Objective The efficacy of systemic corticosteroids in many critical illnesses remains uncertain. Our primary objective was to survey intensivists in North America about their perceived use of corticosteroids in clinical practice. Design Self-administered paper survey.Population Intensivists in academic hospitals with clinical trial expertise in critical illness. Measurements We generated questionnaire items in focus groups and refined them after assessments of clinical sensibility and test-retest reliability and pilot testing. We administered the survey to experienced intensivists practicing in selected -013-9929-3 North American centres actively enrolling patients in the multicentre Oscillation for ARDS Treated Early (OSCILLATE) Trial (ISRCTN87124254). Respondents used a four-point scale to grade how frequently they would administer corticosteroids in 14 clinical settings. They also reported their opinions on 16 potential near-absolute indications or contraindications for the use of corticosteroids. Main results Our response rate was 82% (103/125). Respondents were general internists (50%), respirologists (22%), anesthesiologists (21%), and surgeons (7%) who practiced in mixed medical-surgical units. A majority of respondents reported almost always prescribing corticosteroids in the setting of significant bronchospasm in a mechanically ventilated patient (94%), recent corticosteroid use and low blood pressure (93%), and vasopressorrefractory septic shock (52%). Although more than half of respondents stated they would almost never prescribe corticosteroids in severe community-acquired pneumonia (81%), acute lung injury (ALI, 76%), acute respiratory distress syndrome (ARDS, 65%), and severe ARDS (51%), variability increased with severity of acute lung injury. Near-absolute indications selected by most respondents included known adrenal insufficiency (99%) and suspicion of cryptogenic organizing pneumonia (89%), connective tissue disease (85%), or other potentially corticosteroidresponsive illnesses (85%). Conclusions Respondents reported rarely prescribing corticosteroids for ALI, but accepted them for bronchospasm, suspected adrenal insufficiency due to previous corticosteroid use, and vasopressor-refractory septic shock. These competing indications will complicate the design and interpretation of any future large-scale trial of corticosteroids in critical illness.123 Can J Anesth/J Can Anesth (2013) 60:652-659 DOI 10.1007/s12630 RésuméObjectif L'efficacite´des corticoste´roı¨des syste´miques demeure incertaine pour plusieurs maladies graves. Notre objectif primaire e´tait d'obtenir l'opinion des intensivistes en Ame´rique du Nord concernant leur perception de l'utilisation des corticoste´roı¨des dans la pratique clinique. Méthodologie Sondage auto-administre´sur papier. Population Intensivistes dans des hôpitaux universitaires ayant une expertise en matie`re d'e´tudes cliniques sur les maladies graves. Mesures Les e´le´ments du questionnaire ont e´te´cre´e´s dans des groupes de discussion; nous les ...

IntroductionVasodilatory hypotension is common among intensive care unit (ICU) patients; vasopressors are considered standard of care. However, optimal mean arterial pressure (MAP) targets for vasopressor titration are unknown. The objective of the Optimal VAsopressor TitraTION in patients 65 years and older (OVATION-65) trial is to ascertain the effect of permissive hypotension (vasopressor titration to achieve MAP 60–65 mm Hg) versus usual care on biomarkers of organ injury in hypotensive patients aged ≥65 years.Methods and analysisOVATION-65 is an allocation-concealed randomised trial in 7 Canadian hospitals. Eligible patients are ≥65 years of age, in an ICU with vasodilatory hypotension, receiving vasopressors for ≤12 hours to maintain MAP ≥65 mm Hg during or after adequate fluid resuscitation, and expected to receive vasopressors for ≥6 additional hours. Patients are excluded for any of the following: active treatment for spinal cord or acute brain injury; vasopressors given solely for bleeding, ventricular failure or postcardiopulmonary bypass vasoplegia; withdrawal of life-sustaining treatments expected within 48 hours; death perceived as imminent; previous enrolment in OVATION-65; organ transplant within the last year; receiving extracorporeal life support or lack of physician equipoise. Patients are randomised to permissive hypotension versus usual care for up to 28 days. The primary outcome is high-sensitivity troponin T, a biomarker of cardiac injury, on day 3. Secondary outcomes include