[Clarithromycin consumption at the University Hospital of Liege in 2019. Retrospective study]. / Consommation de la clarithromycine au CHU de Liège en 2019. Etude rétrospective.

Macrolides are one of the treatments of choice in community-acquired pneumonia, either when the clinical and/or biological elements suggest an infection by an intracellular bacteria (so-called atypical), or when the severity of the clinical picture justifies their empirical use. This work is a retrospective monocentric study carried out at the University Hospital of Liege on 25 consecutive patients hospitalized during the year 2019. It aims to specify whether the use of a particular macrolide, clarithromycin, actually meets the national recommendations both in terms of indication, dosage or duration. The results showed justified and adequate use in only 44 % of cases. Nevertheless, the indication was overwhelmingly mentioned in the medical record (96 %). Furthermore, the comparison with national data showed a much higher than average use at the University Hospital of Liege. An action plan is suggested to discuss these results within the Antibiotic Therapy Management Group and then communicate them to the prescribers who are concerned. The aim is to adapt the use of macrolides at the University Hospital of Liege to be more in line with national recommendations.

Les macrolides sont un des traitements de choix dans les pneumopathies communautaires, soit lorsque les éléments cliniques et/ou biologiques suggèrent une infection par une bactérie intracellulaire (dite atypique), soit lorsque la sévérité du tableau clinique justifie d'emblée leur usage empirique. Ce travail est une étude rétrospective monocentrique réalisée au CHU de Liège sur 25 dossiers consécutifs de patients hospitalisés durant l'année 2019. Il vise à préciser si l'usage d'un macrolide particulier, la clarithromycine, répond effectivement aux recommandations nationales, tant en matière d'indication, de posologie ou de durée. Les résultats ont montré un usage justifié et adéquat dans 44 % des cas seulement. Néanmoins, l'indication était très majoritairement mentionnée dans le dossier médical (96 %). Par ailleurs, la comparaison avec les données nationales a montré un usage bien supérieur à la moyenne au CHU de Liège. Un plan d'action est suggéré afin de discuter ces résultats au sein du Groupe de Gestion de l'Antibiothérapie pour, ensuite, les communiquer aux prescripteurs concernés. Cette stratégie est proposée afin d'adapter l'usage des macrolides au CHU de Liège pour qu'il s'accorde davantage avec les recommandations nationales.

[The first wave of COVID-19 in Intensive care]. / La première vague de la COVID-19 aux Soins intensifs, mars-mai 2020.

In December 2019, in Wuhan, a new human infectious pathology was born, COVID-19, consisting above all in pneumoniae, induced by the coronavirus named SARS-CoV-2 because of the respiratory distress it caused (SARS for severe acute respiratory syndrome, and CoV for Coronavirus). A real health and planetary crisis has appeared, much more substantial than that linked to SARS-CoV-1 in 2002-2004 and to MERS-CoV (Middle East Respiratory Syndrome Coronavirus) in 2012. In addition to respiratory damage that can be dramatic, this pathology is complicated by the frequency of cardiovascular, renal and coagulation diseases. Health care systems have had to adapt urgently, in the absence of hindsight from the pathology, and without effective therapeutic weapons. Through this review of the literature, we detail our local practices for the overall management of patients hospitalized in Intensive care.

En décembre 2019, à Wuhan, une nouvelle pathologie infectieuse humaine est née, le COVID-19, consistant avant tout en une pneumonie, induite par le coronavirus nommé SARS-CoV-2 en lien avec l'intensité de la détresse respiratoire qu'il entraîne (SARS pour syndrome respiratoire aigu sévère, et CoV pour coronavirus). Une véritable crise sanitaire et planétaire est apparue, bien plus conséquente que celle liée au SARS-CoV-1 en 2002-2004 et au MERS-CoV (Middle East Respiratory Syndrome Coronavirus) en 2012. Outre une atteinte respiratoire pouvant être dramatique, cette pathologie est complexifiée par la fréquence des atteintes cardiovasculaires, rénales et de la coagulation. Les systèmes de soins de santé ont dû s'adapter urgemment, en l'absence de recul face à la pathologie, et sans armes thérapeutiques efficaces. Au travers de cette revue de la littérature, nous détaillons nos pratiques locales pour la prise en charge globale des patients hospitalisés aux Soins intensifs.

[Acute respiratory distress syndrome]. / Le syndrome de détresse respiratoire aiguë.

