Bébés siffleurs : qui traiter ?

Wheezing in babies is an important clinical problem. Differential diagnosis and prognosis are uncertain as there are no reliable markers for separating non-atopic wheezing from atopic “asthmatic” wheezing. Bronchial hyperresponsiveness cannot be ascertained easily in this age group and, moreover, it is not a reliable predictor of persistence of asthma. Serum markers that will forecast the development of asthma are not sufficiently sensitive. Allergic sensitisation, family history and evidence of atopy in the child are at present the most reliable indicators of future asthma. In babies where these factors exist, long-term treatment with an inhaled steroid is warranted. The possibility of dose-dependent systemic side effects, for which babies are particularly vulnerable, must be taken into account.     

Toxidermies médicamenteuses : quelques nouveautés

Some recent advances regarding drug eruptions will be presented in this short review. An improved definition of ‘drug hypersensitivity syndrome’ has been proposed. New insights on the role of the immune response to drugs will be discussed that challenge the current dogma that reactive metabolites are pivotal to allergic drug reactions. Several randomised controlled trials have shown that a progressive increase in drug dosage decreased the rate of drug eruptions with some ‘high-risk’ medications.     

Syndrome des antiphospholipides « séronégatif » : mythe ou réalité ?

The antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by thrombosis and/or obstetrical manifestations and the persistent presence, at least 12 weeks apart, of antiphospholipid antibodies (aPL) such as lupus anticoagulant (LA) and/or anticardiolipin antibodies (ACL) and/or anti-β2 glycoprotein I antibodies (aβ2GPI). The finding of patients with clinical profile highly suggestive of APS but who are negative for conventional biological criteria has led to the concept of seronegative APS. In the last few years, new antigen targets and methodological approaches have been employed to more clearly identify this syndrome in patients with thrombosis or obstetrical complications without conventional aPL. Although seronegative APS is still controversial, there is increasing recognition of the existence of this subgroup. However, clinical relevance of non conventional aPL need to be confirmed by efforts toward standardizing new biological tools and longitudinal studies involving large cohort of patients.     

Nouveautés en allergologie : eczéma de contact

With respect to contact allergy, the latest observations relate to the allergens and the test methods. Every year there are a few reports of cases of contact allergy to new products and to others that are little known. The most interesting are the allergens that cause the minor epidemics that are reported by cosmetic vigilance committees, for example, cases caused by depilatory waxes, hairdressing products and perfume components. With respect to the test methods, the standard series continues to evolve. Francophone physicians are in the process of bringing up to date a battery that includes allergens that they are likely to encounter and that they believe should be included sooner or later in the european standard series. Finally, it would be interesting to test irritant products to define more precisely patients’ reactivity threshold so that we could identify those who are hyperreactive and candidates for false positive reactions.     

Actualités dans la physiopathologie de la sclérodermie systémique : vers de nouvelles opportunités thérapeutiques

Systemic sclerosis is a rare connective tissue disease characterized by skin and several internal organ fibrosis, systemic vasculopathy and immune abnormalities. Even if fibroblasts and endothelial cells dysfunction, as well as lymphocytes and other immune cells implication are now well described, the exact origin and chronology of the disease pathogenesis remain unclear. Oxidative stress, influenced by genetic and environmental factors, seems to play a key role. Indeed, it seems to be implicated in the early phases of fibrosis development, vasculopathy and in immune tolerance abnormalities shared by all patients, although disease expression is heterogeneous. To date, no curative treatment is available. Even if immunosuppressive treatment or drugs acting on vascular system are proposed for some patients, overall, treatment efficiency remains modest. Only autologous hematopoietic stem cells transplantation, reserved for patients with severe or rapidly progressive fibrosis, has recently demonstrated efficiency, with lasting regression of fibrosis. Nevertheless, this treatment can expose to important, life-threatening toxicity. In the last decade, new mechanisms implicated in the pathogenesis of systemic sclerosis have been unraveled, bringing new therapeutic opportunities. In this review, we offer to focus on recent insights in the knowledge of systemic sclerosis pathogenesis and its implication in current and future medical care.     

Réhabilitation précoce après tumorectomie rénale robot-assistée : quelle satisfaction des patients ?

