Rôle de l'échographie pleuropulmonaire dans la prise en charge de l'insuffisance cardiaque aiguë

L'échographie pleuropulmonaire est un outil diagnostique en plein développement. Réalisé au lit du malade par le clinicien, elle permet de répondre de façon rapide à des questions ciblées. Dans le cadre de l'insuffisance cardiaque elle permet d'affiner les performances diagnostiques, peut être utilisée pour monitorer la réponse au traitement diurétique et permet d'identifier les patients à risque de réadmission hospitalière précoce. Des nombreux protocoles d'échographie pleuropulmonaire ont été proposés en littérature et se distinguent par le nombre de régions thoraciques explorées. Dans ce travail de thèse un protocole simple sur 8 points était autant reproductible qu'un protocole extensif sur 28 points (kappa 0.54-0.62 versus 0.41-0.51) et demandait moins de temps d'exécution (2.8-4.7 minutes versus 6.2-9.3 minutes). L'utilisation des protocoles simples devrait donc être priorisée

Malnutrition-related hyperammonemic encephalopathy presenting with burst suppression: a case report

Background: Hyperammonemia is a common cause of metabolic encephalopathy, mainly related to hepatic cirrhosis. Numerous nonhepatic etiologies exist but they are infrequent and not well known, thus, leading to misdiagnosis and inadequate care. Electroencephalography has a proven diagnostic and prognostic role in comatose patients. Burst suppression is a preterminal pattern found in deep coma states and is rarely associated with metabolic causes. Case presentation: We report the case of an 81-year-old Caucasian man presenting with rapidly progressive somnolence and mutism. Soon after his arrival in our hospital, he developed profound coma. A comprehensive diagnostic workup was unremarkable except for admission electroencephalography showing diffuse slowing of cerebral activity with an intermittent pattern of burst suppression. He was admitted to our intensive care unit for supportive care where malnutrition-related hyperammonemia was diagnosed. His clinical course was spontaneously favorable and follow-up electroencephalography demonstrated normal cerebral activity. Conclusions: Nonhepatic hyperammonemia is a rare and potentially reversible cause of encephalopathy. Ammonia level measurement should be part of the diagnostic workup in patients with unexplained coma, particularly in the setting of nutritional deficiencies or nutritional supply. Detection of diffuse and nonspecific mild to moderate slowing of cerebral activity (theta-delta ranges) on electroencephalography is common. In contrast, to the best of our knowledge, burst suppression has never been described in association with hyperammonemia.</p

Encéphalopathie au céfépime

Since 2017 the world suffers from a piperacillin/tazobactam shortage. Cefepime is then proposed as a broad spectrum antibiotic alternative. Up to 15 % of the patients under treatment develop neurotoxicity, mostly in kidney failure settings. Cefepime serum concentration and electroencephalogram guide diagnosis. Treatment consists in withholding or reducing the dose. Most of the patients recover without neurologic sequelae.Depuis 2017, une pénurie de pipéracilline/tazobactam sévit dans le monde. Le céfépime est proposé comme alternative antibiotique à large spectre. Lors de l’utilisation de cet antibiotique, jusqu’à 15% des patients traités développent une neurotoxicité, se produisant majoritairement en cas d’insuffisance rénale. Le taux sérique et l’électroencéphalogramme permettent d’orienter le diagnostic. La diminution de la posologie, voire l’arrêt du traitement suffisent à corriger les symptômes et les patients ne gardent en général pas de séquelles neurologiques

The human gut mycobiome and the specific role of <i>Candida albicans</i>: where do we stand, as clinicians?

The so-called 'mycobiome' has progressively acquired interest and increased the complexity of our understanding of the human gut microbiota. Several questions are arising concerning the role of fungi (and in particular of Candida albicans), the so-called 'mycobiome', that has been neglected for a long time and only recently gained interest within the scientific community. There is no consensus on mycobiome normobiosis because of its instability and variability. This review aims to raise awareness about this interesting topic and provide a framework to guide physicians faced with such questions

Point of care ultrasonography from the emergency department to the internal medicine ward: current trends and perspectives

The advent of portable devices in the early 80s has brought ultrasonography to the patient’s bedside. Currently referred to as ‘point of care ultrasonography’ (POCUS), it has become an essential tool for clinicians. Initially developed in the emergency and critical care settings, POCUS has gained increasing importance in internal medicine wards in the last decade, with both its growing diagnostic accuracy and portability making POCUS an optimal instrument for everyday clinical assessment and procedures. There is large body of evidence to confirm POCUS’ superiority when compared to clinical examination and standard X-ray imaging in a variety of clinical situations. On the contrary, only few indications, such as procedural guidance, have a proven additional benefit for patients. Since POCUS is highly user-dependent, pre- and post-graduate curricula are needed and the range of use should be clearly defined. This review focuses on trends and perspectives of POCUS in the management of diseases frequently encountered in emergency and internal medicine. In addition, questions are raised regarding the teaching and supervision of POCUS needing to be addressed in the near future

Acute kidney injury with partial Fanconi syndrome in a patient with leptospirosis: a case report