Since its first description in 1967, a lot of progress has been made in understanding the pathophysiology, diagnosis and management of acute respiratory distress syndrome (ARDS). This nosological entity is based on the appearance of a diffuse alveolar damage associating pulmonary epithelial barrier disruption with an alveolar filling, both responsible of profound hypoxemia and important morbi-mortality. Nowadays, ARDS remains a frequent syndrome, associated with various etiologies. Diagnosis is based on the occurrence of acute hypoxic respiratory failure not explained by cardiac insufficiency or volume overload, within 7 days after a recognized risk factor, and in the presence of bilateral pulmonary opacities not fully explained by effusions, atelectasis or nodules on the chest radiography. Survivors present an increased risk of developing cognitive decline, depression, post-traumatic stress, and typical ICU related side-effects such as polyneuropathy and sarcopenia. In this context and not withstanding significant recent progress in the field of mechanical ventilation and extra-corporeal respiratory assistance, early diagnosis remains essential to identify patients with ARDS in order to offer them the most appropriate therapy.

Depuis sa première description en 1967, des progrès majeurs ont été réalisés dans la compréhension de la physiopathologie, le diagnostic et la prise en charge du syndrome de détresse respiratoire aiguë (SDRA). Cette entité nosologique repose sur l'apparition d'un dommage alvéolaire diffus associant une rupture de la barrière épithéliale pulmonaire avec un comblement alvéolaire à l'origine d'une hypoxémie profonde. De nos jours, le SDRA reste un syndrome fréquent, grevé d'une mortalité élevée, et prenant source dans de multiples situations pathologiques. Le diagnostic du SDRA repose sur l'apparition d'une insuffisance respiratoire aiguë hypoxique non expliquée par une insuffisance cardiaque ou une surcharge volémique, dans un délai de 7 jours suivant l'apparition d'un facteur de risque reconnu, en présence d'opacités pulmonaires bilatérales non complètement expliquées par des épanchements, des atélectasies ou des nodules. Les survivants sont à haut risque de développer un déclin cognitif, une dépression, ou un stress post-traumatique en plus des effets secondaires classiques d'une longue hospitalisation en unité de soins intensifs que sont la polyneuropathie ou la sarcopénie. Dans ce contexte, et en dépit de progrès importants dans le domaine de la ventilation mécanique et de l'assistance respiratoire par circulation extra-corporelle, il reste primordial d'identifier précocement les patients souffrant de SDRA afin de leur proposer la thérapeutique la plus appropriée dès les premiers signes cliniques.

[Micra® leadless pacemaker]. / Pacemaker miniature sans sonde de type Micra®.

The Micra® leadless pacemaker has demonstrated both safety and efficacy in the short and mid-term as an alternative to conventional transvenous pacemakers. This technology provides a new solution, especially for patients without conventional venous approach and for older patients with atrial fibrillation presenting with symptomatic bradycardia. The advantages of this approach are multiple : a miniature technology therefore less invasive, short procedure, no stimulation leads, or need to create a surgical pocket with a reduced risk of infection. The pacemaker's battery has a life expectancy similar to that of a conventional transvenous pacemaker. In this article, we discuss the characteristics of Micra® versus the traditional transvenous pacemaker.

Le stimulateur sans sonde Micra® a démontré à la fois sa sécurité et son efficacité, à court et moyen termes, comme alternative aux stimulateurs transveineux conventionnels. Cette technologie apporte une solution nouvelle, en particulier pour les patients sans abord veineux conventionnel et pour les patients plus âgés en fibrillation auriculaire, présentant des phases de bradycardies symptomatiques. Les avantages de cette approche sont multiples : une technologie miniature, donc moins invasive, une procédure courte, l'absence de sonde de stimulation, ou de nécessité de réaliser une poche chirurgicale avec diminution du risque infectieux. La batterie du pacemaker a une espérance de vie similaire à celle d'un pacemaker conventionnel transveineux. Dans cet article, nous discutons les caractéristiques du stimulateur sans sonde Micra® par rapport au stimulateur traditionnel transveineux.

[Severe cardiac arrhythmias]. / Les troubles du rythme cardiaque sévères.

Cardiac arrhythmias are a common cause of admission in the emergency department. Among these, atrio-ventricular conductive disorders and malignant ventricular arrhythmias are among the most severe, requiring prompt and appropriate management to ensure the best prognosis. Knowledge of the pathophysiology and etiology causing these arrhythmias is mandatory in order to understand its management, acute and chronic, and to facilitate the dialogue between emergency physicians and cardiologists.

