Management of asymptomatic bacteriuria: When to screen and when to treat?

Colin Hannesse, Halil Yildiz, Jean Cyr Yombi Published in the journal : April 2021 Category : Internal Medicine

Asymptomatic bacteriuria is defined as the presence of bacteria in the urine without any symptoms. It is very common, especially in the elderly. Despite clear national and international clinical guidelines, asymptomatic bacteriuria is far too often associated with screening and treatment. This strategy proves to be costly and promotes bacterial resistance, while exposing patients to the numerous undesirable effects of antibiotics. Unless specific urinary tract symptoms are present, a urine culture is only required for pregnant women, recent kidney transplant recipients (< 1 month), and prior to any urological procedures that likely cause mucous bleeding. For elderly patients with or without cognitive impairment who haven fallen or are confused, presenting with an otherwise asymptomatic bacteriuria, all infectious etiologies other than urinary causes must first be excluded before initiating any antibiotic therapy.

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D. Douillet, M. Hachez, A-C. Dekeister, M. Thoma, C. Grégoire, L. Levenbergh, R.Cre n, F. Dupriez, B. Rodrigues de Castro, .B. Germeau, C. Steinier, A.Penaloza Published in the journal : April 2021 Category : Emergency

Our Emergency department admits about 75000 patients on average per year, with many of them hospitalized. Emergency medicine is a true transversal specialty, enabling collaboration with colleagues from other departments. The wide range of pathologies, the acute disease phase, as well as the specificity of emergency treatments offers emergency physicians a clear opportunity to embark on research, innovation, and collaboration. The following five subjects illustrate these attractive features of emergency medicine.

• SARS-CoV-2 pandemic initiated a major increase in hospitalizations requirements, in addition to a change in patient flow management. The HOME-CoV rule has been developed to identify a subgroup of low-risk patients that can be treated securely as outpatients.

• The multidisciplinary care of severe trauma is a major challenge in emergency medicine. The potential lesions can indeed be of multiple origins. It is currently admitted that standardized protocols provide substantial benefit in patient care, with a significant impact on patient mortality. Implementation of such procedures in our emergency department has been instrumental for obtaining a supra-regional trauma center certification.

• Pain is a major reason for consultation in emergency departments. Indeed, pain is a true concern for individual patients, as much as for mass emergencies and disasters. Methoxyfluran (Penthrox®), which is an old and almost forgotten drug, has recently undergone new studies that have been published in literature.

• Clinical ultrasound (CUS) is carried out during the clinical examination, which substantially differs from the ultrasound performed in radiology departments. Evidence supports CUS use by emergency physicians at the patient’s bedside either to guide a procedure, help establish a differential diagnosis, select the complementary examinations of choice, or to guide treatments. All these procedures require the building up of a validated curriculum meeting international recommendations.

• Recent studies focused on pulmonary embolism (PE) have explored methods designed to reduce the number of computer tomography (CT) scans required. Given that among patients suspected of exhibiting PE, the prevalence of PE has significantly decreased, most CT examinations could thus be avoided. The 4-level pulmonary embolism clinical probability score (4PEPS) score integrates into a unique score a different method of clinical probability (CP) assessment, proposing a diagnostic strategy based on four levels of CP, resulting in a substantial reduction in imaging testing for patients with suspected PE.

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Atrial fibrillation and diabetes: role of direct oral anticoagulants

Cédric Hermans, Martin Buysschaert Published in the journal : March 2021 Category : Actualité thérapeutique

Non-valvular atrial fibrillation (NVAF) is the most common cardiac arrhythmia, and this condition constitutes a major indication for oral anticoagulant therapy. NVAF is particularly common in diabetic patients, who are at greater risk of developing thrombotic or bleeding complications. Direct oral anticoagulants (DOACs) are progressively replacing vitamin K antagonists (VKAs) among patients with NVAF. They are as effective as VKAs in reducing the risk of cerebral and systemic embolic events, while simultaneously decreasing severe and cerebral bleedings. Several recent studies have demonstrated DOACs to provide the same benefits in terms of efficacy and safety in diabetic versus non-diabetic subjects with NVAF. As suggested by the results of the ENGAGE AF-TIMI 48 study, among the DOACs, edoxaban given to diabetic NVAF patients appears to be associated with a significantly decreased risk of severe bleeding complications compared with VKAs.