IntroductionSeveral enhanced recovery protocols after surgery showed a benefit for postoperative recovery and reduction of hospital lengths of stay. Very few studies evaluated patient's satisfaction about these enhanced recovery protocols. The aim of this study was to evaluate patient's satisfaction about our enhanced recovery protocol for robotic-assisted partial nephrectomy (RAPN).MethodsA validated survey EORTC In PATSAT32 with a specific questionnaire about protocol was sent to the first patients included in the enhanced recovery protocol for RAPN. The survey was sent after the postoperative consultation at postoperative day 30. Responses were anonymous. Satisfaction's scores for EORTC questionnaire were calculated for each dimension with Likert's method. Scores were transformed linearly into a scale ranging from 0 to 100, where 100 represent the highest level of care satisfaction (EORTC method).ResultsA total of 21 patients (50%) returned the completed questionnaire. The overall satisfaction score was 75.1% (37.3; 100) in the EORTC survey. In total, 71.4% of patients (n = 15) were satisfied with the discharge at postoperative day 2 (POD2) and 5 patients (23.8%) found this premature. None of the patients had a negative impression on the clinical pathway. The average overall evaluation on the protocol by patients, on a satisfaction scale of 1 to 10 was 8.9/10.ConclusionIn this study, patients included in the enhanced recovery protocol after RAPN were very satisfied with their pre-, per- and postoperative care. Given patients satisfaction, reduction of LOS, patient's safety and the medicoeconomic advantage, these enhanced recovery protocol have become a priority to develop and evaluate. More large studies are needed to assess the patient's experience with these clinical pathways.Level of evidence4.     

Difficultés de cathétérisme coronaire après TAVI

PurposeCoronary catheterization after transcatheter aortic valve implantation (TAVR) may be challenging. The main objective of the study is to assess the feasibility of coronary catheterization and angioplasty according to each type of valve.Patients and methodWe retrospectively studied coronary angiography or percutaneous angioplasty procedures after TAVR in two different centers. The catheterization success of coronary artery was evaluated according to the quality of engagement in ostium and opacification of the artery. Other indicators were collected including catheters used, fluoroscopy and angiography times, DAP and the volume of the contrast agent.ResultsAmong 1512 TAVR procedures, 33 patients were included. The Sapien 3® valve was implanted in 22 patients and the Evolut® in 11 patients (7 Evolut-R® and 4 Evolut Pro®). Coronary angiography with selective or partially selective catheterization has been successfully performed in all patients with a Sapien 3® valve. In the Evolut® group we identified 3 cases of non-selective catheterization for the right coronary and 1 case for the left coronary. Standard Judkins catheters seem to be the most suitable for both types of valve with very good efficiency.ConclusionThe results of our study is promising for the future of TAVR with a coronary catheterization success rate close to 100% with some difficulties for the Evolut® supra-annular valves. Special attention should be paid to the technique of implantation and orientation of cups in the aortic sinus.     

Cétose ou acidocétose diabétique euglycémique chez des patients diabétiques de type 2 traités par inhibiteurs du SGLT2 : une série de cas cliniques en Belgique

IntroductionSodium-glucose cotransporter type 2 inhibitors (SGLT2i) are new therapeutic agents that improves the management of type 2 diabetes. Clinical trial results for SGLT2i have shown a reduction in blood glucose levels and a decrease in significant cardiovascular and renal complications related to diabetes. However, rare adverse events such as diabetic ketoacidosis have been reported in these clinical trials and in “real life”. These ketoacidosis were atypical because the hyperglycemia was less severe than in traditional acute diabetes, hence the name of “euglycemic” ketoacidosis. We detail a series of local cases associated with the use of SGLT2i in type 2 diabetic patients.MethodsThis was a retrospective consecutive case study, with a review of medical records from 2016 to 2019. We identified 7 single episodes of “euglycemic” ketoacidosis associated with SGLT2i use in individuals with type 2 diabetes.ResultsSeven cases of type 2 diabetic individuals (M/F: 5/2) aged from 51 to 74 years old were analysed. All had symptoms of hyperketonemia (fruity smelling breath, nausea or lack of appetite) and an increase level of capillary β-hydroxybutyric acid despite a glycaemia between 112 and 280 mg/dL. The risk factors for ketoacidosis identified in these patients were: prolonged fasting, infection, dehydration and significantly decreased in insulin secretory function (according to the HOMA model), revealing endogenous insulinopenia before ketoacidosis.ConclusionThe increasing use of SGLT2i in individuals with type 2 diabetes is likely to increase the number of ketoacidosis cases. It is essential to recognise this complication and prevent it according to each patient's risk factors.     

