[Vitamin D intoxication and "milk alkali syndrome"]. / 5 minutes pour apprendre. Intoxication à la vitamine D et « milk alkali syndrome ¼.

A 80-year-old patient treated with calcium bicarbonate for a reflux developed a milk alkali syndrome after a high doses of vitamin D for a conservatively treated heel fracture. The article highlights the milk alkali syndrome as a potential complication of excessive vitamin D supplementation, emphasizing that routine vitamin D testing and supplementation should be limited to specific situations.

Comparative Evaluation of the ABC Score to Other Risk Stratification Scales in Managing High-risk Patients Presenting With Acute Upper Gastrointestinal Bleeding.

OBJECTIVE: The ABC risk score identifies patients at high risk of mortality in acute lower and upper gastrointestinal bleeding (UGIB). We aimed to externally validate the ABC score while comparing it to other prognostication scales when assessing UGIB patients at high risk of negative outcomes before endoscopy. METHODS: UGIB patients from a national Canadian registry (REASON) were studied, with mortality prediction as a primary outcome. Secondary endpoints included prognostication of rebleeding, intensive care unit (ICU) admission, ICU and hospitalization lengths of stay (LOS), and a previously proposed composite outcome measure. Univariable and areas under the receiver operating characteristic curve analyses compared discriminatory abilities of the ABC score to the AIMS65, Glasgow Blatchford Scale (GBS), and clinical Rockall score. RESULTS: The REASON registry included 2020 patients [89.4% nonvariceal; mean age (±SD): 66.3±16.4 y; 38.4% female]. Overall mortality, rebleeding, ICU admission, transfusion and composite score rates were 9.9%, 11.4%, 21.1%, 69.0%, and 67.3%, respectively. ICU and hospitalization LOS were 5.4±9.3 and 9.1±11.5 days, respectively. The ABC score displayed superior 30-day mortality prediction [0.78 (0.73; 0.83)] compared with GBS [0.69 (0.63; 0.75)] or clinical Rockall [0.64 (0.58; 0.70)] but not AIMS65 [0.73 (0.67; 0.79)]. Although most scales significantly prognosticated secondary outcomes in the univariable analysis except for ICU LOS, discriminatory abilities on areas under the receiver operating characteristic curve analyses were poor. CONCLUSIONS: ABC and AIMS65 display similar good prediction of mortality. Clinical usefulness in prognosticating secondary outcomes was modest for all scales, limiting their adoptions when informing early management of high-risk UGIB patients.

[Check-ups in daily practice: myths and reality]. / Check-up en pratique : mythes et réalités.

Regular general health check-ups in asymptomatic patients seem not impacting important outcomes. As such, it is no longer recommended by the Swiss Society of General Internal Medicine as part of its «smartermedicine¼ campaign. Physicians should focus on a medical follow-up based on risk-appropriate screening, regular evaluation of lifestyle habits, monitoring of bio-psycho-social well-being, regular re-evaluation of medication and vaccinations. Prevention during the medical consultation is thus rethought, based on a relationship of trust between doctor and patient, with an exchange of views on the need for interventions and screenings based only on scientific evidence.

Tel qu'il est couramment pratiqué, le check-up ou bilan de santé annuel n'a pas prouvé de bénéfice sur la mortalité, ni sur les événements cardiovasculaires. Ainsi, il n'est plus recommandé par la Société suisse de médecine interne générale dans le cadre de sa campagne « smartermedicine ¼. Les médecins devraient privilégier un suivi médical basé sur les dépistages recommandés selon le profil de risque, l'évaluation régulière de l'hygiène de vie, le suivi du bien-être biopsychosocial, la réévaluation régulière des médicaments et des vaccinations. La prévention lors de la consultation médicale est ainsi repensée en se basant sur une relation de confiance entre le médecin et le patient, avec un échange sur la nécessité des interventions et des dépistages qui reposent uniquement sur des évidences scientifiques.

A new screening tool for SARS-CoV-2 infection based on self-reported patient clinical characteristics: the COV19-ID score.

