.33 vs. 4.00±2.00minutes). One in three patients initially refuses inhaled therapy. Structured counselling at the time of prescribing, with attention to patients' beliefs and family influence, may help reduce these early refusals.
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The OPALE program has been designed to bolster observance of antifibrotic treatments in patients with diffuse interstitial lung disease (ILD). The effectiveness of these treatments depends largely on therapeutic adherence, which is often vitiated by side effects. The objective of this study was to describe the evolution and maintenance of treatment observance among participants in the OPALE program. A retrospective analysis was carried out regarding patients in the OPALE program over the course of nine months. Observance was measured using the Girerd self-administered questionnaire, and side effects were collected based on the participants' declarations. Among the 976 participants in the program, 319 definitively withdrew, including 187 due to treatment discontinuation; satisfactory treatment observance was noted in 67.4%. Notwithstanding distinct side effects, no difference regarding observance was noted among patients on nintedanib as opposed to pirfenidone. No single factor was associated with treatment observance. The OPALE program assessed observance of antifibrotic treatments among patients with ILD. Additional studies ensuring prospective assessment with more adapted tools are called for, the objectives being to confirm these results and to identify factors potentially impacting observance.
Non-small cell lung cancer (NSCLC) remains one of the leading causes of cancer-related mortality worldwide. Immunotherapy has significantly reshaped its treatment, leading to improved survival in a subset of patients. However, failed initial response or acquired resistance may limit the long-term benefits of immunotherapy. Resistance to immunotherapy arises from complex and multifactorial mechanisms. They include intrinsic tumor cell alterations - such as STK11 and KEAP1 mutations, antigen presentation defects, and impaired IFNγ signaling - as well as extrinsic factors related to the tumor microenvironment, including hypoxia, immunosuppressive cell infiltration, and T-cell exclusion. In response, several combination strategies have been explored: immunotherapy with chemotherapy, anti-angiogenic agents, alternative immune checkpoint inhibitors (e.g., CTLA-4, TIGIT, LAG-3), or innate immune modulators (e.g., STING, RIG-I), with encouraging early results. Despite recent progress, current approaches remain primarily focused on the tumor and its microenvironment, often overlooking host-related factors - such as age, comorbidities, dysbiosis, and chronic inflammation - that can significantly impact immune responsiveness. More refined patient stratification, incorporating tumor, immune, and host-derived immune and non-immune biomarkers, is essential to better tailor treatments and improve outcomes. The future of immunotherapy in NSCLC will likely be premised on a holistic understanding of tumor biology, immune dynamics, and host characteristics. Such an integrated approach is key to overcoming current limitations, enabling personalized strategies, and broadening the clinical benefit of immunotherapy to a wider patient population.
In France, the fixed combination fluticasone/umeclidinium/vilanterol (FF/UMEC/VI) is prescribed for the treatment of moderate to severe COPD in adults not adequately treated by LABA/LAMA or ICS/LABA dual therapy since 2018. The aim of our study was to describe the characteristics, prescribing trajectories and care pathways of patients prior to their first prescription of FF/UMEC/VI in France. A retrospective cohort study included all patients aged over 40years with a first prescription of FF/UMEC/VI between 2018 and 2019 in France using data from the SNDS database. Descriptive analysis were conducted in the 3years preceding initiation of this medication. Of the 34,906 patients included, 92% had received a prescription for dual or triple therapy in the 3years prior to starting FF/UMEC/VI. The mean age at inclusion was 69, with a majority of men. A description of the care pathway showed that 68% of patients had moderate exacerbations and 25% had severe exacerbations leading to hospitalization. Our results demonstrate that triple inhaled therapy with FF/UMEC/VI is used in accordance with its marketing authorization in France in the vast majority of cases.
