Modeling individual and relative accuracy of screening tools in geriatric oncology.

BACKGROUND: Classification probabilities reflect to what degree a screening test represents the true disease state and include true positive (TPF) and false positive fractions (FPF). With two tests, one can compare TPF and FPF using relative probabilities which offer advantages in terms of interpretation and statistical modeling. Our objective was to highlight how individual and relative TPF and FPF can be easily estimated and compared within a regression modeling framework. This allows the modeling of tests' accuracy while adjusting for multiple covariates, and thus provides valuable information in addition to the crude TPF and FPF. We illustrate our purpose with the G8 and VES-13 screening tests aimed at identifying elderly cancer patients in need for a comprehensive geriatric assessment (CGA). METHODS: Prospective cohort with a paired design. TPF and FPF of each test, as well as relative TPF and FPF were modeled using log-linear models. RESULTS: G8 detected patients in need for CGA better than VES-13 at the expense of misclassifying a large number of normal patients. Both tests had better TPF with older age and poorer performance status (PS), and for all cancer subtypes compared with prostate cancer. Effect of age and PS on TPF was more pronounced with VES-13. Age affected FPF, but not differentially. CONCLUSIONS: Regression modeling helps provide a thorough assessment of the accuracy of diagnostic tests and should be used more frequently. In the context of screening, we encourage the use of G8 as failing to identify patients in need of a CGA might be more problematic than over-detection. Moreover, although we identified variables associated with the sensitivity of these tests, this association was less pronounced for the G8.

Predictive factors of depressive symptoms of elderly patients with cancer receiving first-line chemotherapy.

BACKGROUND: Depression is the most common psychiatric disorder in geriatrics and oncology. For elderly cancer patients, it has a significant impact on quality of life, morbidity, and mortality. Nevertheless, depression is under-diagnosed and under-treated. Cancer management is key in improving the quality of care in this population. We aim to identify sociodemographic, clinical, and treatment-related factors of depression in elderly patients during chemotherapy, thus allowing early detection of patients in need of specific treatment. Further, we investigate whether chemotherapy efficacy and safety are associated with depression. PATIENTS AND METHODS: A prospective multicenter cohort composed of incident cases of cancer diagnosed in patients 70 years and older, receiving first-line chemotherapy. Depressive symptoms were measured by the Geriatric Depression Scale at baseline and after four chemotherapy cycles. Associations between depressive symptoms during chemotherapy and patients' clinical and treatment characteristics were identified by logistic regression. RESULTS: Among 344 patients measured for depression before chemotherapy, 260 had a second assessment at the fourth treatment cycle. At baseline, 45.4% were depressed, and 44.6% were depressed after the fourth cycle. Independent factors of depression were depressive symptoms at baseline (odds ratio (OR) = 6.7, p < 0.001), malnutrition (OR = 5.1, p = 0.014), and risk of malnutrition (OR = 1.6, p = 0.014). After controlling for missing data, effective chemotherapy was associated with a lower risk of depression (OR = 0.4, p = 0.018). CONCLUSION: We highlight the role of depressive symptoms and nutritional status at baseline, on the occurrence of depressive symptoms during chemotherapy. These factors should be taken into account in any pre-treatment consultation and appropriate nutritional and psychiatric preventative measures established. Copyright © 2016 John Wiley & Sons, Ltd.

Screening older cancer patients: first evaluation of the G-8 geriatric screening tool.

BACKGROUND: Development of a geriatric screening tool is necessary to identify elderly cancer patients who would benefit from comprehensive geriatric assessment (CGA). We develop and evaluate the G-8 screening tool against various reference tests. PATIENTS AND METHODS: Analyses were based on 364 cancer patients aged>70 years scheduled to receive first-line chemotherapy included in a multicenter prospective study. The G-8 consists of seven items from the Mini Nutritional Assessment (MNA) questionnaire and age. Our primary reference test is based on a set of seven CGA scales: Activities Daily Living (ADL), Instrumental ADL, MNA, Mini-Mental State Exam, Geriatric Depression Scale, Cumulative Illness Rating Scale-Geriatrics, and Timed Get Up and Go. We considered the presence of at least one questionnaire with an impaired score as an abnormal reference exam. Additional reference exams are also discussed. RESULTS: The prevalence of being at risk varied from 60% to 94% according to the various definitions of the reference test. When considering the primary reference test, a cut-off value of 14 for the G-8 tool provided a good sensitivity estimate (85%) without deteriorating the specificity excessively (65%). CONCLUSION: The G-8 shows good screening properties for identifying elderly cancer patients who could benefit from CGA.

