[Crushing drugs in geriatric units: an "handicraft" practice with frequent errors which imposed recommendations]. / L'écrasement des médicaments en gériatrie: une pratique « artisanale ¼ avec de fréquentes erreurs qui nécessitait des recommandations.

PURPOSE: Swallowing disorders or psycho-behavioural distress frequently interfere on drug administration in elderly inpatients. Crushing drugs is a common although non validated practice. The objective of this first prospective study, performed in all geriatric units of the Rouen university hospital by a multidisciplinary group, was to assess the crushing practice, from the prescription to the administration of the drugs in order to elaborate corrective measures. METHODS: A survey was performed in June 2009 and included 683 inpatients, 65 years and above, in 23 geriatric units. If a patient received drugs after crushing, we recorded the reason for crushing, what drugs were crushed, the galenic presentations and the technique used for preparation and administration. RESULTS: Two hundred and twenty-one patients (32.3%) (85.5 ± 6.5 years, females 74.2%) received 1528 drugs (6.9 ± 4 per patient) including 966 drugs (63.2%) after crushing (crushed pills or crushed content of opened capsules), mainly in the morning (50.4%). The main reasons for crushing drugs were swallowing disorders and psycho-behavioural distress. Forty-two percent of crushed drugs had a galenic presentation which did not allow crushing. The patient's drugs were crushed together three out of four times and mixed with different vehicules for administration. The material used for crushing (a mortar, 92.6%) was often the same for several patients (59.4%); 83.5% of crushed drugs were immediately administered to the patients, though there were important variations about schedules of administration. CONCLUSION: Crushing drugs expose both to iatrogenic hazards and professional risks. Regional and national recommendations were developed in order to correct the errors linked to this practice.

Risk factors and management of diabetes in elderly French patients.

AIMS: The aim of this study was to assess the characteristics of elderly diabetic patients, evaluate the relationship between glycaemic control and diabetes complications, and compare the day-to-day management of such patients with the published recommendations. METHODS: The study included 238 elderly diabetic patients, for whom data for the past six months' medical history, clinical examination (including ocular fundus) and standard biological tests were collected. RESULTS: The patients' mean age was 82.2+/-7.2, HbA(1c) value was > or =8.5% in 24% of patients and the mean number of cardiovascular risk factors (CVRF) was 4.1+/-0.7 per patient. Dementia or cognitive impairment was present in 68% of patients. Estimated glomerular filtration rate was 30 mL/min or lesser than 16%. Retinopathy was present in 37% of patients, and 64% had a history of infection in the past six months; more than 50% of patients took insulin. The prevalence of retinopathy, cognitive dysfunction and infections were significantly less frequent in patients with HbA(1c) < or =6.5%. There was a positive correlation between the number of CVRF and the number of cardiovascular anomalies (r=0.19, P<0.001). With the exception of HbA(1c), standard paraclinical tests were performed in less than 50% of patients. There was positive agreement between day-to-day HbA(1c) and HbA(1c) target values in 36% of patients. CONCLUSION: Complications and/or associated diseases were more frequent in this cohort of elderly diabetic patients compared with those in studies not based on clinical examinations. Our results highlight the inadequate management, given the frequent discrepancy between day-to-day HbA(1c) and HbA(1c) targets, of such patients.

[Upper gastrointestinal bleeding in patients treated by low-dose aspirin]. / Hémorragies digestives hautes et aspirine à faible dose.

AIM OF THE STUDY: To estimate the number of people treated by low-dose aspirin (<330 mg daily) in France and to evaluate the risk of upper gastrointestinal bleeding associated with low-dose aspirin treatment. SUBJECTS AND METHODS: One thousand six hundred and two patients with upper gastrointestinal bleeding were included between January and June 1996 in 4 French areas. Data about patients characteristics, drugs recently used, and bleeding lesions were prospectively collected. Five hundred seventy five cases were matched for sex, age and area with control people without previous upper gastrointestinal bleeding. Low-dose aspirin intake in the population was estimated from the control group. Aspirin intake in the previous 7 days in cases and in controls was compared by logistic regression, adjusted for other gastrotoxic drugs intake. RESULTS: Low-dose aspirin is taken by about 1.2 millions adults in France. In 1 602 patients, gastrointestinal bleeding was related to a peptic ulcer in 34%. Aspirin was associated with higher risk of upper gastrointestinal bleeding: OR=1.68 (1.03-2.74) with low-dose, and OR 1.42 (0.91-2.21) with higher doses. CONCLUSION: About 2.8% of the population is exposed to low-dose aspirin in France. This treatment seems to be associated with a high risk of upper gastrointestinal bleeding.

