Acta Clinica Belgica最新文献

Objectives: Proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID) is a subtype of monoclonal gammopathy of renal significance (MGRS). PGNMID can present with insidious, slowly progressing kidney damage to overt nephrotic syndrome or rapidly progressive glomerulonephritis. It is a renal-limited disease that often lacks a detectable plasma or B-cell clone and requires kidney biopsy for diagnosis.

Methods: We present the case of a 77-year-old woman who developed nephrotic range proteinuria and progressive chronic kidney disease, despite a normal hematological work-up that showed no evidence of monoclonality.

Results: This case highlights the potential risk for severe renal damage caused by monoclonal proteins, even in the absence of a detectable pathological hematologic clone.

Conclusion: PGNMID requires further research to gain knowledge regarding pathophysiology and potential serum biomarkers for diagnosis as well as therapy response.

Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (POPH) are two distinct pulmonary vascular complications seen in patients with liver disease and/or portal hypertension. HPS is characterized by disturbed gas exchange and hypoxemia because of intrapulmonary vascular dilatations. POPH is defined by pulmonary arterial hypertension, which might lead to right heart failure. HPS affects up to 30% of patients with end-stage liver disease requiring liver transplantation. POPH is rarer and affects 1-5% of this patient population. If not recognized and left untreated, these disorders result in significant mortality. This review provides an update on HPS and POPH and discusses their clinical characteristics, screening and diagnostic modalities, and management, including the place of liver transplantation.

Objectives: Implementation of outpatient parenteral antimicrobial therapy (OPAT), also known as intravenous (IV) antimicrobial treatment at home, has increased in recent years. Ensuring OPAT quality is crucial to achieve positive patient outcomes. However, data on the Belgian quality of OPAT organisation is lacking. We aimed to monitor the organisational quality of OPAT in Belgian hospitals and identify roles of hospital pharmacists involved in OPAT.

Methods: A cross-sectional study applying a web-based survey on OPAT quality was conducted from 2 to 29 April 2024. The survey assessed the presence of six core and five non-core structure indicators, and OPAT-related tasks of hospital pharmacists.

Results: Almost two-thirds (64%; 65/101) of Belgian hospitals answered the survey, with 77% of these hospitals providing OPAT, with an increase since 2023. All 11 structure indicators were present in 6% of hospitals, while 18% had all six core structure indicators.Three of the six core structure indicators were formally present in the majority of the hospitals: a policy on patient selection criteria (76%), a structured OPAT programme (70%), and a dedicated team (64%). In contrast, a system for fast communication between the patient and OPAT team members (50%), a mechanism for urgent clinical discussions (42%), and monitoring of quality indicators (28%) were not formally present in the majority of the hospitals. The primary tasks for hospital pharmacists included overseeing OPAT prescriptions and supplying antimicrobials and related materials.

Conclusion: While the adoption of OPAT is increasing among Belgian hospitals, significant opportunities remain for improving the quality of the OPAT organisation and expanding the OPAT-related tasks of Belgian hospital pharmacists.

Background: Urinary tract infections (UTIs) are one of the most commonly reported infections in Belgian nursing home residents. In older adults, UTI diagnosis and management is complex, often leading to over-diagnosis and irrational antimicrobial use, stressing the need for a guideline approach.

Objectives and methods: A consensus statement on the prevention, diagnosis and treatment of UTIs in older adults residing in nursing homes was developed in a collaborative effort between the Flemish Hospital Outbreak Support Teams, the Flemish Agency for Care and Health, the Association of the Flemish Coordinating and Advising General Practitioners, the Belgian Association of Urology, the Belgian Society for Gerontology and Geriatrics and PhD researchers based on a combination of clinical expertise, (inter)national guidelines and peer-reviewed studies.

Results: Optimizing fluid intake, appropriate toilet behaviour and posture, mobilization and local estrogen therapy in women are of proven value in UTI prevention, whereas the use of cranberry and probiotics is not to be advocated. The importance of avoiding bladder catheterization is stressed. In older nursing home residents, the diagnosis of UTIs remains challenging, mostly due to atypical systemic symptoms. A consensus diagnostic algorithm for UTI among residents with and without a urinary catheter was developed, including the presence of suggestive clinical symptoms and a positive urine culture. Urine dipsticks have a high negative but a low positive predictive value. C-reactive protein point-of-care testing is not recommended. Asymptomatic bacteriuria should not be screened for, in order to avoid unnecessary triggers for treatment. In cystitis, nitrofurantoin is the primary choice for treatment, with fosfomycin as an alternative; in prostatitis and uncomplicated pyelonephritis a fluoroquinolone is the advocated empirical antimicrobial.

