Is the Snoezelen method a non-pharmacological alternative for patients with neurocognitive disorders? / La méthode Snoezelen : une alternative thérapeutique chez les patients ayant des troubles cognitifs ?

Neuropsychiatric disorders are one of the frequent complications of neurocognitive disease, and have an impact on the quality of life of patients and caregivers. Non-phamacologic interventions are recommended as first-line treatment. The Snoezelen method is a multisensory stimulation method based on the assumption that acting on sensoriality can improve neuropsychiatric symptoms and thus quality of life, but its level of evidence is controversial. To explore this, we performed a systematic literature review of randomized controlled articles focusing on the use of the Snoezelen method in patients with cognitive disorders. Eighteen studies were included. The clinical outcomes studied were multiple (behavior, mood, cognition, functional capacities and biomedical parameters). When the Snoezelen method was compared to the "standard activities" group, it appears to be effective on short-term behavior. This was more negligible when the method was compared to others non-pharmacological interventions. Although the Snoezelen method could be effective on mood, cognition, and functional abilities, its level of evidence remains low. Furthers mixed studies (quantitative and qualitative) would be an interesting approach to delve into this topic in the most holistic way by integrating the patients, the caregivers and the cost of the method.

La prise en soin des symptômes neuropsychiatriques de patients ayant des troubles neurocognitifs est basée sur des traitements non médicamenteux. Certains auteurs suggèrent que la méthode Snoezelen pourrait être une alternative thérapeutique. L'objectif de cette revue de littérature était de faire une recherche systématique des essais contrôlés et randomisés ayant analysé l'effet de la méthode Snoezelen sur les patients âgés ayant des troubles cognitifs. Le processus de sélection a permis d'inclure 18 études, ayant des méthodologies hétérogènes. Dans plusieurs études, la méthode Snoezelen pourrait avoir un effet bénéfique, à court terme, sur les troubles du comportement, sur l'humeur, la cognition, ou les capacités fonctionnelles. Cependant, la méthode Snoezelen ne semblait pas être supérieure à d'autres interventions non médicamenteuses et certaines études montraient des résultats discordants. Finalement, le niveau de preuve d'efficacité de la méthode Snoezelen reste faible et des études mixtes (quantitatives et qualitatives) seraient intéressantes à mener pour évaluer l'intérêt de la méthode Snoezelen sur des profils spécifiques de patients ayant des troubles neurocognitifs.

Rapid detection of amoxicillin-susceptible Escherichia coli in fresh uncultured urine: a new tool to limit the use of broad-spectrum empirical therapy of community-acquired pyelonephritis.

Because of the high prevalence of amoxicillin resistance among uropathogens, amoxicillin is not recommended as an empirical treatment of urinary tract infections (UTIs). Quick detection of an amoxicillin-susceptible Escherichia coli (ASEC) would allow prescribing amoxicillin without preliminary broad-spectrum empirical treatment in uncomplicated pyelonephritis. To quickly diagnose UTIs due to ASEC, we developed a real-time PCR that detects in fresh uncultured urine the E. coli-specific gene yccT as well as the blaTEM and blaCTX-M genes. The ASEC rapid test was considered positive if the PCR was positive for the yccT gene but negative for blaTEM and blaCTX-M. The test was compared with culture and susceptibility testing. Among 200 patients with a suspected community-acquired UTI, 61 (30.5%) had a monobacterial UTI due to ASEC. The ASEC rapid test result was obtained in 3 h 13 [95% confidence interval (CI) 3 h 12-3 h 15] and was positive for 43 patients (21.5%). Specificity and sensitivity were 97.8% (95% CI 95.8-99.8%) and 65.6% (95% CI 59.0-72.1%), respectively. Positive and negative predictive values were 93.0% (95% CI 89.5-96.5%) and 86.6% (95% CI 81.9-91.3%), respectively. Owing to its high specificity and positive predictive value, the ASEC rapid test allows the diagnosis of UTI due to ASEC only 3 h after urine sampling. A positive ASEC rapid test may be used to treat uncomplicated pyelonephritis with amoxicillin from the start, without preliminary broad-spectrum empirical treatment. The ASEC rapid test is a promising tool to spare fluoroquinolones and third-generation cephalosporins in UTIs.

