Le post-COVID en hémodialyse chronique

Introduction

Durant la pandémie liée au SARS-CoV-2, les patients en hémodialyse chronique, ne pouvant être confinés, et à cause de leur immunodépression et comorbidités sont à haut risque de développer un COVID-19.

Description

Nous avons étudié les particularités cliniques et évolutives de la maladie chez nos patients.

Méthodes

Nous avons réalisé une étude rétrospective et descriptive incluant 36 patients hémodialysées chroniques infectés par SARS-CoV-2.

Résultats

L’âge moyen de nos patients était de 59,48 ± 16,13 ans ; 63,18 % étaient hypertendus, 41,66 % étaient diabétiques, 22,22 % avaient une insuffisance coronaire et 13,18 % avaient une dyslipidémie. La néphropathie initiale était une néphropathie interstitielle chronique dans 19,44 % des cas suivi par la néphropathie diabétique dans 16,66 % des cas. L’ancienneté en hémodialyse médiane était égale à 2 ans [0,5–23 ans]. L’accès vasculaire était une FAV pour 55,55 % des patients et un cathéter jugulaire pour 13,88 %.

Le taux médian de l’hémoglobine était de 8,85 g/dL [5,9–14 g/dL] avant l’infection et 8,15 g/dL [5,6–14,4 dL/L] après. L’albuminémie, la calcémie et la phosphorémie moyennes étaient de 31,06 g/L, 2,02 mmol/L et 1,64 mmol/L respectivement avant la maladie et de 30,7 g/L, 2,14 mmol/L et 2,08 mmol/L respectivement après. La CRP médiane était respectivement de 13 et 12 avant et après.

Les complications observées étaient une complication thromboembolique (16,66 %), une hémorragie sévère (11,11 %), un sepsis (8,3 %) et une dépendance à l’oxygène (5,55 %).

Le taux de mortalité était de 33,33 %. La cause de décès était un arrêt hypoxique dans la majorité des cas (58,3 %), une poussée de la maladie dans 25 % des cas, une néoplasie dans 2,7 % des cas et un sepsis dans 2,7 % des cas.

Conclusion

Le COVID-19 a de lourdes conséquences sur la morbidité et la mortalité chez les hémodialysés chroniques. La prévention par l’instauration d’une stratégie de vaccination en masse et d’isolement des cas suspects rapidement.

COVID-19 chez les patients hémodialysés : facteurs associés aux formes modérées à sévères

Introduction

La pandémie de coronavirus (COVID-19) a été associée à une morbidité et une mortalité accrue chez les patients hémodialysés (HD). Ce travail vise à déterminer les facteurs associés à la survenue de formes graves.

Description

Cette étude vise à déterminer les facteurs de risque de survenue de formes modérés à sévères d’infection au COVID-19 chez les patients HD.

Méthodes

Cette étude descriptive rétrospective a été réalisée avec les données de 60 patients HD entre 2020 et 2021 atteints d’une infection COVID-19 confirmée afin d’analyser les facteurs de risque potentiels de formes cliniques modérée à sévère.

Résultats

Le taux de formes modérées à sévères était plus important chez les patients HD, touchant 68,3 % des patients. L’âge moyen associé aux formes modérées à sévères était de 63,93 ans, il existe une relation statistiquement significative entre l’âge au-delà de 50 ans et les formes modérées à sévères (p = 0,000), avec une légère prédominance féminine. Les comorbidités les plus observées chez les patients hémodialysés sont l’HTA (29), le diabète (26), les maladies cardiaques (14) et l’obésité (10). Il existe une relation statistiquement significative entre l’existence de HTA chez les patients HD et la survenue d’une forme clinique modérée a sévère. La néphropathie diabétique est la plus fréquente. Les principaux symptômes associés au COVID-19 pour les patients ayant des formes graves étaient la dyspnée, la toux, l’asthénie, la fièvre, les courbatures et la symptomatologie digestive dans 33, 30, 26, 26 et 18 cas respectivement. Il existe une relation significative entre une valeur de CRP supérieure à 150 et les formes modérées à sévères (p = 0,046). Une lymphopénie inférieure à 1000 elt/mm³ a été notée dans 88 % des cas. Dix-sept patients avaient une atteinte au scanner thoracique supérieure à 50 % (p = 0,004). Parmi les patients, 43,9 % sont décédés.

Conclusion

La sévérité de l’infection COVID-19 était associée à la présence de HTA, à l’âge supérieur à 50 ans, au taux élevé de CRP.

Is the Consensual Threshold for Defining High Glucose Variability Implementable in Clinical Practice?

OBJECTIVE

Estimating glycemic variability (GV) through within-day coefficient of variation (%CV_w) is recommended for patients with type 1 Diabetes (T1D). High GV (hGV) is defined as %CV_w > 36%. However, continuous glucose monitoring (CGM) devices provide exclusively total CV (%CV_T). We aimed to assess consequences of this disparity.

RESEARCH DESIGN AND METHODS

We retrospectively calculated both %CV_T and %CV_w of consecutive T1D patients from their CGM raw data during 14 days. Patients with hGV with %CV_T >36% and %CV_w ≤36% were called the "inconsistent GV group".

RESULTS

A total of 104 patients were included. Mean ± SD %CV_T and %CV_w were 42.4 ± 8% and 37.0 ± 7.4% respectively (P < 0.0001). Using %CV_T, 81 patients (73.6%) were classified as having hGV, whereas 59 (53.6%) using %CV_w (P < 0.0001) corresponding to 22 patients (21%) in the inconsistent GV population.

CONCLUSIONS

Evaluation of GV through %CV in patients with T1D is highly dependent on the calculation method and then must be standardized.

