Damage Control Management: from the surgical concept to multidisciplinary care for selected patients

Jean-Paul Lechat Published in the journal : September 2019 Category : Anesthésie-Réanimation

Initially considered specific for the severe polytraumatized patients, the concept of damage control (DC) has been extended to the acute medicine domain with a climax attained following recent attacks. As a result, this condition now mobilizes a series of actors from the chain of care.

In the pre-hospital setting, the DC with its requirement of early bleeding control consisting of setting a tourniquet and a pelvic belt has modified the ABC trilogy into C-ABC: "Control hemorrhages first", prior to "Airway - Breathing - Circulation". In the emergency setting, during the "golden hour", the team leader must assume four different tasks: supervise the lifesaving procedures, initiate the massive transfusion protocols, limit any additional workup to the essentials, and schedule the priority of the surgical action order.

In the operating room, the carrying out of interventions aimed at controlling bleeding and microbial contamination, along with tolerating unstandardized parameters except for temperature control upon admission, must be performed in the second hour, the speed of surgery being now the priority. In the ICU, homeostasis restoration within 36 hours should enable a secondary surgical procedure for anatomical and functional purposes to be conducted. At times, maybe even often, several intermediary interventions are necessary in order to perfectly control the hemorrhage and infection prior to undertaking the final surgery.

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Geriatric Day Hospital : an ambulatory interface for elderly people

Didier Schoevaerdts (1), Christophe Dumont (2), Pierre Hanotier (3), Alain Fournier (4), Dominique Piette (5), Carole Almpanis (6), Serge Biettlot (1), Françoise Detraux (1), Mélanie Sentrie (1), François-Xavier Sibille (1), Pascale Cornette (7) Published in the journal : September 2019 Category : Geriatry

The Geriatric Day Hospital is an ambulatory structure where a diagnostic and therapeutic approach is offered to old frail adults. This is a good therapeutic option, considered to be an alternative to a conventional hospital stay. This article was aimed to describe Belgian geriatric day hospitals based on existing medical literature. It also reports on the history of these geriatric day hospitals, both in Belgium and worldwide. This article has also presented and commented the results, along with comments, pertaining to a meta-analysis and national surveys published since 2007. Compared to published studies, Belgian Geriatric Day Hospitals are more oriented to diagnosis rather than rehabilitation, which is less developed. Day hospitals represent a good opportunity for a comprehensive geriatric assessment performed by an interdisciplinary team and designed to assess geriatric syndromes reflected by functional decline, frailty, falls, memory complaints, poor nutrition, etc. They are considered to constitute a good link between hospitals, general practitioners, and the healthcare network.

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Glucocorticoid-induced muscle atrophy: clinical presentation, physiopathological mechanisms, and therapeutic implications

Pauline Montigny (1), Jean-Paul Thissen (2) , Bernard Lauwerys (3), Frédéric Houssiau (3) Published in the journal : September 2019 Category : Rheumatology

Glucocorticoids (GC) are used in all medical areas because of their anti-inflammatory and immunosuppressive effects. Their undesirable effects are, however, much feared, in particular cortisone-induced myopathy (CD). This condition is characterized by insidious muscle atrophy, exhibiting an important prognostic role. CD is related to the GC-induced imbalance between muscle protein synthesis and degradation, promoting their degradation yet inhibiting their synthesis. We have herein undertaken a review focused on CD’s main pathophysiological mechanisms, along with a discussion on potential targets, such as myostatin, activin receptor Type IIB, TRAF6, and REDD1. To end with, practical recommendations for the fight against CD have been developed, including resistance exercises.

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Semaglutide (Ozempic®), a new weekly GLP- 1 analogue for the treatment of type 2 diabetes mellitus

Michel P. Hermans Published in the journal : July 2019 Category : Actualité thérapeutique

Semaglutide is a GLP-1 analogue recently marketed in Belgium for the treatment of hyperglycaemia in patients with type 2 diabetes, by weekly subcutaneous administration. Among GLP-1 receptor agonists, semaglutide, at a maintenance dose of 0.5 or 1.0 mg/week, is currently the most effective compound for reducing chronic hyperglycaemia and body weight, as monotherapy or in combination with other hypoglycaemic medications, including basal insulin. The SUSTAIN 6 study also suggests a clinical benefit at the cardiovascular level. The tolerance and safety of semaglutide are comparable to those of other GLP-1 receptor agonists currently available in Belgium

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General practitioner’s strategy for dealing with the depressed patient

Eric Constant Published in the journal : July 2019 Category : ECU-Congrès de médecine générale

The general practitioner is confronted daily with patients with depressive symptoms. The first step is to establish a correct differential diagnosis and a first-line treatment plan. Often, this first treatment will have to be reviewed, modified and complexified, in order to allow the patient to obtain a substantial symptomatic improvement and to arrive at symptomatic remission, which should be the goal of any management. Key Words

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Transaminases : When should it be considered?

