Acta Clinica Belgica最新文献

Objectives: Unexpected deaths in the emergency department (ED) are rare but may indicate missed opportunities to detect clinical deterioration. This study aimed to identify risk factors associated with unexpected deaths and to better characterize patients at risk during their ED stay.

Methods: A retrospective study was conducted in the two EDs of CHU Liège between 2019 and 2023. All adult deaths (≥16 years) were extracted from the hospital's electronic health records and classified as expected or unexpected based on predefined criteria. Demographic data, triage levels, vital signs, Early Warning Scores (EWS), Glasgow Coma Scale (GCS), care location, and timing of death were analyzed using R software.

Results: Among 461,958 ED admissions, 823 adult patients died. Of these, 42 (5.1%) were classified as unexpected. These cases were more frequently transported by non-medicalized ambulance (40.5% vs. 27.5%, p = 0.006), assigned lower triage levels (p < 0.001), and less often admitted to the resuscitation room (73.8% vs. 49.8%, p = 0.002). They also presented lower EWS (0-4: 77.4% vs. 48.5%, p = 0.006) and higher initial GCS scores (p = 0.002). In multivariate analysis, a high EWS (≥7) and an altered GCS were both associated with a lower likelihood of unexpected death (OR 0.10, p = 0.03, and OR 0.32, p = 0.05, respectively), indicating that these factors were more frequent among expected deaths.

Conclusion: Unexpected deaths represented 5.1% of ED fatalities and were often preceded by subtle signs such as behavioral changes or mildly abnormal vital signs. Many occurred after initial stabilization, particularly in short-stay areas, underscoring the need to reflect on the organization and role of these units within the hospital system.

Background: Thrombotic microangiopathy (TMA) during pregnancy is most commonly due to hypertensive disorders such as the hemolysis, elevated liver, low platelet (HELLP) syndrome and preeclampsia (PE). In these cases, delivery is the primary therapeutic intervention. However, distinguishing these pregnancy-related TMAs from other etiologies is critical, as alternative or coexisting causes may necessitate additional diagnostic and therapeutic strategies.

Case report: We report a complex and unique case of a pregnant patient with prior bariatric surgery who developed a severe early-onset HELLP. The clinical course was further complicated by posterior reversible encephalopathy syndrome (PRES). Laboratory evaluation demonstrated severe vitamin B12 deficiency and glucose-6-phosphate dehydrogenase deficiency. Due to the rapid maternal deterioration, pregnancy termination was necessary to prevent further maternal morbidity.

Conclusions: This case highlights the complexity of diagnosing and managing TMA during pregnancy. It emphasizes the need for clinical vigilance and a multidisciplinary approach to identify coexisting metabolic or genetic conditions that may influence both maternal and fetal outcomes.

Purpose: Point-of-care ultrasound (PoCUS) offers high diagnostic performance for the assessment of right upper quadrant (RUQ) abdominal pain. We sought to assess the economic impact on society and patients of using PoCUS for RUQ pain assessment.

Methods: This study constitutes a secondary analysis based on a prospective, interventional, multicenter cohort study conducted in five Belgian emergency departments in 2023 that evaluated PoCUS's impact on the diagnostic process for patients with RUQ pain. The comparison was made between the estimated costs based on the diagnostic and therapeutic plan established before PoCUS and the actual costs after PoCUS integration.

Results: Using PoCUS for RUQ pain in the emergency department saved an average of €69.1 per patient (p < 0.01). The Belgian National Institute for Health and Disability Insurance saved an average of €66.5 and the patient €2.6 (p < 0.01). This saving remained significant (p < 0.01) when PoCUS was charged at €25. When the PoCUS result was negative, €57.5 (p < 0.01) were saved and €81.5 when the result was positive (p < 0.01). Total savings for complementary examinations were €61.3 and €7.8 for treatments (p < 0.01).

Conclusion: PoCUS use in abdominal RUQ pain assessment had a positive financial impact on society, even when PoCUS billing costs were taken into account. Costs associated with complementary examinations and treatments were reduced, regardless of whether PoCUS results were positive or negative.

Clinical trial registration: ClinicalTrials.gov NCT05438654.

Background: Spontaneous coronary artery dissection (SCAD) is an uncommon cause of acute coronary syndrome (ACS), particularly in young women without conventional risk factors. Recognition is essential as management differs from atherosclerotic ACS.