biomarkers of injury to other organs (brain, liver, intestine, skeletal muscle); lactate (a biomarker of global tissue dysoxia); resource utilisation; adverse events; mortality (90 days and 6 months) and cognitive function (6 months). Assessors of biomarkers, mortality and cognitive function are blinded to allocation.Ethics and disseminationThis protocol has been approved at all sites. Consent is obtained from the eligible patient, the substitute decision-maker if the patient is incapable, or in a deferred fashion where permitted. End-of-grant dissemination plans include presentations, publications and social media platforms and discussion forums.Trial registration numberNCT03431181.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure with a low rate of complications. It is used in the diagnosis of malignant and benign disease such as sarcoidosis. We report a case a 42-year-old man who had undergone EBUS-TBNA for diagnosis of mediastinal and hilar lymph node enlargement. Sarcoidosis was diagnosed on cytologic examination. Three weeks after the procedure, he developed a mediastinal abscess secondary to EBUS-TBNA. Sarcoidosis may be a risk factor for mediastinal infection complication. A local immune defect related to sarcoidosis may explain this risk. Our case underlines the importance of considering and recognizing this complication, and its possibility should be taken into account when undertaking the procedure for benign disease.

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ObjectivesTo report the effect of psoriasis treatments on the risk of serious infections in pts in PSOLAR.MethodsPSOLAR is a multicenter, intercontinental, longitudinal, disease-based registry for adult pts with psoriasis, who are eligible to receive systemic therapy based on standards of clinical practice. Cumulative incidence rates of serious infections were reported across treatment cohorts of pts exposed to ustekinumab, infliximab, adalimumab, etanercept, other biologics (e.g., discontinued or experimental drugs), and non-biologic therapy (i.e. including and excluding MTX). Pts exposed to cyclosporine and those who were only exposed to a biologic before the start of registry were excluded. Multivariate analyses using Cox hazard regression methodology were used to identify predictors of time to first serious infection and therapies were compared to MTX alone. The overall registry population, as well as subpopulations of new users of biologics was evaluated.ResultsData were analyzed from 11466 pts with psoriasis exposed to a biologic agent or a non-biologic therapy reflecting 22311 pt-years. Demographic and baseline characteristics were generally comparable across cohorts, although the proportions of pts with prior significant infections, cardiovascular disease, and psoriatic arthritis were higher in the infliximab cohort. The cumulative incidence rate of serious infections was 1.45/100PY (n=323) across treatment cohorts, and rates were numerically higher in the infliximab, adalimumab, and other biologics cohorts (2.49, 1.97, and 3.01/100 PY, respectively) compared with the etanercept, ustekinumab, MTX, and non-biologics cohorts (excluding MTX) (1.47, 0.83, 1.28, and 1.05/100PY, respectively). Generally, the most commonly reported serious infections were pneumonia and cellulitis across cohorts. Increasing age, serious infection history, presence of diabetes, infliximab or adalimumab exposure, and current smoking were associated with increased risk for serious infection. In the subpopulation of new users of biologics, only adalimumab was found to be associated with risk of serious infection, while in the narrower subpopulation of bio-naive biologic new users, none of the biologics were found to be associated with serious infection.ConclusionsResults from PSOLAR suggest a higher risk of serious infections with adalimumab and infliximab in comparison with methotrexate; increased risk was not observed with ustekinumab or etanercept.Disclosure of InterestR. Kalb Grant/research support from: Janssen Scientific Affairs, LLC, D. Fiorentino Grant/research support from: Janssen Scientific Affairs, LLC, M. Lebwohl Grant/research support from: Janssen Scientific Affairs, LLC, C. Leonardi Grant/research support from: Janssen Scientific Affairs, LLC, J. Toole Grant/research support from: Janssen Scientific Affairs, LLC, Y. Poulin Grant/research support from: Janssen Scientific Affairs, LLC, A. Cohen Grant/research support from: Janssen Scientific Affairs, LLC, K. Goyal Employee of: Janssen Scientific Affairs, LLC, S. Calabro ...