[The establishment of geriatric intervention group and geriatric assessment at emergency of Henri-Mondor hospital]. / Mise en place de l'équipe d'intervention gériatrique et de l'évaluation gériatrique aux urgences de l'hôpital Henri-Mondor.

BACKGROUND: The official French demographic previsions are a growing number of the older than 75 years elderly people. The Emergency services face this demographic evolution. We describe the establishment of the geriatric intervention group at the emergency of the Henri-Mondor university hospital at Creteil (France) and analyse the results of the geriatric assessment at the short unit care during the first four months. METHODS: We analysed the results of the geriatric assessment of 206 patients during the first four months, by considering the final unit care. The geriatric assessment evaluates functional abilities, cognitive status and thymic function with elderly people validated tests and subjective assessment of nutrition status and the sensorial functions. RESULTS: The statistical analysis of the geriatric assessment results was significant among the different hospitalized groups of patients, for the cognitive status, the nutritional risk and the walk and standing evaluation. CONCLUSION: The results of the geriatric assessment at emergency showed cognitive impairment and gait abnormality in elderly patients were at risk of hospitalization.

Left innominate vein stenosis as a late complication of central vein catheterization.

A patient was seen for acute exercise-induced left superior limb swelling. Phlebography disclosed left innominate vein stenosis and the lack of subclavian vein thrombosis. Ten months earlier, the patient underwent repeated and prolonged central vein catheterization procedures. No other cause of central vein stenosis was evidenced. Emphasis is placed on the symptomatic presenting event, the very late discovery, and the site of stenosis.

Acquired von Willebrand's syndrome with IgM inhibitor against von Willebrand's factor.

This report describes a patient without evident underlying disease, in whom an acquired von Willebrand's syndrome was discovered before surgery. Coagulation abnormalities included a borderline bleeding time, a low retention of platelets on glass beads, decreased levels of factor VIII procoagulant activity (VIIIAHF), factor VIII-related antigen (VIIIAg), and ristocetin-induced agglutination cofactor (VIIIVWF). After cryoprecipitate infusion the patient did not have the expected rise and there was no secondary increment in VIIIAHF. The patient was treated with prednisone for three weeks without significant improvement in the laboratory findings. Spontaneous resolution was observed long after this therapy. The haemostatic abnormalities were attributable to the presence of an inhibitor directed against VIIIVWF. The inhibitor was found in the IgM fraction. Its autoimmune nature is probable although we failed to demonstrate any inhibitory effect of Fab obtained from the patient's purified IgM. Despite the lack of inhibitory effect against VIIIAHF and VIIIAg, the low levels of all three activities of the factor VIII complex could be explained by the short half-life of immune complexes between factor VIII and the inhibitor.

Patients' preferences concerning medical information and surrogacy: results of a prospective study in a French emergency department.

OBJECTIVE: To study the wishes of a sample of French patients about medical information and surrogacy, at a time when the French Ministry of Health is supporting increased patient autonomy. DESIGN: A cohort of competent patients with non-critical illnesses or injuries completed an intention-to-act questionnaire on the amount of medical information they would want to receive should they be hospitalized or in a life-threatening situation. The percentage of patients who would want to have a surrogate if they were in a coma was determined, as well as the identity of the preferred surrogate. The subgroup of patients who were married or living with a partner was evaluated separately to determine how often the spouse/partner was the preferred surrogate. Associations were looked for between patients' wishes and age, sex, educational level, occupation, hierarchical order in the family, and level of confidence in medicine. SETTING: The emergency room of a teaching hospital in the Paris area (France). RESULTS: Of the 1089 patients included in the study, 5. 5 % reported that they would not want any information, 25.3 % that they would want to participate actively in all decisions about their care, and 87.3 % that they would want to be fully informed if they were in a life-threatening situation. Slightly less than one-third of the patients (29.6 %) believed they would not want a surrogate if they developed a coma. Among the patients living with a spouse/partner, 40.6 % (229/561) indicated they would want their spouse/partner to be their surrogate. A significant correlation was observed between wanting more information and wanting a surrogate. Younger patients with a higher educational level were significantly more likely to predict a desire for information and for a surrogate than the other patients. CONCLUSION: Our patients expressed a strong desire to receive extensive information should they become seriously ill, and two-thirds of them reported they would want a surrogate. However, only 40.6 % of the patients living with a spouse/partner would want their spouse/partner to be their surrogate. These data suggest that the time has probably come to propose a nation-wide public hearing on medical information and surrogacy in France.

Fibromuscular dysplasia of the right subclavian artery.

The case of an uncommon form of arterial fibromuscular dysplasia is reported. The anomaly was located in the right subclavian artery. Claudication of the affected limb was the presenting symptom. Angiography was diagnostic in visualizing typical multifocal stenosis of the proximal portion of the right subclavian artery. Complete surgical correction was performed by establishing a carotido-subclavian by-pass graft.

[Münchhausen syndrome]. / Le syndrome de Münchhausen.

Münchhausen's syndrome is characterized by fictitious illnesses associated with hospital peregrination, pseudologia fantastica with a mythomanic discourse that includes strongly structured medical elements, passivity and dependance at examinations, and aggressiveness. The whole picture is so typical that the syndrome can easily be recognized. Cases of Münchhausen's syndrome by proxy (Meadow's syndrome) have been reported during the last few years; the condition concerns children suffering from diseases which are entirely due to their parents and can be compared with the battered child syndrome. In terms of nosology, among pathomimias Münchhausen's syndrome figures as a borderline state. Since it is impossible to establish positive relations with these patients, treatment fails in almost every case.

[Congestive heart failure in the aged. Causes and mechanisms of left ventricular dysfunction]. / Insuffisance cardiaque du sujet âgé. Causes et mécanismes des dysfonctions ventriculaires gauches.