Les arythmies cardiaques sont une cause fréquente d'admission aux urgences. Parmi celles-ci, les troubles conductifs atrio-ventriculaires et les arythmies ventriculaires et supraventriculaires malignes sont à classer parmi les plus sévères. Elles nécessitent une prise en charge rapide et appropriée afin de garantir le meilleur pronostic possible aux patients. La connaissance de la physiopathologie et des étiologies engendrant ce type d'arythmie est nécessaire afin d'en comprendre la prise en charge, aiguë et chronique, et de faciliter le dialogue entre urgentistes et cardiologues.

[Cardiac tamponade]. / La tamponnade cardiaque.

Cardiac tamponade is a vital emergency. It occurs when the accumulation of intra-pericardial fluid exceeds the pericardial adaptation capacity. Pericardial pressure is equalized with that of cardiac cavities and severe heart failure occurs, most often rapidly. Several clinical presentations are possible. The diagnosis is based on the assessment of pericardial effusion and its impact on the heart by echocardiography. Supportive treatments have limited effectiveness. The only emergency treatment is drainage of the pericardium by direct puncture or by surgical approach.

La tamponnade cardiaque est une urgence vitale. Elle survient quand l'accumulation de liquide intra-péricardique dépasse les capacités d'adaptation du péricarde. La pression péricardique s'égalise avec celle des cavités cardiaques et une insuffisance cardiaque sévère s'installe, le plus souvent rapidement. Plusieurs présentations cliniques sont possibles. Le diagnostic repose sur l'évaluation de l'épanchement péricardique et de ses répercussions sur le cœur par échocardiographie. Les mesures de supports ont une efficacité limitée. Le seul traitement d'urgence est le drainage du péricarde par ponction directe ou par abord chirurgical.

[Case report. Pulmonary embolism complicated by angioneurotic edema.] / Le cas clinique du mois. Embolie pulmonaire compliquée d'un œdème laryngé angioneurotique.

Although angioneurotic oedema (AE) is a rare entity, it sometimes leads to devastating consequences. We report the case of an oro-pharyngeal angioneurotic attack following the initiation of a fibrinolysis therapy by alteplase and relay by heparin in a patient with severe acute pulmonary embolism. In view of this original case, we propose to highlight the most recent elements concerning the physiopathology of this disease.

L'œdème angioneurotique (OAN) est une entité rare, dont les conséquences peuvent pourtant être parfois désastreuses. Nous présentons le cas d'un patient atteint d'une embolie pulmonaire grave ayant présenté un œdème angioneurotique oro-pharyngé dans le décours du traitement fibrinolytique et de son relais par héparinothérapie. A la lumière de cette présentation originale, nous proposons de discuter les éléments actuels concernant la physiopathologie de cette maladie et les facteurs favorisant le développement de cette maladie.

[European Society of Cardiology guidelines on cardiac resynchronization therapy]. / Recommandations européennes concernant la thérapie de resynchronisation cardiaque.

Cardiac resynchronization therapy (CRT) is one of the most successful heart failure therapies to emerge in the last 25 years; it is applicable to > 25-30% of patients with symptomatic heart failure. In this article, we summarize the recommendations of the European Society of Cardiology of 2013 on cardiac resynchronization therapy.

[Cardiac amyloidosis, about an atypical case]. / Le cas clinique du mois. Amyloïdose cardiaque, a propos d'un cas atypique.

A 64 year old patient with heart failure due to primary cardiac amyloidosis is described. This case offers the opportunity to review the literature dealing with the cardiac involvement associated with this disorder and the differential diagnosis of restrictive heart disease.

WIMAGINE(®): 64-channel ECoG recording implant for human applications.

A wireless 64-channel ElectroCorticoGram (ECoG) recording implant named WIMAGINE(®) has been designed for clinical applications. This active implantable medical device is able to record ECoG on 64 electrodes with selectable gain and sampling frequency, with less than 0.7 µVRMS input referred noise in the [0.5 Hz - 300 Hz] band. It is powered remotely through an inductive link at 13.56 MHz, communicates wirelessly on the MICS band at 402-405 MHz with a custom designed base station connected to a PC and complies with the regulations applicable to class III AIMD. The design of the housing and the antenna have been optimized to ease the surgery and to take into account all the requirements of a clinical trial in particular patient safety and comfort. The main features of this WIMAGINE(®) implantable device and its architecture will be presented, as well as its performances and in vivo validations.

A wireless 64-channel ECoG recording electronic for implantable monitoring and BCI applications: WIMAGINE.

