Rivaroxaban (Xarelto®): Update on new clinical data and therapeutic perspectives

Cédric Hermans Published in the journal : October 2020 Category : Actualité thérapeutique

Direct oral anticoagulants (AODs), which target coagulation Factors Xa or IIa, represent a major therapeutic innovation. Even if classical anticoagulants, such as vitamin K antagonists (AVK) and low molecular weight heparins, still play a crucial role in preventive or curative treatment, AODs have revolutionized the medical management of thrombotic diseases, concerning both arterial and venous conditions.

In addition to being able to replace conventional anticoagulants in common indications like atrial fibrillation and venous thromboembolic disease, there is a plethora of Xarelto data from recent and original studies, as well as from registries and Phase III sub-analyses, which are currently revolutionizing the modalities and benefits of oral anticoagulation at all stages of life and in a wide spectrum of indications.

This article provides a synthetic and practical review of these data and their therapeutic implications.

Read more

Vogt-Koyanagi-Harada disease in a young man, which was complicated by tuberculosis reactivation and occlusive retinal vasculitis

Zineb Bouterfa, Halil Yildiz, Jean Cyr Yombi, Alexandra Kozyreff Published in the journal : October 2020 Category : Clinical Report

We report the case of a 17-year-old man presenting with bilateral visual loss, panuveitis, exudative retinal detachments, and diffuse choroidal infiltration. The patient also complained of headaches and ear pain. Based on the fundus image analysis, fluoangiography, indocyanine green angiography, and optical coherence tomography, Vogt-Koyagani-Harada disease was diagnosed. The patient received high-dose methylprednisolone along with azathioprine. He responded well to treatment with progressive visual improvement and subretinal fluid disappearance. One month later, his right eye exhibited a sectorial retinal vasculitis with infero-temporal vein branch occlusion and massive sub-retinal hemorrhages. Coagulation screening as well as HIV and syphilis serology were all negative; whereas QuantiFERON was positive. An 18F-FDG PET/CT revealed hypermetabolic mediastinal lymph nodes, and a biopsy confirmed active tuberculosis (TB) infection. Anti-TB quadritherapy was initiated, resulting in cytochrome P450 enzyme induction and lowered steroid treatment efficacy, with consecutive recurrence of choroidal inflammation.

Read more

Esophageal perforation as a consequence of the Heimlich maneuvre

Marie de Broux, Anne Druez Published in the journal : October 2020 Category : Clinical Report

The Heimlich maneuver is a technique designed to clear the airways obstructed by a foreign body, which is able to save life. In rare cases, however, this maneuver can lead to life-threatening complications. Among these undesirable effects figure a few exceptional cases of esophageal rupture. Esophageal perforation is an extremely rare complication of the Heimlich maneuver. Due to this pathology’s high mortality rate and its requirement of rapid multidisciplinary management, it is essential that this clinical entity be known by physicians and be incorporated into their differential diagnosis.

Read more

Incidence and causes of diagnostic errors in emergency medicine

Emilie Jacques, Jean-Marie Jacques Published in the journal : October 2020 Category : Médecine d’urgence

Diagnosis is an incredibly dynamic and complex process, which is prone to errors. We all make many diagnostic errors and this, in every healthcare setting, but particularly so in the emergency department. However, these errors are preventable. It is thus essential to better understand how and why these errors occur; then, some simple steps must be taken to avoid their repetition. Many of these errors pertain to the clinical reasoning process and are due to cognitive errors, although other system-related factors are likely present in most cases.

Read more

Maintaining the cold chain in general medicine

Aurore Girard Published in the journal : October 2020 Category : Médecine Générale

Keeping vaccines requires maintaining the cold chain, which commonly exhibits weaknesses, even in more developed countries. However, the exposure of most vaccines to high temperatures results in some degree of degradation. Moreover, the freezing itself can cause an immediate vaccine degradation. In this context, the conservation of vaccines in the refrigerator at a constant temperature between 2 and 8 °C is a required framework for the general practitioner, which is designed to preserve the vaccines’ properties. The main characteristics of suitable refrigerators must combine the maintenance of temperature (between 2 and 8 °C), an equal temperature distribution, the availability of an evaporator that prevents freezing, a very rapid temperature recovery device, as well as forced air circulation. Domestic refrigerators may suffice for storing small volumes of vaccines. They must display the minimum characteristics required for good storage conditions and undergo the adaptations necessary to their proper use. Additionally, regular temperature monitoring and reporting must be performed using an outdoor thermometer with a probe. These easily manageable elements enable vaccines to be stored in good conditions, with the eventual outcome of optimizing vaccine coverage of the population.