Cardiac malignant lymphoma successfully treated with chemotherapy.

We report the case of an 83-year-old woman with diffuse large B-cell lymphoma located in the right cardiac ventricle revealed by acute congestive heart failure. Complete and long-lasting disappearance of the cardiac tumor was observed with monochemotherapy (cyclophosphamide).

Does age play a role in mylohyoideus muscle function?

Because swallowing disorders are frequent in the elderly, we assessed the relationship between age and mylohyoideus muscle contraction, which is an important component of the initial step in swallowing. In a prospective study, 120 subjects without any personal history of diseases associated with swallowing disorders underwent electromyographic recording (EMG) of mylohyoideus muscle activity. Four groups of equal size (n = 30) were defined according to age (< or = 50, 51-70, 71-85, >85 years). The frequency and duration of mylohyoideus muscle asynchronisms were compared among the four groups. The comparison of mylohyoideus muscle EMG among groups did not show a significant difference in the mean number of asynchronisms, in duration per subject or in the frequency of long-lasting asynchronisms. Asynchronisms were a very frequent event, observed in 98% of subjects, and were mostly short, lasting less than 0.1 s in 90% of subjects. In healthy elderly patients, there was no linear relationship between the mean duration of asynchronisms and ageing. The occurrence of one or more long-lasting asynchronisms or of at least six asynchronisms during a sequence of 10 successive swallows should be considered to be abnormal.

[Cryptosporidium parvum: functional study of the intestinal malabsorption syndrome]. / Cryptosporidium parvum: étude fonctionnelle du syndrome de malabsorption intestinale.

Cryptosporidiosis is an important cause of diarrhea associated with growth retardation in children and severe malnutrition in immunocompromised patients. The pathophysiology is poorly understood. In the suckling rat model, we show that C. parvum infection impairs net electrogenic transport across the ileal mucosa without involvement of prostaglandins, as well as trans- and paracellular permeability and leucine and glutamate absorption. These results provide evidence for the development of an intestinal malabsorptive syndrome during cryptosporidiosis. Unspecific process such as villous atrophy and inflammatory cytokines secretion should be regarded as possible mediators of this syndrome. However, specific mechanisms have to be considered since C. parvum induces a rearrangement of the host enterocyte cytoskeleton which might impaired intracellular trafficking thus reducing the membrane expression of nutrient transporters. Infection and malnutrition are known to be tightly associated, making each other worse. As no specific efficient therapy exists, cryptosporidiosis-induced malnutrition must be taken into account when establishing therapeutic scheme.

[Is cognitive change related to hypothyroidism reversible with replacement therapy?]. / L'altération cognitive au cours de l'hypothyroïdie est-elle réversible avec le traitement substitutif?

PURPOSE: Although cognitive impairment related to hypothyroidism has been investigated, issues regarding treatment have been less extensively studied. The aim of this study was to assess cognitive function in patients with hypothyroidism just before treatment and after hypothyroidism had resolved. METHODS: Standardized psychometric assessment (including ten tests) was done in 30 outpatients with biochemical evidence of hypothyroidism (TSH = 92.1 mU/L, range: 11.4-400) and in 30 control subjects matched for age and gender with normal thyroid function. These tests were repeated twice before treatment and after hypothyroidism had been cured. Statistical analysis was done using the Mann-Whitney U test. RESULTS: The baseline characteristic of patients with hypothyroidism showed that attention, motor speed, memory and visual-spatial organization were significantly impaired. Cognitive decline was significantly greater with increasing age. Cognitive impairment significantly decreased after hypothyroidism had been cured, reaching values obtained in age-matched control subjects. CONCLUSION: Attention, motor speed, memory and visual-spatial organization are significantly impaired in hypothyroidism, particularly in the elderly, suggesting that ageing could have potential effects on cognitive functions. Hormone-replacement therapy leads to normalization of the cognitive functions.

