Malnutrition: a highly predictive risk factor of short-term mortality in elderly presenting to the emergency department.

OBJECTIVES: To identify independent risk factors of mortality among elderly patients in the 3 months after their visit (T3) to an emergency department (ED). DESIGN: Prospective cohort study. SETTING: University hospital ED in an urban setting in France. PARTICIPANTS: One hundred seventy-three patients aged 75 and older were admitted to the ED over two weeks (18.7% of the 924 ED visits). Of these, 164 patients (94.8%) were included in our study, and 157 (95.7%) of them were followed three months after their ED visit. MEASUREMENTS: During the inclusion period (T0), a standardized questionnaire was used to collect data on socio-demographic and environmental characteristics, ED visit circumstances, medical conditions and geriatric assessment including functional and nutritional status. Three months after the ED visits (T3), patients or their caregivers were interviewed to collect data on vital status, and ED return or hospitalization. RESULTS: Among the 157 patients followed at T3, 14.6% had died, 19.9% had repeated ED visits, and 63.1% had been hospitalized. The two independent predictive factors for mortality within the 3 months after ED visit were: malnutrition screened by the Mini Nutritional Assessment short-form (MNA-SF) (OR=20.2; 95% CI: 5.74-71.35; p<.001) and the Cumulative Illness Rating Scale for Geriatrics (CIRS-G) score (OR=1.1; 95% CI: 1.01-1.22; p=.024). CONCLUSION: Malnutrition is the strongest independent risk factor predicting short-term mortality in elderly patients visiting the ED, and it was easily detected by MNA-SF and supported from the ED visit.

[Interest of S100B protein blood level determination for the management of patients with minor head trauma]. / Intérêt du dosage sérique de la protéine S100B dans la prise en charge du patient après traumatisme crânien léger.

Indication of cranial computed tomography (CCT) for patients with head minor injury (MHI) is difficult. Actually, 90% of patients with MHI who have CCT under the present clinical decision rules have normal scans. Serum concentrations of the protein S-100B were recently found to provide useful information. We have investigated whether S-100B concentrations in patients with MHI can provide additional information to improve indication of the need for an initial CCT scan. One hundred five patients with MHI were enrolled in this prospective study, at the French university hospital of Marseille and Clermont-Ferrand. Of the 105 patients studied, 16 exhibited trauma-relevant intracerebral lesions on the CCT scan (CCT+). With a cut-off limit of 0,10 microg/L S-100B, CCT+ patients were identified with a sensitivity level of 100% and a specificity level of 33%. Adding the measurement of S-100B serum concentration to the clinical decision rules for a CCT scan in patients with MHI could allow a 30% reduction in scans.

Mycoplasma pneumoniae pneumonia following assisted ventilation.

BACKGROUND: Mycoplasma pneumoniae pneumonia is regarded as a community-acquired pneumonia, rarely requiring hospitalization, with sporadic cases or limited outbreaks occurring after close contacts with an infected patient. Few reports mention M pneumoniae pneumonia acquired during hospitalization. PATIENTS AND METHODS: M pneumoniae was diagnosed in patients who developed pneumonia following perioperative and postoperative assisted ventilation by the isolation of M pneumoniae from bronchial washing, the detection of M pneumoniae DNA from bronchial washing, and serologic testing for the presence of specific immunoglobulin M (IgM) antibodies. RESULTS: Four patients were diagnosed as having M pneumoniae pneumonia following mechanical ventilation over a 1 1/2-year period. They were men, older than 50 years, and were hospitalized for vascular surgery. They developed febrile hypoxemia and intersticial pneumonia. Isolation of M pneumoniae and detection of M pneumoniae DNA were positive in 1 case; specific IgM antibodies were present in 4 cases. CONCLUSIONS: These observations allow the description of a new clinical entity and highlight the role of M pneumoniae as an agent of nosocomial infections. This diagnosis should be considered in any patient with precocious post-assisted ventilation febrile hypoxemia and diffuse interstitial pneumonia, and empiric treatment protocols may include M pneumoniae in their spectrum.

[Blood loss from diagnostic laboratory tests performed in intensive care units. Preliminary study]. / Spoliations sanguines liées aux prélèvements en réanimation. Etude préliminaire.