Introduction: To speed up antimicrobial susceptibility testing (AST), the European Committee on Antimicrobial Susceptibility Testing (EUCAST) proposed rapid AST (RAST), a disk diffusion method to be read after 4, 6 and 8 hours of incubation. We investigated the feasibility of implementation of RAST in a non-automated lab setting.

Materials & methods: To this end, reference strains as well as a variety of clinical and resistant strains were used to spike sterile hemocultures (BioMérieux BACT/ALERT 3D® and Becton Dickinson BACTEC FX® systems), followed by RAST in comparison to classical long-incubation AST.

Results & conclusion: Our results with reference strains show that reading RAST after 4 hours is frequently too soon to obtain clinical results, and that Streptococcus pneumoniae reference strain did yield readable inhibition zones in RAST when harvested from BioMérieux BACT/ALERT 3D® bottle cultures. In a wider panel of strains, Gram positives RAST results were very similar to standard AST, while with Gram negative species errors were more frequently observed, limiting clinical implementation.

Background: Stroke due to basilar artery occlusion (BAO) is a severe neurovascular condition with only recently proven effectiveness of mechanical thrombectomy as treatment. Early re-occlusion of the basilar artery (RE-BAO) is an even more challenging form of stroke to treat, associated with poor outcomes and still no optimal treatment guidelines. There are only a few reported cases covering this topic thus far.

Case presentation: We present a 52-year-old male patient with RE-BAO treated with a combination of bridging intravenous (IV) tissue plasminogen activator (tPA), mechanical thrombectomy (MT), rescue intraarterial (IA) tPA, and after re-occlusion, repeated bridging IV tPA and repeated MT in a 75-hour time span.

Discussion: In previous trials applying IA tPA after MT showed promising results in patients with anterior circulation stroke. However, our case report implies that using a combined treatment of IV tPA before and IA tPA after MT in posterior circulation shows similar results.

Conclusion: To our knowledge, this is the first case of RE-BAO managed with the aforementioned multimodal treatment. Such an approach recently showed promising results in the anterior circulation, and our report supports the effectiveness of multimodal recanalization treatment in the posterior circulation as well.

Objective: Patients with severe emphysema who do not experience relief with non-invasive therapies such as medication and physical activity may need advanced treatments. Bronchoscopic lung volume reduction using endobronchial valves (EBV) is an alternative therapy that may improve exercise capacity and quality of life in carefully selected cases. This treatment is less invasive compared to lung reduction surgery or transplants.Clinical presentation: In this case report, a rarely described complication after EBV insertion is presented: empyema. Conclusion: However EBV has advantages in selected cases, it can be associated with different complications such as pneumothorax, valve migration, and pneumonia.

Background: VEXAS syndrome encompasses a wide range of rheumatological and hematological manifestations, which often features myelodysplastic syndrome accompanied by either macrocytic anemia or macrocytosis.

Case report: A 61-year-old Sicilian male was referred for a microcytic anemia associated with skin lesions, recurrent fever, involuntary weight loss, recurrent superficial venous thrombosis, migratory polyarthritis and a lung nodule. A hemoglobin electrophoresis uncovered a minor beta-thalassemia contributing to the anemia in addition to the chronic inflammation and vitamin B9/B12 deficiencies. A bone marrow aspiration demonstrated the presence of vacuoles in erythroid and myeloid precursors, as well as dysplasia in all three lineages. This led us to consider VEXAS syndrome which was confirmed by the presence of UBA1 mutation type p.M41T. Low-dose steroids and sarilumab (200 mg every 3 weeks) therapy led to a transient partial remission.

Conclusion: The pivotal insight from this observation centers around the microcytic characteristic of the anemia, with the confounding factor being minor thalassemia, whereas the type of anemia typically associated with VEXAS is macrocytic. This finding may be of particular relevance to patients from regions with endemic thalassemia. Consequently, the presence of microcytic anemia should not hinder clinicians from considering VEXAS syndrome in the appropriate clinical context.