Procalcitonin to reduce exposure to antibiotics and individualise treatment in hospitalised old patients with pneumonia: a randomised study.

BACKGROUND: Treating pneumonia in old patients remains challenging for clinicians. Moreover, bacterial antimicrobial resistance is a major public health threat. OBJECTIVE: The PROPAGE study evaluated the interest of a strategy using serial measurements of procalcitonin (PCT) to reduce the duration of antibiotic therapy in old patients with pneumonia. METHODS: PROPAGE took place from Dec.-2013 to Jun.-2016 in eight French geriatric units. It was a prospective, comparative, randomised, open-label study involving old patients (≥ 80 years) who had initiated antibiotic treatment for pneumonia in the previous 48 h. PCT was monitored in all patients and two decision-making PCT-based algorithms guided antibiotic therapy in patients from the PCT group. RESULTS: 107 patients were randomised (PCT, n = 50; Control, n = 57). Antibiotic therapy exposure was reduced in the PCT group as compared to the Control group (median duration of antibiotic therapy, 8 vs. 10 days [rank-test, p = 0.001]; antibiotic persistence rates on Days 6 and 8, 54% and 44% vs. 91% and 72%) and no significant difference was found in recovery rate (84% vs. 89.5%; Pearson Chi² test, p = 0.402). CONCLUSION: Although, the superiority of the strategy was not tested using a composite criterion combining antibiotic therapy duration and recovery rate was not tested due to the small sample size, the present study showed that monitoring associated with PCT-guided algorithm could help shorten antibiotic treatment duration in the very old patients without detrimental effects. Measuring PCT levels between Day 4 and Day 6 could be helpful when making the decision regarding antibiotic discontinuation. TRIAL REGISTRATION: NCT02173613. This study was first registered on 25/06/2014.

Impact of a transition nurse program on the prevention of thirty-day hospital readmissions of elderly patients discharged from short-stay units: study protocol of the PROUST stepped-wedge cluster randomised trial.

BACKGROUND: In France, for patients aged 75 or older, it has been estimated that the hospital readmission rate within 30 days is 14 %, a quarter being avoidable. Some evidence suggests that interventions "bridging" the transition from hospital to home and involving a designated professional (usually nurses) are the most effective in reducing the risk of readmission, but the level of evidence of current studies is low. Our study aims to assess the impact of a care transition program from hospital to home for elderly admitted to short-stay units. METHODS: This is a multicentre, stepped-wedge cluster randomised trial. The program will be implemented at three times of the transition: 1) during the patient's stay in hospital: development of a discharge plan, creation of a transitional care file, and notification of the primary care physician about inpatient care and hospital discharge by the transition nurse; 2) on the day of discharge: meeting between the transition nurse and the patient to review the follow-up recommendations; and 3) for 4 weeks after discharge: follow-up by the transition nurse. The primary outcome is the 30-day unscheduled hospital readmission or emergency visit rate after the index hospital discharge. The patients enrolled will be aged 75 or older, hospitalized in an acute care geriatric unit, and at risk of hospital readmission or an emergency visit after returning home. In all, 630 patients will be included over a 14-month period. Data analysis will be blinded to allocation, but due to the nature of the intervention, physicians and patients will not be blinded. DISCUSSION: Our study makes it possible to evaluate the specific effect of a bridging intervention involving a designated professional intervening before, during, and after hospital discharge. The strengths of the study design are methodological and practical. It permits the estimation of the intervention effect using between- and within-cluster comparisons; the study of the fluctuations in unscheduled hospital readmission or emergency visit rates; the participation of all clusters in the intervention condition; the implementation of the intervention in each cluster successively. TRIAL REGISTRATION: This study has been registered as a cRCT at clinicaltrials.gov (identifier: NCT02421133 ). Registered 9 March 2015.

Investigation of Potential Injury Patterns and Occupant Kinematicsin Frontal Impact with PMHS in Reclined Postures.

The reality of the autonomous vehicle in a near future is growing and is expected to induce significant change inthe occupant posture with respect to a standard driving posture. The delegated driving would allow sleeping and/or resting in a seatwith a reclined posture. However, the data in the literature are rare on the body kinematics, human tolerance, and injury types insuch reclined postures. The current study aims at increasing the knowledge in the domain and providing useful data to assess therelevance of the standard injury assessment tools such as anthropomorphic test devices or finite element human body models. For that purpose, a test series of three male Post-Mortem Human Subjects (PMHS) were performed in frontal impact at a 13.4 m/sdelta V. The backseat inclination was 58 degrees with respect to the vertical axis. The semi-rigid seat developed by Uriot et al.(2015) was used with a stiffer seat ramp. The restraint was composed of a lap belt equipped with two 3.5 kN load limiters, and ofa shoulder belt equipped of a 4 kN load limiter on the upper anchorage placed in the vicinity of the shoulder. The belts, the semi-rigid seat, and the footrest were equipped with force sensors. The rotations of the seat pan and of the seat ramp were also measured. The PMHS were instrumented with multi-axis accelerometers and Y angular velocity sensors attached to the head, thorax (T1 andT12 vertebrae), and sacrum. Strain gauges were glued onto the anterior face of the L1 to L5 lumbar vertebrae and onto the anteriorface of the iliac wings. To estimate the pelvis kinematics, a rigid support equipped with targets was fixed onto the femur shaft. Prior to test, X-ray imagery was performed to exhibit the initial curvature of the lumbar spine. After the tests, an in-depth necropsywas done, with a specific attention to the lumbar spine. In the chosen test conditions, no lap-belt submarining was observed for the three PMHS. One PMHS sustained an AIS2 pelvic ringfracture and another one sustained an AIS4 injury with complete separation of the left and right sacroiliac joints. Lumbar discruptures and vertebral fractures were observed for the three PMHS (AIS 2 and AIS3 coding). The number of separated rib fractureswere very different from one PMHS to another (0, 6 and 33). Response corridors for the external forces and kinematics were builtand are presented in the paper. The results are discussed by comparing with existing data for which the backseat was in standardposture.