Management of a Mobile Floating Carotid Plaque Responsible for Calcified Cerebral Emboli: A Double Sword of Damocles

Introduction

The management of a rare case of calcified cerebral emboli associated with a mobile carotid plaque (MCP) is reported and discussed.

Report

A 76 year old patient presented with sudden weakness of the left lower limb one month ago, which resolved spontaneously. A cerebral magnetic resonance imaging showed recent multiple infarcts in the right middle cerebral artery (MCA) territory. Computed tomography cerebral angiogram (CTA) revealed calcified cerebral emboli (CCE) in the right MCA territory and an isolated calcified embolus in the M3 segment of the right MCA. No calcification was observed in the aorta. The echocardiogram findings were normal. Trans-oesophageal echocardiography did not show aortic or mitral valve calcifications. A cervical duplex ultrasound (DUS) was performed and demonstrated a highly mobile carotid plaque located in the right carotid bifurcation, contrasting with static CTA imaging showing a common calcified plaque, probably because the plaque appeared against the carotid wall during image acquisition. Antiplatelet and anticoagulation therapy were initiated, and carotid endarterectomy was performed on day two to prevent further embolisation. One month follow up including carotid DUS was satisfactory.

Discussion

A case of mobile carotid plaque responsible for CCE which was diagnosed with DUS dynamic imaging is described, emphasizing the importance of multimodal imaging in such settings. Though the treatment of MCP remains controversial because of the paucity of published cases, carotid endarterectomy was considered to be the safest option to prevent recurrent stroke. Additional clinical data including large series and controlled trials are required to determine the best management of mobile carotid plaques with less than 50% diameter carotid stenosis.

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A 76-year-old man presented with sudden weakness of the left lower limb one month ago, which spontaneously resolved.

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Cerebral MRI showed calcified emboli in the right middle cerebral artery territory.

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Aortic and cervical CTA along with cardiac valves interrogation were negative.

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Ultrasound imaging allowed the identification of a mobile right carotid plaque responsible of a <50% carotid stenosis.

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Carotid endarterectomy was performed to prevent stroke recurrence with favorable outcome.

Percutaneous Trans-venous Femoropopliteal Bypass in Long Occlusions of the Superficial Femoral Artery

PURPOSE

This technical note describes a total percutaneous technique to perform ultrasound and fluoroscopy-assisted femoropopliteal bypass in long superficial femoral artery (SFA) lesions, using standard equipment, through a juxta-anatomical superficial femoral vein (SFV) tunnel.

MATERIALS AND METHODS

Three percutaneous accesses were obtained under ultrasound guidance. The first was retrograde, with crossover maneuver, at the contralateral groin. The second was a proximal SFV-to-SFA stump puncture. The third was a distal popliteal artery-to-popliteal vein puncture. Through the described snaring and capture maneuvers, one single 0.018″ guide wire entered the femoral vein through the SFA stump and re-entered the popliteal artery distally. The fistulous tracts were then dilated and covered stents deployed and post-dilated.

RESULTS

Three patients aged 68 ± 3 years and presenting Rutherford 4 chronic limb ischemia were treated with this technique. The mean SFA lesion length was 22.6 ± 3 cm. The mean procedure duration was 88 ± 18 min. No intraoperative complication occurred. The postoperative course was uneventful. In particular, no deep vein thrombosis occurred. Rutherford stage decreased from 4 to 1 in all patients, with a mean follow-up duration of 6.6 ± 2 months.

CONCLUSION

The main advantage of the technique is avoiding calcification issues by abandoning the trans-arterial recanalization approach for long calcified lesions. The second interest is its feasibility by simple endovascular means without any particular or dedicated device. However, longer follow-up is needed to assess safety and durability.

Impact of transitional care on endocrine and anthropometric parameters in Prader-Willi syndrome

CONTEXT

The transition of patients with Prader-Willi syndrome (PWS) to adult life for medical care is challenging because of multiple comorbidities, including hormone deficiencies, obesity and cognitive and behavioral disabilities.

OBJECTIVE

To assess endocrine management, and metabolic and anthropometric parameters of PWS adults who received (n = 31) or not (n = 64) transitional care, defined as specialized pediatric care followed by a structured care pathway to a multidisciplinary adult team.

PATIENTS AND STUDY DESIGN

Hormonal and metabolic parameters were retrospectively recorded in 95 adults with PWS (mean ± s.d. age 24.7 ± 8.2 years, BMI: 39.8 ± 12.1 kg/m²) referred to our Reference Center and compared according to transition.

RESULTS

Among the entire cohort, 35.8% received growth hormone (GH) during childhood and 16.8% had a GH stimulation test after completion of growth. In adulthood, 14.7% were treated with GH, 56.8% received sex-hormone therapy, whereas 91.1% were hypogonadic and 37.9% had undergone valid screening of the corticotropic axis. The main reason for suboptimal endocrine management was marked behavioral disorders. Patients receiving transitional care were more likely to have had a GH stimulation test and hormonal substitutions in childhood. They also had a lower BMI, percentage of fat mass, improved metabolic parameters and fewer antidepressant treatments. Transitional care remained significantly associated with these parameters in multivariate analysis when adjusted on GH treatment.

CONCLUSION

A coordinated care pathway with specialized pediatric care and transition to a multidisciplinary adult team accustomed to managing complex disability including psychiatric troubles are associated with a better health status in adults with PWS.

La myosite ossifiante circonscrite: à propos d’un cas

Myositis ossificans circumscripta is a benign lesion characterized by focal heterotopic soft tissue ossification, occurring in young people generally after localized trauma. Clinical and radiological appearances may mimic a sarcomatous neoplastic process. We report a case of myositis ossificans occurring after trauma, so as to illustrate the different imaging features of this benign pathology on conventional radiographs and computed tomography.