Varying insulin use in older hospitalized patients with diabetes.

OBJECTIVE: Observation of insulin use in consecutive hospitalized diabetic older patients in acute care wards with reference to nutritional intakes, measures of functional status, and varying clinical situations. METHODS: Prospective case study in a geriatric medicine ward with CGA, dietary intake measure and used insulin dosage. RESULTS: Among 600 inpatients, 90 diabetic subjects were found. Only 12.2 % diabetic patients had MMSE > 23 and 23.3% were unable to eat without assistance. During the stay 54 patients had received insulin. From admission to discharge or death, doses were 0.39 to 0.19 U/kg (SD 0.41-0.15) during palliative care, 0.43 to 0.45 U/kg (SD 0.20-0.20) in the event of failure of oral therapy, 0.38 to 0.42 U/kg (SD 0.18-0.25) if creatinine clearance was 30 ml/min or lower, and 0.38 to 0.27 U/kg (SD 0.24-0.26) in critical diseases. Dietary intake increased in all during the stay with an energy intake close to 20 kCal/kg/d at discharge, except for those in palliative care, who had a final intake of 8.2 kCal/kg/d (SD 9.1). CONCLUSION: Insulin treatment guidelines adapted to this frail diabetic population are necessary.

[Recommendations for the treatment of prostate cancer in the elderly man: A study by the oncology committee of the French association of urology]. / Recommandations pour la prise en charge du cancer de la prostate chez l'homme âgé : un travail du comité de cancérologie de l'association française d'urologie.

The increase in life expectancy combined with the increase in the global incidence of cancers will probably results in an increase in the number of cancers observed in the elderly. The increase in the incidence of prostate cancers in geriatric patients (45% of prostate cancers are diagnosed after 75 years old) is in sharp contrast with the lack of strong scientific data on the topic. By the meantime, oncogeriatrics has been developing for some years now under the guidance of the International Society of Oncogeriatrics. Such an approach aims at palliating the low quality of care of cancers in geriatric patients. The reasons for the low quality of care come from the characteristics of these patients and from the training of the care providers. The authors recall the principles of oncogeriatric evaluation and the classification of patients as it is actually proposed. They describe the main treatments and their results in the geriatric population and they describe the decision process concerning the choice of the treatment. They also suggest some guidelines on the diagnosis of prostate cancer, evaluation of the patients and the treatments of the disease in the elderly. Prostate cancer is almost the perfect model for oncogeriatrics. Urologists should remain the corner stone of its management, whatever the age of their patient.

Alterations in comprehensive geriatric assessment decrease survival of elderly patients with cancer.

INTRODUCTION: A comprehensive geriatric assessment (CGA) evaluating several domains of health is recommended for elderly patients with cancer. Effects of altered domains on the risk of death in this population need to be clarified. The aim of this study was to estimate the independent association of each CGA domain to overall survival (OS). METHOD: Patients included in the ONCODAGE cohort completed a CGA at baseline. Cox models (one per domain) estimated the hazard ratio (HR) of death for each CGA domain. Directed Acyclic Graphs (DAGs) selected specific sets of adjustment factors for each model. RESULTS: The analysis included 1264 patients (mean age: 78 years, women: 70%). Median follow-up was 5.2 years, and 446 patients died. Each altered domain had a detrimental effect on survival, sometimes dependent on gender, age, education or time from inclusion. Nutritional status had a time-varying effect, with higher mortality rates if altered only within the first 3 years of follow-up. In case of altered mobility, the risk of death was higher only for the youngest patients and, in case of altered autonomy, only for the youngest women. An altered neurological state led to higher mortality rates; this effect increased with the level of education. Patients with altered psychological status or more than four comorbidities at baseline had also higher mortality rates. CONCLUSIONS: Patients with an altered CGA domain have a higher risk of death than those without any alteration. The effect of some alterations is different in some subgroups or at a given time of the treatments.

Early changes in isokinetic lower limb muscle strength in recovering geriatric subjects on the basis of nutritional status.

