Acta Clinica Belgica最新文献

Objectives: Recently, eosinophilic Chronic Obstructive Pulmonary Disease (COPD) has been identified as a clinically relevant phenotype, as patients with elevated blood eosinophil counts (BEC) demonstrate a better response to maintenance inhaled corticosteroids (ICS). This real-world study in Belgian primary care describes the distribution of BECs and the ICS use in stable COPD patients.

Methods: This study retrospectively analysed data from two primary care practices using the most recent values retrievable from the electronic health record. Patients were dichotomized based on BEC GOLD thresholds of 100 and 300 cells/µL.

Results: Eighty stable COPD patients (60% male, mean (SD) age of 70.7 (9.7)years, mean FEV1 (SD) of 65.4 (17.5) % Predicted) were included. Amongst them, 46% used ICS maintenance therapy. BEC values ranged from 0 to 667 cells/µL with a median (IQR) of 182 (80-291) cells/µL. 71% and 23% of patients presented BEC > 100 and ≥ 300 cells/µL, respectively. The mean age in the BEC^≥300 group was significantly higher than in the BEC^<300 group (MD = 7.2 y; p = 0.005). No other significant differences in demographic characteristics, dyspnea, FEV1 % Predicted, ≥1 moderate/severe exacerbations in the previous year, current maintenance ICS use, number of comorbidities or Charlson Comorbidity Index were detected between groups.

Conclusion: In this primary care population in Belgium, elevated BECs and maintenance ICS use are prevalent. Besides age, clinical characteristics were comparable between eosinophil-based groups whether the 100 or 300 cells/µL threshold was used.

Trial registration: Not applicable given the retrospective nature of the study.

Objectives: Liver cirrhosis is a leading cause of morbidity and mortality worldwide, with complications such as ascites, spontaneous bacterial peritonitis (SBP), and hepatorenal syndrome (HRS) significantly worsening prognosis. This paper aims to review the pathophysiology, diagnostic approaches, and management strategies for ascites and the complication of it, emphasizing the role of portal hypertension.

Methods: We conducted a comprehensive review of the literature on liver cirrhosis, portal hypertension, ascites formation, and related complications. Existing evidence was evaluated and ranked using the GRADE system: A (high) to D (verly low). Recommendation strength was graded 1 (strong) or 2 (weak).

Results: Portal hypertension is the key factor in ascites development. Non-invasive tools such as liver stiffness measurement (LSM) have proven to be effective in identifying patients at risk for clinically significant portal hypertension (CSPH), thus guiding treatment decisions. Carvedilol, recommended over propranolol, offers superior efficacy in reducing portal pressure. Diuretics, in combination with a moderate sodium-restricted diet, are the first-line treatment for ascites. However, refractory ascites requires advanced interventions. Spontaneous bacterial peritonitis (SBP) remains a major complication in patients with ascites, while hepatorenal syndrome - acute kidney injury (HRS-AKI) demands early recognition and timely vasoconstrictor therapy.

Conclusions: Liver cirrhosis and the complication of it significantly impact patient quality of life and survival. Portal hypertension is a critical driver of ascites and other complications, making early identification through non-invasive diagnostic methods essential for appropriate management. Medical treatments, including non-selective beta-blockers (NSBBs), diuretics, and advanced procedures, offer substantial benefits in controlling ascites and preventing further decompensation.

Objectives: Bone metastases in breast cancer are typically osteolytic but can rarely be osteoblastic. While malignancy-related hypercalcemia is well-known, malignancy-related hypocalcemia is rare and often multifactorial.

Case presentation: We present a case of a 48-year-old woman with metastatic breast cancer who developed severe hypocalcemia due to a combination of expanding osteoblastic bone metastases and hypoparathyroidism after total thyroidectomy. Despite oral and intravenous calcium supplementation, adequate calcium levels were not achieved until the patient responded to systemic therapy with Trastuzumab Deruxtecan (T-DXd), a HER2-directed antibody-drug conjugate.

Conclusion: This case underscores the challenges in finding the cause of and managing hypocalcemia in patients with complex oncological histories and emphasizes the need for close calcium monitoring in patients with bone metastases, particularly those with additional risk factors such as hypoparathyroidism or treatment with anti-resorptive drugs.

Objectives: To illustrate the diagnostic challenges, as well as the importance of early recognition of rare immunotherapy-induced complications, presenting a case and literature of sarcoid-like granulomatous reaction.

Methods: This report presents a case of asymptomatic hypercalcemia, revealing a sarcoid-like granulomatosis in a patient with metastatic melanoma, treated with an immune checkpoint inhibitor (ICI). In the discussion, an overview of the existing literature is provided through a PubMed search.

Results: Thorough investigations are essential to rule out disease progression and other possible explanations. Ultimately, biopsy with extensive staining led to the diagnosis of sarcoid-like granulomatosis. As there is no consensus in treatment, we suggest a case-by-case assessment, if possible by discussion within the multidisciplinary treatment team, to decide discontinuation of the causal ICI-therapy or the use of systemic steroids as supportive therapy.

Conclusion: This case demonstrates the importance of a broad differential diagnosis when identifying an asymptomatic hypercalcemia as well as new CT-graphic lesions, since the diagnosis of sarcoid-like granulomatosis can avoid not only unnecessary changes in treatment plans, avoiding toxicity, but also be a sign of good prognosis.

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.