Les kystes hydatiques cardiaques à propos de 17 cas opérés

Cardiac hydatid cyst is a rare parasitic disease. The purpose of this study was to describe the clinical, pathological features and the outcome of the surgical treatment of cardiac hydatid disease in our unit over a twenty-year period.MethodsBetween May 1994 and May 2014, seventeen cases of cardiac hydatid cysts were operated at our unit. Overall, twelve patients were male (mean age 25 ± 13 years). All patients were complaining of dyspnea and 71% presented with chest pain. The diagnosis, based on histological examination, was suspected on echocardiography and computed tomography of chest.ResultsOur study revealed five possible locations, which were in decreasing order of frequency: left ventricle, interventricular septum, right ventricle, left atrium and pulmonary artery. The surgical procedure was a controlled puncture and aspiration of the cyst content, with cystectomy (69%), or pericystectomy (31%). The resulting cavity left open in 6 cases (37.5%) or carefully closed in 10 (62.5%). Hospital mortality was 11.8% (n = 2). Morbidity was marked by conduction abnormalities (n = 2), bleeding and hematoma of the residual cavity that required surgical treatment (n = 3). Eleven patients were followed with a mean period of 40.5 ± 19.4 months. At follow-up, neither late deaths nor recurrence have occurred.ConclusionCardiac hydatid cyst is a serious disease whose treatment is surgical. Cystectomy and pericystectomy remain the two surgical techniques able to offer good chance of cure with acceptable morbidity and mortality.     

Corticosurrénalomes: actualités thérapeutiques

Adrenocortical cancer (ACC) is a rare aggressive malignancy with a poor prognosis (5-year survival: 45 %). Their management requires multidisciplinary expertise. Complete resection by an expert surgeon is the only curative treatment. Very few adjuvant treatments are available and their efficacy is not fully proved. Adjuvant mitotane therapy increases the disease-free survival in the majority of patients after surgery but further studies are needed to determine patients in whom this treatment is the more beneficial. Blood concentrations of mitotane between 14 and 20 mg/l are necessary to have a full efficiency but this therapeutic window may cause side effects difficult to control. When aggressive parameters are present, radiotherapy is proposed. In case of residual or unresectable disease, combination of chemotherapy and mitotane is conventionally proposed. FIRM-ACT study establishes that EDP (etoposide, doxorubicine et cisplatine) is the most effective chemotherapy for progressive ACC. The first results of treatment with tyrosine kinase inhibitors, in patients with progressive disease despite one or two lines of chemotherapy are disappointing but this may be partly explained by the interaction with mitotane which reduces the plasma concentrations of sunitinib in particular. Clinical trials are underway to assess the effectiveness of other targeted therapies, including treatments acting on the IGF-1 receptor.     

Facteurs prédictifs de long séjour en réanimation après chirurgie cardiaque programmée de l’adulte : étude rétrospective monocentrique sur 5 ans et demi

AimThe aim of our study was to identify predictors for prolonged ICU stay following elective adult cardiac surgery under cardiopulmonary bypass.Patients and methodsA retrospective study was conducted during 5 years and a half period. Were included, patients age ≥ 18 years old, underwent elective cardiac surgery under cardiopulmonary bypass. Patients who died within 48 hours of surgery were excluded. Prolonged ICU stay was defined as stay in the ICU for 48 hours or more.ResultsDuring the review period, 610 patients were included. One hundred and sixty-four patients have required a prolonged ICU stay (26.9 %). In multivariate analysis, 5 predictors were identified: ejection fraction < 30 % (OR 19.991, IC 95 % [1.382–289.1], P = 0.028], pulmonary hypertension (OR 2.293, IC 95 % [1.058–4.973], P = 0.036), prolonged ventilation (≥ 12 hours) (OR 4.026, IC 95 % [2.407–6.733], P < 0.001). Number of blood units transfused (OR 1.568, IC 95 % [1.073–2.291], and postoperative acute renal failure (OR 2.620, IC 95 % [1.026–6.690], P = 0.044]. Prolonged ICU stay is significantly associated with prolonged hospital stay (17 days vs 13 days ; P < 0.001) and higher in hospital mortality (22 % vs. 3 %, P < 0.001).ConclusionThe identification of these patients at risk of prolonged ICU stay is crucial. It will aid to plan prophylactic measures to optimize their support.