BACKGROUND: In older people, the decrease in muscle mass and strength has a bad effect on functional status. Malnutrition and lack of physical activity exacerbate this phenomenon. OBJECTIVE: The main purpose of this study was to estimate isokinetic lower limb muscle strength in recovering older subjects on the basis of nutritional status. DESIGN: Twenty-eight elderly subjects hospitalized for an acute event (85.8 +/- 6 years), including 16 malnourished, were enrolled in this study when clinically stable (T0). Re-assessment at one-month was performed in nine after oral supplementation and conventional physiotherapy (T1). The Maximal Peak Torque (MPT) of the ankle plantar flexors was estimated in concentric mode at 30 and 60 degrees /s. The MPT of the knee flexors and extensors was evaluated in the same mode at 30 degrees /s, 60 degrees /s and 120 degrees /s. All patients underwent a nutritional examination with anthropometric measures, dietary intake survey, biochemical indexes and determination of the medial gastrocnemius volume by magnetic resonance imaging. RESULTS: At T0, whatever the muscle group tested (except at 120 degrees /s for the knee), the MPT appeared significantly lower in the malnourished group. At T1, the increase in MPT (plantar flexors) in malnourished patients was greater at 60 degrees /s (+23.8 %) than at 30 degrees /s (+14.8 %). Correlations between MPT and nutritional parameters were observed in the malnourished group only at T1 and in the normal-nourished group. CONCLUSION: Isokinetic assessment seems to be a pertinent method to estimate lower limb muscle strength in older and frail subjects. Early modifications in strength were observed in malnourished patients who received oral supplementation and physiotherapy.

[Significance of cholesterol levels in patients 75 years or older]. / Quelle signification pour le taux de cholestérol après 75 ans?

Increasing comorbidity with aging reduces the predictive power of cardiovascular risk factors. From the age of 70 onward, total cholesterol levels decrease, perhaps associated with changes in the composition of some lipoprotein fractions. In subjects older than 75 years, being in the lowest quartile of cholesterol, insulinemia or serum albumin concentrations is associated with increased mortality. Cholesterol levels below 189 mg/dL in subjects older than 75 years should be considered an early sign of unidentified comorbidity or of rapid functional decline. HDL cholesterol levels, rather than total or LDL cholesterol, were inversely associated with increased mortality from ischemic coronary disease and stroke appears to rise as HDL cholesterol levels fall, rather than total or LDL cholesterol. On the other hand, LDL concentrations below 106 mg/dL and HDL concentrations below 36 mg/dL were associated with an increased risk of death from infectious disease. Stroke incidence, in particular, ischemic stroke, is highest in subjects older than 75 years. HDL cholesterol levels above 35 mg/dL appear to have a protective effect against ischemic stroke in subjects younger than 70 years. Two interventional drug studies investigating the effects of two statins (simvastatin and pravastatin) found that in subgroups of subjects older than 75 these drugs were associated with a reduction in all-cause mortality and cardiovascular morbidity, regardless of total cholesterol levels, but had no short-term effect on cognitive function.

[How to care for elderly patients with cognitive impairment?]. / Comment prendre en charge les personnes âgées souffrant de troubles cognitifs ?

Mild cognitive impairment occurs frequently with ageing, concerning memory complaint, attention and executive dysfunction without any consequence on the activities of daily living. They are strongly linked to the presence of vascular risk factors in adulthood. Nevertheless with the continuous progression of life expectancy, the incidence of dementia drastically increases after sixty-five years of age and the number of old people with dementia is expected to increase by 75% in 2030 in France. Caring for elderly patients with cancer needs to face the possibility of cognitive impairment and its consequences on a good comprehension of diagnosis and treatment and ability to properly take medication. Comprehensive geriatric assessment can help to diagnose cognitive impairment and evaluate the consequences on instrumental activities of daily living (IADL) and activities of daily living (ADL). Home care may be organised with the help of the family or social workers. Physiotherapy and speech rehabilitation are often useful. Assistance for housekeeping, shopping and cooking may be financed by social organisations such as APA in France. Complex cases must be referred to case managers in homes for patients suffering for Alzheimer's disease (MAIA) who liaise between doctors and home carers with good results.

Emergency gastrointestinal surgery in the elderly.