A wireless, low power, 64-channel data acquisition system named WIMAGINE has been designed for ElectroCorticoGram (ECoG) recording. This system is based on a custom integrated circuit (ASIC) for amplification and digitization on 64 channels. It allows the RF transmission (in the MICS band) of 32 ECoG recording channels (among 64 channels available) sampled at 1 kHz per channel with a 12-bit resolution. The device is powered wirelessly through an inductive link at 13.56 MHz able to provide 100mW (30mA at 3.3V). This integration is a first step towards an implantable device for brain activity monitoring and Brain-Computer Interface (BCI) applications. The main features of the WIMAGINE platform and its architecture will be presented, as well as its performances and in vivo studies.

A wireless multichannel EEG recording platform.

A wireless multichannel data acquisition system is being designed for ElectroEncephaloGraphy (EEG) recording. The system is based on a custom integrated circuit (ASIC) for signal conditioning, amplification and digitization and also on commercial components for RF transmission. It supports the RF transmission of a 32-channel EEG recording sampled at 1 kHz with a 12-bit resolution. The RF communication uses the MICS band (Medical Implant Communication Service) at 402-405 Mhz. This integration is a first step towards a lightweight EEG cap for Brain Computer Interface (BCI) studies. Here, we present the platform architecture and its submodules. In vivo validations are presented with noise characterization and wireless data transfer measurements.

[Tachycardia-related cardiomyopathy: a case report]. / Cardiomyopathie rythmique.

Tachycardia-mediated cardiomyopathy is a form of dilated cardiomyopathy and heart failure induced by a persistent/chronic supraventricular or ventricular tachyarythmia. The incidence and the patho-physiology remain unspecified. Sometimes related to a previous cardiomyopathy, the diagnosis is always retrospective, but important because of the clinical and the significant haemodynamic improvement following the control of heart rate.

[Clinical case of the month. Atrial flutter with rapid ventricular response (1:1 atrioventricular conduction) caused by flecaïnide]. / Le cas clinique du mois. Flutter auriculaire avec réponse ventriculaire rapide (conduction auriculo-ventriculaire 1:1) lors d'un traitement par flécaïnide.

We report a case of 1:1 flutter in a patient taking flecaïnide for atrial fibrillation. We discuss the mechanism of the arrhythmia, its treatment and the preventive attitude to be adopted.

[Symptomatic left ventricular dysfunction and Behçet disease. Report of 2 cases]. / Dysfonction ventriculaire gauche symptomatique et maladie de Behçet. A propos de 2 cas.

Behçet's disease is associated with cardiac complications which may affect all three cardiac layers in 1 to 6% of cases. Although pericardial and coronary disease are the most common, the myocardium may also be affected. The clinical presentation may be left ventricular dysfunction with signs of dilated cardiomyopathy. The cause of the left ventricular dysfunction is usually coronary artery disease but it can also be inflammatory, resulting in a myocarditis with normal coronary arteries. The authors report two cases of Behçet's disease with symptomatic left ventricular dysfunction presenting as dilated cardiomyopathy with normal coronary arteries in one of the cases. Recent echocardiographic studies suggest that the incidence of myocardial disease is underestimated in this pathology: 20 to 35% of patients with Behçet's disease but no cardiac symptoms had left ventricular diastolic dysfunction. A more attentive investigation of left ventricular diastolic function in these patients should enable earlier diagnosis of this complication.

Speciation of arsenic and selenium compounds by ion-pair reversed-phase chromatography with electrothermic atomic absorption spectrometry. Application of experimental design for chromatographic optimisation.

An off-line system is proposed consisting of ion-pair reversed-phase liquid chromatography, collections of fractions at the outflow of the column and furnace atomic absorption spectrometry. The so-called system allowed determination of both arsenic and selenium species mainly found in the environment and in mammals (arsenite, arsenate, monomethylarsonate, dimethylarsinate, selenite, selenate, selenocystamine, selenocystine, selenomethionine and selenoethionine). In order to study the retention behaviour of these compounds and to estimate the optimal conditions for the chromatographic separation, central composite designs were used to evaluate the influence of the eluent parameters such as pH, tetrabutylammonium phosphate (TBA) concentration and sodium hydrogenphosphate amounts. The retention factors of each species and the selectivity were established as response criteria. Response surfaces and isoresponse curves were drawn from the mathematical models and enabled one to determine the optimal conditions and to visualise the method robustness. The predicted optimal zone was situated at pH 5.5-6.5, 4.0 mM Na2HPO4 and 3.0-4.0 mM TBA. Regression models suggested linearity for the studied compounds in the range 25-200 microg selenium and arsenic per litre investigated.