BACKGROUND: While several studies aimed to identify risk factors for severe COVID-19 cases to better anticipate intensive care unit admissions, very few have been conducted on self-reported patient symptoms and characteristics, predictive of RT-PCR test positivity. We therefore aimed to identify those predictive factors and construct a predictive score for the screening of patients at admission. METHODS: This was a monocentric retrospective analysis of clinical data from 9081 patients tested for SARS-CoV-2 infection from August 1 to November 30 2020. A multivariable logistic regression using least absolute shrinkage and selection operator (LASSO) was performed on a training dataset (60% of the data) to determine associations between self-reported patient characteristics and COVID-19 diagnosis. Regression coefficients were used to construct the Coronavirus 2019 Identification score (COV19-ID) and the optimal threshold calculated on the validation dataset (20%). Its predictive performance was finally evaluated on a test dataset (20%). RESULTS: A total of 2084 (22.9%) patients were tested positive to SARS-CoV-2 infection. Using the LASSO model, COVID-19 was independently associated with loss of smell (Odds Ratio, 6.4), fever (OR, 2.7), history of contact with an infected person (OR, 1.7), loss of taste (OR, 1.5), muscle stiffness (OR, 1.5), cough (OR, 1.5), back pain (OR, 1.4), loss of appetite (OR, 1.3), as well as male sex (OR, 1.05). Conversely, COVID-19 was less likely associated with smoking (OR, 0.5), sore throat (OR, 0.9) and ear pain (OR, 0.9). All aforementioned variables were included in the COV19-ID score, which demonstrated on the test dataset an area under the receiver-operating characteristic curve of 82.9% (95% CI 80.6%-84.9%), and an accuracy of 74.2% (95% CI 74.1%-74.3%) with a high sensitivity (80.4%, 95% CI [80.3%-80.6%]) and specificity (72.2%, 95% CI [72.2%-72.4%]). CONCLUSIONS: The COV19-ID score could be useful in early triage of patients needing RT-PCR testing thus alleviating the burden on laboratories, emergency rooms, and wards.

Occupational risk of SARS-CoV-2 infection and reinfection during the second pandemic surge: a cohort study.

OBJECTIVES: This cohort study including essential workers, assessed the risk and incidence of SARS-CoV-2 infection during the second surge of COVID-19 according to baseline serostatus and occupational sector. METHODS: Essential workers were selected from a seroprevalence survey cohort in Geneva, Switzerland and were linked to a state centralised registry compiling SARS-CoV-2 infections. Primary outcome was the incidence of virologically confirmed infections from serological assessment (between May and September 2020) to 25 January 2021, according to baseline antibody status and stratified by three predefined occupational groups (occupations requiring sustained physical proximity, involving brief regular contact or others). RESULTS: 10 457 essential workers were included (occupations requiring sustained physical proximity accounted for 3057 individuals, those involving regular brief contact, 3645 and 3755 workers were classified under 'Other essential occupations'). After a follow-up period of over 27 weeks, 5 (0.6%) seropositive and 830 (8.5%) seronegative individuals had a positive SARS-CoV-2 test, with an incidence rate of 0.2 (95% CI 0.1 to 0.6) and 3.2 (95% CI 2.9 to 3.4) cases per person-week, respectively. Incidences were similar across occupational groups. Seropositive essential workers had a 93% reduction in the hazard (HR of 0.07, 95% CI 0.03 to 0.17) of having a positive test during the follow-up with no significant between-occupational group difference. CONCLUSIONS: A 10-fold reduction in the hazard of being virologically tested positive was observed among anti-SARS-CoV-2 seropositive essential workers regardless of their sector of occupation, confirming the seroprotective effect of a previous SARS-CoV2 exposure at least 6 months after infection.

[Acute hepatitis as an inaugural presentation of systemic lupus erythematosus]. / Hépatite aiguë comme présentation inaugurale d'un lupus érythémateux systémique.

Systemic lupus erythematosus (SLE) is a complex multiorgan autoimmune disease with varied clinical and laboratory manifestations. Although common in lupus disease, liver test disturbance is rarely seen as a primary manifestation at diagnosis. In this case report, we describe acute hepatitis as the initial presentation of SLE in a young woman.

Le lupus érythémateux systémique (LES) est une maladie autoimmune multiorganique complexe aux manifestations cliniques et biologiques variées. Bien que fréquente au cours de la maladie lupique, une perturbation des tests hépatiques est rarement observée comme manifestation principale au moment du diagnostic. Dans ce cas clinique, nous décrivons une hépatite aiguë comme présentation initiale d'un LES chez une jeune femme.

