Association between Vitamin D Deficiency and Prognosis after Hip Fracture Surgery in Older Patients in a Dedicated Orthogeriatric Care Pathway.

OBJECTIVES: Vitamin D deficiency is common in patients undergoing hip fracture surgery (HFS) and has been found to be associated with poor post-operative outcome in other settings. This study aimed to analyze the association between vitamin D status and prognosis after HFS. DESIGN: Observational, prospective, single-center study. SETTING AND PARTICIPANTS: All patients admitted in a peri-operative geriatric unit between 2009 and 2020 for HFS were included. MEASUREMENTS: A moderate vitamin D deficiency was defined by a vitamin D level between 25 and 75 nmol/l and a severe deficiency by a vitamin D level <25 nmol/l. Primary endpoint was mortality 6 months after surgery. Secondary endpoints were bacterial infections and delirium during hospitalization. Odds ratio (OR) and 95% confidence interval (95%CI) were computed using logistic regression models with adjustment for confounders. RESULTS: 1197 patients were included (median age 87 years, IQR [82-91]). Median vitamin D level was 55 nmol/l (IQR [30-75 nmol/l]). Moderate and severe vitamin D deficiencies were reported in 53% and 21% of patients, respectively. There was no significant association between moderate or severe vitamin D deficiencies and 6-month mortality (OR 0.91, 95%CI [0.59-1.39], and OR 1.31, 95%CI [0.77-2.22], respectively), bacterial infection (OR 0.89, 95%CI [0.60-1.31] and OR 1.55, 95%CI [0.99-2.41], respectively), nor delirium (OR 1.03, 95%CI [0.75-1.40], and OR 1.05, 95%CI [0.70-1.57], respectively). CONCLUSION: Vitamin D deficiency was not associated with mortality, bacterial infection or delirium after HFS. Our results suggest that comorbidities, functional status and post-operative complications are the main determinants of post-operative outcome after HFS.

[Elderly patients and intensive care: Systematic review and geriatrician's point of view]. / Réanimation du sujet âgé : revue de la littérature et point de vue du gériatre.

The global population is aging and intensive care unit admission rate of elderly patients is dramatically increasing. The objective of this review is to provide an overview of the literature about the management of elderly patients in intensive care unit and more specifically about epidemiology, admission criteria, mortality, functional prognosis and ethical aspects. We also discuss the data on cardiorespiratory arrest, shock, acute respiratory failure and delirium. The mortality rate of patients over 80 years old in intensive care unit can reach up to 70% at 1year, but is dependent on many factors, such as comorbidities or frailty. Above all, more than half of elderly patients recover their long-term autonomy. Their quality of life is comparable to that of the same age population. Considering that the first 3months after an intensive care unit stay are the most decisive in terms of vital and functional prognosis, we will discuss strategies to improve care through the creation of dedicated intensive care-geriatrics networks.

Utility of 123I-FP-CIT SPECT for dementia diagnoses and therapeutic strategies in elderly patients.

OBJECTIVES: Evaluation of the influence of single photon emission computed tomography (SPECT) of the dopamine transporter (123I-FP-CIT) on diagnosis and treatment strategies in elderly patients with mild dementia. DESIGN: Retrospective study. SETTING: Geriatrics memory clinic. PARTICIPANTS: Consecutive ambulatory patients who had 123I-FP-CIT SPECT for a suspicion of DLB. MEASUREMENTS: Clinical diagnoses before SPECT were compared with imaging results. RESULTS: 46 patients were included. Pre imaging clinical hypotheses were probable DLB in 14, possible DLB in 21 and alternate diagnoses in 11. Rates of abnormal imaging in these groups were respectively 71%, 43% and 18%. Overall, diagnoses were revised in 37% of the cases. Four patients with probable DLB had normal imaging. Their number of core criteria did not differ from the remainder (2.75 ± 0.5 vs. 2.1 ± 0.6), but hallucinations in 2 patients were not well formed and detailed as usual in DLB. Among 38 patients free of antipsychotics, rates of abnormal scans were 36% in patients with questionable parkinsonism, 57% in definite parkinsonism, 67% in patients with no parkinsonism. Among 9 patients on Levodopa, 6 had normal scans and Levodopa was stopped. CONCLUSION: We show a significant impact of 123I-FP-CIT SPECT on diagnoses, even in cases of definite parkinsonism or probable DLB. In the latter, scarcity of hallucinations, especially if there are not well formed and detailed, should prompt 123I-FP-CIT SPECT.