Perrine Vande Berg, Peter Stärkel (1) Published in the journal : July 2019 Category : ECU-Congrès de médecine générale

An elevation in aminotransferases may be of multiple etiologies and should be investigated. In this article, the different etiologies of increased aminotransferase blood levels are being reviewed, with a systematic approach to interpret transaminase alterations proposed. It is essential to establish whether aminotransferase blood levels are either acutely or chronically disturbed. A thorough assessment of personal and family past-medical history and exposure to toxics, medications, and dietary supplements should be obtained. Subsequently, given an acute perturbation, a baseline blood assessment for various viral etiologies must include HBs antigen, anti-HBc antibody, and IgM antibodies for hepatitis A, hepatitis E, EBV, CMV, HSV, VSV, and HIV. A liver Doppler ultrasound should be performed to exclude vascular etiologies.

Concerning chronic disturbances, alcohol consumption must be detailed, and metabolic syndrome sought using physical examination and biological parameters. In addition, one should screen for hepatitis B and C viral infection and for hemochromatosis (ferritin levels and transferrin saturation). In a second step, liver autoimmune and genetic diseases are to be looked for. A Doppler ultrasound of the liver should be performed in the event of chronic perturbation with the aim to assess the presence of steatosis and signs of cirrhosis. Any patient with severe acute hepatic impairment and chronic B or C viral infection or autoimmune, metabolic, and genetic disorders must be referred to a specialized centre.

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Doctor, I have tingling hands

Olivier Barbier, Xavier Libouton (1) Published in the journal : July 2019 Category : ECU-Congrès de médecine générale

Complaints of tingling and numbness in the hands are common. These paresthesias are most often indicative of a compressive neuropathy affecting the nerves of the hand. Compression of the median nerve in the carpal tunnel is the most common, followed by compression of the ulnar nerve in the cubital tunnel at the elbow. More rarely, the median nerve is compressed at the arcade of the pronator teres in the forearm and the ulnar nerve in the Guyon’s canal at the wrist. Other compression sites also affecting the radial nerve, mainly under fibromuscular tunnels (distributed from the thoracic outlet to the distal part of the limb), and cervical root compressions may also cause paresthesias. The diagnosis is mainly clinical, but can be complemented by electromyography and ultrasound. The treatment is usually conservative in early stages, consisting in avoiding stress on the nerve and in corticosteroid infiltrations. If symptoms persist, surgical decompression gives good results and prevents sequelae if performed sufficiently early.

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Doctor, my fingers are curling

Xavier Libouton, Olivier Barbier (1) Published in the journal : July 2019 Category : ECU-Congrès de médecine générale

A patient who consults for curling fingers is a common situation in hand surgery. Based on history taking, it is possible to distinguish between an acute and chronic condition. In acute cases, patients often report a trauma. The differential diagnosis includes tendon injury or osteoarticular involvement, which are not discussed here.

In case of chronic symptoms, two pathological conditions must be considered, namely Dupuytren's disease and trigger finger. The diagnosis is mainly clinical, but can be assisted by ultrasound if necessary. For Dupuytren's disease, the treatment is usually conservative as long as the palm of the hand can be completely laid down on a flat surface. When this is no longer possible, treatment of the symptom, i.e. contracture, may be considered. Collagenase (Xiapex®) injections are the currently preferred treatment option. To date, there is no cure for this disease. Regarding trigger finger, corticosteroid infiltrations are the first-line treatment to be privileged. First-line surgery should only be considered in case of secondary trigger finger, where studies have shown a trend towards recurrence following infiltrations.

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Doctor, I have an ache in my hand

Olivier Barbier, Xavier Libouton (1) Published in the journal : July 2019 Category : ECU-Congrès de médecine générale

Hand and wrist osteoarticular pain usually results from osteoarthritis-related degenerative alterations. Osteoarthritis has two main causes: age-related spontaneous degeneration and post-traumatic degeneration. Traumas lead to direct osteoarticular lesions or instability secondary to bone deformities and ligamentous lesions. The treatment of primary osteoarthritis, dominated by rhizarthrosis (base of the thumb), is initially conservative, using anti-inflammatory drugs (per os and by local massages) and resting splints. Corticosteroid or hyaluronic acid infiltrations can be used as second-line treatment. Finally, surgical prosthetic or non-prosthetic arthroplasty usually yields good results in more severe cases. In post-traumatic situations, early recognition of instability may allow surgical stabilization to be performed so as to prevent pain and secondary degenerative lesions. Radiography, CT-arthrography and MR-arthrography are the examinations of choice to complete the clinical examination.

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Endometriosis: When should it be considered?

Jean Squifflet, Vassiliki Samartzi 1 Published in the journal : July 2019 Category : ECU-Congrès de médecine générale

Three steps play a key role when assessing patients with suspected endometriosis.

First step: Patient’s clinical history and symptoms (dysmenorrhea, dyspareunia, dyschesia and chronic pelvic pain). Although there is no evidence of a relationship between patient’s symptoms and the presence and severity of endometriotic lesions, the implemented or proposed medical / surgical treatment depends on the context in which endometriosis is observed.

The second step is the physical examination, including evaluation of the posterior vaginal fornix and of the Douglas pouch, which detects more lesions that are missed on ultrasonography and magnetic resonance imaging.

The third step is imaging. A recent meta-analysis found no difference in the detection of endometriotic lesions between ultrasound and magnetic resonance imaging, but these examinations should be performed by a radiologist with expertise in this field.

To date, the final diagnosis of endometriosis is made by laparoscopy with biopsies of the lesions.

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