[European guidelines for the diagnosis and management of acute pulmonary embolism]. / Recommandations européennes concernant le diagnostic de l'embolie pulmonaire.

Pulmonary embolism (PE) is the third cause of cardiovascular death in industrialized countries. The difficulty lies on the diagnosis and is linked to the clinical pre-sentation which is often non-specific. The use of diagnostic scores and paraclinical examinations help the clinician in the management and assessment of the risk of death. This article aims to optimize knowledge and management of pulmonary embolism by revising the latest recommendations from the European Society of Cardiology 2019.

L'embolie pulmonaire (EP) représente la troisième cause de décès cardiovasculaire dans les pays industrialisés. La difficulté réside dans le diagnostic et est liée à la présentation clinique qui est souvent aspécifique. L'utilisation de scores diagnostiques et d'examens paracliniques permet d'aider le clinicien dans la prise en charge et l'évaluation du risque de mortalité. Cet article a pour objectif d'optimaliser les connaissances et la prise en charge de l'embolie pulmonaire en parcourant les dernières recommandations de la Société Européenne de Cardiologie de 2019.

[Left ventricular non-compaction : diagnosis and management]. / Non-compaction du ventricule gauche : diagnostic et prise en charge.

Isolated left ventricular non-compaction (LVNC) is a congenital disorder characterized by prominent myocardial trabeculations and deep intertrabecular recesses. Although LVNC is diagnosed by echocardiography and cardiac magnetic resonance, there is no evidence-based imaging diagnostic criteria. Affected individuals are at risk of left ventricular failure, life-threatening arrhythmias and cardio-embolism. The diagnosis may be difficult in the atypical forms. The management remains controversial and depends on the clinical manifestations. Familial forms exist, ordering for genetic counseling. The aim of this article is to optimize the knowledge and the management of LVNC by reminding the diagnostic criteria used.

La non-compaction du ventricule gauche (NCVG) est une malformation congénitale caractérisée par la présence de trabéculations proéminentes et des récessus intertrabéculaires profonds. Bien que la NCVG puisse être diagnostiquée par l'échocardiographie ou l'imagerie par résonance magnétique (IRM) cardiaque, il n'y a actuellement pas de critère permettant un diagnostic formel. Les patients atteints sont à risque de présenter une insuffisance cardiaque, des arythmies malignes et des événements thrombo-emboliques. Le diagnostic peut être difficile dans les formes atypiques. La gestion thérapeutique est controversée et dépend de la présentation clinique. Les formes familiales existent, justifiant un conseil génétique. Cet article a pour objectif d'optimaliser les connaissances et la prise en charge de la NCVG en rappelant les critères diagnostiques actuels.

Susceptibility to Exercise-Induced Muscle Damage: a Cluster Analysis with a Large Sample.

We investigated the responses of indirect markers of exercise-induced muscle damage (EIMD) among a large number of young men (N=286) stratified in clusters based on the largest decrease in maximal voluntary contraction torque (MVC) after an unaccustomed maximal eccentric exercise bout of the elbow flexors. Changes in MVC, muscle soreness (SOR), creatine kinase (CK) activity, range of motion (ROM) and upper-arm circumference (CIR) before and for several days after exercise were compared between 3 clusters established based on MVC decrease (low, moderate, and high responders; LR, MR and HR). Participants were allocated to LR (n=61), MR (n=152) and HR (n=73) clusters, which depicted significantly different cluster centers of 82%, 61% and 42% of baseline MVC, respectively. Once stratified by MVC decrease, all muscle damage markers were significantly different between clusters following the same pattern: small changes for LR, larger changes for MR, and the largest changes for HR. Stratification of individuals based on the magnitude of MVC decrease post-exercise greatly increases the precision in estimating changes in EIMD by proxy markers such as SOR, CK activity, ROM and CIR. This indicates that the most commonly used markers are valid and MVC orchestrates their responses, consolidating the role of MVC as the best EIMD indirect marker.

[Blunt cerebrovascular injury]. / Le cas clinique du mois. Accident vasculaire ischémique, secondaire à un polytraumatisme chez un enfant.

A blunt cerebrovascular injury (BCVI) can cause severe cerebral ischemic sequelae. The diagnosis is tricky and often entails a latency period. Adequate treatment at this time will dramatically reduce mortality and morbidity. The Denver protocol guides the selection of the patients to be screened. Current treatment is based on heparin, anticoagulant antiplatelet drugs, interventional radiology and surgery. The treatment is based on a dynamic strategy.