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Ongoing therapeutic revolution in primary Type 1 hyperoxaluria

Arnaud Devresse, Nathalie Godefroid, Nada Kanaan Published in the journal : March 2021 Category : Nephrology

Primary hyperoxaluria Type I (PH1) is an autosomal recessive disease caused by the functional defect of hepatic alanine-glyoxylate aminotransferase, which results in overproduction of oxalate. The condition can be especially devastating for the kidneys, leading to end-stage renal disease (ESRD) during the first two to three decades of life in most patients. Currently, while the conservative treatment options are limited, they often prove inefficient in preventing ESRD. Consequently, many PH1 patients require kidney transplantation, and liver transplantation as well, which is currently the only definitive treatment option for counteracting the hepatic metabolic defect. Nevertheless, a therapeutic revolution is underway. Indeed, innovative drugs are currently being tested in clinical trials, and some preliminary data reveal their impressive efficacy in reduce hepatic oxalate overproduction. This paper reviews the current knowledge on this subject.

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Osteoid osteoma of the elbow, a rare condition that mimics inflammatory synovitis in a young patient: diagnosis and treatment

Daniel Glesener, Jean-François De Wispelaere, Jean-François Nisolle, Yves Boutsen Published in the journal : March 2021 Category : Clinical Report

An osteoid osteoma is a small benign bone tumor of young adults, usually involving the appendicular skeleton’s extra-articular portions of the lower limbs and spine, causing inflammatory pain of nocturnal recrudescence. We present the case of a 16-year-old patient with a rare intra-articular osteoma location of the distal humerus, complicated by a reactive arthritis. This condition can provoke irreversible functional impotence in case of delayed diagnosis and management. Ambulatory CT-guided percutaneous radiofrequency thermo-ablation, which is less invasive than surgical options, has become the gold treatment standard. This case report illustrates the atypical clinical, diagnostic, and therapeutic features of this rare pathology.

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Granulomatous reaction to silicone fillers following breast prosthesis rupture

Laeticia Famerée, Céline De Halleux, Liliane Marot, Claire Dachelet, Carlos Graux, Hugues Fierens Published in the journal : March 2021 Category : Clinical Report

The foreign body granuloma skin reactions to silicone fillers at the injection area have been widely reported in the literature, and they may even occur several years after the injection. Several cases of silicone migration into adjacent areas have been reported. On the other hand, and to the best of our knowledge, concomitant occurrences of granulomas at very old injection sites owing to massive silicone release following breast prosthesis ruptures have not yet been published.

The description of "siliconomas" or granulomas as a reaction to silicone is well established in the literature, though the exact underlying pathophysiological mechanism is not completely elucidated. This clinical case raises the question of a potential immune-mediated sensitization, which is deemed secondary to rupturing of silicone breast prosthesis. While these undesirable events are rare, they may become more common due to the rise in breast implant operations, given that most of them are silicone gel-filled implants.

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Social accountability in healthcare: What is the role of our medical faculty and of our graduates in this domain?

Jean-François Denef, Dominique Pestiaux, Louis Van Maele, Ségolène de Rouffignac Published in the journal : March 2021 Category : Faculty information

In a world that is undergoing profound and accelerated mutations, medical schools are increasingly challenged and they must adapt and innovate in order to meet their societal requirements. During the last century, the concept of social accountability has gained momentum, thereby reflecting the need to render everyone aware of their interdependence with the whole society. Medical schools are getting organized to progressively implement this accountability, and its principles and projects, as well. In addition, this paper illustrates the commitment of the medical school of Université catholique de Louvain to become a socially-accountable institution.