OBJECTIVE: To assess the volume of blood samples withdrawn for laboratory testing in intensive care unit (ICU) patients and to determine the influence of the resulting blood loss on transfusion requirements in patients staying in the ICU for more than seven days. STUDY DESIGN: Prospective clinical open study. PATIENTS: Fifty patients treated in the ICU over the 3-month study period, neither admitted for a systematic postoperative monitoring, nor experiencing bleeding or haemolysis. METHODS: For each patient the following data were obtained: duration of ICU stay, volume of the daily withdrawn blood, the concentration of haemoglobin (Hb) at the time of ICU admission, ICU discharge and before each transfusion, volume of transfused blood. RESULTS: A mean volume of 62 +/- 29 mL.d-1 of blood was taken. It decreased from 85 +/- 6 mL on admission day, to 66 +/- 6 mL after seven days and 60 +/- 8 mL after 14 days. About 27% of the withdrawn blood was rejected (initial blood reflowing through cannula and connection tube). Twenty-one patients (42%) had a length of stay greater than 7 days. In this population, a first group (13/21) was given transfusions of packed red cells during their hospitalisation and a second group (8/21) was not transfused. The mean volume of blood taken per day (67 +/- 21 mL.d-1 vs 55 = 15 mL.d-1) and the total volume (1.204 +/- 810 mL vs 810 +/- 389 mL) were not significantly higher in the transfused group. Conversely, the mean haemoglobin concentration on ICU admission (97 +/- 22 g.L-1 vs 136 +/- 26 g.L-1) was significantly lower (P = 0.001) in the transfused patients. CONCLUSION: Blood losses from blood withdrawal for laboratory tests are important and in agreement with the results of other reports. It is generally accepted that iatrogenic blood loss of this magnitude can cause anaemia if repeated over a prolonged period. Conversely, our data suggest that blood sampling does not contribute significantly to anaemia and transfusion requirements in patients with a prolonged ICU stay.

Is systematic preoperative screening for muscle relaxant and latex allergy advisable?

We investigated a female population prior to general anaesthesia, using skin prick tests with latex and muscle relaxants to appraise the validity and feasibility of a systematic preoperative screening for these substances. Anaesthetists performed skin tests, and positive and doubtful tests were checked in our allergy department. Of 114 patients, 42 had uninterpretable tests because of dermographism (28 patients) or suppression of skin reactivity (14 patients). Among the other 72, nine had a positive or doubtful test to latex, and seven a positive or doubtful test to one or more muscle relaxants. After checking, only four sensitizations to latex and one to muscle relaxant were confirmed. In conclusion, a systematic screening for latex and muscle relaxant allergy is not advisable. In contrast, screening for latex allergy in selected high-risk groups (spina bifida, health-care workers) is necessary.

Monitoring of pefloxacin serum concentrations in intensive care unit patients: comparison of a new immunoassay with high-performance liquid chromatography.

Serum quinolone concentrations are not routinely measured in clinical practice. However, in order to optimize quinolone treatment, monitoring of serum concentrations could sometimes be useful particularly in critically ill patients. A new enzyme-linked immunosorbent assay (ELISA) that permits direct determination of pefloxacin in serum is described. To validate this new assay, pefloxacin concentrations were measured in 314 serum samples from 74 intensive care unit patients treated with pefloxacin (400 mg i.v. twice daily). Reference concentrations were obtained by reverse phase high-performance liquid chromatography (HPLC) with spectrofluorometric detection. Results showed that concentrations measured by ELISA correlated very well with those by HPLC (r = 0.957; y = 1.03 and x -0.15). In this population, the concentrations found by ELISA varied between individuals (Cmin = 0.70-39 micrograms/ml; Cmax = 5.2-40 micrograms/ml). However, 86% of the measured Cmax and Cmin levels were adequate for optimal pefloxacin therapy. Only 11% of Cmin and 14% of Cmax were below the optimal values (i.e., 2 and 8 micrograms/ml, respectively). These results suggest that despite the large therapeutic index of pefloxacin, monitoring of its serum concentrations using a rapid ELISA technique may be useful for optimal antimicrobial treatment of certain intensive care unit patients.

Atopy and anaphylactic reactions to suxamethonium.

Muscle relaxants are widely used for general anesthesia and may be responsible for IgE-dependent anaphylactic reactions (AR). A controversial issue in the field of drug allergy is whether ARs are more frequent or severe in atopic subjects. Thus, we performed a case-control study comparing the distribution of various clinical and biologic signs of atopy. The case group included 32 patients with a history of AR to suxamethonium, the most commonly used muscle relaxant. The control group included 128 subjects, matched to the case group according to age, gender, and socioeconomic status. The case group consisted mainly of young and middle-aged women. Distribution of symptoms suggestive of atopy and of skin tests and specific IgE to common aeroallergens was similar in both groups. In contrast, total serum IgE level was much higher in the case group, suggesting the presence of specific IgE against suxamethonium or other drugs. Thus, despite previous studies in the literature, atopy is not a risk factor for the occurrence of anaphylactic reactions to muscle relaxants. As AR to suxamethonium is a pure model of an IgE-dependent drug allergy, our data do not support a relationship between atopy and allergic drug reactions.