Does treatment of constipation improve faecal incontinence in institutionalized elderly patients?

OBJECTIVE: to evaluate whether faecal incontinence can be improved by treatment of constipation in elderly patients with faecal incontinence associated with impairment of rectal emptying. DESIGN: a prospective randomized study with a 2-month follow-up. SETTING: five long-term care units. SUBJECTS: 206 patients with daily faecal incontinence associated with chronic rectal emptying impairments such as faecal impaction received either a single osmotic laxative (group I) or an osmotic agent along with a rectal stimulant and weekly enemas (group II). MEASUREMENTS: episodes of faecal incontinence and associated details of soiled laundry (used as indicators of the workload for caregivers). We performed periodic digital rectal examinations on group II patients to evaluate whether treatment resulted in complete and long-lasting rectal emptying. We compared data between groups and in group II between persistently constipated patients and patients with complete rectal emptying. RESULTS: the frequency of faecal incontinence did not significantly differ between the two groups. The 23 patients in group II who had complete rectal emptying had 35% fewer episodes of faecal incontinence and 42% fewer incidents of soiled laundry than the rest of the group. CONCLUSIONS: when long-lasting and complete rectal emptying is achieved by laxatives, the number of episodes of faecal incontinence as well as the workload for caregivers is reduced.

[Digestive complications of aspirin]. / Complications digestives de l'aspirine.

INTRODUCTION: This review focuses on aspirin-related gastrointestinal side-effects and the mechanism by which aspirin causes gastrointestinal damage. CURRENT KNOWLEDGE AND KEY POINTS: Aspirin causes direct gastric damage by topical irritant effects and indirect damage via systemic inhibition of cyclooxygenase synthesis and microcirculation injury. The question of a possible synergistic relation between the presence of Helicobacter pylori infection and aspirin use on gastric damage is not resolved. The pathogenesis of small intestinal and colonic damage is less well understood; an increase in intestinal permeability and free radical synthesis are suggested. Gastric damage predominates. Gastroduodenal lesions from aspirin have been documented in endoscopy studies. The lesions occur rapidly, even for low-dose aspirin. The association of aspirin consumption with upper gastrointestinal bleeding has been well established. The main risk factors are advanced age, concomitant use of nonsteroidal antiinflammatory drugs and history of ulcer. Low-dose aspirin are associated with increased risk of gastrointestinal bleeding and this risk is dose-dependant. Chronic aspirin consumption can cause iron deficiency anaemia. Uncomplicated gastric ulcer (but not uncomplicated duodenal ulcer) is associated with aspirin use, with relative risk 3. Other upper gastrointestinal complications have been reported: stenosis and perforation. Aspirin can also damage other areas of the gastrointestinal tract. Oesophageal injuries (oesophagitis and stricture) have been reported. Aspirin is associated with variceal bleeding episodes in patients with cirrhosis. The adverse effects of aspirin on the small bowel are perforation, bleeding, increasing permeability. The adverse effects of aspirin on the large intestine are perforation, bleeding, collagenous colitis and anorectal stenosis with suppositories containing aspirin. Direct clinical data regarding prophylaxis with co-administration of a protective drug are not yet available for aspirin. FUTURE PROSPECTS AND PROJECTS: Patients should be made aware of adverse gastrointestinal effects due to aspirin. Further studies regarding prophylactic therapy of low-dose aspirin induced gastroduodenal lesions, which identify a subset of patients who may be at higher risk than the low-dose aspirin population as a whole, are warranted.

[Drug use in the elderly. Undesirable drug effects in the elderly: epidemiology and prevention]. / Médicaments et sujets âgés. Les effets indésirables des médicaments chez le sujet âgé: épidémiologie et prévention.

A COMMON PROBLEM: Adverse drug effects are common and severe in patients over 70. Most concern widely prescribed drugs or drugs with small safety margins. CLINIC: It is important to recognize the most frequently encountered modes of expression including cardiovascular, metabolic and neuropsychiatric manifestations. The effects of bleeding and low blood sugar are particularly severe. PREVENTION: Certain pharmacological favoring factors are closely related to the aging process. A large number of iatrogenic side effects could however be avoided if the patientís clinical situation is carefully considered in light of the risk of drug interactions, the patientís behavior (observance errors), or prescriber behavior (inappropriate prescriptions in light of the therapeutic goals).