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Creativity and reactivity in infanto-juvenile pyschiatry at the Saint-Luc clinics

Delphine Jacobs1, Alexandre Riolo2, Sophie Symann1, Anne Wintgens1, Emmanuel de Becker3 Published in the journal : February 2021 Category : Psychiatrie infanto-juvénile

The COVID-19 crisis has had a particular impact on the mental health of children and youth. Access to care has been rendered more complex, owing to interposed screens, management limitations, and a decreased possibility for calling on third instances. This contribution highlights several support areas presented by the Psychiatric Service for Children and Adolescents of the Saint-Luc clinics.

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Acute respiratory distress in relation to COVID-19 and beyond

Charles Pilette, Grégory Reychler, Nicolas Audag, Anne-Claire Latiers, Stéphanie Quennery, William Poncin, Gimbada Mwenge, Giuseppe Liistro, Charlotte Smetcoren, Frank Aboubakar, Sophie Gohy, Silvia Berardis, Antoine Froidure Published in the journal : February 2021 Category : Pneumology

In 2020, COVID-19 mobilized pulmology experts along with other colleagues specializing in infectious diseases, emergency physicians, as well as intensivists. This occurred within a concerted effort, especially with the aim to reach a consensus in managing the infectious and inflammatory diseases at Cliniques Universitaires Saint-Luc. The physiotherapy team was mobilized from the very first hours of the pandemic; they were indeed involved in optimizing respiratory care for these patients. Original work and the "field" experience of our physicians and physiotherapists turned out to be instrumental in clarifying essential concerns. These latter included the best interface for delivering high-flow oxygen therapy, as well as the usefulness of supplying positive pressure continuous positive airway pressure (CPAP) to numerous patients with severely hypoxemic SARS-CoV-2 pneumonia, in addition to defining the most appropriate aerosol therapy in this pandemic context.

The follow-up of chronic respiratory disease-affected patients represented another challenge. Indeed, we were obliged to implement alternative methods, including teleconsultations, which particularly applied to the first CONIV-19 wave. Nevertheless, the year 2020 witnessed the arrival on the European market of targeted cystic fibrosis therapies as well as self-injectable biologics for severe Type 2 asthma, along with the multidisciplinary management of the ever-increasing number of cases suffering from diffuse interstitial pathologies. Notably, our department distinguished itself through original COVID-19 studies that were conducted in respiratory disease (cystic fibrosis, severe asthma patients) patient cohorts. Another distinctive feature pertaining to our department was the shedding light on the aging mechanisms involved in certain genetic pulmonary fibrosis forms, as well as on telomere length regulation, the latter being a risk factor for COVID-19 severity. Lastly, while lung cancers remain at the top of the "serial killer" list, these gloomy statistics are likely to change in the near future, owing to the progress made in molecular biology. This progress enables us today, and will do it even more tomorrow, to initiate and implement a personalized medicine management for certain cancer types.

These clinical and research transfer activities clearly demonstrate the pulmologists’ desire to work at the patient's bedside, in an effort to offer him the most appropriate specific care, in line with our academic hospital’s missions. This latter includes an active contribution to further developing medical and scientific knowledge in this field. Notably, this issue is at the heart of the 2020 news.

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2020 innovations in Nephrology

Hélène Georgery, Fabienne Oguz, Nathalie Demoulin, Michel Jadoul, Arnaud Devresse, Johann Morelle Published in the journal : February 2021 Category : Nephrology

In 2020, a large-sized randomized study provided reassuring results about the cardiovascular safety of febuxostat, a xanthine oxidase inhibitor used for the treatment of symptomatic hyperuricemia.

The cardiovascular and renal benefits of sodium-glucose co-transporter 2 (SGLT-2) inhibitors were confirmed in 2020, and their indications even extended. Notably, the DAPA-CKD trial demonstrated that dapagliflozin is strongly nephroprotective in both proteinuric diabetics and non-diabetics. Thus, the standard of care for managing these patients is likely to soon include an SGLT2- inhibitor in addition to an angiotensin converting enzyme inhibitor or angiotensin II receptor blocker.

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