[The clinical impact of treatment discrepancies recorded for 200 patients in an acute geriatric unit]. / Impact clinique des divergences de traitement constatées chez 200 patients conciliés dans un service de gériatrie aiguë.

INTRODUCTION: Medication reconciliation is a process used to identify and prevent medication errors at care transition points in hospitals. The present study's main objectives were to quantify the frequency of inadvertent discrepancies (IDs) per patient and estimate the seriousness of the IDs' clinical impact. PATIENTS AND METHODS: This was a prospective, single-center study performed in a 38-bed acute geriatric unit. All patients hospitalized over a 70-day period were included in the study. RESULTS: Over a 70-day period, 200 patients were included (mean±SD age: 85.5±5.9). A total of 316 IDs were recorded in 117 patients (58.5%, i.e. 1.58 per patient). One third of the IDs were considered to be serious or even life-threatening. Omission was the most common type of ID (58%). Cardiovascular drugs were most frequently involved in IDs (33%). CONCLUSION: We observed an average of more than one ID per patient, when comparing drug treatment at home and drug treatment upon admission to hospital. A third of these IDs may be clinically significant. Geriatric populations with polypharmacy and multiple comorbidities are particularly sensitive to this type of error. Medication reconciliation can detect and correct IDs. Collaboration between physicians and pharmacists will improve the quality of patient care and reduce the iatrogenic risk.

IANA (International Academy on Nutrition and Aging) Expert Group: weight loss and Alzheimer's disease.

Weight loss, together with psychological and behavioural symptoms and problems of mobility, is one of the principal manifestations of Alzheimer's disease (AD). Weight loss may be associated with protein and energy malnutrition leading to severe complications (alteration of the immune system, muscular atrophy, loss of independence). Various explanations have been proposed such as atrophy of the mesial temporal cortex, biological disturbances, or feeding behaviours; however, none has been proven. Prevention of weight loss in AD is a major issue. It requires regular follow-up and must be an integral part of the care plan. The aim of this article is to review the present state of scientific knowledge on weight loss associated with AD. We will consider four points: the natural history of weight loss, its known etiological factors, its consequences and the various management options.

Lean mass plays a gender-specific role in familial resemblance for femoral neck bone mineral density in adult subjects.

INTRODUCTION: Whether the femoral neck bone mineral density (FN BMD) of children may be better predicted from that of their parents when taking into account the anthropometry of the children was assessed in a healthy adult sample consisting of 86 mother-daughter, 32 mother-son, 32 father-daughter, and 23 father-son pairs from 128 families. Heritability for FN BMD, which is considered to be a measurement of general resemblance, was defined as the regression coefficient of the mean of the parents' BMD. Among the anthropometric factors, lean mass was the most strongly associated with FN BMD following the adjustment for age in women (r=0.52, p<0.0001) and men (r=0.25, p=0.02). After adjustment for age, calcium intake, physical activity, and menopause and hormonal replacement therapy if relevant, heritability estimates (h2) for FN BMD were 0.68+/-0.23 [95% credible interval (CI): 0.15-0.99] in father-daughter pairs, 0.40+/-0.17 (95% CI: 0.08-0.74) in mother-daughter pairs, and 0.19+/-0.15 (95% CI: 0.01-0.57) in father-son pairs. Adjustment for lean mass of children increased the h2 for FN BMD in mother-son pairs [from 0.24+/-0.17 (95% CI: 0.01-0.57) to 0.66+/-0.18 (95% CI: 0.26-0.95)]. The present results show that FN BMD is heritable in adult father-daughter pairs (7.2% of a daughter's FN BMD variance was explained by the father's FN BMD) and that taking into account the lean mass of sons might improve the prediction of their FN BMD based on that of their mother's (reduction of sons' FN BMD residual variance by 5.1%). Taking the lean mass of children into account might improve the prediction of their FN BMD by 9.1% in daughters and by 18.1% in sons, irrespective of their parent's FN BMD. These results, obtained using a Bayesian regression model, have to be confirmed in further studies involving a greater number of adult parent-offspring pairs of both genders before extrapolation to clinical practice.