UNLABELLED: AGING PROCESS: Aging can be defined as an association of senescence and disease states. Aging induces changes in adaptive processes, modifying heart failure pathophysiology. MECHANISMS: In a population over 75, half of the patients with congestive heart failure have normal left ventricular systolic function. Heart failure in these patients results from ventricular diastolic dysfunction. Hypertension and coronary heart disease are the main causes of heart failure. THERAPEUTIC IMPLICATIONS: Identifying the etiology and the underlying mechanism (systolic or diastolic) are essential steps guiding further management.

[Congestive heart failure in the aged. Diagnosis]. / Insuffisance cardiaque du sujet âgé. Diagnostic.

THREE DIAGNOSTIC PITFALLS: The difficulty in diagnosing congestive heart failure in the elderly subject is basically caused by three factors. First, clinical expression is often atypical. Secondly, severity is often underestimated as the prevalence of asymptomatic systolic dysfunction increases with age. Half of all cases of left ventricular systolic dysfunction go unrecognized if clinical signs alone are considered. Finally, the pathophysiology of diastolic dysfunction, which predominates in the over 75 population, is still poorly understood. COMPLEMENTARY EXPLORATIONS: As the clinical signs are the same whatever the mechanism of the ventricular dysfunction, echocardiography is the key exploration for diagnosis and for guiding management. Comorbidity is often a confounding factor preventing precise diagnosis and risk stratification.

[Congestive heart failure in the aged. Therapeutic management]. / Insuffisance cardiaque du sujet âgé. Prise en charge thérapeutique.

TOWARDS OPTIMAL CARE: It is essential to distinguish between systolic and diastolic dysfunction to achieve optimal management of patients with congestive heart failure. Data is lacking in the literature for validation of the guidelines usually applied in the elderly population. A specific analysis of therapeutic management of diastolic heart failure has never been performed. Altered response to drugs and associated disease states argue for an assessment of therapeutic options. The therapeutic objectives to test are different in the elderly population where quality of life and morbidity are more important than mortality criteria. In clinical practice, the empirical approach still predominates over evidence based medicine. THERAPEUTIC GOALS: At the acute phase, volume overload requires rapid action diuretics and a treatment of the triggering cause. For chronic situations, diet and lifestyle play a major role (reduced salt intake, regular exercise). Drug therapy, particularly converting enzyme inhibitors have been found to be quite effective. Rehabilitation and secondary preventive measures are the only validated methods proven to improve quality of life.

[Urinary tract infections in the elderly]. / Infections urinaires du sujet âgé.

DEFINITIONS: Age over 65 years is generally used to define the elderly population. Urinary tract infections are increasingly frequent after this age. Comorbidity and living conditions in the elderly have a particular incidence on the clinical expression and the bacterial flora involved. Besides these elements, altered cognitive capacity and abnormal urinary function prior to the infection and lead to an atypical clinical presentation. ASYMPTOMATIC BACTERIURIA: Systematic screening has produced a large body of literature on asymptomatic bacteriuria. Our review of the literature leads to the conclusion that systematic bacteriology tests are not warranted in the elderly population in general due to the subsequent risk of germ selection and erroneous diagnosis. PRACTICAL ATTITUDE: The diagnosis of urinary infection must be evidence-based, taking into account the patient's history and ruling out other diagnoses. In all cases, antibiotics must be carefully adapted to the patient's situation and titrated to kidney function.

[Acute Actinobacillus actinomycetem comitans aortic endocarditis]. / Endocardite aortique aiguë à Actinobacillus actinomycetem comitans.

A 55 year old man presented an acute massive primary aortic endocarditis, with blood cultures showing the presence of Actinobacillus actinomycetem comitans. The rapidly worsening character of this endocarditis, which required an emergency valve replacement, was the hallmark of this case. The clinical and haemodynamic signs of the often missed massive acute aortic incompetence are recalled.

[Hepatitis of the secondary syphilis (author's transl)]. / Hépatite syphilitique secondaire de l'adulte.

A case of syphitic hepatitis is reported. This rare manifestation during the second stage, is characterised by a important cholestasis and a moderated cytolysis. The biologic pattern and the histologic findings allow the difference with viral hepatitis. The manifestation is more frequent in homosexual people. The specific treatment is quickly effective and the short and long-term prognosis is good.

[Severe somatic complications of acute alcoholic intoxication]. / Grandes complications somatiques de l'alcoolisation aiguë.

Acute alcohol ingestion can affect life expectancy and is directly responsible for 3,500 deaths per year. Acute lung diseases are mainly caused by pneumococci, Gram negative bacilli and anaerobic germs, and are often due to multiple microbes. In this case, evolution toward abscess can be feared. Septicaemia and enterobacterial peritonitis are frequently observed in cirrhotic patients. Ethanol, hypokaliemia and hypophosphoraemia also lead to rhabdomyolysis. Rhabdomyolysis can be complicated with acute renal failure and hyperkaliaemia. Alcoholic ketoacidosis and the hypoglycaemia favored by prolonged inadequate nutrition, are corrected by infusion of glucose solutions. Hyponatraemia can be complicated by convulsions and central pontine myelinolysis. Minor forms of alcoholic hepatitis remiss after stopping alcohol intoxication. The major forms can evolve toward fatal encephalopathy; treatment with corticosteroids improves the prognosis in severe hepatitis. The cardiac failure with lactic acidosis in shoshin beriberi rapidly evolves to collapsus; treatment is based on emergency administration of vitamin B1. Management of patients in acute alcohol episodes requires great vigilance. Careful clinical examination and biological tests should eliminate severe somatic complications before concluding to simple alcoholic intoxication.