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.
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.
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.
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.
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.
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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.
French guidelines on the management of primary spontaneous pneumothorax (PSP) were first communicated in 2022 and subsequently published in 2023. They emphatically promoted outpatient management. We aimed to assess current therapeutic management of PSP following the release of these guidelines. A nationwide online survey was conducted to evaluate therapeutic management strategies for large PSP without signs of severity. A standardized questionnaire was sent via the French Society of Respiratory Diseases (SPLF) and the French Federation of Pulmonology (FFP). One response per center was requested. All in all, 98 responses were collected from physicians (91 pulmonologists) representing 81 healthcare facilities, including 33 (40.7 %) general hospitals and 29 university hospitals (35.8 %). The majority of centers managed PSP through hospitalization (71.6 %), primarily via chest tube drainage (64.2 %), most often using small-bore chest tubes (≤14 French, in 76 % of cases). Outpatient management was practiced in 27.2 % of facilities, mainly using chest drainage with a one-way mini-valve (21 %). Analgesic prescriptions and sick leave duration significantly varied. Following publication of the French guidelines, PSP management has remained predominantly hospital-based, although small-bore chest tubes are commonly used. Outpatient care remains underdeveloped and should be encouraged. Any future update of these guidelines would need to provide more detailed recommendations on analgesia and sick leave.
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Active tuberculosis disease (ATB) remains feared in patients treated with TNF inhibitors. For that reason, screening for latent tuberculosis infection (LTBI) is currently performed before the start of treatment. Therapeutic patient education (TPE) should consequently help reduce the risk of infection during treatment. We report the case of a 19-year-old female patient hospitalized for disseminated tuberculosis. She had been treated for two years with adalimumab for Crohn's disease. Screening for LTBI had been performed before the initiation of anti-TNF treatment and was negative. Three months after returning from a four-month study trip to South Africa, the patient nevertheless developed disseminated tuberculosis and was repeatedly hospitalized. The disease was at once pulmonary, lymphatic, ocular, and splenic. Antituberculosis treatment consisted of quadruple therapy for two months followed by dual therapy for an additional 10 months. The patient was disabled for one year and suffered some radiological sequelae. Traveling to a country with high tuberculosis endemicity is a risk factor for ATB in patients undergoing anti-TNF therapy. Antibioprophylaxis may have been considered prior to the trip.
In 2022, the French National Health Authority launched a task force for experimentation of low-dose chest CT screening in patients at high risk of lung cancer. In 2023, a study was conducted in the Haut-Rhin region (France) to assess the feasibility of a program involving ten general practitioners. The patients included were prescribed a low-dose chest CT (<100mGy.cm). If the result was negative, follow-up CT was scheduled after one year and then every other year in the absence of risk factors other than smoking. Indeterminate results necessitated a repeat CT at three months, while positive results led to referral to a pulmonologist. The primary endpoint was the proportion of patients having undergone the first screening CT. One hundred and twenty-six patients were included (median age 58.5 years, 54.8% women) and 117 patients (92.9%) underwent the first CT. The median time between prescription and CT completion was 14 days, and the median radiation dose was 78.6 mGy.cm. One hundred and eight scans were negative (92.3%), and nine indeterminate (7.6%), all of which were subsequently reclassified as negative after follow-up. The high completion rate demonstrates good adherence to the program. These encouraging results need confirmation through the analysis of follow-up CTs.
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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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.
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.