The complications associated with cystic fibrosis and the daily management of the disease can have significant social, familial, and professional repercussions. The objective of this study was to assess adult patients' knowledge regarding their rights and social support options, along with their access to social care. Between May 2021 and December 2023, we conducted a prospective monocentric study at the University Hospital of Reims, including adult patients diagnosed with cystic fibrosis. A questionnaire assessing their knowledge in this area was utilized. The analysis included 61 patients (64% male; mean age: 29.2 years). In 73% of cases, patients reported being assisted by their social circle in managing administrative tasks. Information sources were diverse, and most patients had already met with a social worker. While the quality of information received was generally rated as good, one-third of the participants felt that the topic of social support was insufficiently addressed. Ten patients were unaware of their being enrolled in the long-term illness coverage program. Half of patients were receiving adult disability benefits. Adult patients often rely on their social support network for the performance of administrative and social tasks. Improved information on social benefits and the organization of specifically targeted workshops are desired by patients.
Non-small cell lung cancer (NSCLC) remains a leading cause of cancer-related death. In addition to tumor stage, host-related factors play a critical role in determining outcomes. Data from the French Epithor database and institutional cohorts have consistently highlighted a "lung cancer paradox": while underweight is associated with increased mortality, overweight and obesity seem to confer a survival advantage. Morphometric studies have confirmed that skeletal muscle mass, which is assessed in terms of psoas or total muscle area, is an independent predictor of prognosis. On a parallel track, simple biomarkers such as preoperative C-reactive protein (CRP) and prealbumin have demonstrated strong prognostic value, as they are closely linked to systemic inflammation and intratumoral immune infiltration. More recently, patient height and height-normalized weight (sH and sHNW) have emerged as novel independent prognostic factors, once again underscoring the relevance of morphomic measures other than BMI. Integration of simple and reproducible anthropometric indices (BMI, height, sHNW), body composition, and biological markers (CRP, prealbumin) provides a more comprehensive framework for risk stratification. This enriched approach may help to optimize perioperative management, identify high-risk patients, and refine indications for adjuvant or immune-based therapies in cases of resectable NSCLC. Although BMI alone is only a crude measure, when interpreted within an integrative model it retains prognostic significance. The combining of nutritional, inflammatory, and morphometric parameters yields a robust overall representation of patient status, paving the way toward personalized prognostic assessment and improved therapeutic decision-making.
Triple therapy with Elexacaftor, Tezacaftor and Ivacaftor (ETI) has transformed the management of cystic fibrosis. The aim of this study was to describe the patients under treatment who do not show improvement in FEV1. In a single-center retrospective study of 63 adults, data were collected over the 12 months before and after initiation of ETI. Patients were classified as "improved FEV1" (FEV1 gain≥5% at 12 months of ETI) and "stable FEV1" (FEV1 gain<5%). The patients in our study were at least 18 years old, suffered from cystic fibrosis, and had initiated a course of treatment by elexacaftor/tezacaftor/ivacaftor (ETI) between December 2019 and December 2021. They presented with either homozygosity or heterozygosity for the Phe508del mutation, with minimal function of the CFTR gene. At 12 months of ETI, an improvement in sweat chloride (-56 [-34; -69] mmol/L), FEV1 +17 [9; 24] % pred), RV/TLC ratio (-6 [-10; -3] %), walking distance +28 [14; 82] m and BMI (+1.5 [0.7; 2.6] kg/m2) was observed. Aside from the RV/TLC ratio, the improvement was similar between the "stable FEV1" (7 patients) and "improved FEV1" (56 patients) groups. A benefit in terms of sweat chlorine, BMI, walking distance and exacerbations was observed in patients whose FEV1 remained stable on ETI. This observation underlines the importance of multiparametric evaluation of patients treated with CFTR modulators.
Inhaled treatments represent a pillar in pneumology management, especially insofar as they allow for optimal local delivery of therapeutic agents. In addition to bronchodilators and corticosteroids, numerous inhalation-based treatments exist. Some of them are little known by clinicians, such as mucolytic drugs, antibiotics, saline solutions, morphine derivatives, prophylactic agents such as pentamidine, etc. Each of these treatments has specific indications and requires specific means of administration according to the nature of the medicine, the type of nebulizer being used, and a given patient's clinical characteristics. The present narrative review of the literature describes and synthesizes the indications and modalities of these different treatments, to the exclusion of asthma, COPD, cystic fibrosis, and ventilated intensive care patients.