The main problem in management of elderly patients who present to the emergency department with abdominal pain is related to difficulties in establishing a diagnosis, because of frequently impaired communication as well as to unusual clinical and laboratory presentations, resulting in delayed management. Early use of pertinent imaging may reduce this delay. Surgical procedures in the elderly do not differ from those in younger patients, but their associated morbidity is different. Assessing co-morbidities and patient frailty, as well as taking into consideration the diagnosis, patients' wishes and status should help in decision-making. Therapeutic decisions should involve surgeons, anesthesiologists and geriatricians alike, both pre- and postoperatively, with the goal of optimizing patients' rehabilitation and offering good and appropriate care while ensuring the humane, social and financial aspects.

Functional and metabolic early changes in calf muscle occurring during nutritional repletion in malnourished elderly patients.

BACKGROUND: Metabolic alterations in skeletal muscle associated with malnutrition and the potential reversibility of such alterations during refeeding are not fully understood. OBJECTIVE: We characterized early changes in muscle during refeeding in malnourished, hospitalized elderly subjects. DESIGN: Muscle function, metabolism, and mass were evaluated in 24 clinically stable patients (11 were malnourished) by using isokinetic plantar flexor torque measurements and nuclear magnetic resonance (NMR) imaging for medial gastrocnemius mass assessment and 31P and 13C NMR spectroscopy for inorganic phosphate (Pi), phosphocreatine, and glycogen quantitation. RESULTS: Malnourished subjects had lower muscle mass (P < 0.02) and tended to have lower strength than did control subjects. In malnourished subjects, muscle strength increased after refeeding (P < 0.01) whereas muscle mass was unchanged. The ratio of Pi to ATP was lower in malnourished than in control subjects (P < 0.001) and increased during refeeding (P < 0.01). The mean ratio of phosphocreatine to ATP was lower in malnourished than in control subjects (P < 0.01) and increased to control values after refeeding. Muscle glycogen showed a scattered distribution for malnourished subjects; the mean value did not differ significantly from that of control subjects, either at baseline or after refeeding. CONCLUSIONS: The lower ratio of phosphocreatine to ATP in malnourished subjects could have resulted from either lower total muscle creatine or reduced oxidative capacities. High or normal glycogen associated with a low Pi-to-ATP ratio in malnourished subjects suggested preferential use of lipid over carbohydrate for energy supply, which is known to reduce muscle performance. The data suggest that normalization of muscle metabolite content after refeeding improves muscle strength in malnourished subjects.

Atheromatous renal disease.

PURPOSE: Atheroma as a cause of renal failure has been largely overlooked. We wanted to report our experience with atheromatous renal disease over a 12-year period. PATIENTS AND METHODS: Observations on 32 cases of various forms of renal failure in patients with atheromatous renal disease are presented. These patients had been hypertensive for an average of 10.2 +/- 9.2 years. The length of deterioration was an average of 17 months, and at presentation renal insufficiency was severe, with serum creatinine levels of (mean +/- SD) 616 +/- 358 mumol/liter (6.8 +/- 4.0 mg/dl). At this stage, the clinical picture was indistinguishable from other common causes of chronic renal failure in the elderly. Thus, the precise diagnosis would have been overlooked without an aggressive diagnostic workup. All patients underwent angiography and six patients underwent renal biopsy. RESULTS: In 22 cases, renal insufficiency was mainly due to atheromatous stenosis of renal arteries. In six of six patients, the results of renal biopsy showed cholesterol crystal embolism. In four additional cases, there was clinical or histologic evidence of extrarenal cholesterol embolism. In eight, renal artery plaques coexisted with cholesterol embolism. In two patients, renal failure was due only to cholesterol embolism. Renal atheromatous stenoses were developing, as shown on serial angiographies performed in five cases. In seven cases, stenoses involved both the main trunks of renal arteries and several intrarenal branches of too small a diameter to allow reconstructive surgery or percutaneous transluminal angioplasty. In addition, the general condition of most patients was so poor as to preclude surgery. Dialysis was begun in 11 patients, four other patients died, and renal failure was managed conservatively in 11. When undertaken, reconstructive surgery was successful in five of six patients. CONCLUSIONS: Atheromatous renal disease is a frequent and easily overlooked cause of chronic renal insufficiency. It is not only due to renal artery stenosis but also to complex intrarenal lesions, with multiple stenoses of intrarenal vasculature and cholesterol embolism. It should be diagnosed by early angiography and renal biopsy, before the stage of multivisceral complications and at a time when surgery can still be undertaken.