Read more

Reflection on the contribution of artificial intelligence to medical practice

Théophile Godfraind Published in the journal : September 2020 Category : Médecine et IA

Artificial intelligence (AI) refers to the simulation of human intelligence by machines with integrated computer programs. AI analyzes data and contributes to decision making. The computer performs human-like tasks based on algorithms. Moore's law says that computer performance increases exponentially and doubles every 18 months. On this basis, AI would surpass human intelligence by 2050. Machine learning mimics the human brain. It is fed by big data, which is a mass of heterogeneous data that are processed at a rate far beyond human capacity and in which exploitable data can be gathered. In addition to this virtual branch of AI, there is also the physical branch of robots. It has been shown that physicians surpass current diagnostic programs with respect to medical diagnosis. However, in the case of mammography, while no single AI algorithm outperformed radiologists, overall diagnostic accuracy was improved when using a set of AI algorithms combined with radiologist assessment in a single-reader screening. Only the physicians who have empathy, unlike the machines that lack this skill, may diagnose the disease. Patients’ confidence must come at the top of researchers’ priority list. Nat Med 26, 301 (2020).

Read more

Management of diabetic foot infections: practical recommendations and recommended use of antibiotics

Laura Orioli, Bernard Vandeleene, Dan Putineanu, Caroline Briquet, Hector Rodriguez-Villalobos, Jean-Cyr Yombi Published in the journal : September 2020 Category : Endocrinologie et Nutrition

Infections are a common complication of the diabetic foot ulcer. They are recognized as a factor of poor prognosis for both the foot and the patient. Their management is complex, requiring multidisciplinary collaboration. Our article summarizes the general principles of the management of diabetic foot infections, mainly based on the new recommendations of the International Working Group for the Diabetic Foot (IWGDF). It also presents the recommendations on the use of antibiotics, based on the PEDIS classification, as applied in the Saint-Luc University Hospital.

Read more

Pharmacological treatment of motor symptoms of Parkinson's disease

Eric Mormont Published in the journal : September 2020 Category : Neurology

This article presents the different pharmacological classes and therapeutic strategies employed at the different stages of Parkinson's disease. To date, only symptomatic treatments exist. Levodopa remains the most effective treatment with the best benefit-risk ratio. It is the initial treatment of choice for most patients. In order to delay the onset of motor complications, such as dyskinesia or end-of-dose akinesia, dopamine agonists or monoamine oxidase B inhibitors may be proposed as first-line treatment to young patients with mild disability. Motor fluctuations can be improved by adjusting the levodopa dosing frequency or by adding a dopamine agonist, monoamine oxidase inhibitor, or catechol-O-methyltransferase inhibitor. Disabling dyskinesias can be improved by reducing the levodopa dose or using amantadine. Patients with severe motor complications may benefit from a treatment with Duodopa® or subcutaneous apomorphine.

Read more

What should be taken into account from the 2019 recommendations of the European Atherosclerosis Society and European Society of Cardio-logy concerning dyslipidemia management for preventing atherosclerotic cardiovascular disease?

Olivier S. Descamps, Johan De Sutter, Ann Mertens, Caroline Wallemacq, Michel Langlois, Ann Verhaegen, Ernst Rietzschel, Guy De Backer Published in the journal : September 2020 Category : Internal Medicine

Several members of the Belgian Societies of Atherosclerosis and Cardiology have revisited in the form of 10 questions the main points of the new recommendations of the European Atherosclerosis Society (EAS) and European Society of Cardiology (ESC) concerning dyslipidemia management for preventing atherosclerotic cardiovascular disease (AVD). These new guidelines are underpinned by a number of key concepts, including the certainty that LDL cholesterol is the major cause underlying the development of atherosclerosis, that reducing LDL cholesterol helps diminish cardiovascular risk, that this cardiovascular benefit is the same regardless of how this reduction is met (nutrition, statin, ezetimibe, or PCSK9 inhibitor), and that there is neither a lower limit to this effect nor any danger at all of extremely low LDL cholesterol levels. To effectively put this knowledge into practice, a step-by-step approach is recommended; thereby enabling us to weight the intensity of the preventive approach based on individuals’ overall MCVA risk and their baseline (untreated) LDL-C levels.

Read more

Pathophysiology of NASH: Have new risk factors been identified?

Nicolas Lanthier Published in the journal : September 2020 Category : Hépato-gastroentérologie

Due to the rising prevalence of obesity, non-alcoholic fatty liver disease (NAFLD) has become the leading cause of chronic liver disease worldwide. NAFLD refers to a disease spectrum that encompasses steatosis and non-alcoholic steatohepatitis (NASH). NASH, which is the inflammatory subtype of NAFLD, has a clear potential of progression to fibrosis and cirrhosis, and can be associated with the need for transplantation. Identification of NAFLD and NASH is important in order to prevent disease worsening and to provide adequate tools for counteracting the causal factors. Risk factors associated with NAFLD and NASH include clinical comorbidities such as the metabolic syndrome, which is more relevant than high body mass index. Further recently identified characteristics, such as dietary composition, intestinal dysbiosis, genetic predisposition, altered brown adipose tissue, muscle alterations, circadian clock disruption or environmental chemicals, are presented in this review.

Read more