Laura Orioli, Bernard VandeleenePublished in the journal : March 2017Category : Diabétologie
The ulcer of the foot is a complication occurring in 20% of diabetic patients. Diabetic neuropathy is the primary cause, with infection and arteritis profoundly influencing its management and prognosis. Evaluation should be systematically conducted using the PEDIS classification. The evaluation and management of the diabetic foot ulcer require a multidisciplinary and interprofessional medical and paramedical team. The dialogue between the different lines of care, along with the respect of their respective roles, proves equally crucial. Therefore, deep and extensive infection, Charcot foot, and severe arteritis all require patient management in a reference center.
Multiple factors may account for the chronic toxicity of synthetic glucocorticoids (GCs), which are (too) widely prescribed in clinical practice. The relative potency of the GCs used, daily dose administered, duration of treatment, route and time of administration, as well as individual factors like age, genetic factors, or significant co-morbidity, such as renal or hepatic failure, determine the delay in the occurrence of potentially serious complications, including the suppression of the corticotropic axis. The concomitant use of drugs affecting the metabolism and/or the action of these glucocorticoids must also be considered. While the selected treatment strategy should take into account all these factors, it must also consider the desired effects and proofs of efficacy. Whenever possible, short-term treatment or non-systemic administration of glucocorticoids should be preferred. Iatrogenic Cushing's syndrome is characterized by specific complications, including posterior subcapsular cataract, benign intracranial hypertension, osteonecrosis of the femoral and humeral heads, tendon ruptures, pancreatitis or psychotic crisis. Suppression of the hypothalamus-pituitary-adrenal (HPA) axis can be assumed in patients receiving over 16mg of methylprednisolone per day (or equivalent dose) for at least 6 weeks and in those exhibiting clinical Cushing’s syndrome. On the contrary, this condition is rather unlikely in patients receiving nonparenteral corticosteroids for less than 3 weeks. In other situations, adrenal function must be assessed before considering glucocorticoid withdrawal. This comprises the measurement of morning plasma cortisol levels, in addition to a short corticotropin (ACTH) stimulation test. If the results confirm either complete or partial suppression of the HPA axis, treatment with hydrocortisone (20mg/day in the morning) should be administered until recovery of adrenocortical function.
Recent studies have demonstrated that most genetically-determined adrenal lesions responsible for Cushing's syndrome display abnormal cell differentiation resulting in the development of paracrine regulation loops that favor cortisol hypersecretion. In bilateral adrenal macronodular hyperplasia tissues, the causative gene mutations appear to lead to pseudo-gonadal differentiation of a subpopulation of adrenocortical cells, resulting in aberrant ACTH synthesis. In primary pigmented adrenocortical disease (PPNAD) and in some cortisol-secreting adenomas, activation of the protein kinase A (PKA) pathway is directly responsible for upregulation of the serotonergic signaling pathway . These original observations provide new insights into the pathophysiology of primary adrenal Cushing's syndrome. They also suggest that illicit intraadrenal paracrine regulatory mechanisms may be regarded as valuable targets for new pharmacological treatments of hypercortisolism. These original therapeutic approaches could represent valuable alternatives to adrenal surgery and the currently used anticortisolic drugs which are responsible for various side-effects.
The occurrence of early pubic hair often causes concern to both families and physicians. Whereas, in the majority of cases, this is only a normal variant called premature adrenarche, this condition may also be related to potentially serious diseases, such as congenital adrenal hyperplasia, adrenal tumors, or gonadal tumors, which must be correctly diagnosed and managed appropriately.
Assessing cortisol levels is recommended in the event of suspected hypercorticism like Cushing's syndrome, as well as in the event of hypocorticism like adrenal insufficiency. Cortisol testing is therefore a major tool for clinicians, and especially for endocrinologists, with particular attention required for selecting the most appropriate cortisol measurement tool in relation to clinical expectations. Most of the current assays while being automated rely on immunoassays. It should, however, be noted that the standardization process for cortisol assays has not yet been fully completed, with still significant inter-method variations. The clinicobiological relationship thus appears paramount in order to best select the most appropriate cortisol assessment method.
The IQON spectral CT scanner manufactured by Philips Healthcare has been installed at the beginning of May 2016 in our department of radiology. The CT scanner is performing all types of examinations but is more dedicated to patients referred from the emergency unit. We are performing an average of 40 patients per day with approximately half of them coming directly from the emergency room. After a few months of use, this machine with a 4 cm coverage, rotation time of 0.27 sec and spectral data analysis “on demand” appears especially designed for emergency cases and will definitely change our work-up of such patients where CT constitutes the front line examination with a major role in patient triage. The Spectral Diagnostic Suite is designed to display the spectral data very rapidly after the CT acquisition. The radiologist is able to load the images and analyze the spectral data within 2-3 minutes. In the scenario of emergency situations, some characteristics of the spectral CT seem very promising. The aim of this article is to share with you our preliminary experience of the IQON CT and highlight the applications which seem to be the most useful in the emergency situations.