Alternaria alternata is a mold commonly found in both indoor and outdoor environments. It can induce IgE-mediated sensitization, leading to symptoms such as rhinitis and, in some cases, severe asthma. However, allergic reactions resulting from the accidental ingestion of food contaminated with Alternaria have only rarely been reported. We report two cases of patients with respiratory allergies who were sensitized to Alternariaalternata, with asthma exacerbations in humid environments and during summer thunderstorms. Following the ingestion of mold-contaminated food, both patients experienced anaphylaxis. (1) Male, 33 years old: skin prick-tests (SPT) and sIgE were positive only for Alternariaalternata (sIgE rAlt a1 at 10.5kU/L). Multiplex IgE (ISAC®) revealed strong sensitization to Alt a1 and less sensitization to Thaumatin-Like Protein (TLP) from kiwi. (2) Male, 58 years old: SPTs were are positive for pollen and Alternaria; sIgE was positive only for Alternaria alternaria (sIgE rAlt a1 at 1.59kU/L). The ingestion of food contaminated with aeroallergens can trigger severe allergic reactions in sensitized patients, as described in "pancake syndrome" associated with dust mite contamination. In the present cases, reactions were related neither to true food allergy nor to cross-reactivity between aeroallergens and food allergens, but rather to food contamination with Alternariaalternata. These findings highlight the importance of comprehensive allergy evaluation in asthmatic patients, including systematic assessment for food-related allergic reactions.
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As a rare bacterial infection caused by Tropheryma whipplei, Whipple's disease often manifests systemically, most commonly with rheumatological and/or digestive symptoms. An unusual pulmonary pathology, it may be considered as non-specific granulomatosis. We report on the case of a 57-year-old man presenting with mediastinal lymphadenopathy, which was discovered incidentally during an episode of pulmonary embolism. Notwithstanding negative bacterial cultures, adenomegaly PCR testing confirmed the hypothesis of T. whipplei infection. Following antibiotic therapy, significant clinical and radiological improvements were observed. Although uncommon, Whipple's disease should be considered as a possibility when unexplained granulomatous pulmonary involvement occurs. An early diagnosis, followed by appropriate antibiotic therapy, generally leads to a favorable outcome.
The Asthma Control Test (ACT) is an easy-to-use tool assessing the level of asthma control. However, interpretation in a population of severe asthma patients with obesity may be partially biased due to symptoms directly associated with obesity. The RAMSES study is a nationwide cohort of severe asthma patients. In this pilot study, we considered a subgroup of patients recruited in our center, compared the ACT scores of obese and non-obese severe asthma patients, and analysed associations between ACT scores and phenotypic features. Forty non-obese and 25 obese severe asthmatics were included in the study. The ACT score did not differ between the two groups, nor was it correlated with body mass index. Unlike the non-obese group, the ACT score in the obese group was not associated with number of exacerbations (P=0.158), number of hospitalizations (P=0.840), or the HADS anxiety (P=0.105) and depression (P=0.056) scores. Our results suggest that the ACT score may not fully reflect asthma control in the obese severe asthma population. They rather tend to indicate a distinct severe asthma and obesity phenotype, in which a low ACT score would not be associated with number of exacerbations or psychological burden, thereby highlighting the primordiality of comprehensive assessment and multidisciplinary management.
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Sarcoidosis is a systemic inflammatory disease characterized by heterogeneous organ involvement and an unpredictable clinical course. Although clinical assessment often focuses on objective measures of disease activity, many patients experience persistent symptoms that substantially impair their quality of life. Fatigue, cognitive disorders, dyspnea and pain are common and often markedly underestimated, particularly when objective disease activity appears limited. These symptoms may significantly interfere with daily life activities and work commitment, even in patients with clinically stable disease. Relying solely on organ involvement or traditional clinical parameters may therefore lead to an incomplete assessment of work ability. A holistic approach, integrating clinical findings with patient-reported outcomes and psychosocial factors, is essential. Explicit attention to quality of life and limitations in daily activities is conducive to an accurate evaluation of functional capacity, improved patient-physician communication, and individualized support aimed at achieving sustainable participation in work and society.
