2021 innovations in internal medicine and infectiology

 Halil Yildiz, Lucie Pothen, Chantal Lefebvre, Julien De Greef, Leila Belkhir, Anne Vincent, Fabien Roodhans, Jean-Luc Balligand, Jean Cyr Yombi, Philippe Hainaut Published in the journal : February 2022 Category : Médecine interne et maladies infectieuses

The so-called “general” internal medicine is a specialty that takes care of patients with multiple diseases or complex pathologies. The internist is therefore an unavoidable actor in management of hospitalized patients, while being a privileged contact for general practitioners.

In general, internists are in charge of treating various pathologies, including inflammatory diseases, auto-immunes diseases, or vascular diseases. They are also major actors in polyadenopathy diagnosis, treatment of thromboembolic diseases, diagnosis of neoplasias of undetermined origin, diagnosis and treatment of sarcoidosis or vasculitis, as well as diagnosis of fever and inflammatory syndromes of unknown origin. Their expertise is primarily based on diagnosis (with eventually referring the patients to other specialties, such as oncologist, inflammatory bowel disease specialist, or hematologist) and treatment of various affections. Another aspect of this specialty consists of diagnosis and management of infectious diseases, including acquired immuno-deficiency syndrome, tuberculosis, tropical fever, as well as COVID-19.

We wish to share this multifaceted aspect of our specialty means of presenting several 2021 therapeutic innovations.

Read more

Mots-clés  Néphrite lupique, traitement, cible, polyarthrite rhumatoïde, diagnostic, prise en charge

 Farah Tamirou, Charlotte Baert, Pauline Montigny, Frédéric A. Houssiau, Emilie Sapart, Aleksandra Avramovska, Laurent Meric de Bellefon, Stéphanie de Montjoye, Stéphanie Dierckx, Adrien Nzeusseu, Valérie Pirson, Tatiana Sokolova, Maria Stoenoiu, Patrick D Published in the journal : February 2022 Category : Rheumatology

The current standard of care for lupus nephritis has so far been based on sequential immunosuppressive therapy aimed to induce a response, called induction therapy, and to prevent relapse, called maintenance therapy. The results of this approach are deemed unsatisfactory, with only 20-30% of complete renal responses observed at 6-12 months, with at least 20% of patients suffering from chronic kidney failure and 5-20% from end-stage kidney disease at 10 years post-diagnosis. Herein, we have briefly discussed two new treatments, consisting of belimumab and voclosporin, recently registered by drug agencies in the aftermath of controlled trials that demonstrated their superiority given in addition to standard immunosuppressive therapy. Further progress in rheumatoid arthritis is being based on further integrating goals, such as monitoring patients' daily symptoms and well managing co-morbidities like cardiovascular disease. An improved understanding of its pathophysiology has enabled translational research designed to develop new therapeutic strategies including numerous targeted biological and synthetic agents.

Read more

2021 technological innovations in radiotherapy

 Xavier Geets, Antoine Delor, Emmanuel Bonnarens, Françoise Vanneste, Loic Vander Veken Published in the journal : February 2022 Category : Radiothérapie

Though often misunderstood, radiation therapy is a local cancer treatment that Is offered to nearly half of all patients on their cancer journey.

To be safe and effective, radiation therapy requires extreme precision in delivering the dose to destroy the tumor, while minimizing exposure to radiation of nearby organs and potential treatment toxicities. In its relentless quest for precision, the radiotherapy department of the Cliniques universitaires Saint-Luc benefited in 2021 from major technological innovations that have revolutionized the care of our patients.

To illustrate, our department was equipped with the Ethos® LINAC, which was a first in Belgium, offering an adaptive radiotherapy solution based on artificial intelligence. This new therapy renders it possible to automatically and rapidly adapt the radiation ballistics to the patient's anatomical changes, at each radiotherapy session.

Besides the anatomical changes that occur from session to session, breathing is another source of ballistic inaccuracy. Indeed, breathing induces a cyclic and often irregular movement of tumors and organs within the thorax and upper abdomen. In order to avoid such movements, our department has set up a technique of irradiation synchronized to breathing, or more precisely, which is delivered during repeated apneas of the patient induced by mechanical ventilation.

Finally, a 3D printer was also made available in the department. It allows for the creation of individualized objects for patients, thus improving the quality of treatment and protection of the patient during irradiation. When technological evolution rhymes with clinical revolution, both caregivers and patients can only look forward to the radiotherapy of tomorrow, which will be increasingly personalized, effective, and safe.

