Acta Clinica Belgica最新文献

Background: Over 90% of patients with penicillin allergy do not have a true penicillin allergy. This allergy label can lead to inappropriate antibiotic prescription, a higher risk of treatment failure and toxicity, and higher rates of infections with multidrug-resistant organisms. Penicillin allergy delabeling strategies are increasingly reported and should be included in antimicrobial stewardship programs.

Objectives and methods: Development and phased implementation of a structured and proactive screening tool and decision algorithm for delabeling presumed penicillin allergy in the preoperative consultations of three non-university hospitals within the same locoregional network. Risk categorization was integrated into a user-friendly screening questionnaire, and streamlined actions were developed through interdisciplinary consensus.

Results: The questionnaire was implemented in two pilot phases, with adaptations through feedback from the users and other hospital networks working on penicillin allergy delabeling throughout Flanders. Among a total of 8.659 patients screened, 600 patients (6.93%) reported penicillin allergy, categorized as no risk, low, or high risk of penicillin allergy. 91 patients (15.17%) could be directly delabeled, and 33 patients (5.5%) were delabeled through patient file analysis or further testing.

Conclusion: A screening tool for proactive detection of penicillin allergy was developed. This study demonstrates that a substantial proportion of patients with a presumed penicillin allergy can be delabeled non-medically by administering a structured questionnaire, offering a step up towards comprehensive allergologic questioning and patient file analysis, with eventual additional testing in selected patients. The screening tool needs to be validated in a prospective trial including definitive categorization.

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.

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.

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.

Background: In this work, an innovative two-tier feature-optimized deep learning model is proposed for kidney stone detection in CT images. The framework uses a new modified ConvNeXt learning model to capture complex image patterns from CT images, along with the use of a LightGBM classifier.

Methods: A two-tier optimization strategy is implemented to refine the detection process. Initially, Dynamic Channel Pruning is used within the ConvNeXt architecture to identify and retain the most informative channels during feature extraction. By dynamically evaluating the importance of each channel, this step processes the most relevant channels, reducing computational complexity and highlighting critical features. Then, the Pufferfish Optimization Algorithm (POA) is applied for optimal feature selection. This optimization helps isolate the most discriminative features for kidney stone detection. Additionally, POA is applied to adjust the hyperparameters of the LightGBM classifier to increase classification accuracy and efficiency.

Results: The proposed model achieves the highest accuracy of 97.8%, compared with other models.

Conclusion: The proposed model achieves enhanced detection accuracy and efficiency through the use of Dynamic Channel Pruning and Pufferfish Optimization. This model offers a promising solution for kidney stone detection in CT images.

Background: This study sought to investigate the effects of polycystic kidney disease and tolvaptan administration on mucociliary clearance.

Methods: The cross-sectional study enrolled 30 patients with autosomal dominant polycystic kidney disease undergoing tolvaptan therapy, 30 patients with autosomal dominant polycystic kidney disease not on tolvaptan, and 30 healthy volunteers. Nasal mucociliary clearance time was determined using the saccharin transit time test, with a 1 mm diameter saccharin particle carefully placed on the anteromedial surface of the inferior nasal concha. Comparisons of mucociliary clearance time were then performed between the groups.

Results: In our study, the average mucociliary clearance time for patients with polycystic kidney disease was determined to be 9, in contrast to an average of 11 in the control group. A comparative analysis of patients receiving tolvaptan and those not receiving tolvaptan revealed an identical average mucociliary clearance time of 9 for both cohorts (p = 0.706). Furthermore, patients treated with tolvaptan demonstrated an average urine specific gravity of 1004, significantly lower than the 1011 observed in the non-tolvaptan group (p = 0.001).

Conclusion: This study indicates that the administration of tolvaptan yielded a beneficial impact on hydration status; however, this improved hydration did not translate into a significant effect on mucociliary clearance. Furthermore, the mucociliary clearance times recorded in the patient group were found to be in alignment with those typically associated with chronic kidney disease cohorts.

Aim: First Responder [FR] systems are associated with improved outcomes. However, this evidence has very low certainty. We aimed to explore - using real-life data - the reality of out-of-hospital cardiac arrest [OHCA] in a Belgian municipal region where there currently is no such system.

Methods: We explored the hypothetical potential for an FR in all cases of OHCA attended by the physician-staffed emergency medical services [EMS] team of Ghent University Hospital [07/2020-06/2021].