Case presentation: A 27-year-old woman with no cardiovascular history presented to the emergency department with acute left-sided chest pain radiating to the left arm. Initial evaluation showed elevated troponin levels and an electrocardiogram with nonspecific ST-segment changes. Transthoracic echocardiography revealed mildly reduced left ventricular systolic function (≈45%) with apical hypokinesia. She was initially treated with aspirin, while dual antiplatelet therapy was deferred pending definitive diagnosis. Coronary computed tomography angiography demonstrated a short-segment, high-grade stenosis of the proximal left anterior descending (LAD) artery with features suggestive of SCAD. Subsequent invasive coronary angiography confirmed the diagnosis, showing a severe (~90%) LAD stenosis with TIMI 2 flow. Given the lesion severity and impaired coronary flow, percutaneous coronary intervention with drug-eluting stent implantation was performed, successfully restoring TIMI 3 flow.

Discussion: SCAD often presents with nonspecific ECG findings, and initial troponins may be normal in a substantial proportion of patients, contributing to diagnostic delay. While coronary CT angiography may aid diagnosis in selected cases, invasive angiography remains the gold standard. Management requires careful consideration of lesion characteristics and clinical stability, as conservative treatment is often preferred but not always feasible.

Conclusion: SCAD should be considered in young women presenting with ACS-like symptoms, even in the absence of cardiovascular risk factors. Timely diagnosis and individualized management are essential to optimize outcomes.

Background: Large language models (LLMs) have emerged as transformative healthcare tools for clinical documentation, diagnostic reasoning, and medical education. However, effective utilization requires understanding prompt engineering principles-the strategic design of inputs to optimize performance while mitigating hallucination, bias, and outdated information.

Methods: This narrative review synthesizes evidence from a structured PubMed search through December 2025 using terms including "large language models," "prompt engineering," "clinical decision support," and "retrieval-augmented generation." We included peer-reviewed studies and systematic reviews from 2023 onwards, supplemented by manufacturer benchmarks (acknowledged as non-peer-reviewed), informed by a Belgian Society of Internal Medicine symposium (December 2025).

Results: Effective clinical prompt engineering requires four elements: role definition, context provision, task formulation, and output specification. Structured frameworks-RTF (Role-Task-Format) for routine tasks and BRAIN (Background, Role, Aim, Instructions, Next steps) for complex scenarios-provide systematic approaches. Advanced techniques including chain-of-thought reasoning, few-shot prompting, and retrieval-augmented generation (RAG) enhance performance. RAG improves accuracy by 9.8-16.3% while reducing hallucinations by 11.8-18%. A meta-analysis of 36 studies found pooled LLM accuracy of 72% on medical licensing examinations.Critical limitations persist: studies demonstrate an inverse correlation between model confidence and accuracy, with lower-performing models paradoxically exhibiting higher confidence. Independent clinical validation remains limited.

Conclusions: LLMs offer efficiency gains while requiring careful implementation. Physicians must develop prompt engineering competency, combining structured frameworks, RAG grounding strategies, and persistent human oversight for safe clinical integration. Prompt engineering literacy represents an essential emerging clinical skill.

Background: The association between age of onset or diabetes duration and all-cause mortality in individuals with type 2 diabetes (T2D) remains incompletely characterized. We aimed to clarify this relationship.

Methods: On February 8, 2025, we searched CINAHL, Scopus, PubMed, Cochrane Central, Embase, and Web of Knowledge for observational studies and post-hoc or subanalyses of randomized controlled trials (p-h/sa of RCTs) assessing the relationship between age of onset or diabetes duration and all-cause mortality. We pooled relative risks (RRs) using a random-effects model and assessed heterogeneity with Cochran's Q test and I² statistic. A leave-one-out sensitivity analysis confirmed the robustness of results. The protocol was not registered.

Results: Thirty-seven studies involving 2,857,346 participants were included. Earlier T2D onset was associated with higher all-cause mortality (pooled RR = 1.54; 95% CI: 1.03-2.32). When adjusting for current age, later onset correlated with lower mortality (pooled RR = 0.60; 95% CI: 0.44-0.83). Longer diabetes duration was linked to increased mortality (pooled RR = 1.43; 95% CI: 1.14-1.79), regardless of adjustment.

Conclusion: Earlier-onset T2D is consistently associated with higher all-cause mortality, suggesting it may serve as an important risk marker, though causality is not established. Asymmetry in funnel plots and Egger's tests suggests possible publication bias. Future well-designed studies should explore causal mechanisms to inform interventions.

Background: Anemia is the second most common comorbidity among patients with chronic kidney disease. Renal tubulointerstitial lesions in patients with primary glomerular disease may result in anemia. This study aims to demonstrate the relation between interstitial fibrosis (IF) grades and anemia parameters in patients with primary glomerulonephritis (PGN).

