Cessation of oral anticoagulants in antiphospholipid syndrome.

Objective To study the outcome of patients with antiphospholipid syndrome (APS) after oral anticoagulant treatment cessation. Methods We performed a retrospective study of patients with APS experiencing cessation of oral anticoagulant and enrolled in a French multicentre observational cohort between January 2014 and January 2016. The main outcome was the occurrence of recurrent thrombotic event after oral anticoagulation cessation. Results Forty four APS patients interrupted oral anticoagulation. The median age was 43 (27-56) years. The median duration of anticoagulation was 21 (9-118) months. Main causes of oral anticoagulant treatment cessation were switch from vitamin K antagonists to aspirin in 15 patients, prolonged disappearance of antiphospholipid antibodies in ten, bleeding complications in nine and a poor therapeutic adherence in six. Eleven (25%) patients developed a recurrent thrombotic event after oral anticoagulation cessation, including three catastrophic APS and one death due to lower limb ischemia. Antihypertensive treatment required at time of oral anticoagulants cessation seems to be an important factor associated with recurrent thrombosis after oral anticoagulant cessation (15.2% in patients with no relapse versus 45.5% in patients with recurrent thrombosis, p = 0.038). Oral anticoagulant treatment was re-started in 18 (40.9%) patients. Conclusion The risk of a new thrombotic event in APS patients who stopped their anticoagulation is high, even in those who showed a long lasting disappearance of antiphospholipid antibodies. Except for the presence of treated hypertension, this study did not find a particular clinical or biological phenotype for APS patients who relapsed after anticoagulation cessation. Any stopping of anticoagulant in such patients should be done with caution.

Prolonged suppressive antibiotic therapy for prosthetic joint infection in the elderly: a national multicentre cohort study.

During prosthetic joint infection (PJI), optimal surgical management with exchange of the device is sometimes impossible, especially in the elderly population. Thus, prolonged suppressive antibiotic therapy (PSAT) is the only option to prevent acute sepsis, but little is known about this strategy. We aimed to describe the characteristics, outcome and tolerance of PSAT in elderly patients with PJI. We performed a national cross-sectional cohort study of patients >75 years old and treated with PSAT for PJI. We evaluated the occurrence of events, which were defined as: (i) local or systemic progression of the infection (failure), (ii) death and (iii) discontinuation or switch of PSAT. A total of 136 patients were included, with a median age of 83 years [interquartile range (IQR) 81-88]. The predominant pathogen involved was Staphylococcus (62.1%) (Staphylococcus aureus in 41.7%). A single antimicrobial drug was prescribed in 96 cases (70.6%). There were 46 (33.8%) patients with an event: 25 (18%) with an adverse drug reaction leading to definitive discontinuation or switch of PSAT, 8 (5.9%) with progression of sepsis and 13 died (9.6%). Among patients under follow-up, the survival rate without an event at 2 years was 61% [95% confidence interval (CI): 51;74]. In the multivariate Cox analysis, patients with higher World Health Organization (WHO) score had an increased risk of an event [hazard ratio (HR) = 1.5, p = 0.014], whereas patients treated with beta-lactams are associated with less risk of events occurring (HR = 0.5, p = 0.048). In our cohort, PSAT could be an effective and safe option for PJI in the elderly.

[Survey on antibiotic prescription practices for palliative care terminally ill patients of 75 years old and more]. / Enquête de pratique sur les modalités de prescription des antibiotiques en phase terminale de soins palliatifs chez les patients de plus de 75 ans.

Infections commonly occur terminally ill oldest patients in palliative care and questioned about antimicrobial use. The aim of this study was to describe practitioners' habits. METHOD: ancillary study on antibiotic modalities according to the setting of care from a national practices survey based on self administered questionnaire sent by e-mail in 2017. RESULTS: 220 practitioners/327 used antibiotic, 136 worked in hospital department (52 geriatricians), 20 nursing home and 64 general practitioners (GP). GP declared less palliative care patients (6/year). The antibiotic goal was symptomatic relief for 181 (82.3%) without statistically significant difference between groups. GP (25%) were the group that most collected patient opinion for antibiotic prescription. Nursing home (23%) and GP (18%) reported more urinary tract symptoms than others (11.7%) (P=0.003). Geriatricians (59.6%) declared significantly less urinary analysis than GP (90%) (P=0.0009). 212 doctor (96.4%) faced side effect (SI): more allergic reaction and less administration difficulties than the other groups. The stop decision was collegially took (156, 70,9%) significantly more in hospital (121, 89%) than in community (25, 39.1%) (P<0.001). Patient wishes were noted by 30 (46.96%) only GP. CONCLUSION: Even if practice and number of patients follow up differ from each place of care, doctors' intention in antibiotic use respect palliative care goal to relieve discomfort. It is hard to diagnose infection and complementary exam are scarce. A repeated individualized evaluation with patient, his surrounding and his medical referent participation, is mandatory to give a constant adapted level of care in every place of care.