Results: Of the 200 attended cases, 76% were residential; 54% were unwitnessed. Bystander CPR occurred in 36.5%, a public-access AED was used in only three cases. Eleven patients survived beyond hospital discharge, all but one with good neurological outcomes. In 60%, we considered an FR obsolete from start (due to irreversible death, existing advance directive, resourceful setting, early EMS arrival, OHCA not recognized, or EMS witnessed). Another 10% were traumatic OHCA, a category universally excluded. Although impossible to identify those cases from the remaining 30% (n = 60) that would truly benefit, the actual number is likely far lower due to a.o. the likelihood of prolonged no-flow in unwitnessed residential OHCA (one-third or complicating contexts, victim accessibility, or FR availability).

Conclusion: There might be added value for an FR system in selected populations, but the associated cost-effectiveness ratios and the potential for harm should not be ignored. Better identification of victims potentially benefitting at the system point of entry is crucial.

Purpose: To unmask the alarming prevalence, intricate antimicrobial resistance patterns, and consequential clinical outcomes of World Health Organization (WHO) priority pathogens causing device-associated infections in critical care settings - a frontier analysis of silent pandemic threatening modern healthcare.

Methods: This groundbreaking retrospective study analysed data from 5,398 patients at risk for central line-associated bloodstream infections (CLABSI) and 15,416 patients for catheter-associated urinary tract infections (CAUTI) spanning 2021-2024. Microbial isolates were categorized according to WHO's priority pathogen classifications. Antimicrobial susceptibility profiles were comprehensively analysed using Clinical and Laboratory Standards Institute guidelines, with statistical analyses elucidating pathogen distribution dynamics, resistance mechanisms, and mortality correlations.

Results: Striking findings revealed WHO priority pathogens dominated the microbial landscape, constituting 76.47% of CLABSI and 82.14% of CAUTI isolates - with critical priority organisms overwhelmingly predominant (83.34% and 91.3%, respectively). Carbapenem-resistant Enterobacterales (CRE) emerged as the formidable leading threat (39.5% of CLABSI, 72.7% of CAUTI), while Carbapenem-resistant Acinetobacter baumannii (CRAB) demonstrated exceptional virulence with devastating mortality (93.33%). The study unveiled unprecedented levels of multidrug resistance, with most therapeutic options rendered ineffective; only colistin maintained universal efficacy against gram-negative isolates despite its concerning toxicity profile. Dramatic disparities in infection outcomes revealed CLABSI-associated mortality rates (71.79%) significantly eclipsed CAUTI (39.13%), establishing infection type as a critical independent predictor of survival.

Conclusions: This landmark investigation exposes the crossroad between WHO priority pathogens and healthcare-associated infections, sounding an urgent alarm for global healthcare systems. Our findings provide crucial evidence-based guidance for recalibrating therapeutic approaches, optimizing antimicrobial selection, and prioritizing infection control measures in intensive care settings worldwide.

Objective: This study aimed to assess changes in muscle mass and strength in patients hospitalized due to a diabetic foot ulcer, and to evaluate the impact of malnutrition at admission on these parameters.

Methods: This prospective observational cohort study included patients from February 2021 to July 2024. Anthropometric measurements, handgrip strength tests, and impedance analyses were conducted. Diagnosis of malnutrition was based on the Global Leadership Initiative on Malnutrition criteria. All patients received nutritional support during their hospital stay.

Results: Seventy-eight DFU patients (74% men, median age 72 years, median BMI 27.6 kg/m²) were recruited. Half of them was malnourished. Median hospital stay was 28 days. Overall, muscle mass and handgrip strength at admission and discharge did not differ significantly (18.31 ± 2.05 versus 18.08 ± 2.11 kg/m² and 26.02 ± 10.27 versus 26.45 ± 11.45 kg respectively). At admission, muscle mass was 17.25 ± 1.66 kg/m² in malnourished patients versus 19.37 ± 1.85 kg/m² in non-malnourished patients (p < 0.001), muscle strength was 24.82 ± 9.39 kg versus 27.23 ± 11.07 kg respectively (non-significant). Muscle mass change in malnourished patients was -0.039 ± 1.35 versus -0.562 ± 1.21 kg/m² for non-malnourished. Muscle strength change for malnourished patients was 0.4 (-8.3 to 15) and 0 (-2.90 to 2.70) kg for non-malnourished. Both changes were not significantly different.

Conclusion: DFU Patients exhibited no significant changes in muscle mass or strength during hospitalization, regardless of nutritional status at admission. Malnutrition did not significantly affect changes in muscle mass or strength during hospitalization. These findings indicate that the current clinical approach including nutritional counselling and support, appears to stabilize muscle health in this relatively immobile and fragile population.