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.
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.
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.
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.
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.
Carmen Bartha*, Ruxandra-Iulia Milos **, Michele Yerna *, Alina Petrica ***Published in the journal : July 2019Category : Observations cliniques
Sudden cardiac arrest caused by pulmonary embolism (PE) is highly refractory to conventional cardiopulmonary resuscitation (CPR). Systemic thrombolytic therapy has been shown useful for return of spontaneous circulation on patient resuscitation. Nevertheless, thrombolysis during CPR is still controversial due to the risks of severe bleeding complications. While the work-up for securing PE diagnosis can delay therapy initiation, thrombolysis should be administered as early as possible when it is considered during CPR. Thus, in selected cases presenting features highly indicative of PE, the pragmatic initiation of thrombolysis under ongoing CPR could significantly improve the patient outcome.
Diane Declaye (1), Olivier Aerts (2), Alexia Kervyn (3), Laurence de Montjoye (1), Laura Nobile (1), Didier Ebo (4), Marie Baeck (1)Published in the journal : July 2019Category : Dermatology
We report on the “PEAU’se dermatologique” meeting held on June 18, 2018, organized by the Dermatology department of the Cliniques universitaires Saint-Luc, which was focused on immuno-allergology. The first part of the meeting, presented by Professor Didier Ebo, Head of the Department of Immunology and Allergology at UZA (Universitair Ziekenhuis Antwerpen), addressed the problem of “Perioperative hypersensitivity reactions”. The second part, presented by Professor Olivier Aerts (UZA), was dedicated to "Atypical aspects of contact dermatitis".
Alexis Lheureux (1), Olivier Nonclercq (2), Jean-Louis Mathias (3), Natalya Korogod (4), Emmanuelle Opsommer (4), Anne Berquin (1 )Published in the journal : July 2019Category : Médecine Physique et Réadaptation
Several screening tools have been validated to identify patients at risk of developing chronic low back pain, including the Örebro Musculoskeletal Pain Screening Questionnaire (OMPSQ, long and short versions) and Start Back Screening Tool (SBST). The purpose of this study was to aid the clinicians choose the tool that best suits their needs. A preliminary validation of the French version of the short OMPSQ has demonstrated that the tool’s psychometric properties are comparable to those of the original version. In a literature review, 101 papers were analyzed. Overall, the three questionnaires exhibited moderate predictive properties. The OMPSQ was designed to be a prognostic tool, whereas the SBST was to be a treatment-allocating tool. Knowledge and attitudes of rehabilitation professionals (mostly physiotherapists) from two medium-sized hospitals were also evaluated. Overall, most of the respondents did not know these questionnaires. When provided with the questionnaires, their global attitude was positive, despite several concerns being formulated. In conclusion, valid tools exist for identifying at-risk patients. However, substantial efforts must still be made towards the appropriate education of healthcare professionals.
Julie Paul (1), Amaya Lopez-Sierra (1), Sara Palumbo (2), Pascale Cornette (3), Patricia Dessart (2)Published in the journal : July 2019Category : Geriatry
Many geriatric patients are discharged from acute hospitalization, exhibiting functional decline. This acute functional decline constitutes a reason for the patient to be considered for an admission to the rehabilitation ward. The inpatient rehabilitation process is particularly challenging for these complex patients. This process requires medical skills to be able manage the medical complications in relation with co-morbidities, along with geriatric skills to be able to cope with various geriatric syndromes (polymedication, denutrition, cognitive disorder, and falls). Finally, some know-how in rehabilitation medicine is also required to be able to supervise a specific rehabilitation process (weight bearing and resistance exercises, dysphagia, incontinence rehabilitation, or orthotics and prosthesis).
A co-management model associating a geriatrician and physical medicine specialists is a possible approach to address this complex issue. In this paper, we further describe this co-management model, along with our particular experience at Valida hospital in this field.
Despite the sustained discussions and consultations of these recent years about hospital networks and the role of different hospitals, still much ambiguity exists as to the role of academic hospitals. This analysis puts innovation in medicine forward as the primary mission of these hospitals. Academic hospitals currently face a multitude of challenges, such as the lack of financial resources for academic missions and the concentration of complex and rare diseases, to only name the most important ones.