Explicit definitions of potentially inappropriate prescriptions of antibiotics in hospitalized older patients.

CONTEXT: The use of explicit definitions of potentially inappropriate prescriptions of antibiotics (antibiotic PIPs) might constitute an innovative means to fight against antimicrobial resistance. Explicit definitions of PIPs can reduce the rate of inappropriate prescriptions, but explicit definitions of antibiotic PIPs in geriatric medicine are currently lacking. The objective of the study was to develop explicit definitions of antibiotic PIPs for hospitalized older patients. METHOD: We performed a qualitative study of focus groups involving geriatricians and infectious disease specialists. The study complied with the Consolidated Criteria for Reporting Qualitative Research. Transcripts of audio recordings were analyzed in a two-step independent reviewing process. The exact wording of the definitions was validated by a steering committee, an independent expert group, and the focus group participants. RESULTS: The four focus groups comprised 28 stakeholders. Our analysis identified 65 explicit definitions of antibiotic PIPs: 47 (73%) concerned misuse, 15 (23%) concerned overuse and three (5%) concerned underuse. Most definitions were related to critically important antibiotics: 11 (17%) for fluoroquinolones, eight (12%) for amoxicillin-clavulanic acid, eight (12%) for cephalosporins, seven (11%) for aminoglycosides, and five (8%) for carbapenems. CONCLUSION: To address the public health challenge of antimicrobial resistance, our study generated explicit definitions for antibiotic PIPs in older patients. We intend to refine and to validate these definitions through a national Delphi survey; the resulting consensus might provide key messages for prescribers and open up perspectives for reducing the incidence of antibiotic PIPs.

[Recommendations of the Infectious Disease Committee of the French Association of Urology. Diagnosis, treatment and monitoring candiduria]. / Recommandations du comité d'infectiologie de l'AFU. Diagnostic, traitement et suivi des candiduries.

The candiduria are frequently encountered in urology. We present the recommendations of the Infectious Diseases Committee of the French Association of Urology for diagnosis, treatment and monitoring of urinary tract infections. C. albicans is the most frequently isolated species, representing 60% of the isolates. Immunosuppression, diabetes mellitus, age extremes of life, the presence of catheters or procedures on the urinary tract are risk factors for Candida urinary tract infection. The candiduria is usually asymptomatic and does not need treatment. Only 4-14% of patients with candiduria have symptoms of urinary infection. It is necessary before choosing candiduria isolated on a first urinalysis to eliminate contamination by conducting a second harvest. In patients surveyed, the removal of the material allows the resolution of the candiduria nearly half the time and represents the first step of management. Oral fluconazole is the recommended treatment for cystitis (400 mg on day 1 and 200 mg daily for 7 to 14 days). In cases of pyelonephritis without associated candidemia, the first-line therapy is fluconazole (3-6 mg/kg/day) for 14 days or amphotericin B at a dose of 0.5 to 0.7 mg/kg/day with or not associated to flucytosine when potentially resistant strain (C. glabrata).

Determinants of doctors' antibiotic prescriptions for patients over 75 years old in the terminal stage of palliative care.

INTRODUCTION: Notwithstanding high prevalence of presumably bacterial infections in elderly persons (EP) in palliative care (PC), there exists no recommendation on the role of antibiotic therapy (ABP) in this type of situation. OBJECTIVE: To describe the determinants of antibiotic prescription by general practitioners (GP) and by doctors practicing in institutions (DPI) for patients>75 years, in end-of-life situations in PC. METHOD: Descriptive investigation by anonymous self-administered questionnaire disseminated in France by e-mail. RESULTS: A total of 301 questionnaires analyzed: 113 GP, 188 DPIs. The latter were mainly geriatricians (69, 36.6%) and infectologists/internists (41, 21.8%). Sixty-three (55,75%) GPs and 144 (78.7%) DPIs stated that they had prescribed antibiotics. Practice in "EHPAD" retirement homes or intensive care was often associated with non-prescription of antibiotics. Age, PC training and number of patients monitored bore no influence. Family involvement in decision-making was more frequent for GPs than for DPIs. The main purpose of antibiotic therapy was to relieve different symptoms (fever, respiratory congestion, functional urinary signs). Most of the doctors (81%) had previously encountered complications (allergy, adverse effect), which represented the main causes of treatment discontinuation. CONCLUSION: Antibiotic use in end-of-life EPs in PC seems frequent. In accordance with the principle of beneficence, its goal of often symptom-related; that said, in the absence of scientific data, antibiotic prescription in end-of-life situations should be individualized in view of observing the other ethical caregiving principles (beneficence, non-maleficence, justice, patient autonomy) and re-evaluated daily.