Methods: 358 biopsy-proven PGN patients were included for this retrospective, cross-sectional study. We recorded the biopsy findings, demographic, clinical, and laboratory parameters of all patients on the biopsy day. The IF/cortical tissue ratio was calculated and classified into three groups; none, mild and moderate-severe IF.

Results: The mean age of the patients was 43.0 ± 13.8 years, and 54.5% of patients were male. Anemia was present in 41.6% of patients. Hemoglobin and hematocrit decreased across rising IF categories (Hb: 13.1 vs 12.6 vs 12.3 g/dL; p = 0.026; post hoc difference driven by no IF vs moderate - severe IF, p = 0.046). However, in multivariable models, lower transferrin saturation, higher CRP, and lower eGFR were independently associated with anemia, whereas IF was not an independent determinant.

Conclusion: In PGN, IF severity correlates with lower hemoglobin, but does not independently predict anemia after accounting for iron status, inflammation, and kidney function. Anemia appears mainly related to iron availability, inflammatory conditions, and eGFR rather than IF.

Background: Osteofascial compartment syndrome (OCS) refers to a series of clinical syndromes caused by acute ischemia and hypoxia of the tissues inside a fascial compartment. OCS secondary to acute leukemia is extremely rare. Coagulopathy is a common phenomenon in acute promyelocytic leukemia (APL), which often leads to various bleeding complications.

Clinical presentation: We report the first case of APL complicated by OCS. The elderly female experienced differentiation syndrome, left forearm OCS, and rhabdomyolysis during the induction treatment. The coagulopathy ultimately resulted in a fatal cerebral hemorrhage.

Conclusion: Compared to the more commonly reported OCS associated with chronic leukemias, OCS secondary to APL is particularly perilous.

Objectives: Outpatient parenteral antimicrobial therapy (OPAT) offers a safe, effective, and resource-sparing alternative to inpatient treatment for various infections. Despite its widespread adoption globally, the implementation of OPAT programs in Belgium has been limited until recently. This study evaluates the safety, efficacy and healthcare impact of an OPAT program at a university hospital in Liège, Belgium.

Methods: We conducted a retrospective observational study at a 1038-bed tertiary teaching hospital, including patients who received OPAT between January 2018 and December 2021. Electronic medical records were reviewed for demographics, diagnoses, treatment regimens, adverse events, and outcomes. Potential risk factors for adverse events and treatment failure were investigated.

Results: A total of 352 OPAT episodes in 327 patients were analyzed. The most frequent indications were bloodstream infections (29.8%) and urinary tract infections (27.8%). Continuous antibiotic administration was used in 60.6% of cases, with a median OPAT duration of 16 days. Clinical cure was achieved in 86.4% of patients. Unplanned readmission linked to OPAT, infection-related death, drug-related adverse events, and line-related complications occurred in 8.2%, 1.1%, 5.1%, and 4.2% of episodes, respectively. Risk factors for adverse outcomes were identified, including cirrhosis, hematological malignancies, osteoarticular infections, chronic renal failure, and the use of specific antibiotics. The program avoided a mean of 1692 hospitalization days per year, underscoring its significant healthcare impact.

Conclusion: This study highlights the favorable outcomes and safety profile of the OPAT program at our tertiary teaching hospital. Tailored interventions and careful antibiotic selection are warranted for specific patient groups.

Introduction: Long-term use of benzodiazepines and Z-drugs (BZRA) remains widespread, despite guidelines recommending short-term use and highlighting the harms. On 1 February 2023, a tapering pilot program was launched in Belgium to facilitate deprescribing BZRA by enabling community pharmacists (CPs) to compound capsules with stepwise gradual dose reductions.

Aim: This study aims to explore the CPs' role in this program and the barriers and facilitators they encounter within the program.

Methodology: A cross-sectional survey study evaluating barriers and facilitators was conducted. Participants were randomly selected from the National Database of Community Pharmacies. Results were analyzed descriptively using the Theoretical Domains Framework to identify influences on behaviour change.

Results: Out of 2000 CPs contacted, 328 participants (16.4%) completed the survey. CPs rated their overall satisfaction with the program with a mean score of 7.4/10. Key facilitators identified included the relationship of trust between the patient, CP and general practitioner (GP), the patient's confidence in the CP's role in the program and the specific program elements. The most significant barriers were the CPs' perceived lack of interest from GPs and patients.

Conclusion: The Belgian pilot program has been positively received by CPs. Success factors are the interdisciplinary collaboration (social influences) and the specific elements of the program itself (environmental context and resources). To better understand the factors influencing participation, a qualitative in-depth exploration of CPs, GPs and patients perspectives of the tapering program is recommended. Furthermore, implementation outcomes, the sustainability of BZRA cessation and the benefits patients experience from discontinuation need to be investigated.