Validation of a radioreceptor assay technique for monitoring pharmacological active material during intensive diazepam tetanus therapy.

The present study's aim was to monitor the daily plasma levels of diazepam and its metabolites in two tetanic patients who were receiving very strong doses of diazepam in continuous infusion. The kinetics of high doses of diazepam were estimated. These plasma levels were determined selectively using gas-liquid chromatography (GLC), then correlated with a global estimation by radioreceptor-assay (RRA). At the end of the infusion, the kinetics of diazepam and of RRA active material were calculated using a linear, open, two compartment model. Muscle-relaxant and residual sedative effects were clinically monitored. The mean concentrations of diazepam (2.33, 0.60 micrograms/ml), desmethyldiazepam (3.27, 1.00 micrograms/ml) and oxazepam (0.73, 0.47 micrograms/ml) estimated by GLC and of RRA active material (5.62, 1.08 micrograms/ml) correlated better when active metabolites were considered (r = 0.898) than when diazepam alone was taken into account (r = 0.730), indicating that these metabolites influence the overall activity of the parent compound. Half-lives of RRA results (52.6 h for patient 1 and 82.5 h for patient 2) were higher than those of diazepam estimated using GLC results (21.2 h for patient 1 and 42.3 h for patient 2). This could be related to the contribution of the active metabolites and might explain the residual sedative effect observed for at least seven days following cessation of the diazepam (DZP) infusion.(ABSTRACT TRUNCATED AT 250 WORDS)

[Anaphylactic complications due to suxamethonium]. / Accidents anaphylactiques au suxaméthonium.

A study was carried out on 36 patients who had presented with an anaphylactic reaction when they had been received anaesthetic induction agents including suxamethonium. After having been examined, they were assessed with various immunoallergic tests (skin tests, LHL, a search for specific anticholine IgE antibodies). They were compared with a group of 120 control patients with the same age, sex and professional characteristics. This study confirmed the part played by specific IgE antibodies in accidents involving suxamethonium. The specificity of the tests that could be used for the diagnosis was excellent. However, as far as sensitivity of the tests went, skin tests and LHL were more sensitive than the search for specific IgE antibodies. There was no statistical relationship between the limit for skin reactions and the degree of histamine release of the level of anticholine IgE antibody.

Leukocyte histamine release to suxamethonium in patients with adverse reactions to muscle relaxants.

In an earlier study we confirmed the usefulness of intradermal skin tests and histamine release in diagnosis of patients reactive to muscle relaxants, and we suggested an IgE-mediated reaction rather than an idiosyncratic mechanism. In a later study, we studied the relationship between (Formula: see text) that is one of the muscle relaxants producing the most frequent adverse reactions under anesthesia. Histamine release was measured in five patients with increasing concentrations of suxamethonium in the presence or absence of human serum albumin in Tris buffer. Suxamethonium by itself without any carrier in the buffer could, in vitro, act as a true allergen on target leukocytes in the sensitized patients' group. Acetylcholine (20 and 200 micrograms/ml) did not induce significant histamine release in five patients with positive histamine release in the presence of suxamethonium. Preincubation of leukocytes from 11 patients for 30 min with 20 and 200 micrograms of acetylcholine in Tris albumin CA++ Mg++ buffer decreased the histamine release induced by suxamethonium (10 micrograms/ml); mean maximal histamine release of 46% +/- 4.2 was reduced to 31.4 +/- 5.8 and 7% +/- 4 (p less than 0.001), respectively. However, in eight control subjects similar concentrations of acetylcholine did not change the maximal histamine release induced by anti-IgE (0.2 micrograms/ml). In the same way acetylcholine did not modify histamine release induced by Dermatophagoides pteronyssinus extract (1/10,000 w/v) in six patients allergic to this allergen. This study suggests that suxamethonium acts as a true allergen and that acetylcholine or one of its metabolites may act as a hapten inhibitor in the model of histamine release induced by suxamethonium.(ABSTRACT TRUNCATED AT 250 WORDS)