Plasma exchange in the intensive care unit: Technical aspects and complications.

BACKGROUND: Data on plasma exchange therapy in the intensive care unit (ICU) setting are scarce. We aimed to describe the technical aspects and the adverse events associated with the procedure in critically ill patients. METHODS: All adult patients treated by plasma exchange in the medical ICU of the Saint-Louis university hospital between January 1, 2013 and March 31, 2015 were prospectively included. RESULTS: We report on 260 plasma exchange procedures performed in 50 patients. The centrifugation technique was used for 159 (61%) procedures and the filtration technique for the other 101 (39%) procedures. Both techniques had similar efficacy to treat hyperviscosity syndrome (n = 18). Seventy (26.9%) of the 260 plasma exchange procedures were reported with at least one adverse reaction. Centrifugation and filtration techniques had similar rates of adverse reactions (23.9 vs. 31.7%, P = .19). Hypotension was the most reported (n = 21, 8%) and correlates with a low hematocrit before therapy. Most complications were related to allergic reactions to the replacement fluids. Coagulation disorders depended on the type of replacement fluid. The post-exchange fibrinogen level was decreased by 54% [48;66] with albumin 5%, and 4% [-5;17] with plasma frozen within 24 h. Twenty-three (22.8%) of the 101 filtration procedures experienced filter clotting. Filter clotting was associated with a higher volume exchange prescribed when compared to procedures without filter clotting (4600 [4000;5000] ml vs. 3900 [3600;4800] ml, P < .01). CONCLUSION: Plasma exchange is a relatively safe and generally well-tolerated procedure in the ICU setting. Most adverse events are unpredictable and related to minor allergic reactions.

[Diabetes mellitus and cognition: is there a link?]. / Diabète et cognition: existe-t-il un lien ?

The occurrence of diabetes and dementia is very high in older patients. The fact that both conditions are concurrent raises the question of a possible link between the two. Cognitive functions of non-demented patients with diabetes have been extensively studied. In type 1 diabetes, only a mild decrease of the speed of information processing and of the psychomotor efficiency has been shown. Cognitive decline seems to be related to poor metabolic control and not to hypoglycaemia. In older patients with type 2 diabetes, memory and executive functions have been found impaired. Longitudinal studies of the literature have shown that diabetic patients have a higher chance of developing dementia than non-diabetic patient, with a relative risk (RR) between 1.26 and 2.83. The risk of vascular dementia was increased in 3 out of 5 studies, with a RR ranging between 2 and 2.6. With regard to Alzheimer's disease, the results are conflicting. Half of the studies found an increased risk in diabetic patients (RR: 1.3-2). The possible causal mechanisms of dementia in diabetic patients remain hypothetical. MRI studies showed varying degrees of cortical atrophy, cerebral infarcts and deep white matter lesions. In neuropathological studies, senile plaques and neurofibrillary tangle were not found with higher severity in the brain of diabetic patients than in the brain of age-matched controls. Several hypotheses have been raised to explain the relationship between diabetes and cognitive decline. Micro and macrovascular changes in the brain could induce cerebral hypoxia and ischemic conditions resulting in cellular death or white matter lesions. The occurrence of vascular lesions might reduce the threshold at which dementia will occur in Alzheimer disease. The deposition of advanced glycation end products doesn't spare the brain and they have been found in senile plaques, where they can reduce the solubility of proteins such as the beta amyloid and Tau proteins. Some authors favour the hypothesis of a brain insulin resistance because, in a few small studies, insulin was found to improve memory.

Drug-related readmissions to medical units of older adults discharged from acute geriatric units: results of the Optimization of Medication in AGEd multicenter randomized controlled trial.

OBJECTIVES: To assess the effect of an intervention on drug-related problem (DRP; adverse drug reactions, adherence problems, underuse)-related readmission rates in older adults. DESIGN: Ancillary study from a 6-month, prospective, randomized, parallel-group, open-label trial. SETTING: Six acute geriatric units in Paris and suburbs. PARTICIPANTS: Six hundred sixty-five consecutively admitted individuals were included: 317 in the intervention group (IG) and 348 in the control group (CG) (aged 86.1 ± 6.2, 66% female). INTERVENTION: Discharge-planning intervention combining chronic drug review, education, and enhanced transition-of-care communication. MEASUREMENTS: Chronic drugs at discharge of the two groups were compared. An expert committee blinded to group assignment adjudicated whether 6-month readmission to the study hospitals was related to drugs. RESULTS: Six hundred thirty-nine individuals were discharged and followed up (300 IG, 339 CG). The intervention had no significant effect on drug regimen at discharge, characterized by prescriptions that are mostly appropriate but increase iatrogenic risk. Three hundred eleven readmissions occurred during follow-up (180 CG, 131 IG), of which 185 (59.5%) were adjudicated (102 CG, 83 IG). For 16, DRP imputability was doubtful. Of the remaining 169, DRPs were the most frequent cause for readmission, with 38 (40.4%) readmissions in the CG and 26 (34.7%) in the IG (relative risk reduction = 14.3%, 95% confidence interval = 14.0-14.5%, P = .54). The intervention was associated with 39.7% fewer readmissions related to adverse drug reactions (P = .12) despite the study's lack of power. CONCLUSION: Drug-related problem prevention in older people discharged from the hospital should be a priority, with a focus on improving the monitoring of drugs with high iatrogenic risk.

A new multimodal geriatric discharge-planning intervention to prevent emergency visits and rehospitalizations of older adults: the optimization of medication in AGEd multicenter randomized controlled trial.

OBJECTIVES: To determine whether a new multimodal comprehensive discharge-planning intervention would reduce emergency rehospitalizations or emergency department (ED) visits for very old inpatients. DESIGN: Six-month prospective, randomized (Zelen design), parallel-group, open-label trial. SETTING: Six acute geriatric units (AGUs) in Paris and its surroundings. PARTICIPANTS: Six hundred sixty-five consecutive inpatients aged 70 and older (intervention group (IG) n = 317; control group (CG) n = 348). INTERVENTION: Intervention-dedicated geriatricians different from those in the study centers implemented the intervention, which targeted three risk factors for preventable readmissions and consisted of three components: comprehensive chronic medication review, education on self-management of disease, and detailed transition-of-care communication with outpatient health professionals. MEASUREMENTS: Emergency hospitalization or ED visit 3 and 6 months after discharge, as assessed by telephone calls to the participant, the caregiver, and the general practitioner and confirmed with the hospital administrative database. RESULTS: Twenty-three percent of IG participants were readmitted to hospital or had an ED visit 3 months after discharge, compared with 30.5% of CG participants (P = .03); at 6 months, the proportions were 35.3% and 40.8%, respectively (P = .15). Event-free survival was significantly higher in the IG at 3 months (hazard ratio (HR) = 0.72, 95% confidence interval (CI) = 0.53-0.97, P = .03) but not at 6 months (HR = 0.81, 95% CI = 0.64-1.04, P = .10). CONCLUSION: This intervention was effective in reducing rehospitalizations and ED visits for very elderly participants 3 but not 6 months after their discharge from the AGU. Future research should investigate the effect of this intervention of transitional care in a larger population and in usual acute and subacute geriatric care.