Intrafamilial cluster of pulmonary tuberculosis due to Mycobacterium bovis of the African 1 clonal complex.

A new clonal complex of Mycobacterium bovis present at high frequency in cattle from west central African countries has been described as the African 1 (Af1) clonal complex. Here, the first intrafamilial cluster of human tuberculosis cases due to M. bovis Af1 clonal complex strains is reported. We discuss hypotheses regarding modes of transmission.

Comprehensive geriatric assessment in older patients suffering from infective endocarditis. A prospective multicentric cohort study.

OBJECTIVES: The aim was to describe the impact of infective endocarditis (IE) on functional, cognitive and nutritional statuses, and to estimate the influence of these parameters on surgical management and mortality. METHOD: This was a prospective study over 13 months in 14 French hospitals, including patients ≥75 years of age with definite or possible IE. A comprehensive geriatric assessment (CGA) was performed during the first week of hospitalization, including a retrospective estimation of functional status 2 months before hospitalization, and 3 months after. RESULTS: A total of 120 patients were included (mean age 83.1 ± 5.0 (75-101) years). IE was associated with a dramatic impairment of functional status between 2 months prior hospitalization and the first geriatric evaluation (90.8% able to walk vs. 35.5% (p < 0.0001), ADL (Activities in Daily Living) 5.0 ± 1.7 vs. 3.1 ± 2.1 (p < 0.0001)). The 19 operated patients (15.8%) had less comorbidities (cumulative illness rating scale geriatric 10.8 ± 8.2 vs. 15.3 ± 7.1 (p 0.0176)), better functional (ADL 5.9 ± 0.4 vs. 4.9 ± 1.8 (p 0.0171) and nutritional (mini nutritional assessment 20.4 ± 5.0 vs. 17.3 ± 6.2 (p 0.0501)) statuses than non-operated patients. Among all infectious, cardiac and geriatric parameters, body mass index (HR 0.9, range 0.8-1, p 0.05) and ADL at the time of the first evaluation (HR 0.7, range 0.6-0.9, p 0.002) were the sole independent predictors of the 3-month (32.5%) and 1-year mortality (42.5%). Three months later, the 57 assessed patients only partially recovered their ADL (3.7 ± 1.9 vs. 5.3 ± 1.4 2 months prior hospitalization and 4.6 ± 1.9 at the first CGA; p < 0.0001). CONCLUSION: Functional and nutritional abilities are crucial components that can be accurately explored through a CGA when managing IE in oldest patients.

[Original presentation of relapsing polychondritis: four cases]. / Manifestations originales au cours de la polychondrite atrophiante: à propos de quatre cas.

INTRODUCTION: The diagnosis of relapsing polychondritis is difficult as various manifestations may be encountered aside the characteristic episodes of recurrent chondritis. CASE REPORTS: From the retrospective analysis of the medical charts of patients presenting with relapsing polychondritis seen at Nîmes hospital between 1995 to 2006, four were selected for their original extra-cartilaginous manifestations. Case 1: relapsing polychondritis was diagnosed at the time of a thromboembolic event associated with a right uveitis, left temporomandibular arthritis and bilateral sensorineural deafness. Case 2: relapsing polychondritis occurred in a patient with history of bilateral sensorineural deafness with punctuated keratitis followed by a relapsing cutaneous leucocytoclastic vasculitis. Case 3: relapsing polychondritis associated with recurrent thromboembolic disease and a Sweet's syndrome and case 4: relapsing polychondritis presenting with a febrile erythema. CONCLUSION: The reported observations highlight the difficulty of the initial diagnosis of relapsing chondritis and the variety of the extra-chondritis manifestations that could be observed in this disease.

[Familial Mediterranean fever]. / La fièvre méditerranéenne familiale.