[General characteristics of the new oral anticoagulants]. / Caractéristiques générales des nouveaux anticoagulants oraux.

Treatment with vitamin K antagonists are subject to a common iatrogenic mainly characterized by hemorrhagic stroke. Their narrow therapeutic range associated with variability largely explains this phenomenon. New oral anticoagulants (NOAC) are now available. dabigatran (Pradaxa®) is a direct and specific thrombin inhibitor. It is excreted mainly by the kidney and is the only which can be dialyzed. Rivaroxaban (Xarelto®) and apixaban (Eliquis®) are factor X activated direct inhibitors. They are highly bound to plasma proteins and are metabolized mainly by the liver, via CYP3A4. All NOAC are substrates of P-glycoprotein (P-gp). Due to pharmacological changes, some populations at risk were identified: patients with hepatic impairment, renal impairment, elderly patients or low weight. Some pharmacokinetic or pharmacodynamic drug interactions alter the concentration and the expected impact of NOAC. The NOAC does not require biological monitoring. They interfere with the routine coagulation tests which should be interpreted with caution. Specific tests exist and can be used in case of emergencies. Currently, no antidote is available. The new oral anticoagulant look promising in the elderly. However, certain rules must be followed to reduce the risk of iatrogenic.

Hypovitaminosis D in geriatric inpatients: a marker of severity of chronic diseases.

BACKGROUND AND AIMS: Hypovitaminosis D is associated with adverse health outcomes including several bone and non-bone chronic diseases. It remains unclear whether hypovitaminosis D leads to more numerous or more severe chronic diseases. Our aim was to determine whether there was an association between serum 25-hydroxyvitamin D deficiency (i.e., 25OHD ≤25 nmol/L) and, respectively, the number and severity of chronic diseases assessed with the Kaplan- Feinstein index (KFI) among geriatric inpatients. METHODS: Two hundred and forty older Caucasian adults admitted between December 2008 and September 2009 to the geriatric acute care unit of Angers University Hospital, France (mean 84.6±0.4 years; 68.8% women) were included in this cross-sectional study. Serum 25OHD, KFI score and number of chronic diseases (i.e., diseases lasting at least 3 months or running a course with minimal change, whatever their nature or site) were assessed. Subjects were divided into 2 groups according to 25OHD concentration (either deficient for 25OHD ≤25 nmol/L, or non-deficient for 25OHD >25 nmol/L). Age, gender, use of vitamin D supplements, number of chronic diseases, serum parathyroid hormone and season tested were used as potential confounders. RESULTS: Mean serum 25OHD concentration was 35.2 ± 1.7 nmol/L. The 102 (42.5%) subjects with 25OHD deficiency had higher KFI compared with their counterparts (p=0.008). Vitamin D deficiency was not significantly associated with the number of chronic diseases (adjusted ß=-0.37 with p=0.216), but with KFI (unadjusted ß=1.33 with p=0.008; adjusted ß=1.37 with p=0.010). CONCLUSIONS: Irrespective of the number of chronic diseases, 25OHD deficiency was associated with the severity of chronic diseases.

[Vitamin D in the elderly: 5 points to remember]. / Vitamine D chez la personne âgée : les 5 points à retenir.

Vitamin D is a secosteroid hormone. Vitamin D receptors are present in the majority of body tissues. The manifestations of hypovitaminosis D - linked to dysfunction of target tissues - are various, including osteoporosis, cancer, tuberculosis, hypertension, multiple sclerosis, depression, dementia, sarcopenia, propensity to fall… The serum 25-hydroxyvitamin D threshold value to avoid these adverse health events is around 30 ng/mL. Only 15% of the elderly reach this target concentration. For the remaining 85% with no supplements, the severity of hypovitaminosis D appears to be a biomarker of chronic diseases and of frailty. Conversely, the supplementation for correction of hypovitaminosis D positively impacts bone and non-bone morbidities - such as risks of falls and fractures - and reduces the mortality rate. A daily intake of at least 800-1,000 IU supplemental vitamin D(3) per day is the key.