Acta Clinica Belgica最新文献

Patients with liver disease experience complex haemostatic changes leading to a state of 'rebalanced haemostasis' that may shift towards bleeding or thrombosis due to complications like kidney dysfunction, bacterial infection, or acute-on-chronic liver failure. Traditional coagulation tests inadequately capture haemostasis in cirrhosis, whereas advanced assays like thrombin generation assay and viscoelastic testing offer better insights but remain limited in clinical outcome prediction or guiding pre-procedural prophylaxis.Contrary to the traditional view of cirrhosis as a bleeding disorder, recent evidence highlights a paradox of higher venous thromboembolism incidence in hospitalised cirrhotic patients. Misconceptions about 'auto-anticoagulation' and concerns about anticoagulation safety hinder consistent thromboprophylaxis. Emerging data suggest that low molecular weight heparin is safe and effective in cirrhotic patients, supporting more evidence-based thromboprophylaxis. For thrombotic events or conditions like atrial fibrillation, therapeutic anticoagulation is recommended, and may offer additional benefits, such as attenuating liver fibrosis and portal hypertension. However, anticoagulation is not established as a core therapy in cirrhosis, given safety concerns in advanced disease.Bleeding remains a significant challenge in cirrhosis, with management focusing on specific aetiologies, including portal hypertension or procedural injuries. In pre-procedural planning, there is a trend of unnecessary blood product use, often based on an assumed bleeding risk. Rational pre-procedural planning should minimize unnecessary transfusions, optimise modifiable risks, and include a plan for managing potential bleeding.This review aims to clarify the 'coagulation paradox' in cirrhosis, promoting a nuanced, individualized approach to managing bleeding and thrombosis in chronic liver disease.

Objective: This study investigates the screening practices for congenital cytomegalovirus (cCMV) in Flanders, Belgium, with the aim of determining the frequency of neonatal screening and the number of diagnoses resulting from it.

Methods: Flemish hospitals with maternity facilities were asked for data on the number of infants screened for cCMV (PCR-CMV on saliva or urine), and diagnosed with cCMV (positive PCR-CMV on urine before the age of 3 weeks). Screening and diagnosis rates were compared across geographic regions and screening policies. We defined that at least 3% of neonates should be screened, given the prevalence of common screening indications (i.e. microcephaly and IUGR), and evaluated whether the empirical incidence of cCMV (0.5%) was approached.

Results: Fifty of 57 eligible hospitals participated. Overall, 1.65% of infants were screened and 0.12% were diagnosed with cCMV. Few hospitals screened 3% or more of infants (14/50), and measured an incidence of 0.5% or more (6/50). Hospitals using targeted screening policies conducted fewer screenings (median 1.5% vs 94.2%, p < 0.001) and diagnosed fewer infants (median 0.10% vs 0.54%, p < 0.001) compared to hospitals that screened universally.

Conclusion: There was important variability in cCMV screening practices across Flanders. Most hospitals screened fewer than 3% of infants, i.e. lower than the prevalence of microcephaly, a clinical feature that warrants testing for cCMV. Failure to diagnose cCMV in a timely manner limits the opportunities for early treatment with valganciclovir (secondary prevention) and morbidities such as hearing loss (tertiary prevention). There is a pressing need to enhance the knowledge and vigilance of perinatal healthcare professionals in Flanders, ensuring infants at risk of cCMV are appropriately identified and receive timely care.

The incidence of hepatocellular carcinoma (HCC) is rising, with a shift towards Metabolic Dysfunction-associated Steatotic Liver Disease becoming the dominant risk factor in Western countries. Significant advances in treatment have broadened the range of available therapeutic options. For this reason, clinical decision-making, along with a multidisciplinary team approach, plays a crucial role in improving patient outcomes. Following several landmark trials, immune checkpoint inhibitor-based therapy has now become the established first-line standard of care for advanced HCC. Additionally, the application of immunotherapy is shifting to include patients with earlier stages of HCC. Research on the combination with locoregional therapies for intermediate-stage HCC has recently reported positive results, and other phase III trials in the same patient population and early-stage HCC are currently in progress. Furthermore, a growing number of reports support the safety and efficacy of immunotherapeutic agents as potential adjuncts for downstaging of HCC, thus facilitating successful liver transplantation. We will discuss the published and ongoing trials in the expanding field of immune checkpoint inhibitor-based therapy for different stages of HCC.

Objectives/background: We aimed to investigate routine urinalysis practices in Belgian laboratories and verify these findings against the 2023 European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) European Urinalysis Guideline.

Methods: A questionnaire was developed to collect information on pre- to postanalytical aspects of urine test strip and particle analysis. The questionnaire was distributed by Sciensano to all Belgian laboratories, licensed to perform urine particle analysis.