Tertatolol in chronic renal failure. A pharmacokinetic study.

Pharmacokinetics of tertatolol were investigated in 22 hypertensive patients (12 men and 10 women; mean age +/- SD: 52.6 +/- 12.3 years) with chronic renal failure defined by a mean creatinine clearance (Clcr) of 24.6 +/- 15.9 mL/min/1.73 m2 (range: 6.2 to 68.7). A daily single dose of 5 mg tertatolol was administered orally for 4 weeks, except in the 72 h following the first administration. Plasma samples and urine collections were carried out over 72 h after the first (D0) and the last dose (D27). After the first administration, tertatolol was rapidly absorbed (time to peak concentration: 1.2 +/- 0.7 h) and peak concentration was 160 +/- 80 ng/mL. Plasma concentrations decreased following a biphasic curve, with two half-lives of 2.5 +/- 1.1 and 17.0 +/- 8.5 h, respectively. These parameters were not modified by repeated administration of tertatolol and did not significantly correlate with Clcr either at D0 or at D27. Plasma levels were stable along the study with similar areas under plasma curves following the first and the last dose (P = NS). In addition, plasma levels extrapolated from first dose data did not significantly differ from those observed during repeated dosage. Plasma levels of the 4-OH metabolite which possesses a beta-blocking activity were low, inconstantly detectable, not related to the degree of renal impairment, and no accumulation occurred after chronic dosage. Renal excretion of tertatolol and 4-OH tertatolol was significantly increased by repeated administration (P less than .01) and correlated well with Clcr either at D0 or at D27. Four week treatment was well tolerated and significantly improved Clcr (+6.5%, P less than .02). In conclusion, tertatolol was well tolerated and did not accumulate in patients with renal failure of various degrees. The usual daily single dose of 5 mg may be kept unchanged whatever the degree of renal impairment.

Prospective audits of quality of PEM recognition and nutritional support in critically ill elderly patients.

BACKGROUND AND AIMS: Undereating is a frequent concern in acute care geriatric settings and is supposed to worsen the outcomes of the underlying diseases, while the quality of nutritional support could be improved. METHODS: Two consecutive and prospective audits (A and B) with team training over a 1 year period investigated the quality of malnutrition recognition and nutritional support and outcomes in immobilized, critically ill elderly subjects. RESULTS: Audit A included 170 patients (86.3+/-6.1 years old) and audit B, 232 patients (86.3+/-6.3), respectively 20.6% and 31.4% of the hospitalized population. Misclassifications occurred in A in 54.0% compared to 34.05% in B (P < 0.001). 32.6% in A versus 86.9% in B adequately received oral supplements (P = 0.02). Significant risk factors for the adverse outcomes in the combined two audits were: dementia (RR: 1.8, 95%CI: 1.0 to 3.0, P= 0.04) and dehydration (RR: 2.0, 95%CI:1.0 to 4.1, P= 0.05) for pressure ulcer incidence; stroke (RR: 8.8, 95%CI: 4.8 to 16.0, P < 0.001) for pressure ulcer prevalence at discharge; neoplasms (RR: 1.1, 95%CI: 1.0 to 1.2, P = 0.02) for nosocomial infections; bladder indwelling for urinary tract infections (RR: 4.8, 95%CI: 2.9 to 7.7, P<< 0.001); swallowing problems for pulmonary infections (RR: 5.4, 95%CI: 2.8 to 10.5, P < 0.001); venous indwelling for septicaemia (RR: 5.4, 95%CI: 1.3 to 23. 3, P= 0.02). However, after adjustment on significant risk factors, the outcome rate was similar in audit B: death rate: A (15.6%), B (14.2%); length of stay: A (17.3+/-10.4 days), B (17.4+/-10.0); pressure ulcer incidence: A (26.4%), B (20.2%), (83% were erythema); pressure ulcer prevalence at discharge: A (14.7%), B (10.3%), (40% were erythema); nosocomial infections: A (26.4%), B (19.0%). CONCLUSION: The improvement of malnutrition recognition and nutritional support was not followed by a perceptible decrease in adverse outcome rate, this latter being mainly related to the underlying conditions of these critically ill elderly patients.