Latent tuberculosis infection (LTBI) in children under 18 years of age is a mandatorily notifiable condition for which tuberculosis preventive treatment (TPT) is recommended. However, the comprehensiveness of TPT has yet to be extensively analyzed. We report on the experience of the Alpes-Maritimes Tuberculosis Control Center. In 2023 and 2024 in the Alpes-Maritimes department, 284 LTBIs in children under 18 years of age were detected and reported. LTBI was linked to the screening of unaccompanied minor migrants (UMMs) (256 children), to an investigation on the case of a tuberculosis patient (20 children), and to the screening of minor migrants accompanied by their parents (eight children). The median age and sex ratio (M/F) differed between the UMM group and the "case investigation" and "accompanied minors" groups, with respectively 16 years and 9.7 for the UMMs, 11 years and 0.8 for the "case investigation" group, and 12 years and 0.6 for the "accompanied minors" group (P<0.05). TPT completeness was 54% in the UMMs, and 100% in the other two groups (P<0.05). TPT comprehensiveness was high among minors who were surrounded by their parents, but less satisfactory among UMMs.
Coccidioidomycosis is a fungal infection endemic to the southwestern United States, particularly Arizona. Rare in Europe, it can lead to diagnostic delays insofar as its clinical and radiological features may mimic lung cancer, mycobacterial and/or bacterial diseases. We report a case of pulmonary and mediastinal coccidioidomycosis diagnosed in France following travel to an endemic area by a 68-year-old immunocompetent woman, a former smoker, who presented with a persistent cough and constitutional symptoms (fatigue, weight loss and anorexia). Chest computed tomography revealed a paramediastinal mass in the middle lobe as well as ipsilateral mediastinal lymphadenopathy. Given the patient's age, clinical deterioration, and heavy smoking history, lung cancer was initially suspected but rapidly ruled out after direct examination, reverse transcription quantitative real-time polymerase reaction (RT-qPCR), and serology had confirmed the presence of coccidioidomycosis. Due to several risk severity factors, treatment with fluconazole was promptly initiated, leading to clinical and radiological improvement. Rarely reported in France, pulmonary and mediastinal coccidioidomycosis can mimic the clinico-radiological presentation of bronchopulmonary cancer. Diagnosis relies on thorough travel history, careful assessment of symptoms, and mycological confirmation - often requiring repeated serological sampling.
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Frailty is a complex and multidimensional clinical syndrome characterized by decreased physiological reserves. It, results in increased susceptibility to adverse health outcomes. In 2001, Fried et al. established the phenotypic diagnostic criteria for frailty. Owing to the frequency, prognostic implications, and potential reversibility of frailty, systematic screening is recommended for all individuals over the age of 65. Several tools are currently available for the purposes of screening, assessment, and diagnosis. Fibrotic interstitial lung diseases (ILDs) occur predominantly in elderly patients. The reported prevalence of frailty in this population varies depending on the diagnostic criteria employed. In a prospective cohort of more than 1,500 patients, Guler et al. demonstrated that frailty was associated with a heightened risk of mortality and functional decline. In a related study, the same team reported that frailty was associated with a higher risk of antifibrotic dose reduction and deteriorated quality of life. These findings suggest that enhanced recognition and management of frailty could help optimize therapeutic care and improve the quality of life of patients with fibrotic ILDs.
While the SARS-CoV-2 pandemic has left a lasting impression, the long-term effects of this virus, such as persistent symptoms or long COVID, remain unclear. However, recommendations from learned societies for improving these symptoms exist and are being applied by a number of respiratory rehabilitation centers. In this paper, we provide a summary of the specificities of long COVID care in the context of respiratory rehabilitation, particularly as regards respiratory symptoms, fatigue, cognitive disorders, and cardiovascular symptoms and, more specifically, vegetative dysautonomia. The key elements of support are Therapeutic Patient Education (TPE) and activity management and fractionated exercise (PACING). While the effects of respiratory rehabilitation are highly promising, with potential improvement in symptoms and exercise capacity, the level of evidence remains low to moderate. Structured and coordinated multidisciplinary work is of paramount importance as a means of providing for these individuals the best possible support on their road to recovery. Further studies are needed to improve the level of evidence on the effectiveness of rehabilitation in cases of long COVID.