[Hip fracture in elderly patients: emergency management and indicators]. / Fracture du col du fémur et urgences gériatriques: prise en charge, organisation et indicateurs.

Hip fracture is a common condition associated with a poor outcome with 20-30% one-year mortality in the elderly. Autonomy and quality of life remains key considerations in this population. Emergency management should consider associated diseases and treatments, as well as fall and fracture. Management should target particular conditions such as pain, anemia and transfusion, time to surgery and occurrence of pressure sores, and should consider these as quality criteria. In this way, a new approach must be evaluated and requires an optimal cooperation between emergency physician, orthopaedic surgeon, anaesthetists and geriatrician. Place and interest of new models of care such as orthogeriatrics unit have to be determined.

Scurvy in hospitalized elderly patients.

OBJECTIVES: The aim of this study was to systematically screen hospitalized elderly patients for clinical symptoms of scurvy and to confirm the diagnosis with biological measures. SETTINGS: Geriatric acute care ward. MEASUREMENTS: Scurvy symptoms (one or more among perifollicular hyperkeratosis, petechiae or bruises, haemorrhagic features caused by venous puncture, severe gingivitis). We compared associated diseases, nutritional status, need for assistance for feeding, serum albumin, transthyretin, B9 and B12 vitamins, iron status and Serum Ascorbic Acid Level (SAAL) and outcome (in-hospital mortality) between scurvy and scurvy free patients. RESULTS: 18 patients with clinical symptoms of scurvy (scurvy group) were identified out of 145 consecutive patients (12%). They were compared to 23 consecutive control patients with no clinical symptoms of scurvy (scurvy-free group). SAAL was significantly lower (1.09 +/- 1.06 vs 4.87 +/- 4.2 mg x L-1, p < .001) and vitamin C deficiency more frequent (94 vs 30 %, p < .001) in the scurvy group. Moreover, in scurvy group, coronary heart disease (39 vs 9 %, p=.028), need for assistance for feeding (56 vs 13 %, p=.006) and in-hospital deaths (44 vs 9 %, p=.012) were more frequent. CONCLUSION: Ninety-four percent of patients with clinical symptoms of scurvy had vitamin C deficiency. Our results suggest that in hospitalized elderly patients, clinical symptoms allow scurvy diagnosis. Scurvy could be a frequent disease in elderly patients admitted to acute geriatric ward.

[Transfusion in clinical practice in geriatric wards]. / Enquête transversale sur la transfusion dans les services de gériatrie.

PURPOSE: In the absence of specific recommendations on blood transfusion in elderly subjects, we carried out a survey to assess transfusion practices in geriatric medicine. METHODS: A descriptive, national, cross-sectional survey was conducted in 14 French geriatric departments (12 teaching hospitals and two general hospitals). In each department, five patients receiving transfusions were randomly selected in order to analyze their characteristics, the indications of blood transfusion, the criteria for and the methods of transfusion compared with Afssaps recommendations on transfusion thresholds. RESULTS: Data were analyzed for 70 patients (mean age 86+/-7 years, sex ratio female to male 1.8, with an average of five+/-two pathologies and six+/-three treatments). The indicators of poor tolerance included confusion (23 %), somnolence (22 %), acute heart failure (17 %) or coronary heart disease (16 %), and differed from the Afssaps criteria in the majority of cases. The transfusion threshold that were considered in the absence of poor tolerance (45 % of transfusions) differed from that recommended by Afssaps in 26 % of cases. The main adverse event in transfusion recipients was heart failure. CONCLUSION: When criteria for poor anaemia tolerance or transfusion thresholds are considered, transfusion practices in geriatric subjects have specific features. Further studies are needed to validate the appropriateness of the practices described in this survey.