[Importance of best practice adherence in upper gastrointestinal bleeding]. / 5 minutes pour apprendre - Importance du suivi des directives internationales lors d'hémorragie digestive haute.

Adherence to international guidelines limits the potentially deleterious consequences for patients with upper gastrointestinal bleeding (UGIB). We report the case of 81-year-old patient admitted for UGIB due to a stomach ulcer (Forrest IIb), with a high risk of rebleeding. Antiaggregation was stopped for 8 days which contrasts with international guidelines that recommend stopping treatment only for 3 to 5 days. Fortunately, he did not present any cardiovascular complication during his stay (near miss). In addition, the patient was left fasting for several days, which necessitated parenteral nutrition, resulting in diabetic decompensation and an extended length of stay.

[The use of ultrasound in IBD: an essential tool?] / Échographie dans les maladies inflammatoires chroniques de l'intestin†: nouvel outil indispensable†?

Crohn's disease (CD) and ulcerative colitis (UC) are chronic inflammatory bowel diseases (IBD) characterized by an inflammation of the digestive tract wall. Current guidelines recommend a «treat to target¼ management and a "tight control" of the inflammation for an optimal follow-up. Intestinal ultrasound, due to its low cost, its feasibility at bed side, its absence of preparation and its non-invasive character, has proved its place in the diagnosis and the follow-up of IBD. It allows the evaluation of various parameters of the lumen, the intestinal wall, the mesentery, the vascularization as well as complications.

La maladie de Crohn (MC) et la rectocolite hémorragique (RCH) sont des maladies inflammatoires chroniques de l'intestin (MICI) caractérisées par une inflammation de la paroi du tube digestif. Les recommandations de prise en charge suggèrent de viser une cible thérapeutique et de procéder à une évaluation régulière de l'inflammation appelée «â€…contrôle serré ¼ (tight control en anglais). Le but est de proposer une adaptation thérapeutique si la cible n'est pas atteinte (concept du treat-to-target). L'échographie, par son faible coût, sa faisabilité au lit du malade, son absence de préparation colique et son caractère non invasif, a démontré sa place dans le diagnostic et le suivi des MICI. Elle permet d'évaluer divers paramètres de la lumière, de la paroi intestinale, du mésentère, la vascularisation et de rechercher des complications.

Physician Assessment and Feedback During Quality Circle to Reduce Low-Value Services in Outpatients: a Pre-Post Quality Improvement Study.

BACKGROUND: The impact of the Choosing Wisely (CW) campaign is debated as recommendations alone may not modify physician behavior. OBJECTIVE: The aim of this study was to assess whether behavioral interventions with physician assessment and feedback during quality circles (QCs) could reduce low-value services. DESIGN AND PARTICIPANTS: Pre-post quality improvement intervention with a parallel comparison group involving outpatients followed in a Swiss-managed care network, including 700 general physicians (GPs) and 150,000 adult patients. INTERVENTIONS: Interventions included performance feedback about low-value activities and comparison with peers during QCs. We assessed individual physician behavior and healthcare use from laboratory and insurance claims files between August 1, 2016, and October 31, 2018. MAIN MEASURES: Main outcomes were the change in prescription of three low-value services 6 months before and 6 months after each intervention: measurement of prostate-specific antigen (PSA) and prescription rates of proton pump inhibitors (PPIs) and statins. KEY RESULTS: Among primary care practices, a QC intervention with physician feedback and peer comparison resulted in lower rates of PPI prescription (pre-post mean prescriptions per GP 25.5 ± 23.7 vs 22.9 ± 21.4, p value<0.01; coefficient of variation (Cov) 93.0% vs 91.0%, p=0.49), PSA measurement (6.5 ± 8.7 vs 5.3 ± 6.9 tests per GP, p<0.01; Cov 133.5% vs 130.7%, p=0.84), as well as statins (6.1 ± 6.8 vs 5.6 ± 5.4 prescriptions per GP, p<0.01; Cov 111.5% vs 96.4%, p=0.21). Changes in prescription of low-value services among GPs who did not attend QCs were not statistically significant over this time period. CONCLUSION: Our results demonstrate a modest but statistically significant effect of QCs with educative feedback in reducing low-value services in outpatients with low impact on coefficient of variation. Limiting overuse in medicine is very challenging and dedicated discussion and real-time review of actionable data may help.