Read more

Innovations in the psychiatry service for children and adolescents

 Francoise Poncin, Anne Wintgens, Emmanuel de Becker Published in the journal : February 2022 Category : Psychiatrie infanto-juvénile

Facing the multiple repercussions of the pandemic crisis in terms of young patients’ and their entourage’s mental health, we have maintained our creativity within the psychiatric service for children and adolescents of our clinics. As part of this contribution, we have highlighted two axes for the past year 2021, the first concerning a specific clinical activity based on multi-disciplinarity, with emphasis made on the aspects of prevention, awareness, preparation, and adaptation; the second involved the field of teaching in a domain as complex as it is feared.

Read more

2021 innovations in pulmonology

 Charles Pilette, Thierry Pieters, Antoine Froidure Published in the journal : February 2022 Category : Pneumology

In pulmonology, the year 2021 was marked by significant progress towards personalized medicine, particularly in the fields of asthma, interstitial diseases, and bronchopulmonary cancer. In asthma, the advent of anti-IgE and anti-IL-5 (and soon anti-IL-4R) biologics rendered it possible to wean a substantial number of patients off oral corticosteroids, with additional beneficial effects on exacerbations or lung function (1). It has therefore become essential to refer patients with severe asthma, especially those being corticosteroid-dependent, to a specialized center (2), where the management can either confirm or infirm the indication for a biologic agent, meaning after excluding difficult asthma causes, and then implement, as necessary, a progressive weaning protocol of oral corticosteroids (3). The department has been participating to a large European study that is designed to better define the criteria for (non)response to these biological treatments (4). In interstitial diseases, a personalization of the diagnostic and therapeutic approach is currently underway by integrating all the clinical, radiological, and biological patient characteristics. A good example to mention was the identification of mutations in the telomerase complex genes, with relevant therapeutic implications in terms of responses to anti-fibrotic treatments (5) and adaptation of immunosuppressive treatments in the event of lung transplantation (6). The department was and still is involved in conducting phenotyping studies of interstitial diseases complicating inflammatory rheumatism, in collaboration with the rheumatology department, along with fundamental explorations in mucosal immunology (7). In lung cancer, clinical studies conducted in 2021 were aimed at refining the positioning of anti-PD1/PD-L1 immunotherapy in non-small-cell bronchial cancer, with our department participating in some of them in its cancer center. Finally, the department remained involved in the management of COVID patients, and as a reference center for immuno-allergological reactions and contraindications to vaccines, as well (8).

Read more

2021 innovations in orthopedic surgery and traumatology

 Maïte Van Cauter, Pierre Pirlot, Pierre-Philippe Guilmot, Loïc Thoreau, Maxime Bonnelance, Gautier Beckers, Hervé Poilvache, Daniel Morcillo, Vincent Druez, Jean-Emile Dubuc, Nadia Irda, Ludovic Kaminski, Simon Vandergugten, Alin Sirbu, Karim Tribak, Dan Published in the journal : February 2022 Category : Chirurgie orthopédique et traumatologie

The year 2021 enabled us to shed light on the impact of minimally-invasive techniques in hip arthroplasty surgery, continued progress in knee arthroplasty, place of unconventional strategies in the control of implant infections, and interest of a new surgical positioning for performing shoulder arthroscopy techniques.

The optimization of surgical techniques in hip arthroplasty renders it now possible to identify those patients for whom a postoperative blood control proves necessary but also, therefore, for optimizing the patients before the intervention in order to reduce the risk of postoperative anemia and transfusion requirement. The benefit of knee replacement surgery has so far not matched that of hip replacement. Nevertheless, the development of resurfacing strategies respecting the individual anatomy of the patient, supported by modern technology and particularly robotization and using custom-made implants, augurs well for significant progress. Infection is a serious complication of arthroplasty surgery. To the classic strategies were added new therapeutic approaches, such as two-stage surgery in one stage and a better definition of the place of long-term suppressive antibiotic therapy.

Finally, an optimal position for patients benefitting from shoulder arthroscopy is that in the supine position, avoiding the disadvantages of semi-sitting and lateral decubitus positions, with the first associated with increased anesthetic risks and the second with surgical difficulties in the event of conversion to an open approach, with a risk of injury to the brachial plexus.