Les lésions artérielles des vaisseaux du cou et de l'encéphale par traumatisme fermé peuvent provoquer de graves séquelles ischémiques cérébrales. Leur diagnostic est délicat et requiert très souvent une période de latence. Une thérapeutique adéquate à ce moment peut considérablement réduire la mortalité et la morbidité. Le protocole de Denver vise à déterminer quel patient doit être dépisté. Le traitement actuel fait appel à l'héparine, aux antiagrégants, à la radiologie interventionnelle et à la chirurgie. La stratégie thérapeutique est dynamique.

Greater eccentric exercise-induced muscle damage by large versus small range of motion with the same end-point.

Several factors can affect the magnitude of eccentric exercise (ECC)-induced muscle damage, but little is known regarding the effect of the range of motion (ROM) in ECC-induced muscle damage. The purpose of this study was to investigate whether elbow flexor ECC with 120° of ROM (from 60° of elbow flexion until elbow full extension - 180° [120ROM]) induces a greater magnitude of muscle damage compared with a protocol with 60° of ROM (120-180° of elbow flexion [60ROM]). Twelve healthy young men (age: 22 ± 3.1 years; height: 1.75 ± 0.05 m; body mass: 75.6 ± 13.6 kg) performed the ECC with 120ROM and 60ROM using different arms in a random order separated by 2 weeks and were tested before and 24, 48, 72 and 96 h after ECC for maximal voluntary isometric contraction torque (MVC-ISO), ROM and muscle soreness. The 120ROM protocol showed greater changes and effect sizes (ES) for MVC-ISO (-35%, ES: 1.97), ROM (-11.5°, ES: 1.27) and muscle soreness (19 mm, ES: 1.18) compared with the 60ROM protocol (-23%, ES: 0.93; -12%, ES: 0.56; 17°, ES: 0.63; 8 mm, ES: 1.07, respectively). In conclusion, ECC of the elbow flexors with 120° of ROM promotes a greater magnitude of muscle damage compared with a protocol with 60° of ROM, even when both protocols are performed at long muscle lengths.

[End of life care in the elderly]. / Gérer la fin de vie chez le sujet âgé.

The increase in life expectancy is associated with a good quality of life until a very old age. However, the unavoidable aging process eventually affects the autonomy of the patient and may force the individual to live in a nursing home. The alteration of sensorial functions and the increased number of degenerative diseases may finally induce a physical and psychological burden that might lead to resort to palliative care, end of life sedation, and in some cases, euthanasia.

[Implementation of a massive transfusion protocol in an emergency department]. / Mise en place d'un protocole de transfusion massive dans un service d'urgences.

We present here the massive transfusion protocol implemented in our institution in 2013. It will improve our management of critical massive bleeding, a situation which is rare in in our hospital, but carries a high mortality risk.

[Which is the place of the human being inside the recommendations, multidisciplinary oncological meetings, and treatment plan?]. / Quelle est la place de l'humain au sein des recommandations, des concertations oncologiques multidisciplinaires et du projet thérapeutique?

Nowadays, the cancer patient has access to a highly technical, more and more targeted and increasingly individualized medicine. And the human being in that matter ? Numerous tools have been developed to help physicians and caregivers to reconcile contemporary medicine and the rights of the patient. Among these are multidisciplinary oncology meetings and treatment guidelines published by national and international scientific societies. The patients care must be cross-disciplinary and evidence-based. This shared decision-making process should at the end be in accordance with the wishes of the patient. This approach should allow him/her to maintain autonomy and be the main actor in the decision-making process.

[Clinical case of the month. An unusual sepsis]. / Un sepsis mystérieux.

Lemierre's syndrome is a rare, but significant pathology to recognize. It most often affects young patients in good health; a late diagnosis can be fatal. It consists in an anaerobic septicemia (usually, Fusobacterium necrophorum) originating from a suppurative thrombophlebitis of the internal jugular vein. Infection occurs during a common sore throat and spreads by contiguity. The clinical presentation is a sepsis with pulmonary embolisations, but other sites of dissemination can also occur. Treatment consists of prolonged intravenous antibiotherapy associated with supportive therapy, if needed. Anticoagulation remains controversial. The outcome is favorable in most cases provided diagnosis and treatment are early; mortality however remains significant, around 5%.

[Iodinated contrast media and iodine allergy: myth or reality?]. / Produits de contraste iodés et "allergie a l'iode" mythe ou réalité ?

The term "iodine allergy" is an old phrase that refers to a reaction to iodinated contrast media. After a brief review of definitions, pathophysiological mechanisms and risk factors of this clinical entity, management is urged immediate and delayed according to the most recent recommendations from the literature. We underline that iodine allergy, as such, does not really exist.

[Continuous sedation: practical and ethical aspects]. / Sédation continue: considérations pratiques et éthiques.