The impact of implementing a psychiatric emergency hotline on the reduction of acute hospitalizations in a Swiss tertiary hospital.

BACKGROUND: Inpatient treatment is not the most beneficial treatment setting for many patients with psychiatric disorders and overcrowding is a recurrent problem for psychiatric hospitals. Therefore, it is important to develop strategies to limit avoidable inpatient treatment. This study sought to evaluate the impact of an emergency hotline that was developed to better manage psychiatric patients, particularly for identifying those requiring a hospital admission. METHODS: This pre-post intervention quality improvement study compared changes in the management of psychiatric patients' admission before and after the introduction of an emergency hotline where a specialist in psychiatry examines all inpatient referral from private practitioners. Main outcomes were the change in proportion of hospital admissions after referral from a private practitioner before and within 3 months after the intervention. Secondary outcomes were the average length of hospital stay, proportion of non-voluntary admission, the time required for triage and the impact of the intervention on treatments' costs. Fisher's Exact test was used to test the primary hypothesis of difference in the proportion of hospitalized patients before and after introduction of the emergency hotline. Secondary outcomes were tested with Student's t-test for continuous variables and Fishers's Exact test for proportions. RESULTS: Among 45 admission requests from private practitioners during the 3 months after introduction of the new emergency hotline, 25 (55.6%) were accepted as inpatient treatment, while 20 (44%) were redirected to more appropriate outpatient treatments. There was a highly significant difference from the baseline period during which all 34 requests were accepted (44% vs 100%, p < 0.001). In addition, for the patients hospitalized after the introduction of the emergency hotline there was a trend-level reduction of the average length of stay (9.32 days vs 17.35 days). CONCLUSION: Implementation of an emergency hotline manage by a specialist in psychiatry for admissions to acute psychiatric wards is feasible and simple to use. Importantly, it allows to significantly decrease the proportion of hospitalizations. Additional studies are needed to assess the generalizability of these exploratory results to other health care settings.

Unenhanced computed tomography (CT) utility for triage at the emergency department during COVID-19 pandemic.

BACKGROUND: Unenhanced chest computed tomography (CT) can assist in the diagnosis and classification of coronavirus disease 2019 (COVID-19), complementing to the reverse-transcription polymerase chain reaction (RT-PCR) tests; the performance of which has yet to be validated in emergency department (ED) setting. The study sought to evaluate the diagnostic performance of chest CT in the diagnosis and management of COVID-19 in ED. METHODS: This retrospective single-center study included 155 patients in ED who underwent both RT-PCR and chest CT for suspected COVID-19 from March 1st to April 1st, 2020. The clinical information, CT images and laboratory reports were reviewed and the performance of CT was assessed, using the RT-PCR as standard reference. Moreover, an adjudication committee retrospectively rated the probability of COVID-19 before and after the CT calculating the net reclassification improvement (NRI). Their final diagnosis was considered as reference. The proportion of patients with negative RT-PCR test that was directed to the referent hospital based on positive CT findings was also assessed. RESULTS: Among 155 patients, 42% had positive RT-PCR results, and 46% had positive CT findings. Chest CT showed a sensitivity of 84.6%, a specificity of 80.0% and a diagnostic accuracy of 81.9% in suggesting COVID-19 with RT-PCR as reference. Concurrently, corresponding values of 89.4%, 84.3% and 86.5% were retrieved with the adjudication committee diagnosis as reference. For the subgroup of patients with age > 65, specificity and sensitivity were 50% and 80.8%, respectively. In patients with negative RT-PCR results, 20% (18/90) had positive chest CT finding and 22% (4/18) of those were eventually considered as COVID-19 positive according to the adjudication committee. After CT, the estimated probability of COVID-19 changed in 10/104 (11%) patients with available data: 4 (4%) were downgraded, 6 (6%) upgraded. The NRI was 1.92% (NRI event -2.08% + NRI non-event 5.36%). No patient with negative RT-PCR but positive CT was eventually directed to hospital. CONCLUSION: Chest CT showed promising sensitivity for diagnosing COVID-19 across all patients' subgroups. However, CT did not modify the estimated probability of COVID-19 infection in a substantial proportion of patients and its utility as an emergency department triage tool warrants further analyses.

Seroprevalence of anti-SARS-CoV-2 antibodies 6 months into the vaccination campaign in Geneva, Switzerland, 1 June to 7 July 2021.