Growth hormone therapy in elderly people: an age-delaying drug?

The aims of this review are to present a brief overview of growth hormone (GH) physiology and to summarize the studies of GH treatment in adults. Special attention has been paid to randomized controlled trials. Studies have revealed a partial deficiency of GH secretion in the elderly. GH secretion on the average declines by 14% with each decade in normal adults after 20 years of age. Aging has a central effect on the GH secretion and peripheric effect on insulin-like growth factor 1 (IGF-1) through changes in the body composition. GH administration may attenuate several important decrements in body composition and in function associated with aging. GH may also have very potent anabolic effects in surgical situations. Short-term side-effects of GH therapy include edema, carpal tunnel syndrome and arthralgia. A number of agents such as oral GH-releasing peptides (GHRPs) increase GH secretion; they may be an alternative to GH treatment in the future. Further studies of GH replacement are needed, examining issues such as dosage, tolerance and efficacy before the widespread use of GH in the elderly is advocated.

Nutritional status of healthy elderly persons living in Dordogne, France, and relation with mortality and cognitive or functional decline.

OBJECTIVE: Description of the nutritional status of healthy elderly people and investigation of its longitudinal relationship with mortality and cognitive or functional decline. DESIGN: Longitudinal study. SETTING: In Dordogne, France. SUBJECTS: A total of 169 French elderly community dwellers aged 68 y and older from in the PAQUID (Personnes Agées QUID) study were included. Dietary intake was assessed by a 3 day food record and a dietary history. Self-reported weight and height were used to calculate the body mass index (BMI, kg/m(2)). Mortality, activities of daily living (ADL), instrumental activities of daily living (IADL) and the Mini Mental State Examination (MMSE) were measured at 5 y follow-up. RESULTS: Nutritional intake and BMI vary according to age and sex. Men generally have a higher nutritional intake than women. Intake decreases with age especially in men. Among the 169 subjects, 22 died. When analyzed by logistic regression, there was no relation between markers of risk of poor nutrition and mortality but a BMI greater or equal 27 at baseline was associated with a increased risk of 5 y mortality (OR=6.27, 95% CI 1.29-30.37) adjusted for sex and age. With regard to cognitive decline, subjects with a BMI greater or equal than 23 kg/m(2) had 3.6 times lower chance of presenting a decline in the subsequent 5 y adjusted by age and sex (OR=0.28, 95%, CI 0.09-0.90). BMI ranging between 23 and 27 was associated with a significantly decreased risk of IADL disability (OR=0.31, 95% CI 0.10-0.93) in multivariate analyses. CONCLUSION: In apparently healthy elderly people a BMI ranging between 23 and 27 is associated with lower risks of functional and cognitive declines in the subsequent 5 y.

Prevalence and mechanisms of hyperhomocysteinemia in elderly hospitalized patients.

BACKGROUND: Plasma homocysteine concentrations increase with age and remain an independent risk factor for vascular disease in the elderly. There are negative correlations between plasma homocysteine and serum folate and vitamin B12 concentrations. Two mechanisms, poor nutritional status, and chronic atrophic gastritis, could explain hyperhomocysteinemia. OBJECTIVE: The purpose of the study was to determine prevalence and mechanisms of hyperhomocysteinemia in older hospitalized patients. DESIGNS: During a 12-month period, all the consecutive hospitalized patients who underwent gastric endoscopy were recruited in this observational prospective study. Clinical, histological, and biological data concerning nutritional status, gastric analysis, homocysteine, vitamin B12, and folate concentrations were collected during the study for each included patient. RESULTS: One hundred and ninety six patients (132 women and 64 men, mean age: 85.3 5.7 years) were included. Hyperhomocysteinemia (>or= 18 mmol/l) was diagnosed in 45.4 %, cobalamin deficiency in 13.3 %, and folate deficiency in 11.7 % patients. Hyperhomocysteinemia was significantly correlated to cobalamin deficiency (r = - 0.21; p = 0.005). In a sub group of patients without hypothyroidism, or chronic renal impairment, univariate and multivariate analysis showed a significant association between hyper homocysteinemia and low MNA (OR: 0.92; 95% CI 0.85-0.99), and low albumin (OR: 0.92; 95% IC: 0.83-0.99; p = 0.04). No correlation was found between homocysteine concentrations and chronic atrophic gastritis or Helicobacter pylori infection. CONCLUSION: Hyperhomocysteinemia seems to be frequent in the elderly and is associated with poor nutritional status rather than chronic atrophic gastritis.