Results: Sixty-six percent of the Belgian laboratories (75/113) participated. The responding laboratories served physicians in private (25%), hospital (60%) and university hospital (15%) setting. All laboratories performed test strip and particle analysis, predominantly automatically (97% and 96%, respectively). In addition, most laboratories (87%) used intelligent verification criteria to optimize diagnostic accuracy. Almost all laboratories (≥90%) screened and reported a minimal biochemistry panel (glucose, protein, pH, ketones) and particle count (red and white blood cells). Independent of the technology, a notable variability was observed regarding medical cut-off values and advanced particle differentiation and reporting. Internal quality control was extensively performed for urine test strip (91%) and particle analysis (96%), while external QC was less common (32% and 36%, respectively). Consequently, only few laboratories were ISO15189 accredited for urine test strip (15%) and particle analysis (17%).

Conclusion: There is considerable variability in current urinalysis performed in Belgian laboratories. The 2023 EFLM urinalysis guideline has the potential to guide clinical laboratories towards improving their urinalysis practices. Additional efforts are required to implement these recommendations into clinical practice in Belgium.

Objectives: Urinary tract infections (UTIs) are an important cause of empiric antibiotic (over)treatment at the emergency department (ED). To enhance empiric antibiotic choices, mapping the national and local microbiology and antimicrobial resistance (AMR) patterns is crucial. This study aims to examine resistance patterns at a Brussels ED and to identify risk factors for AMR to evaluate current treatment guidelines and help combat AMR.

Methods: Adult patients undergoing urinalysis at the ED of a Brussels tertiary care hospital with positive urine cultures were included. Descriptive microbiological mapping of UTI or asymptomatic bacteriuria (ASB) micro-organisms was performed. Potential risk factors of antibiotic resistance in Gram-negative bacteria were assessed by using logistic regression analysis.

Results: Out of 96 patients with Gram-negative bacteria in urinary culture, the predominant uropathogen was Escherichia coli (58.3%), with 8.6% being extended spectrum beta-lactamase (ESBL)-producing strains. Overall, fosfomycin (29.2%) and nitrofurantoin (28.6%) showed the highest resistance rates. Ceftriaxone revealed lower resistance rates (13.1%) compared to ciprofloxacin (17.0%) and cefuroxime (18.4%). Temocillin exhibited the lowest resistance rate (8.2%) especially against ESBLs (0%). Ciprofloxacin resistance increased with age (OR 1.05 [1.01-1.10]) and recurrent UTIs (OR 4.79 [1.18-19.42]). Male gender was associated with higher odds of temocillin resistance (OR 5.79 [1.18-28.34]).

Conclusion: In the studied Belgian ED setting, ceftriaxone seems slightly safer than ciprofloxacin, especially for recurrent UTI patients. However, overall, and especially in patients at risk for ESBL-producing bacteria, temocillin would be an even better choice in our setting. National microbiological data should be reviewed to support recommending temocillin as a first-line antibiotic in patients presenting with upper UTI.

Introduction: Antisynthetase syndrome (ASyS) is a rare idiopathic inflammatory myopathy (IIM), characterised by the presence of anti-aminoacyl tRNA synthetase antibodies. Significant clinical heterogeneity often results in delayed or missed diagnoses. While corticosteroids are the primary treatment for ASyS, immunosuppressants are frequently added as steroid-sparing agents. In cases where conventional therapies have limited efficacy, the use of biological disease-modifying anti-rheumatic drugs (bDMARDs) is increasingly being explored. Given the suggested role of interleukin 6 (IL-6) in the onset and progression of ASyS, its inhibition could be a potential therapeutic option. Nevertheless, the clinical effects of IL-6 blockade remain to be awaited, given the unpredictability of its anti- and pro-inflammatory effects. Off-label use of IL-6 antagonists has shown favourable results in selected cases with ASyS.

Material and methods: In this manuscript we present two patients with insufficient response to conventional treatment who received tocilizumab and sarilumab, two bDMARDs targeting IL-6.

Results: Both patients had significant improvement in follow-up laboratory and pulmonary parameters as well as clinical symptoms with an additional corticoid-sparing effect. The treatment was well tolerated.

Conclusion: Future randomised clinical trials in a selected ASyS patient population could elucidate the efficacy of IL-6 inhibition in this specific IIM subgroup.

Objectives: To review the current indications for liver transplantation (LT) in cirrhosis, including evolving criteria for hepatocellular carcinoma (HCC) and other malignancies, how donor organ allocation is established, and to address challenges of long-term complications post-transplantation.

Methods: A comprehensive review of the literature was conducted to evaluate advancements in LT indications, pretransplant evaluation protocols, organ allocation strategies, and management approaches for long-term post-transplant complications.

Results: Liver transplantation remains the definitive treatment for cirrhosis and offers substantial survival benefits for patients with early-stage HCC. Recent advancements have expanded eligibility criteria to include patients with multiple comorbidities, advanced-stage HCC, and select malignancies, provided they meet specific selection criteria. The increasing demand for donor organs has driven innovations in donor pool expansion, which presents new challenges in recipient management, including the need for tailored pretransplant workups and strategies to mitigate long-term complications.