[Consensus statement on severe dementia]. / Consensus sur la démence de type Alzheimer au stade sévère.

Under the auspices of the French Society of Gerontology and Geriatrics, a multidisciplinary group of experts, including geriatricians, neurologists, epidemiologists, psychiatrists, pharmacologists, and public health specialists developed consensus recommendations about care for patients with severe dementia. They defined 21 recommendations for general practitioners, long-term care physicians, and specialists, based on the knowledge currently available (2005). The aim of care at all stages is to mitigate the quality-of-life of patient, caregiver, and family insofar as possible, combining care and future planning until the end of life. Management, to take into account problems including nutritional status, behavior disorders, and ability (or inability) to perform activities of daily living, must be global, multidisciplinary, and coordinated and must optimize use of local medical and social resources. The group also stressed the importance of clinical research to improve knowledge of disease course and assess management strategies and recommended specific area for research.

[Consensus statement on severe dementia]. / Consensus sur la démence de type Alzheimer au stade sévère.

Under the auspices of the French Society of Gerontology and Geriatrics, a multidisciplinary team including geriatritians, neurologists, epidemiologists, psychiatrists, pharmacologists and public health specialists developed a consensus on care for patients with severe dementia. They defined 21 recommendations for general practitioners, long-term care physicians and specialists based on knowledge available in 2005. At all stages of the disease, the objective of care is to improve as much as possible quality-of-life for the patient and his/her family, including a life project until the end of life. It is always possible to do something for these patients and their family: nutritional status, behavior disorders, and incapacities to deal with basic activities of daily life have to be taken in consideration. Resource allocation and proximity care have to be targeted. Research areas necessary to improve the care of patients with severe dementia has been selected.

Subacute meningoencephalitis in a subset of patients with AD after Abeta42 immunization.

BACKGROUND: AD is characterized by cerebral deposition of beta-amyloid plaques with amyloid beta-peptide (Abeta) 42 as the major peptide constituent, along with neurofibrillary tangles and neuronal loss. In transgenic mice, active immunization against Abeta42 removes these plaques and improves cognitive function. A Phase I study in AD patients demonstrated good safety and tolerability of multiple injections of aggregated Abeta42 (AN1792) with QS-21 as adjuvant. METHODS: Three hundred seventy-two patients with mild to moderate AD were randomized to receive IM injections of AN1792 or placebo (4:1) at baseline and at months 1, 3, 6, 9, and 12 in a multicenter Phase II safety, tolerability, and pilot efficacy study. Dosing was terminated after four early reports of meningoencephalitis, but follow-up continued. The study remains blinded, and further results will be reported after its termination. RESULTS: Symptoms and laboratory findings consistent with meningoencephalitis occurred in 18 of 298 (6%) patients treated with AN1792 compared with 0 of 74 on placebo (p = 0.020). Sixteen of the 18 had received two doses, one had received one dose, and one had received three doses of the study drug before symptoms occurred. The median latency from the first and last injections to symptoms was 75 and 40 days. No case occurred later than 6 months after the first immunization. Anti-Abeta42 antibody titers were not correlated with the occurrence or severity of symptoms or relapses. Twelve patients recovered to or close to baseline within weeks, whereas six remain with disabling cognitive or neurologic sequelae. All 18 patients remain alive to date (December 31, 2002), 6 months to >1 year after symptom onset. CONCLUSIONS: Postvaccination meningoencephalitis occurred without clear relation to serum anti-Abeta42 antibody titers. Potential mechanisms such as T-cell and microglial activation may be responsible and are under consideration to develop a safer anti-Abeta immunotherapy for AD.

Differential influence of physical activity on lumbar spine and femoral neck bone mineral density in the elderly population.