[Effects of hypomagnesemia]. / Les effets de l'hypomagnésémie.

INTRODUCTION: The clinical consequences of plasmatic magnesium variations are underecognized in clinical practice. The dosage of plasmatic magnesium is underused and not reliable. Moreover, hypomagnesemia is often associated with other metabolic disorders (hypocalcemia, hypokaliemia), which are responsible for several symptoms. CASE REPORT: We report an 85-year-old man who presented with repeated bronchospasm, confusion, and abdominal and muscular pain, attributed to low magnesium serum level. We then review pathophysiology, various etiologies, clinical features, diagnostic challenge and treatment of low magnesium serum level. CONCLUSION: Hypomagnesemia is poorly known and diagnosed. Therapeutic issues have not been clearly defined.

[Transfusion in elderly patients]. / Transfusion chez les patients âgés.

The frequency of anemia is responsible of a frequent use of transfusion in elderly patients. However, transfusion in elderly patients requires several warnings. First, semiology of elderly patients is characterized with atypical clinical signs, and anemia tolerance is often difficult to appreciate. Second, numerous comorbidities make of elderly patients an heterogeneous population, in which guidelines are poorly applicable. Last, elderly patients are particularly sensitive to iatrogenic events, and the haemodynamic overload related to transfusion has to be carefully managed. All these difficulties raise the need of prospective studies on transfusion in elderly patients to validate clinical practice.

[Medical comorbidity in Alzheimer's disease: baseline characteristics of the REAL.FR Cohort]. / Comorbidités et maladie d'Alzheimer: données à l'inclusion de la cohorte gériatrique REAL.FR.

PURPOSE: Alzheimer's disease (AD) evolves over about ten years with cognitive decline that can be considered as linear. Comorbidities are frequent in geriatric population. The major objective of this study is to determine whether comorbidity influences natural history of AD. MATERIALS AND METHODS: This is a prospective, multicentric French study (REAL.FR) of a cohort of ambulatory patients suffering from AD from a mild to a moderately severe stage, with a Mini-Mental State between 10 and 26, and followed with a caregiver. We evaluated the comorbidities and they were quantified using the Charlson index. RESULTS: We analysed 579 AD patients enrolled between April 2000 and June 2002. Majority of patients were women (72%). Average age and MMS average score were respectively 77.4 +/- 7.1 and 20.1 +/- 4.5. Cardiovascular diseases were the most frequent comorbid conditions (34%), before sensorial handicap (23%), and neurological diseases (18%) apart from dementia. Four AD patients groups differed according to the comorbidities figures, from none to more than three (maximum 8). Average Charlson index was 1.5 +/- 0.9. CONCLUSION: The follow-up of the four AD patients groups, differentiated by the comorbidities figures, should allow to precise the influence of comorbidities on the AD evolution. Charlson index could be used to quantify the comorbidities in the cohort's follow-up. However, this index, validated in a cohort of cancer patients, show limits for its use in geriatric population.

In vivo induction of endothelial apoptosis leads to vessel thrombosis and endothelial denudation: a clue to the understanding of the mechanisms of thrombotic plaque erosion.