Cryptosporidium parvum infection in suckling rats: impairment of mucosal permeability and Na(+)-glucose cotransport.

Na(+)-glucose transport and transepithelial permeability were investigated during symptomatic acute cryptosporidiosis in newborn rats. The infection resulted in a significant (P < 0.01) decrease in the ileal short-circuit current and a nonsignificant fall in the transepithelial potential difference and conductance. In glucose-stimulated conditions, the rise in ileal short-circuit current and transepithelial permeability were significantly lower in Cryptosporidium parvum-infected rats than in controls (delta Isc = 3.24 +/- 1.21 microA.cm-2 vs delta Isc = 5.09 +/- 2.23 microA.cm-2 in infected and control animals, respectively; P < 0.001; delta PD = -0.35 +/- 0.13 mV vs delta PD = -0.44 +/- 0.14 mV for infected and control animals, respectively; P < 0.01). Electrical parameters were not affected by addition of the cyclooxygenase inhibitor indomethacin in either Cryptosporidium-infected newborn rats or controls. Horseradish peroxidase and mannitol flux studies demonstrated a significant decrease (P < 0.05) in transepithelial molecular permeability in infected enterocyte rats, HRP flux = 380, range 68-5570 ng.cm-2, and mannitol flux = 1.06, range, 0.34-1.44%.cm-2.min-1, compared with controls rats, HRP flux = 4446 range, 1121-124,363 ng.cm-2, and mannitol flux = 1.99, range, 0.57-5.09%.cm-2.min-1; P < 0.05. These effects could originate from C. parvum-induced alteration of intracellular trafficking of pinocytosis vesicles and therefore account for the decrease in permeability to solute and macromolecules, together with impaired transcellular nutrient transport, in suckling rats.

[Upper digestive hemorrhage in patients over 80 years of age: incidence and prognostic factors]. / Hémorragies digestives hautes du sujet âgé de plus de 80 ans: fréquence et facteurs pronostiques.

OBJECTIVES: The aim of this study was to assess the incidence and the prognosis of upper gastrointestinal hemorrhage in patients aged over 80 years. METHODS: Between January and December 1993, among 360 patients admitted for upper gastrointestinal hemorrhage, 63 were older than 80 years (18%). Data were prospectively collected in all patients. RESULTS: Before admission, 8 experienced a lipothymia and 3 a shock. The median initial hematocrit was 29%. Endoscopy was performed in 59 patients and a cause was determined in 49 (83%). The main cause of bleeding was gastric and duodenal ulcer (n = 26, 53%) and ten of them were graded Forrest < or = IIb. Endoscopy did not contribute in 10 patients and was impossible in 4 because of an hemodynamic failure. Gastrotoxic drugs intake was found in 28 patients: non steroidal anti-inflammatory drugs (n = 14) and aspirin (n = 14). Endoscopic injection therapy was performed in the 10 patients with gastric or duodenal ulcer < or = Forrest IIb and permanent hemostasis was achieved in 8 out of 10. No further bleeding was seen in 53 patients (84%), while bleeding persisted in 4 and rebleeding occurred in 6 (9.5%) (3 duodenal ulcers, 2 gastric carcinomas and 1 esophageal varices bleeding). Only one patient required emergency surgery (rebleeding duodenal ulcer). The overall mortality was 12/63 (19%):50% of the deaths were related to hemorrhagic complications and 50% to concomitant disease. Only one patient among those taking gastrotoxic drug died from bleeding. The risk factors of death from bleeding were: initial shock (P = 0.02), lipothymia before admission (P = 0.02), rebleeding (P < 0.01), persistence of bleeding (P < 10(-4)). Gastrotoxic drugs intake was associated with a favorable prognosis (P < 0.05). The prognosis was not significantly affected by an initial hematocrit < 30% or blood units transfused > or = 4. CONCLUSIONS: People older than 80 years account for a large proportion of upper gastrointestinal bleeding (18%). The more common cause is gastric or duodenal ulcer. Mortality in these patients is high (19%). An initial shock or lipothymia, rebleeding or persistence of bleeding worsens prognosis. Gastrotoxic drugs intake is frequent (44%), but is associated with a good prognosis.