[Aphasia in elderly patients]. / L'aphasie du sujet âgé

Aphasia is common in elderly patients in the context of vascular or neurodegenerative disorders. In some cases, aphasia is an isolated symptom, occurring suddenly after a stroke, or developing progressively as a primary progressive aphasia. The diagnosis and treatment are then very similar in older and younger patients. Therapy may be more complicated because of the high prevalence, in older patients, of associated non linguistic symptoms (attentional and dysexecutive symptoms, behavioral and psychological symptoms or sensorial deficits), fatigability, and comprehension deficits. It may then become very difficult to recognize aphasia among all these disorders and to appreciate the physiopathology. A complete evaluation of language, cognitive functions, psychopathology, and behavior is very helpful, as are neuroimaging techniques (MRI is the most relevant). A good knowledge of classical aphasic pictures associated with stroke, Alzheimer disease or related disorders, is highly recommended. Rehabilitation must be proposed even for older patients, so far as aphasia alters the communication abilities. It must be kept in mind that associated symptoms may limit considerably the therapy.

[Geriatric units at the beginning of the 2020 COVID-19 epidemic in France]. / Les unités de gériatrie au début de l'épidémie du Covid-19 de 2020 en France.

The COVID-19 epidemic that started in November in China became a national epidemic from March 16, 2020 with the declaration of population containment in order to reduce the spread of the virus in France. From March 17 to March 27, 2020, the monitoring unit of the French society of geriatrics and gerontology decided to conduct a survey to analyze the implementation of the mobilization of geriatric units, given that this epidemic had shown that it resulted in excess mortality mainly among the elderly. The survey was able to bring together the response of 34 services, nine of which were located in a high epidemic cluster zone. Dedicated acute geriatric units for patients infected with COVID-19 were present in eight facilities, only outside the cluster zones. Nine geriatric follow-up and rehabilitation services were dedicated, an additional telemedicine activity concerned 35% of the facilities, and family listening and tablet communication facilities concerned 36% of the facilities. This survey is a snapshot of an initial moment in the epidemic. It provides an opportunity to describe the context in which this epidemic occurred in terms of geriatric policy, and to assess the responsiveness and inventiveness of these services in meeting the needs of the elderly.

Haemorrhagic complications of vitamin k antagonists in the elderly: risk factors and management.

In patients >75 years of age, the two main indications for oral anticoagulant therapy with vitamin K antagonists (VKAs) are treatment of venous thromboembolic disease and prevention of systemic embolism in patients with nonvalvular atrial fibrillation. In both indications, a target International Normalized Ratio of 2.5 (range 2.0-3.0) is recommended. Bleeding is the adverse effect feared by physicians that most limits the use of VKAs in older frail patients. In this paper, we discuss (i) the risk of VKA-related bleeding with advancing age; (ii) the severity of bleeding complications and particularly the risk of intracranial haemorrhage in older patients; (iii) the risk factors for bleeding related to patient characteristics; and (iv) the risk factors or determinants for bleeding related to treatment variables (warfarin induction and maintenance administration, instability of anticoagulation, poor compliance and patient's education level, and concomitant use of drugs). Avoiding over-anticoagulation and/or reducing periods of overdosing in the course of oral anticoagulant treatment with tailored monitoring may help to minimise the risk of bleeding in older patients.

Initiation of warfarin therapy in elderly medical inpatients: a safe and accurate regimen.

PURPOSE: Elderly patients are at high risk of over-anticoagulation when treated with warfarin, especially during treatment induction. We developed a simple low-dose regimen for starting warfarin therapy in elderly inpatients. The daily maintenance dosage is predicted from the international normalized ratio (INR) measured the day after the third daily intake of a 4-mg dose. We conducted a prospective multicenter study to evaluate the accuracy and safety of this regimen. METHODS: We studied 106 elderly (age >or=70 years) inpatients (mean [+/- SD] age, 85 +/- 6 years; range, 71 to 97 years) who had a target INR of 2.0 to 3.0. Accuracy in predicting the daily maintenance dose from INR value on day 3 was evaluated. RESULTS: The predicted daily maintenance warfarin dose (3.1 +/- 1.6 mg/d) correlated closely with the actual maintenance dose (3.2 +/- 1.7 mg/d; R(2) = 0.84). The predicted dose was equal to the actual dose in 77 patients (73%; 95% confidence interval [CI]: 64% to 81%) and within 1 mg in 101 patients (95%; 95% CI: 91% to 99%). The mean time needed to achieve a therapeutic INR was 6.7 +/- 3.3 days (median, 6.0 days); the mean time needed to achieve the maintenance dose was 9.2 +/- 4.5 days (median, 7.0 days). None of the patients had an INR >4.0 during this period. One fatal bleeding event was recorded in a patient with an INR in the therapeutic range. CONCLUSION: Our warfarin induction regimen was simple, safe, and accurate in predicting the daily maintenance warfarin dose in elderly hospitalized patients.