Familial Mediterranean Fever (FMF) is the most frequent monogenic auto-inflammatory disease. FMF is an autosomal recessive disease, which affects populations from Mediterranean origin and is associated with MEFV gene mutations encoding for the protein pyrin. Pyrin activation enhances the secretion of interleukin 1 by myelo-monocytic cells. Main features of the disease are acute attacks of serositis mainly located on the abdomen, less frequently on chest and joints, accompanied by fever and biological inflammatory markers elevation. Usually attacks last 1 to 3 days and spontaneously stop. A daily oral colchicine intake of 1 to 2mg/day is able to prevent attack's occurrence, frequency, intensity and duration among most patients. Colchicine is also able to prevent the development of inflammatory amyloidosis, the most severe complication of FMF. This state of the art article will focus on the diagnosis of FMF, the treatment and an update on the pathophysiology including the recent described dominant form of MEFV-associated new auto-inflammatory diseases.

[Longitudinal epiphyseal bracket of the first metatarsus (delta bone)]. / Pont épiphysaire longitudinal déformant du premier métatarsien ou "métatarse delta"

PURPOSE OF THE STUDY: The longitudinal epiphyseal bracket (LEB) or delta bone is a rare congenital ossification anomaly generally observed in finger or toe phalanges but occasionally in the metatarsus or metacarpus. LEB is initially composed of cartilage forming a bracket linking the proximal and distal epiphyses and causing defective growth of the primary ossification focus. Changes in bone growth secondary to the presence of a LEB would be the cause the angle malformations and length discrepancies observed in these subjects. This raises significant therapeutic problems and repeated surgical interventions when the diagnosis is not established early enough. The clinical presentation of LEB of the first metatarsus is similar to metatarsus adductus or hallux varus primus. The particular aspect on the plain x-ray enables the diagnosis. MATERIAL AND METHODS: We operated five feet presenting LEB of the first metatarsus in three children aged on average 23 months (range 8 months to 3 years 10 months). The cartilage bracket was removed, followed by metatarso-phalangeal centromedullary pinning. We studied the course of the angle and length deformities and report outcome at mean follow-up of 4 years 11 months (range 2 years to 3 years 10 months). RESULTS: Clinical improvement with correction of the angle deformities was observed in all feet. The length discrepancies did not resolve completely. The degree of correction depended on the age at the time of surgery. DISCUSSION: In light of the results obtained in this series and considering the negative prognosis of late surgical management, it would be advisable to obtain a plain x-ray of the foot in all children presenting metatarsus adductus associated with a short first ray.

[Evolution and prognosis of adult onset Still's disease. A monocentric study of 17 patients]. / Profils évolutifs et marqueurs pronostiques de la maladie de Still de l'adulte. Analyse d'une série monocentrique de 17 patients.

UNLABELLED: Adult-Onset Still's disease (AOSD) is a rare condition of unknown origin with various presentations and unpredictable outcome. The aim of this study was to analyse clinical and biological presentation, and outcome of patients admitted to an internal medicine service. METHOD: A retrospective cohort design with prospective follow-up was used. All the patients admitted to our internal medicine service for AOSD between January 1998 and March 2004 were included. RESULTS: According to Yamaguchi's classification criteria, 17 patients were analysed with a mean age at onset of 37.3 years and a 2.4 sex-ratio (female/male). Mean follow-up length was 52.1 months. Eight patients developed a monocyclic systemic form, 8 a polycyclic systemic form and 1 a chronic articular form. Arthralgia (87%) and arthritis (53%) were less frequent than in other series. Sixteen patients were treated: 14 by corticosteroids, 6 by non-steroid anti-inflammatory drugs, 5 by methotrexate, 2 intravenous polyglobulin and one by anti-TNF drug. Patients with a corticodependant or corticoresistant form had more polyarthritis at the onset of the disease (3/6 vs 0/11, P=0.029). DISCUSSION: In internal medicine activity, AOSD without oligo- or polyarthritis may be more frequent than expected according to the literature. Corticotherapy alone is often efficient in these AOSD form without synovitis, and methotrexate use is uncommon.

[Menopause: where are we three years beyond WHI?]. / Menopause: où en sommes-nous trois ans après la WHI?

The WHI triggered a great debate on Menopausal Hormonal Therapy. We now know that HT should not be used in cardio-vascular prevention. Many studies have yet been published regarding it's influence on breast cancers. Risks should be modulated in respect with the type of treatment and the targeted population. Only recently menopaused women or women suffering from invalidating menopausal symptoms should benefit from HT. When an HT is needed, the authors recommend the use of trans-cutaneous estrogens combined with natural oral progesterone. Every HT should be prescribed individually, according to the patient's aspirations and expectations.