Monique Decat, Gersende Debie, Naima Deggouj, Anaïs GregoirePublished in the journal : February 2017Category : Otologie
The management of hearing-impaired patients has taken a leap forward with the reimbursement of partially-implantable middle ear implants. Formerly, patients with neurosensory hearing loss (i.e., related to the destruction of the inner ear) could only benefit from hearing aids or cochlear implants provided they were totally deaf. Most of them were not satisfied with their hearing aids. Partially- or even fully-implantable middle ear implants were already available, but their costs were fully borne by the patient (between 10,000 and 18,000 euros approximately).
Jean-François Baurain, Jean-Pascal Machiels, François DuhouxPublished in the journal : February 2017Category : Oncologie
Major advances in medical oncology were observed in 2016. This article highlights some of these advances. Firstly, a new therapeutic class, the CDK4/6 inhibitors (palbociclib, ribociclib), was discovered, arousing major interest. When combined with hormonotherapy, these inhibitors were shown to increase overall survival of ER-positive metastatic breast cancer patients by several months. Secondly, PARP inhibitors (niraparib) that block one of the two DNA repair mechanisms were shown active in all relapsing ovarian cancer patients with a response to platinum-based chemotherapy. Finally, immunotherapy is now generally regarded as an essential therapeutic modality in the treatment of cancer, with shapes of some survival curves suggesting that some patients could be definitely cured. Ipilimumab, an anti-CTL-4 antibody, was shown able to increase the global survival of resected Stage III melanoma patients at high risk of relapse. The combination of anti-PD1 and CTLA-4 antibodies proved superior to the respective monotherapies in the treatment of metastatic melanoma. Anti-PD1 antibodies currently represent the standard of care in the treatment of metastatic head and neck cancers, kidney cancers, and lung cancers. The administration of these antibodies was associated with a very specific, autoimmune toxicity, which was at times severe or even fatal if not recognized and treated early. All these treatments are presently accessible at the King Albert II Cancer Institute.
Edward Fomekong 1 MD ; Denis Dufrane 2 MD, PhD; Bruno Vande Berg 3 MD, PhD; Christian Raftopoulos 1 MD, PhDPublished in the journal : February 2017Category : Neurochirurgie
In 2016, the neurosurgery department of the Cliniques universitaires Saint-Luc, Brussels, published an application of a scaffold-free osteogenic three-dimensional (3D) graft made of adipose-derived mesenchymal stem cells (AMSCs) in patients undergoing minimally-invasive transforaminal lumbar interbody fusion (MI-TLIF). Three patients with degenerative spondylolisthesis were included in the study, one with Level 1 and two with Level 2 disease. In order to obtain AMSCs, fatty tissue was collected from the abdomen by means of liposuction and differentiated afterwards in our cell/tissue bank. Clinical outcomes, including the Oswestry Disability Index (ODI) and visual analog scale (VAS), as well as fusion status, were assessed preoperatively and for up to 12 months’ post-surgery. At 12 months, all four operated AMSC levels could be assessed (n= 4). Our results showed that Grade 3 fusion could be confirmed at two levels out of four. Mean VAS score improved from 8.3 to 2, and ODI also improved from 47% to 31%. No donor site complication was observed. This study demonstrated that a scaffold-free 3D graft made of AMSCs can be manufactured and used as a promising alternative for spinal fusion procedures. Nevertheless, further studies involving larger patient series are required in order to confirm the technique's effectiveness.
Although it was hoped for that joint replacement surgery would provide longer-lasting results through the development of uncemented implants and low-friction bearings, and despite its indications being extended to younger patients, total hip arthroplasty does not allow for an implant with sufficient longevity to prevent us from considering a later revision. Moreover, replacement does not systematically offer the comfort of a native joint. The development of techniques designed to preserve the native joint and slow down or avoid osteoarthritis is therefore of particular interest. The realization of a periacetabular osteotomy (PAO) in hip dysplasia falls within this framework, increasing the acetabular coverage by a reorientation of the acetabulum. The use of preoperative three-dimensional reconstruction and planning help the surgeons to predict corrections. The use of cutting guides and an intraoperative scanner ensure accuracy and control throughout the whole intervention. PAO should therefore be recognized as the treatment of choice for acetabular dysplasia in young adults, prior to the occurrence of osteoarthritis.