Continuous sedation is an acknowledged medical practice in the management of refractory symptoms at the end of life. Guidelines and recommendations have been proposed in palliative care. This paper presents the state-of-the-art (definitions, indications, technical aspects) on continuous sedation followed by an ethical reflection essentially based on the "double effect" principle, on the impact on life expectancy and the assimilation of continuous sedation as a "natural death". Distinction between continuous sedation and legal euthanasia is clarified.

Intracranial subdural hematoma following spinal anesthesia: case report and review of the literature.

Postdural puncture headaches represent one of the main complications of spinal anesthesia. Sometimes, they can reveal the presence of an intracerebral hemorrhage or intracranial subdural hematoma. Atypical postdural puncture headaches or secondary alterations of a typical headache, and particularly the disappearance of its postural character, must prompt to search for another cause. Early diagnosis and careful and rapid management are mandatory. We here report the case of a 53-year-old woman who presented with an intracranial subdural hematoma following spinal anesthesia for hallux valgus surgery performed 48 hours earlier. The implications of such a diagnosis are then discussed, in the light of the existing literature.

Liver transplant donation after cardiac death: experience at the University of Liege.

OBJECTIVE: Donation after cardiac death (DCD) has been proposed to overcome in part the organ donor shortage. In liver transplantation, the additional warm ischemia time associated with DCD procurement may promote higher rates of primary nonfunction and ischemic biliary lesions. We reviewed the results of liver transplantation from DCD. PATIENTS AND METHODS: From 2003 to 2007, we consecutively performed 13 controlled DCD liver transplantations. The medical records of all donors and recipients were retrospectively reviewed, evaluating in particular the outcome and occurrence of biliary complications. Mean follow-up was 25 months. RESULTS: Mean donor age was 51 years, and mean intensive care unit stay was 5.4 days. Mean time between ventilation arrest and cardiac arrest was 9.3 minutes. Mean time between cardiac arrest and arterial flushing was 7.7 minutes. No-touch period was 2 to 5 minutes. Mean graft cold ischemia time was 295 minutes, and mean suture warm ischemia time was 38 minutes. Postoperatively, there was no primary nonfunction. Mean peak transaminase level was 2546 UI/mL. Patient and graft survival was 100% at 1 year. Two of 13 patients (15%) developed main bile duct stenosis and underwent endoscopic management of the graft. No patient developed symptomatic intrahepatic bile duct strictures or needed a second transplantation. CONCLUSIONS: Our experience confirms that controlled DCD donors may be a valuable source of transplantable liver grafts in cases of short warm ischemia at procurement and minimal cold ischemia time.

IgG4-related pleural disease in a patient with a history of unknown origin acute pancreatitis: a case report and review of the literature.

Immunoglobulin G4-related disease is a rare autoimmune systemic disease with the capability of involving every organ. The disease is microscopically defined by a diffuse tissular inflammation with an infiltration of IgG4 positive plasma cells in the affected organs. IgG4 disease has an increasing incidence in the last few years with a growing interest in its pathophysiology still misunderstood to date. Despite the growing recognition of this pathology, the literature still does not allow to propose a simple diagnostic algorithm. In this article, we present a case of a 56-year-old man with a history of unknown etiology acute pancreatitis and a unilateral pleural effusion.

Diagnostic and prognostic use of bispectral index in coma, vegetative state and related disorders.

PRIMARY OBJECTIVE: This study investigates (1) the utility of the bispectral index (BIS) to distinguish levels of consciousness in severely brain damaged patients and, particularly, disentangle vegetative state (VS) from minimally conscious state (MCS), as compared to other EEG parameters; (2) the prognostic value of BIS with regards to recovery after 1 year. RESEARCH DESIGN: Multi-centric prospective study. METHOD AND PROCEDURES: Unsedated patients recovering from coma were followed until death or transferal. Automated electrophysiological and standardized behavioural assessments were carried out twice a week. EEG recordings were categorized according to level of consciousness (coma, VS, MCS and Exit MCS). Outcome was assessed at 1 year post-insult. MAIN OUTCOMES AND RESULTS: One hundred and fifty-six EEG epochs obtained in 43 patients were included in the analyses. BIS showed a higher correlation with behavioural scales as compared to other EEG parameters. Moreover, BIS values differentiated levels of consciousness and distinguished VS from MCS while other EEG parameters did not. Finally, higher BIS values were found in patients who recovered at 1 year post-insult as compared to patients who did not recover. CONCLUSION: EEG-BIS recording is an interesting additional method to help in the diagnosis as well as in the prognosis of severely brain injured patients recovering from coma.

[Blink and you live: the locked-in syndrome]. / Le Locked-In Syndrome: la conscience emmurée.