Conclusion: The field of liver transplantation continues to evolve, with broader indications and innovative approaches to donor pool expansion. These advancements necessitate careful patient selection, rigorous pretransplant evaluation, and effective long-term management strategies to optimize outcomes for transplant recipients.

Objectives: In this study, the capacity of End-tidal carbon dioxide (EtCO2) levels to predict the risk of major cardiovascular events (MACE) in patients diagnosed with acute coronary syndrome and the relationship between risk scoring systems (TIMI, GRACE, HEART) and EtCO2 values were examined.

Methods: EtCO2 values of the patients in the study were measured with a capnography device. Each patient's MACE status was recorded.

Results: The results we found in our study are as follows: (i) EtCO2 values were significantly lower in the group with MACE (n = 45) than in the group without MACE (n = 288) (p < 0.05). (ii) According to ROC analysis, EtCO2 was effective in predicting one-month mortality (AUC = 0.81, p < 0.00). (iii) The optimal EtCO2 cut-off point was 30 mmHg. This threshold value provided both sensitivity and specificity for the risk of MACE. (IV) Significant associations were found between EtCO2 and GRACE, TIMI and HEART scoring systems. EtCO2 values were significantly higher in the low-risk groups. (V) EtCO2 was significantly different in all three risk scoring systems in the non-MACE group, but only with the GRACE score in the MACE group.

Conclusion: This study demonstrated that EtCO2 is a valuable indicator for predicting the risk of MACE in patients with ACS.

Background: ANCA-associated vasculitis (AAV), and nephrotic syndrome encompassing diseases including minimal change disease (MCD), focal and segmental glomerulosclerosis (FSG), membranous nephropathy (MN), remain a challenge due to their varied immunological characteristics. Recent therapeutic advancements have highlighted the importance of understanding these diseases' immunological landscapes.

Methods: This study analyzed transcriptomics data from renal glomerular tissues of patients with AAV, FSG, MCD, MN, and normal controls. Utilizing an immune-related gene set of 883 genes, methods including Gene Set Variation Analysis (GSVA), LASSO regression, and Weighted Correlation Network Analysis (WGCNA) were used. Predictions of immune cell compositions were made through CIBERSORT, TIMER, MCPcounter, and quanTIseq algorithms.

Results: The study revealed distinct immunogenetic pathways enriched in each disease: hematopoietic cell lineage in ANCA, linoleic acid metabolism in FSG, PPAR signaling in MCD, and drug metabolism in MN. Classifiers based on immune gene expression showed high accuracy (AUC: ANCA 0.812, FSG 0.99, MCD 1, MN 0.888). Co-expression modules and PPI networks highlighted unique pathways for each disease. Predictions of immune cell composition showed elevated macrophages in FSG and MN, with Treg levels elevated across all four diseases compared to normal controls and highest in FSG. Correlation analyses demonstrated significant associations between classifier scores and immune cell types.

Conclusion: This study offers accurate classifiers for AAV, FSG, MCD, and MN, and reveals distinct immunological pathways. These findings advance personalized treatments and highlight potential therapeutic targets in AAV and nephrotic syndrome. Further research should validate these results for clinical applications.

Objectives: This study aimed to evaluate an expanded matrix-assisted laser desorption-ionization-time of flight mass spectrometry (MALDI-TOF MS) database for the identification of Haemophilus species other than H. influenzae (Hi).

Methods: A total of 144 Haemophilus species, cultured from respiratory samples from people (living) with cystic fibrosis, were identified with MALDI-TOF MS and 16S rRNA sequencing. Of these, 99 Haemophilus strains showed >99% similarity with the best matching strain in the National Center for Biotechnology Information (NCBI) database and were assigned to a single Haemophilus subspecies using both MALDI-TOF MS and 16S rRNA sequencing. The MS profiles of a subset of strains (n = 58/99) were added to the Bruker MALDI-TOF MS database. Subsequently, 270 different strains that were analyzed previously in a routine setting were re-analyzed.

Results: 16S rRNA sequencing reliably identified 99/144 Haemophilus strains (>99% similarity). H. haemolyticus 16S rRNA identification was suboptimal since only 3/21 H. haemolyticus strains attained a similarity of >99% with H. haemolyticus 16S rRNA sequence in the NCBI database. Expansion of the MALDI-TOF MS database improved the number of reliable identifications only moderately for H. haemolyticus, H. influenzae and H. paraphrohaemolyticus (<10%). By contrast, improved identification was more outspoken for H. parahaemolyticus, H. parainfluenzae, H. sputorum and H. pittmaniae (>85%).

Conclusion: 16S rRNA sequencing is a valuable method for the identification of Haemophilus sp. other than Hi. Expansion of the MALDI-TOF MS database, based on 16S rRNA sequencing results, increased the proportion of reliable identifications and in this study resulted in an increase of 10% of Haemophilus sp. other than Hi strain identifications.