BackgroundUp-to-date seroprevalence estimates are critical to describe the SARS-CoV-2 immune landscape and to guide public health decisions.AimWe estimate seroprevalence of anti-SARS-CoV-2 antibodies 15 months into the COVID-19 pandemic and 6 months into the vaccination campaign.MethodsWe conducted a population-based cross-sectional serosurvey between 1 June and 7 July 2021, recruiting participants from age- and sex-stratified random samples of the general population. We tested participants for anti-SARS-CoV-2 antibodies targeting the spike (S) or nucleocapsid (N) proteins using the Roche Elecsys immunoassays. We estimated the anti-SARS-CoV-2 antibodies seroprevalence following vaccination and/or infection (anti-S antibodies), or infection only (anti-N antibodies).ResultsAmong 3,355 individuals (54.1% women; 20.8% aged < 18 years and 13.4% aged ≥ 65 years), 2,161 (64.4%) had anti-S antibodies and 906 (27.0%) had anti-N antibodies. The total seroprevalence was 66.1% (95% credible interval (CrI): 64.1-68.0). We estimated that 29.9% (95% Crl: 28.0-31.9) of the population developed antibodies after infection; the rest having developed antibodies via vaccination. Seroprevalence estimates differed markedly across age groups, being lowest among children aged 0-5 years (20.8%; 95% Crl: 15.5-26.7) and highest among older adults aged ≥ 75 years (93.1%; 95% Crl: 89.6-96.0). Seroprevalence of antibodies developed via infection and/or vaccination was higher among participants with higher educational level.ConclusionMost of the population has developed anti-SARS-CoV-2 antibodies, despite most teenagers and children remaining vulnerable to infection. As the SARS-CoV-2 Delta variant spreads and vaccination rates stagnate, efforts are needed to address vaccine hesitancy, particularly among younger individuals and to minimise spread among children.

[Management of hypertension in hospitalized patients]. / Modification du traitement antihypertenseur durant le séjour hospitalier.

International guidelines for high blood pressure are regularly updated for outpatient monitoring, but there is currently no consensus on its definition and management in hospitalized patients. Recent evidence in the literature suggests that extrapolation of treatment targets from the outpatient to the inpatient setting may be at best unnecessary and at worst detrimental to the patient, increasing the risk of adverse events and the rate of avoidable readmission.

Les directives internationales pour l'hypertension artérielle sont régulièrement mises à jour pour le suivi ambulatoire. Toutefois, à l'heure actuelle, il n'existe pas de consensus quant à sa définition et sa prise en charge en milieu hospitalier. Selon des données récentes de la littérature, l'extrapolation des cibles thérapeutiques du milieu ambulatoire au milieu hospitalier peut au mieux s'avérer inutile et au pire préjudiciable pour le patient, en augmentant le risque d'effets indésirables et le taux de réadmission évitable.

[Point-of-care ultrasound for the diagnosis of small bowel occlusion: practical implications for emergency and primary care use]. / Échographie clinique dans le diagnostic de l'occlusion du grêle - Implications pratiques au cabinet et aux urgencies.

Point-of-care ultrasound is a diagnostic tool that is gaining increasingly more ground in general and emergency practice; it allows the clinician to answer certain precise questions, including the presence of a small bowel occlusion. For this indication, ultrasound is useful in rapidly establishing a diagnosis and planning further work up.

L'échographie est un outil diagnostique en plein essor dans la pratique quotidienne des centres d'urgence, mais également dans les cabinets médicaux généralistes ; elle permet de répondre à un certain nombre de questions précises, dont celle de la présence d'une occlusion de l'intestin grêle. Dans cette indication, l'échographie permet de rapidement s'orienter et diriger les examens complémentaires.

[Sleep disturbances related to nocturnal nuisances in elderly inpatients]. / Troubles du sommeil liés aux nuisances nocturnes chez les patients âgés hospitalisés.

Several environmental factors play a role in the poor quality of sleep of hospitalized patients, such as noise pollution, nocturnal awakenings for the administration of medication or the taking of vital signs, the discomfort of the beds, the luminosity or even certain night-time equipment. To cope with these insomnia problems in the hospital setting, patients often request drug treatment, which leads to over-prescription of sedatives, such as benzodiazepines. This leads to serious side effects such as an increased risk of falling, confusion and respiratory depression. This hostile hospital environment must be taken into account before considering specific treatment.