INTRODUCTION: The Locked-In syndrome (LIS) is defined by: (i) the presence of sustained eye opening (bilateral ptosis should be ruled out as a complicating factor); (ii) preserved awareness; (iii) aphonia or hypophonia; (iv) quadriplegia or quadriparesis; and (v) a primary mode of communication that uses vertical or lateral eye movement or blinking. Acute ventral pontine lesions are its most common cause. Following such brainstem lesions patients may remain comatose for some time and then gradually awaken, remaining paralyzed and voiceless, superficially resembling the vegetative state. BACKGROUND: It has been shown that more than half of the time physicians fail to recognize early signs of awareness in LIS. Given appropriate medical care, life expectancy may be several decades but the chances of good motor recovery remain small. Eye-controlled computer technology now allows LIS patients to communicate and control their environment. Recent studies show that most LIS patients self-report meaningful quality of life and the demand for euthanasia is infrequent. CONCLUSION: Patients suffering from LIS should not be denied the right to die--and to die with dignity--but also they should not be denied the right to live--and to live with dignity and the best possible pain and symptom management and revalidation.

[Predicting prognosis in post-anoxic coma]. / Comment prédire l'évolution du coma post-anoxique?

Most patients who remain comatose for a few hours after a period of global cerebral ischemia have a poor prognosis. Early identification of these patients is desirable to reduce uncertainty about treatment and non-treatment decisions, and to improve relationships with the family. The absence of pupillary light response and corneal reflexes, absent or stereotyped extension motor response to noxious stimulation (3 days after insult); myoclonus status epilepticus; absence of cortical N20 response on somatosensory evoked potential studies; generalised suppression or burst-suppression EEG and serum neuron-specific enolase above 33 microg/L (sampled 1-3 days after insult) have been shown to predict poor outcome. We here propose an algorithm to help intensive care physicians' clinical decision making in post-anoxic coma.

[The hemolytic uremic syndrome: prime reason for acute renal failure in children]. / Le syndrome hémolytique et urémique. Première cause d'insuffisance rénale aiguë de l'enfant.

The Hemolytic Uremic Syndrome (HUS) is the prime cause for acute renal failure in children. The HUS is a combination of hemolytic anemia, thombopenia and acute nephropathy: all signs of a thrombotic microangiopathy. Onset occurs generally in infancy and is often associated with severe bloody diarrhea. Most of those cases are caused by Escherichia coli O157:H7 witch produces an exotoxin responsible for the microangiopathy. We discuss the treatment of HUS based on the experience acquired since 1994 in our Paediatric Intensive Care Unit (PICU), University of Liege. The frequent association of dehydration, multi-systemic impairment and reno-vascular hypertension justifies the early admission for PICU-surveillance. This allows the difficult fluid balance management in a setting of renal and pre-renal failure.

Reversal of neurological deficit with naloxone: an additional report.

We report the repeated improvement in neurological function following naloxone administration in a patient who developed acute hemiplegia after an intracranial neurological procedure. The mechanisms responsible for the neurological deficit and for its reversal by naloxone are discussed. A review of the literature suggests that the beneficial effect of naloxone can result from an improvement in haemodynamic status or from metabolic effects that could be favorable during cerebral ischaemia.

Evaluation of acute normovolemic hemodilution for surgical repair of craniosynostosis.

This clinical report investigated the potential benefit of acute normovolemic hemodilution (ANH) as a blood-saving technique in the surgical repair of craniosynostosis. Over a 4-year period, 34 healthy children undergoing surgical repair of scaphocephaly or pachycephaly were randomly assigned to two groups of 17 patients each. Patients of the first group (ANH group) were submitted to ANH (target Ht: 25%) immediately before surgery and patients of the second group (Control group) were not. During surgery, estimated blood loss was compensated with a 5% albumin solution and no autologous or homologous blood was transfused. At the end of surgery, intraoperative blood loss (mean +/- SD) calculated on the basis of the Ht value and the children weight was 21.3+/-8% of the estimated blood volume (EBV) in the ANH group and 24+/-6.6% in the Control group. Children of the ANH group received their autologous blood (18.9+/-3.3% of EBV) systematically at the end of surgery. In the postoperative period, homologous blood was transfused when the Ht value was equal or less than 21%. Both groups were comparable regarding age, weight, type of craniosynostosis, duration of surgery, EBV, and preoperative Ht value. No difference was observed between ANH and Control groups in the number of patients who received homologous blood (15/17 and 14/17, respectively), in the amount of homologous blood transfused (17+/-4.7% and 19.6+/-6.3% of the EBV, respectively), and in the Ht value before hospital discharge (29.4+/-5.0% and 30.7+/-4.9%, respectively). In conclusion, this report suggests that ANH reduces neither the incidence of homologous transfusion nor the amount of homologous blood transfused in this series of children undergoing surgical repair of craniosynostosis.