[Diagnostic value of pulsed Doppler in atheromatous renal insufficiency. A study of 32 patients]. / Intérêt diagnostique du Doppler pulsé dans l'insuffisance rénale athéromateuse. Etude de 32 patients.

RATIONALE: atheromatous stenosis of both renal arteries, or of the artery of a functionally solitary kidney is a frequent cause of renal failure in the elderly. Atheromatous Ischemic Renal Insufficiency (AIRI) can be ameliorated by surgery or angioplasty. However, such procedures can be hazardous in a patient with extensive aortic atheromatous plaques. This justified a study of the validity of Pulsed Doppler (PD), a diagnostic procedure less invasive than renal angiography in AIRI. OBJECTIVES: to evaluate the diagnostic interest of PD in AIRI, using renal angiography as a criterion of adequacy. METHODS: renal arteries PD (Ultramak-4, 3.5 and 5 Mhz probes) followed by renal angiography (Seldinger). "Significant" stenosis = 50% on angiography. "Positive" PD = turbulences and/or acceleration. PATIENTS: 32 patients were investigated for suspected AIRI on the grounds of 1) age greater than 50; 2) atheromatous background and 3) renal insufficiency with no other evident etiology, or rapidly declining GFR in such a patient treated with ACE inhibitors. RESULTS: 16/32 angiographies disclosed significant stenosis of at least 1 renal artery. 56 renal arteries were investigated with both angio. and PD. Prevalence of stenoses was 16/56. PD had 93.7% sensitivity and 55% specificity. Positive predictive value was 45.5% and negative predictive value was 95.7%. Specificity was 80% when PD disclosed acceleration. CONCLUSIONS: negative PD is sufficient argument to reconsider the indication of renal angiography in a high risk pt with suspected AIRI.

[Incidence, risk factors and adequation of early readmission among the elderly]. / Incidence, facteurs de risque et adéquation des réhospitalisations à court terme de personnes âgées.

BACKGROUND: The objectives of the study were to estimate the incidence of readmission one month after discharge, to determine the proportion of planned readmissions and of those avoidable, and to identify risk factors associated with early readmissions in elderly admitted to an acute geriatric unit. METHODS: A prospective study was conducted on a sample of 322 patients, 75 years of age or older, discharged from an acute geriatric service. A phone follow-up was realized one month after discharge. A multivariate logistic regression model was used to identify risk factors for readmission. RESULTS: Global incidence of early readmission was 16.2% (that is 50 rehospitalizations), 18.0% of which were planned. Among the 21 readmissions to the same service, five were avoidable according to the Appropriateness Evaluation Protocol. Logistic regression analysis identified three patient characteristics that were independent predictors of early readmission, which were: a need of help for locomotion (OR=4.38, p=0.002), a negative answer to the question "do you feel that your life is empty?" (OR=2.22, p=0.02) and a short length of stay (p<0.02). CONCLUSION: A better knowledge of risk factors should allow targeting patients at high risk of early hospital readmission, which should profit by preventive interventions during the first hospitalization. Two domains of possible action were identified in this study: a sufficient length of stay and a better attention to patients with reduced autonomy, especially for those who go back home after discharge.

[Growth hormone in adults. An elixir of youth?]. / L'hormone de croissance chez l'adulte. Un élixir de jouvence?

Studies have revealed a partial deficiency of growth hormone (GH) secretion in the elderly. Aging has a central effect on the GH secretion and probably a peripheral effect on insulin-like growth factor 1 (IGF-1) or somatomedin C through changes in body composition. Simultaneously therapeutic efficiency of recombinant GH was confirmed in adults with GH deficiency. These notions have led to some controlled trials of GH treatment in elderly. Further studies of GH replacement are needed, examining issues such as dosage, tolerance (still inadequate) and efficacy before the widespread use of GH or IGH-F 1 in the elderly is advocated.