Background: Leptospirosis is an underdiagnosed bacterial infection with nonspecific symptoms, hence, a diagnostic challenge. Identifying a case of leptospirosis in Switzerland is uncommon. Although kidney complications are frequent in severe forms, including tubular dysfunction, observing this complication is rare in our country. We report the case of a patient with leptospirosis and kidney dysfunction, which was notable for proximal tubulopathy. This case report describes the diagnosis and management of this patient's tubular dysfunction. Case presentation: A 34-year-old Caucasian male known for alcohol and drug abuse presented to our emergency department suffering from severe pain in the lower limbs, jaundice, and fever with flu-like symptoms. Physical examination was not contributory. Blood tests showed cytopenia, elevated inflammatory markers, acute kidney injury, and altered liver function tests with predominant cholestasis. Urinalysis showed proteinuria and significant glycosuria without concomitant hyperglycemia. Leptospirosis was suspected and confirmed by both positive serum polymerase chain reaction and elevated immunoglobulin M for Leptospira interrogans. The patient was treated with intravenous amoxicillin-clavulanate and doxycycline for 7 days. After antibiotic treatment, symptoms disappeared, and kidney dysfunction completely resolved. Conclusion: Our case focuses on the description of leptospirosis-related acute kidney injury with proximal tubular dysfunction, which is a rare finding in Switzerland.</p

Rôle de l’échographie ciblée dans la prise en charge de l’insuffisance cardiaque

Heart failure is a common disease and one of the main reasons of hospital admission. It is a rich research field, marked by regular novelties in the management of heart failure. In the last decades point-of-care ultrasonography has been more prominent in internal medicine, particularly for the management of heart failure. A structured training is required to acquire core competencies. In heart failure, this bedside tool includes focused lung, cardiac and vascular ultrasonography. The combination of these modalities raises diagnostic accuracy, reduce time to diagnosis in dyspneic patients and plays a role in adaptation of decongestive therapy.L’insuffisance cardiaque est une pathologie fréquente et l’un des principaux motifs d’admission à l’hôpital. La recherche clinique, riche dans ce domaine, marque régulièrement le paysage médical de nouveautés dans sa prise en charge. L’échographie ciblée s’est développée de manière importante ces dernières années en médecine interne, en particulier pour la prise en charge de l’insuffisance cardiaque. L’apprentissage de celle-ci nécessite une formation structurée pour l’acquisition des compétences de base, permettant l’exploration ciblée du cœur, des vaisseaux et de l’appareil pleuropulmonaire au lit du patient. La combinaison de ces modalités améliore la précision diagnostique, diminue le délai diagnostique lors de dyspnée, et joue un rôle dans l’adaptation du traitement décongestif

Risk stratification in patients with acute pulmonary embolism: current evidence and perspectives

Risk stratification is one of the cornerstones of the management of acute pulmonary embolism (PE) and determines the choice of both diagnostic and therapeutic strategies. The first step is the identification of patent circulatory failure, as it is associated with a high risk of immediate mortality and requires a rapid diagnosis and prompt reperfusion. The second step is the estimation of 30-day mortality based on clinical parameters (e.g., original and simplified version of the pulmonary embolism severity index): low-risk patients without right ventricular dysfunction are safely managed with ambulatory anticoagulation. The remaining group of hemodynamically stable patients, labeled intermediate-risk PE, requires hospital admission, even if most of them will heal without complications. In recent decades, efforts have been made to identify a subgroup of patients at an increased risk of adverse outcomes (intermediate-high-risk PE), who might benefit from a more aggressive approach, including reperfusion therapies and admission to a monitored unit. The cur-rent approach, combining markers of right ventricular dysfunction and myocardial injury, has an insufficient positive predictive value to guide primary thrombolysis. Sensitive markers of circulatory failure, such as plasma lactate, have shown interesting prognostic accuracy and may play a central role in the future. Furthermore, the improved security of reduced-dose thrombolysis may enlarge the indication of this treatment to selected intermediate-high-risk PE

POCUS : diagnostiquer la pneumonie par l’échographie pleuropulmonaire

Point-Of-Care Ultrasonography (POCUS) has emerged to support the diagnosis process and management strategies. Its use for the diagnosis of pneumonia has been shown to be reliable and effective over the past decade. Various ultrasonography patterns exist, none of which are pathognomonic for pneumonia. Therefore, POCUS findings must be interpreted in association with the clinical setting. POCUS enables early identification of complications such as parapneumonic effusion and pulmonary abscess. It also provides guidance for invasive procedure such as thoracocentesis and pleural drainage. The forthcoming results of the Swiss OCTOPLUS study will provide data on the clinical and economic impact of a diagnostic strategy based on targeted lung ultrasonography.L’échographie ciblée, aussi connue sous le terme de Point-Of-Care Ultrasonography (POCUS), a émergé comme outil essentiel dans la démarche diagnostique et la stratégie de prise en charge des patients. Son utilisation pour le diagnostic de la pneumonie a été démontrée comme fiable et performante depuis plus d’une décennie. Plusieurs profils échographiques existent mais aucun n’est pathognomonique de la pneumonie. L’examen échographique est ainsi indissociable du contexte clinique. Le POCUS permet en outre la recherche précoce de complications (épanchement parapneumonique et abcès pulmonaire) et le guidage des gestes invasifs (thoracocentèse et drainage thoracique). Les résultats à venir de l’étude suisse OCTOPLUS permettront d’en savoir plus sur l’impact clinique et économique d’une stratégie diagnostique basée sur l’échographie pleuropulmonaire