[The year 2023 placed in perspective by hospital internists]. / Année 2023 mise en perspective par les internistes hospitaliers.

This article features a selection of ten topics chosen, reviewed, and commented for you by chief residents at the Department of Internal Medicine at Centre hospitalier universitaire vaudois (CHUV). This selection synthesizes the novelties and essential reminders of 2023 in internal medicine. By analyzing the standout publications of the year, it offers an overview of progress in diagnosis and patient management within the hospital and their transition to outpatient care. From oral anticoagulation to community-acquired pneumonias, encompassing the management of heart and kidney failure, each key aspect is explored. This compilation provides practitioners with an essential resource to remain at the forefront of current developments, thereby stimulating more informed and effective care for patients.

Cet article propose une sélection de dix sujets choisis, revus et commentés pour vous par les cheffes et chefs de clinique du Service de médecine interne du Centre hospitalier universitaire vaudois (CHUV). Cette sélection synthétise les nouveautés et rappels essentiels de 2023 en médecine interne. En analysant les publications phares de l'année, elle offre une vue d'ensemble des progrès dans le diagnostic et la prise en charge des patients intrahospitaliers et leur transition ambulatoire. De l'anticoagulation orale aux pneumonies communautaires en passant par la prise en charge des insuffisances cardiaque et rénale, chaque aspect clé est exploré. Cette compilation fournit aux praticiens une ressource essentielle pour rester à la pointe des développements actuels, stimulant ainsi des soins plus éclairés et efficaces pour les patients.

Transcaval versus Supra-Aortic Vascular Accesses for Transcatheter Aortic Valve Replacement: A Systematic Review with Meta-Analysis.

A growing body of evidence suggests that extrathoracic vascular accesses for transcatheter aortic valve replacement (TAVR) yield favorable outcomes and can be considered as primary alternatives when the gold-standard transfemoral access is contraindicated. Data comparing the transcaval (TCv) to supra-aortic (SAo) approaches (transcarotid, transsubclavian, and transaxillary) for TAVR are lacking. We aimed to compare the outcomes and safety of TCv and SAo accesses for TAVR as alternatives to transfemoral TAVR. A systematic review with meta-analysis was performed by searching PubMed/MEDLINE and EMBASE databases for all articles comparing TCv-TAVR against SAo-TAVR published until September 2023. Outcomes included in-hospital or 30-day all-cause mortality (ACM) and postoperative complications. A total of three studies with 318 TCv-TAVR and 179 SAo-TAVR patients were included. No statistically significant difference was found regarding in-hospital or 30-day ACM (relative risk [RR] 1.04, 95% confidence interval [CI] 0.47-2.34, p = 0.91), major bleeding, the need for blood transfusions, major vascular complications, and acute kidney injury. TCv-TAVR was associated with a non-statistically significant lower rate of neurovascular complications (RR 0.39, 95%CI 0.14-1.09, p = 0.07). These results suggest that both approaches may be considered as first-line alternatives to transfemoral TAVR, depending on local expertise and patients' anatomy. Additional data from long-term cohort studies are needed.

Extrathoracic Against Intrathoracic Vascular Accesses for Transcatheter Aortic Valve Replacement: A Systematic Review With Meta-Analysis.

Alternative vascular accesses to transfemoral access for transcatheter aortic valve replacement (TAVR) can be divided into intrathoracic (IT)-transapical and transaortic- and extrathoracic (ET)-transcarotid, transsubclavian, and transaxillary. This study aimed to compare the outcomes and safety of IT and ET accesses for TAVR as alternatives to transfemoral access. A systematic review with meta-analysis was performed by searching PubMed/MEDLINE and EMBASE databases for all studies comparing IT-TAVR with ET-TAVR published until April 2023. Outcomes included in-hospital or 30-day all-cause mortality (ACM), 1-year ACM, postoperative and 30-day complications. A total of 18 studies with 6,800 IT-TAVR patients and 5,032 ET-TAVR patients were included. IT accesses were associated with a significantly higher risk of in-hospital or 30-day ACM (relative risk 1.99, 95% confidence interval 1.67 to 2.36, p <0.001), and 1-year ACM (relative risk 1.31, 95% confidence interval 1.21 to 1.42, p <0.001). IT-TAVR patients presented more often with postoperative life-threatening bleeding, 30-day new-onset atrial fibrillation or flutter, and 30-day acute kidney injury needing renal replacement therapy. The risks of postoperative permanent pacemaker implantation and significant paravalvular leak were lower with IT-TAVR. ET-TAVR patients were more likely to be directly discharged home. There was no statistically significant difference regarding the 30-day risk of stroke. Compared with ET-TAVR, IT-TAVR was associated with higher risks of in-hospital or 30-day ACM, 1-year ACM and higher risks for some critical postprocedural and 30-day complications. Our results suggest that ET-TAVR could be considered as the first-choice alternative approach when transfemoral access is contraindicated.

[Acute respiratory failure†: non-invasive hospital management]. / Insuffisance respiratoire aiguë†: prise en charge hospitalière non invasive.

Acute respiratory failure is a complex physiopathological process and the choice of the most appropriate therapy has to be made between standard oxygen therapy (SOT), high-flow oxygen therapy through nasal cannula (High-Flow Nasal Cannula (HFNC)), non- invasive ventilation (NIV) or invasive ventilation. HFNC can deliver a higher and consistent inspired fraction of oxygen than SOT, but has not clearly demonstrated a clinical advantage over other methods. NIV is a therapy of choice in the management of acute exacerbation of chronic obstructive pulmonary disease and acute cardiogenic pulmonary edema, but its effectiveness in other indications is questionable. In any case, early detection of treatment failure is essential to avoid late tracheal intubation, which is associated with increased mortality.

L'insuffisance respiratoire aiguë est un processus physiopatho logique complexe et le choix de la thérapie la plus indiquée doit être fait entre l'oxygénothérapie standard (OS), l'oxygénothérapie à haut débit par canule nasale (High-Flow Nasal Cannula (HFNC)), la ventilation non invasive (VNI) ou la ventilation invasive. Le HFNC permet de délivrer une fraction inspirée d'oxygène plus élevée et constante que l'OS, mais n'a pas clairement démontré d'avantage clinique par rapport aux autres méthodes. La VNI est une thérapie de choix lors d'exacerbation aiguë de bronchopneumopathie chronique obstructive et d'œdème aigu du poumon cardiogénique, mais son efficacité dans les autres indications reste discutée. Dans tous les cas, la détection précoce de l'échec thérapeutique est primordiale afin d'éviter une intubation trachéale tardive, associée à une augmentation de la mortalité.