Plusieurs facteurs environnementaux jouent un rôle dans la mauvaise qualité du sommeil des patients hospitalisés, tels que les nuisances sonores, les réveils nocturnes pour l'administration de médicaments ou la prise de signes vitaux, l'inconfort des lits, la luminosité ou encore certains équipements nocturnes. Pour faire face à ces problèmes d'insomnie en milieu hospitalier, les patients sont souvent demandeurs d'un traitement médicamenteux, ce qui mène à une surprescription de sédatifs, tels que les benzodiazépines. Il s'ensuit des effets secondaires potentiellement dangereux comme un risque accru de chute, un état confusionnel ou encore une dépression respiratoire. L'environnement hospitalier hostile doit davantage être pris en compte avant d'envisager un traitement spécifique.

[Computed tomography (CT) utility for diagnosis and triage during COVID-19 pandemic]. / Utilité du CT-scan thoracique pour le diagnostic et le triage des patients suspects de COVID-19.

The nasopharyngeal smear with PCR analysis is the first diagnostic test proposed to confirm infection with COVID-19 SARS-CoV-2. However, its usefulness in emergency centers is limited due to its imperfect sensitivity (56-83 %), limited availability and the time required to obtain results. For this reason, the chest CT-scan has been proposed as a rapid triage tool for diagnosis in these suspect Covid-19 patients. However, its specificity is limited, exposing to the risk of over-diagnosis, and further data are needed to confirm its usefulness, and to highlight the possible prognostic value of the CT, in detecting early lesions associated with poor outcome, indicating the need for admission to intensive care.

Le frottis nasopharyngé avec analyse par PCR est le premier test diagnostique proposé pour confirmer une infection à SARS-CoV-2, virus de la maladie COVID-19. Son utilité dans les centres d'urgence est cependant limitée du fait de sa sensibilité imparfaite (56 à 83 %), de sa disponibilité restreinte et du délai pour l'obtention des résultats. Aussi, le CT-scan thoracique a été proposé comme outil de triage rapide pour poser le diagnostic chez ces patients suspects de COVID-19. Toutefois, sa spécificité est limitée, exposant au risque de surdiagnostic. Des données complémentaires sont nécessaires pour confirmer son utilité et lui attribuer une éventuelle valeur pronostique, capable de déceler des lésions associées à une mauvaise évolution, indiquant la nécessité d'une admission aux soins intensifs.

[Inappropriate red blood cells transfusion]. / Conséquences des transfusions sanguines inappropriées.

International guidelines suggest that a liberal transfusion policy is not only unnecessary but can also prove harmful in certain situations. Blood transfusion is a costly act involving risks of infection, allergic and hemodynamic. Optimizing the use of this scarce and expensive resource becomes necessary. The case report depicts perfectly the potential complications of a transfusion policy considered too liberal, while emphasizing the importance of clinical judgment in each situation.

Selon les recommandations internationales, une politique de transfusion libérale est non seulement inutile, mais peut aussi s'avérer néfaste dans certaines situations. La transfusion sanguine comporte en effet des risques infectieux, allergiques et hémodynamiques. Il est donc nécessaire d'optimiser l'utilisation de cette ressource rare et coûteuse. La vignette clinique illustre parfaitement les complications potentielles d'une politique de transfusion jugée trop libérale, tout en insistant sur l'importance du jugement clinique dans chaque situation.

[Indirect consequences of PSA testing for prostate cancer screening]. / Conséquences indirectes du dosage du PSA dans le dépistage du cancer de la prostate.

Prostate cancer screening remains controversial as the reduction in mortality is outweighed by overdiagnosis and overtreatment. Prostate specific antigen (PSA) testing remains a recurring issue for primary care physicians. Although the last guidelines recommend against the screening, everyone agreed on the importance of the shared decision-making process to inform the patient about the potential benefits and harms of screening. Existing decision support tools can help in this complex discussion. This clinical case report depicts the infectious risks of prostate biopsy that are often underestimated.