This study investigates the relationship between lifetime physical activity and bone mineral density (BMD) at various sites in 129 healthy men and women aged 72.1 +/- 6.5 years. BMD was measured by dual energy x-ray absorptiometry, and physical activity was assessed by using the QUANTAP system (Quantification de l'Activité Physique), a standardized and structured computer-assisted interview tool designed to assess lifetime physical activity. Linear regression models controlling for age, gender, height, body mass, lean mass, and smoking habits were performed. Higher levels of sporting activity during youth were associated with greater lumbar spine BMD ( p < .001). Similarly, femoral neck BMD was greatest in subjects who reported regularly taking part in sports over the previous 20 years ( p <. 05) and during their whole lifetime ( p < 0.05). Sporting activity at the time of bone mass development increases subsequent lumbar spine BMD, and more recent sporting activity contributes to the preservation of femoral neck BMD. These results suggest that physical activity has a differential influence on BMD at different sites and at different ages, possibly related to the processes of bone construction and bone aging taking place at the time.

Segregation analysis and variance components analysis of bone mineral density in healthy families.

Bone mineral density (BMD) was measured in 1992-93 in 129 nuclear families, including 258 parents and 183 children, and was analyzed for familial resemblance factors. BMD measurements were adjusted on weight and age. Segregation analysis rejected the monogenic hypothesis and exhibited a strong polygenic component. Variance components analysis was then used to estimate the parameters of a multivariate normal model including an additive polygenic component, a common environment factor, and a residual specific to each individual. The genetic component was independent of sex and age. The common environmental factor was not significant. The variance of the residual specific factor appeared to be a quadratic function of age, reaching its minimum value at 26.4 years. Consequently, the maximum value for heritability (ratio of genetic variance to total variance) is observed at this age (h2 = 0.84). According to this model, the correlation between two relatives is a function of the ages of each individual in the pair.

[Value of calculation of the kappa coefficient in the evaluation of an imaging method]. / Intérêt du calcul du coefficient kappa dans l'évaluation d'une méthode d'imagerie.

Radiologists are often confronted to the choice of the most appropriate statistic tool for evaluating diagnostic imaging methods. Using a radiological literature example, the Kappa agreement test is herein described and its applications are determined. Although widely performed to determine the inter-rater agreement, this test is also suited for the confrontation of two or more diagnostic imaging methods applied on the same subjects and providing categorical data. It procures the degree of agreement between the different methods.

Environmental and genetic factors affecting bone mass. Similarity of bone density among members of healthy families.

OBJECTIVE: To evaluate the relative importance of environmental and genetic factors in the determination of bone mineral density (BMD) and to quantify the risk of low BMD in healthy young adults in relation to the BMD of their parents. METHODS: Dual-energy x-ray absorptiometry study of a series of 129 nuclear families (441 subjects), including 183 children over age 15, was performed. Correlation of BMD in children with BMD in their parents was studied in a linear model, taking into account environmental factors. Logistic regression was used to quantify the relative risk of lower BMD according to the parents' BMD level. RESULTS: BMD was significantly correlated with weight, height, and body mass index (BMI) in all family members, and with parents' alcohol consumption and with physical activity in fathers and sons. The BMD of the children correlated with that of their parents (r = 0.27). The child's BMI, his/her father's BMD and daily calcium intake, and his/her mother's BMD, BMI, and body fat accounted for 41.4% of the variance in the child's BMD. A son had a 3.8 times higher risk of having a low BMD if his father had a low BMD, and a daughter had a 5.1 times higher risk if her mother had a low BMD. CONCLUSION: The BMD of children in healthy families was related to the BMD of their parents as well as to environmental factors, confirming the contribution of genetic inheritance in the determination of bone density in young adults, especially in girls.

Phosphorus magnetic resonance spectroscopy: a noninvasive technique for the study of occlusive arterial leg disease and peripheral vasodilator therapy.

Using 31P nuclear magnetic resonance spectroscopy of the calf muscle, the authors studied patients with peripheral arterial occlusive disease. They studied PCr depletion and intracellular pH during aerobic exercise in patients and controls. The phosphocreatine (PCr) index ([PCr]/([PCr] + [Pi])) at rest was correlated with blood flow measured by plethysmography. During aerobic exercise a greater decrease in pH was obtained in patients (p < 0.03). They also studied the work necessary to reach a PCr index = 0.5 during ischemic exercise. This workload was lower in patients than in controls: 32.99 +/- 3.04 J vs 58.89 +/- 8.55 J, p < 0.05. After vasodilator therapy the workload was improved in patients: 32.99 +/- 3.04 J vs 38.85 +/- 3.54 J, p < 0.05. These results suggest that therapy resulted in improved tissue perfusion in patients.