BACKGROUND: The mechanisms of thrombosis on plaque erosion are poorly understood. We examined the potential role of endothelial apoptosis in endothelial erosion and vessel thrombosis. METHODS AND RESULTS: Segments of New Zealand White rabbit femoral arteries were temporarily isolated in vivo. One artery was incubated with staurosporin for 30 minutes, whereas the contralateral artery was incubated with saline and served as control. Three days later, thrombosis was evaluated angiographically and histologically. TUNEL score in the endothelial layer was significantly increased in staurosporin-treated arteries compared with controls (2.43+/-0.30 versus 0.93+/-0.44, respectively; P=0.001). Large areas of endothelial denudation were detectable in staurosporin-treated vessels, whereas endothelium integrity was almost preserved in the saline group. Vessel thrombosis occurred in 58% of staurosporin-treated arteries (7 of 12) but in only 8% of saline-treated segments (P<0.01). Immunoreactivities for tissue factor, platelets, and fibrin were detectable within the thrombus. Addition of ZVAD-fmk (0.1 mmol/L) significantly reduced the occurrence of thrombosis (1 of 7 arteries or 14%, P=0.04). These results were confirmed in balloon-injured atheromatous arteries. CONCLUSIONS: In vivo induction of endothelial apoptosis leads to both vessel thrombosis and endothelial denudation. Endothelial apoptosis may be a critical step in the transition from a stable endothelialized plaque to plaque erosion and thrombosis.

[The elderly and dementia: clinical approach]. / Sujets âgés et syndrome démentiel: approche du clinicien.

When you take care of elderly, you need to evaluate cognitive functions due to the frequency of dementia. However, before this evaluation, you must be aware of difficulties that you will encounter. You have to determine general characteristics of elderly patients and use geriatric reasoning in order to list pathologies that can interfere with cognitive functions. Thereafter, you need to precise frontiers between normal cognitive functions and dementia. When dementia is confirmed, CT scan or MRI appears very useful to exclude a cause of reversible dementia or to precise the nature of dementia. CT scan or MRI are useful during dementia to define the etiology of dementia or acute deterioration during evolution. A close collaboration between radiologist and clinician is mandatory to avoid diagnostic errors.

Sinus histiocytosis with massive lymphadenopathy in Rwanda: report of eight cases with immunohistochemical and ultrastructural studies.

The clinico-pathological, immunohistochemical and ultrastructural features of eight cases of sinus histiocytosis with massive lymphadenopathy (SHML) recorded in Rwanda from 1975 to 1980 are reported. The main histopathological features were a massive enlargement of the lymph node sinuses which were filled with large histiocytes, a great number of which phagocytosed blood cells, especially lymphocytes, and an important proliferation of plasma cells in the medullary cords. The pathogenesis of this syndrome is discussed, particularly the role of immunological disorders challenged by a chronic, but non-specific, infectious state. The ultrastructural study revealed no micro-organisms and no Langerhans' granules. Immunohistochemical staining revealed two interesting features: the presence of immunoglobulins in the cytoplasm of the histiocytes indicating the presence of an immune phagocytosis and the absence of lysozyme and alpha 1-antichymotrypsin (alpha 1-AC) from the histiocytes. The significance of the latter phenomenon is still unknown.

[Secreting tumors of the testis (author's transl)]. / Les tumeurs sécrétantes du testicule.

We have observed a secreting tumor of the testis classified as an intermediate malignant teratoma type A. This hormone secreting tumor was associated to bilateral gynecomasty. Surgery with radiotherapy were followed by disappearance of all symptoms for two years. Hormone levels, that were abnormal, returned to normal. Next to seminomas, testis teratomas are grouped in different types according to their differentiation, from well organized tissues to totally anaplastic cells. Clinical manifestations of these lesions are essentially dependent on their secretory capacity. Gynecomasty secondary to oestrogenic production of chorionic gonadotrophins or pituitary hormones, is the usual symptom; one may encounter hyperthyroidism or hypercortisolism. Generally, resection of the tumor is followed by a return to normal hormone values; recurrence of pathological values is often a sign of metastatic evolution. The treatment is orchidectomy with radiotherapy or eventually with chemotherapy.

[Osseous desmoid fibroma of the mandible. An unusual case in a 15-month-old infant]. / Fibrome desmoïde osseux du maxillaire inférieur. Cas exceptionnel d'un enfant de quinze mois

The authors present a rare case, unique in the literature, of an osseous desmoid fibroma in which the histological diagnosis was made at the age of fifteen months. The signs were of a slight swelling with complete trismus of the mandible. After excision of the tumour, with a resultant defect in the superior ramus of the mandible, the trismus disappeared spontaneously after two weeks.