Subcutaneously administered antibiotics: a national survey of current practice from the French Infectious Diseases (SPILF) and Geriatric Medicine (SFGG) society networks.

A national survey was performed to explore antibiotic prescription by the subcutaneous (sc) route among French infectious diseases and geriatric practitioners. Among the participating physicians, 367 (96.1%) declared administering sc antibiotics at some point. Ceftriaxone was prescribed sc by all but one, and ertapenem, teicoplanin, aminoglycosides and amoxicillin by 33.2%, 39.2%, 35.1% and 15.3%, respectively. The sc route was resorted to mainly in case of unavailable oral, intravenous or intramuscular routes, especially during palliative care. Pain, skin necrosis and lack of efficacy were the main adverse effects, reported by 70.8%, 12.8% and 19.9% of practitioners, respectively. Further studies are needed to precise the indications, modalities and tolerance of sc antibiotic use.

[Leiomyosarcoma and Stauffer syndrome]. / Léiomyosarcome et syndrome de Stauffer.

INTRODUCTION: Stauffer's syndrome is a non-metastatic anicteric cholestasis and an inflammatory syndrome usually associated with renal cell carcinoma. EXEGESIS: We present a case report of an eighty-four-year-old woman who had a leiomyosarcoma revealed by Stauffer's syndrome, which disappeared after surgery. CONCLUSION: Abnormal secretion of interleukin-6 by the leiomyosarcoma could explain this syndrome. The association of Stauffer's syndrome and leiomyosarcoma has never been described.

Subcutaneous and intravenous ceftriaxone administration in patients more than 75 years of age.

OBJECTIVE: We wanted to compare the first line intravenous administration of ceftriaxone to a subcutaneous administration in patients more than 75 years of age. METHOD: We performed a retrospective monocentric study on all patients more than 75 years of age admitted to the Ales hospital between January 1 and December 31, 2011, having received at least two doses of ceftriaxone intravenously (IV) or subcutaneously (SC). RESULTS: One hundred and forty-eight patients (70 females/78 males patients) were included, 110 received ceftriaxone IV and 38 SC. They were a mean age of 84.7 years, older in the SC group (86.9 years) than in the IV group (83.9 years) (P = 0.0052). The SC group patients presented more frequently with dementia (57% vs. 25% P = 0.001), were more often bedridden (22% vs. 7% P = 0.023), had a higher mean World Health Organization status (3.13 vs. 2.76, P = 0.0181), and higher ADL score (7.79 vs. 5.76, P = 0.0056). There was no statistical difference for isolated bacteria, site of infection, death rate, and patients cured. CONCLUSION: Subcutaneous ceftriaxone administration seems to be preferred for fragile elderly patients independently of disease severity. This administration is not associated to an impaired effectiveness or to an increased death rate.

Evaluation of empirical antibiotherapy for acute community-acquired pneumonia prescribed in emergency departments.

OBJECTIVE: The authors assessed the management of community-acquired pneumonia (CAP) and empirical antibiotic prescription in a primary care center. METHOD: A retrospective study was made on medical charts of patients admitted to the emergency department for CAP. RESULTS: Seventy-six patients were included. Their mean age was 65years for a sex ratio of 1.81. Fever (83%) and cough (72%) were the most common symptoms. Chest X-ray was abnormal in 86%. The median CRP value was 138mg/L (58-235). The median Fine's score was 85.5 (60-127). Blood cultures were sterile for 82.5% of samples. Pneumococcal and legionella antigenuria were performed for 70% of patients, only one was positive for legionella. Antibiotherapy was prescribed to 18 patients before hospitalization. Amoxicillin-clavulanic acid was the most frequently prescribed empirical treatment (48.5%), followed by ceftriaxone (15%). The therapeutic adequation index was calculated at a median of 1.7 by three investigators (0-3.7). Kendall's concordance coefficient for the three investigators was good at 0.86 (P<0.0001). Close to 39% of antibiotic prescription had a bad therapeutic adequation index more than three. DISCUSSION: Our clinical, radiological, and microbiological data was quite similar to reported data from teaching hospital series except for severity that seemed lower in primary care centers. The therapeutic adequation index is a useful tool to assess the adequacy of antibiotic prescription.