[Central pontine myelinolysis: apropos of an oligosymptomatic form]. / Myélinolyse centropontine: à propos d'une forme paucisymptomatique.

The authors report a case of paucisymptomatic central pontine myelinolysis (CMP). A 66 years old female had severe hypochloronatremia and hypokaliemia due to diuretic. Despite a slow hydroelectrolytic correction, she presented with dumbness and seizure. CT scan showed hypodensity of protuberance and magnetic resonance imaging (MRI) shown hypersignal of protuberance and undercortex, compatible with central and extra pontine myelinolysis. The long term clinical outcome was good, as MRI's data. Rapid and important correction of severe hyponatremia should be the most important factors of demyelination, secondary to interference with cerebral adaptation mechanisms to hypoosmolality. These factors were not present in this case.

Thymoma with immunodeficiency (Good's syndrome) associated with selective cobalamin malabsorption and benign IgM-kappa gammopathy.

We have described the first case, to our knowledge, in which recurrent respiratory tract infections were the primary manifestation of thymoma with immunodeficiency (Good's syndrome) associated with cobalamin malabsorption and immunoglobulin M-kappa (IgM-kappa) M component. The intrinsic factor receptor activity was dramatically decreased in a mucosal homogenate prepared from ileal biopsies. This decreased activity could be the principal cause of the malabsorption of labelled cobalamin which was observed in the presence of intrinsic factor. However, it could be the consequence of the cobalamin deficiency, as it is known that a cobalamin deficiency can affect the assimilation of cobalamin, even in presence of exogenous intrinsic factor.

[Focus on a quick reading of nailfold capillaroscopy]. / Mise au point d'une lecture accélérée de la capillaroscopie peri-unguéale.

The diagnostic value of nailfold capillaroscopy was assessed through blind analysis of a continuous series of 307 examinations and a method for quick reading of nailfold capillaroscopy was elaborated with discriminant analysis. The best criteria for predicting the existence of a systemic disease were: major dystrophies (megacapillary, neocapillary and regressive capillary), minor dystrophies and capillary bed abnormalities, especially in patients presenting with vascular disorders of the upper extremities. Capillaroscopic stages and existence of systemic disease were significantly correlated. Discriminant analysis could globally predict the existence of a systemic disease with age and 4 criteria. In subjects with vascular disorders of the upper extremities it needed only age and 3 criterias (abnormal coloration, major dystrophy presence and percentile of minor dystrophies greater than 15%) but without higher diagnostic value (94.2% of patients with systemic disease and 65.6% of patients without systemic disease were correctly classified). Discriminant analysis allows quick reading of nailfold capilloroscopy in the first examination of patients with vascular disorders of the upper extremities.

[Herpetic meningoencephalitis in the elderly. Apropos of 13 cases]. / Méningoencéphalite herpétique du sujet âgé. A propos de 13 observations.

In a retrospective analysis of 13 cases of Herpes simplex encephalitis (mean age: 67.2 +/- 6.4 years; ten women, three men), the authors conclude that this infection is more often due to Herpes simplex virus 1 in the elderly. Diagnosis is difficult at an early stage, and must be suspected in case of confusion (9/13), especially feverish (11/13), associated with neurological signs (10/13), and particularly epilepsy (5/13). It requires a lumbar puncture which collect a clear and lymphocytic fluid. Prognosis of this encephalitis depends on early diagnosis and an presumptive therapy with acyclovir. EEG is helpful showing periodic activity (10/13). CT scan and MRI can show unspecific abnormalities, but often too late. Laboratory findings will secondarily confirm the diagnosis quite frequently, using new Elisa methods. Polymerase chain reaction allows earlier diagnosis. Geriatric cases seem more often due to reinfection or to endogen virus reactivation rather than to primary infection.