Read more

2021 innovations in geriatric oncology

 Frank Cornélis, Pascale Cornette Published in the journal : February 2022 Category : Oncogériatrie

Geriatric assessment (GA) in elderly patients suffering from cancer was instrumental to a better understanding of patient health requirements. In 2021, two randomized clinical trials were published showing that the implementation of GA-guided interventions can be associated with decreased chemotherapy toxicity without compromising survival.

Read more

Novelties and innovations in neurosurgery: What conclusions can be drawn from the year 2021?

 Vincent Joris, Tévi Morel Lawson, Christian Raftopoulos Published in the journal : February 2022 Category : Neurochirurgie

The year 2021 saw a series of advances in neurosurgery.

Surgery for epilepsy that is refractory to medical treatment continues to be perfected with improved invasive assessments, as well as a refinement in surgical approaches aimed to limit neurological damage, while reducing the relevance of comitial seizures as much as possible.

Since the new classification based on molecular biology, brain tumor surgery has benefited from a better understanding of the natural evolution of these tumors.

Read more

2021 innovations in nephrology

 Valentine Gillion, Johann Morelle, Michel Jadoul, Nathalie Demoulin Published in the journal : February 2022 Category : Nephrology

In 2021, Kidney Disease: Improving Global Outcomes (KDIGO) published the updated guidelines concerning the management of glomerular diseases. Herein, we have briefly discussed several key points in regard to the management of the three most common glomerular diseases in adults. Next, we have reviewed the clinical benefits, considering both renal and cardiovascular perspectives, which were observed in Type 2 diabetics with chronic kidney disease (CKD), randomized to either finerenone or placebo. Based on these encouraging data, we can assume that this molecule will soon belong to the armamentarium deemed able to delay CKD progression in Type 2 diabetics. Lastly, we have discussed the results of a recent trial showing that chlorthalidone, a thiazide diuretic, proves to be still effective in Stage 4 CKD and this, in contrast to the prevalent dogma.

Read more

2021 Innovation in hematology

 Marie-Christiane Vekemans, Violaine Havelange, Eric Van Den Neste, Sarah Bailly, Catherine Lambert,Nicole Straetmans, Xavier Poiré, Stefan N. Constantinescu, Cédric Hermans Published in the journal : February 2022 Category : Hematology/Oncology

The year 2021 was rich in innovations in regard to both malignant and benign hematological diseases, with the most relevant of which discussed below.

- In recent years, the prognosis of multiple myeloma has been greatly improved, yet the disease remains as yet incurable. Current strategies aim to achieve optimal disease control at diagnosis using four-drug regimens designed to delay relapse, while in relapsed patients, innovative alternatives like immunotherapy are being employed to effectively re-arm the immune system, and this represents a real hope for patients suffering from this chronic disease.

- The management of chronic myeloid leukemia is still evolving. Since 2001, tyrosine kinase inhibitors have revolutionized its prognosis, but they are also responsible for toxicities. One of the current therapeutic goals is to achieve a sufficiently deep and prolonged response, thereby enabling tyrosine kinase inhibitors to be discontinued and remission maintained.

- Myelofibrosis is a myeloproliferative neoplasm with poor prognosis. The only curative treatment available to date is peripheral stem cell allograft, which can be applied at least for some patients. New therapeutic agents are currently being investigated, which are highly promising not only on account of their efficacy on symptoms and splenomegaly, but also for their potential anti-fibrotic and reducing effect on the mutated clone. Certain agents are in clinical assays in combination with JAK2 inhibitors.

- Several recent studies have suggested that CAR-Ts were likely to emerge as the second-line treatment of choice for patients suffering from aggressive lymphomas, while secondarily reducing the number of autologous stem cell transplants.

- Patients with acute myeloid leukemia and TP53-mutated myelodysplastic syndromes still represent a challenging population to treat with low and only short-lived response rates. The advent of APR-246, which restores TP53 activity, is likely to increase the number of responders among these very high-risk patients.

- Beyond its well-known involvement in heparin thrombocytopenia, platelet factor 4 (PF4) plays a major role in the very rarely observed thrombosis with thrombocytopenia occurring in association with COVID-19 adenoviral vector vaccines. Inhibition of FXI is expected to emerge as a promising anticoagulation strategy with reduced bleeding risk, while induction of antithrombin deficiency by interfering RNA is likely to prevent bleeding in hemophilia A and B patients, either with and without inhibitors.

- Concerning the management of immune thrombocytopenic purpura, targeted therapies are currently being favored owing to their lower toxicity and individualized platelet count targets.

Read more