Le dépistage du cancer prostatique reste controversé car la baisse de la mortalité est contrebalancée par les inconvénients de la surdétection et du surtraitement. La question du dosage du PSA (prostate specific antigen) revient toutefois de manière récurrente lors des consultations des médecins de premier recours. Bien que les recommandations récentes parlent plutôt en défaveur du dépistage, tous les acteurs concernés s'accordent sur l'importance de la décision partagée pour éclairer le patient sur les implications du dosage du PSA. Des outils d'aide à la décision existent et peuvent être utiles dans cette discussion complexe. La vignette clinique ci-après illustre les risques infectieux, souvent sous-estimés, de la biopsie de prostate consécutive à un dosage du PSA.

Clinical Parameters Correlate With Endoscopic Activity of Ulcerative Colitis: A Systematic Review.

BACKGROUND & AIMS: Optimal management of patients with ulcerative colitis (UC) requires assessment of disease activity-usually by endoscopy, which is invasive, costly, and not risk free. We performed a systematic review to determine whether clinical symptoms correlate with findings from endoscopy assessments of patients with UC. METHODS: We performed a systematic review of publication databases from January 1980 through July 2018 to identify clinical trials and observational studies reporting correlations among symptoms, disease activity index scores and/or patient reported outcomes (rectal bleeding and/or stool frequency), and endoscopic disease activity. Correlations were ascertained in patients with active vs inactive disease and by disease extent and treatment type. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Because of significant heterogeneity, meta-analysis was not possible. Results were synthesized qualitatively and systematically. RESULTS: Our final analysis included 23 studies (1 randomized trial, 22 observational studies) comprising 3320 patients with UC. The studies used a variety of measures to assess clinical activity, endoscopic activity, and measures of correlation (sensitivity, specificity, correlation coefficients, area under the receiver operator curve). Overall, studies were at moderate-high risk of bias. Composite clinical measures, including rectal bleeding and stool frequency, had moderate to strong correlations with endoscopic disease activity; the absence of rectal bleeding identified patients with inactive disease with higher levels of sensitivity than normalization of stool frequency. In general, symptoms correlated more strongly with endoscopic activity in patients with left-sided colitis than extensive colitis. The effect of different medications on the correlation between clinical and endoscopic activity has not been well studied. CONCLUSIONS: In a systematic review, we found a moderate to strong correlation between clinical activity, particularly the combination of rectal bleeding and stool frequency, and endoscopic activity in patients with UC. Although these clinical assessments could help prioritize patients for endoscopic evaluation in resource-limited settings, challenges associated with treating patients based on symptoms alone preclude adaptation of current management algorithms.

Low endoscopy bleeding risk in patients with congenital bleeding disorders.

INTRODUCTION: Haemophilia A and haemophilia B, von Willebrand disease (VWD), factor VII deficiency and factor XI deficiency are congenital bleeding disorders predisposing to bleeding during invasive procedures. The ageing population of people with congenital bleeding disorders will likely increasingly require gastrointestinal endoscopy. The bleeding risk postgastrointestinal endoscopy and optimal prophylactic treatment regimens are not well described. METHODS: We performed a retrospective chart review at the McGill University Health Centre. Adult patients with haemophilia A or B, VWD, FVII deficiency and FXI deficiency who underwent gastrointestinal endoscopic procedures were included. Bleeding prophylaxis included combinations of plasma-derived factor (VWD) or recombinant factor (haemophilia A and haemophilia B), desmopressin and/or tranexamic acid. Our primary outcome was the 72-hour postendoscopy bleeding rate. RESULTS: One hundred and four endoscopies were performed in 48 patients. Haemophilia A (45.3% of endoscopies) was the most common bleeding disorder, followed by VWD (38.5%), FXI deficiency (8.7%), haemophilia B (4.8%) and FVII deficiency (2.9%). All patients were reviewed by the Haemophilia Treatment Center with peri-procedure treatment protocols put in place as required. The overall 72-hour bleeding rate was 0.96%, confidence interval (CI) 95% (0.17%-5.25%). The colonoscopic postpolypectomy bleeding rate was 1/21 (4.8%, CI 95% (0.9%-22.7%)) in comparison with the general population rate of 0.3%-10% for high-risk endoscopy (including colonoscopic polypectomy). CONCLUSION: To the best of our knowledge, this is the largest study describing patients with inherited bleeding disorders undergoing gastrointestinal endoscopy. The bleeding risk is not significantly higher to the general population when haemostatically managed by a team experienced in bleeding disorders.