Application of central composite designs for optimisation of the chromatographic separation of monomethylarsonate and dimethylarsinate and of selenomethionine and selenite by ion-pair chromatography coupled with plasma mass spectrometric detection.

Central composite designs (CCDs) were used in the study of the ion-pair chromatographic separation of arsenic and selenium species in tap water: monomethylarsonate, dimethylarsinate, selenomethionine and selenite. The ternary eluent consisted of tetrabutylammonium phosphate (TBA), sodium hydrogenphosphate (Na2HPO4) and 1% acetonitrile. CCD allowed the investigation of the influence of the eluent parameters, which varied from 0.5 to 4.2 mmol l-1 Na2HPO4, 0.5 to 4.2 mmol l-1 TBA and pH 4.9 to 8.2, on the capacity factors (k') of arsenic and selenium compounds. Furthermore, another mathematical model that permitted the variation of the chromatographic selectivity of species, computed from their retention data to be followed, was investigated. This showed the ability to locate the optimum conditions within the experimental design, so that arsenic and selenium species could be simultaneously quantified with good efficiency and resolution. A comparison between the predicted and the experimental response values was made in order to assess the prediction quality of the model. Response surfaces and isoresponse curves obtained from the mathematical models allowed the determination of the optimum chromatographic conditions and the robustness of the method. The predicted optimum zone allowing satisfactory determination of both arsenic and selenium compounds was pH 5.5-6.5, 2.5 mmol l-1 Na2HPO4 and 3.0-4.0 mmol l-1 TBA.

Comparison of high dose buprenorphine treatments of opiate dependent outpatients in four healthcare networks.

AIMS: The aim of this study was to compare the various clinical practices in four health care networks and to access how the variations in treatment effected the outcome in opiate-dependent patients. METHODS: A retrospective study was carried out with 71 participating general practitioners. These were chosen from a group of 354 practitioners from four health care networks. Each practitioner could enroll up to 5 patients who were currently undergoing treatment with high-dose buprenorphine(HDB). The patients treatment had to have been initiated between the 1(st) of February 1996 and the 31(st) of October 1996, and excluded any patients who had lapsed on their treatment during the first month. Patients were selected until a total of 75 cases were enrolled from each network. Data were then collected retrospectively between June and December 1997. Information collected concerned the initial stage of treatment, the stabilizing stage or level of treatment and followed up data on the most recent prescriptions. RESULTS: The final patient maintenance totals were high for all four care networks (82.7 to 96% of patients were still being followed by their doctor at the final evaluation). A positive outcome as indicated by reduction of risk and decreased social vulnerability was also observed in all networks. Additionally, in each network there was a clear correlation between prescription practices and patient behavior. For example, the prescription of HDB at a daily dose of less than 6.2mg was associated with a higher rate of benzodiazepine use; and prescription of several daily doses of HDB was associated with a higher percentage of injecting patients. CONCLUSION: This retrospective study provides evidence that general practitioner care of drug-dependent patients as outpatients, within a health care network helps to stabilize patient visits, allows treatment of associated comorbidities and favors social rehabilitation. The prescription of HDB as a single daily dose, individually adapted for each patient, optimizes the outcome and reduces misuse.

[Follow-up of opioid addicts treated with high-dose buprenorphine in a health care network. National retrospective study. Experience of French general physicians]. / Suivi de patients pharmacodépendants aux opiacés traités par buprénorphine haut dosage à partir de réseaux de soins. Etude rétrospective nationale. Expérience de médecins généralistes français.

AIMS: This study was designed to examine the profile of drug-dependent outpatients treated by general practitioners working in a health care network and to evaluate the impact of treatment with high-dose buprenorphine on their medical and social status. METHODS: A retrospective study was undertaken by 71 general practitioners, selected at random from physicians in four health care networks. Data for the period between June and December 1997 concerning the initial prescription, the first stabilization prescription and the most recent prescription, was collected retrospectively. RESULTS: Among the outpatients included in this study, high-dose buprenorphine treatment resulted in a clear reduction in the use of heroin (69.9%) and benzodiazepine (57.1%). It also reduced associated risks of infection and social vulnerability. CONCLUSION: This retrospective study seems to show that care by general practitioners proceeds satisfactorily. The majority of opiate-dependent outpatients were compliant with treatment and successfully reintegrated into society. This method of treatment will be effective if specialised training is given to the general practitioners within the framework of a health care network.