[Vitamin B 12 deficiency in the aged]. / Carence en vitamine B12 chez le sujet âgé.

A COMMON CONDITION: Vitamin B12 deficiency is common in the elderly. Search for deficiency should be undertaken whenever the clinical situation could lead to vitamin deficiency whether macrocytic anemia is present or not as its development may come late. PATHOPHYSIOLOGICAL IMPLICATIONS: The potential relationships between degenerative neuropsychiatric disorders and cerebrovascular or cardiovascular disease, mainly via hyperhomocysteinemia, emphasize the importance of searching for vitamin B12 deficiency in the elderly. SPECIFIC CAUSES: In the elderly, it is important to recognize specific causes of vitamin B12 deficiency, mainly resulting from vitamin malabsorption.

Extensive laboratory assessment of nutritional status in fit, health-conscious, elderly people living in the Paris area. Research Group on Aging.

OBJECTIVE: Nutritional status-related biological indexes were measured in fit, health-conscious elderly subjects in order to establish reference values for people over 70 years. SUBJECTS: 103 men and 90 women aged 70-89 years living freely in the Paris area volunteered to participate. METHODS: Nutritional status was assessed by anthropometric and biochemical methods. RESULTS: Serum protein and amino acid status was similar to that of young adults, with only 5.2% of the elderly subjects showing transthyretin concentrations < 0.20 g/L, as well as decreased essential amino acid levels. Iron status, assessed in terms of serum and erythrocyte ferritin levels, total iron binding capacity and erythrocyte protoporphyrin tended to be satisfactory, but iron depletion was detected in 8.8% of the subjects. Serum ferritin levels were elevated in 19.7% of the subjects. Folate and vitamin B12 status was satisfactory, while hypovitaminosis D was observed in 48.2% of cases. CONCLUSION: Our findings suggest that, in aging uncomplicated by disease, nutritional status is similar to that in younger adults, although the range of values tended to be wider, with a higher risk of certain nutrient deficiencies.

[Fractures from falls in elderly patients: are they neuropsychiatric emergencies?]. / Les fractures par chutes chez les personnes âgées: sont-elles des urgences neuro-psychiatriques?

To identify a possible link between mental impairment and spontaneous fall-related fractures, we studied two groups of elderly hospitalized patients for physical and cognitive status. The study population consisted of 120 patients admitted for post-surgical rehabilitation after fall-related fractures (FRF). The patients were living at home when the accident occurred. The mean age was 81.0 years; 110 women, mean age 81.2 +/- 8.1; 10 men, mean age 82.8 +/- 8.5 years). The control group consisted of 81 patients hospitalized for somatic conditions who had never had falls or fractures (46 women and 35 men, mean age 79.4 +/- 5.7 years). The following cognitive tests were used: Folstein's MMSE, Benton's visual recall, and the Rey figure with both subtests (copy: RC; and recall: RM). In the study population (95%) 114 patients had previously fallen and 44 (38%) had had fractures, 65% had cardiovascular disease, compared to 6% of the controls. The respective mean psychometric scores for each test in the study and control population were as follows: MMSE: 18.92 +/- 6.45 vs 24.2 +/- 3.2 (normal value > 25); P = 4.5 x 10(-8). Benton: 11.03 +/- 4.91 vs 15.69 +/- 3.2 (normal value > 25); P = 2.3 x 10(-8). RC: 14.84 +/- 9.9 vs 25 +/- 7.6 (normal value > 30); P = 4.5 x 10(-8). RM: 4.55 +/- 4.5 vs 9.04 +/- 5.7 (normal value > 22); P = 2.17 x 10(-8). Despite these patient's apparently normal social facade, they had a far mode marked and significated mental deterioration than the controls.(ABSTRACT TRUNCATED AT 250 WORDS)

[Double mitral orifice. Apropos of a case]. / Double orifice mitral. A propos d'une observation.

The authors report a case of Double Mitral Orifice (DMO), existing in isolation and type 3 by the Floch Prigent classification. This rare anomaly is often associated with another congenital malformation, dominated by intra-atrio-ventricular defect. Two-dimensional echocardiography is the essential diagnostic factor. Hemodynamic consequences may be nil, but mitral insufficiency and/or stenosis may complicate this malformation. Treatment may be summarised as abstention, surgical repair or valve replacement, according to the severity of lesions.

False positive diagnosis of arterial hypertension: the diagnostic errors and their avoidance.

Arterial hypertension is a risk factor both for morbidity and mortality. The diagnosis usually depends on the auscultation method using the cuff and the mercury manometer, which remains the international reference method. However, this indirect method is the source of numerous errors, sometimes important, which are related variously to the equipment used, the observer, the conditions under which the measurement is taken and sometimes to the patient. Such errors can in turn lead to therapeutic overdosage and to unnecessary treatment, which may be dangerous. "Pseudohypertension" is a typical example of the problems. Various means have been proposed to improve the reliability of measurements, above all the physician must adhere strictly to the correct routine. The use of self-registering equipment, provided it is scientifically assayed, can be considered for incidental measurements or for ambulant use. The ambulant measurement of arterial pressure promises to be of diagnostic, therapeutic and prognostic value, but further experience is required to confirm these impressions.

Free erythrocyte protoporphyrin assay in the diagnosis of iron deficiency in the anemic aged subject. A prospective study of 103 anemic patients.

We determined the relative value of the free erythrocyte protoporphyrin (FEP) assay compared to those of total iron-binding capacity (TIBC) and serum ferritin in the diagnosis of iron deficiency in a population of elderly anemic subjects. One hundred and three patients, 65 to 98 years old (mean +/- SD: 81.5 +/- 8.8), with hemoglobin levels of less than 110 milligrams (mean +/- SD: 97 +/- 12, range 53-109) were included in the study. In the patients with iron-deficiency anemia due solely to chronic bleeding, mean values for the three parameters were highly different from those in patients without chronic bleeding. In the patients with anemia due to an association of chronic bleeding and chronic inflammation, the mean FEP value was very significantly different (p less than 0.001) from that in the patients with chronic inflammation but without bleeding, whereas this was not the case for TIBC or serum ferritin. The sensitivity of FEP in the diagnosis of iron deficiency due to chronic bleeding in this population of anemic subjects was 60% (specificity 90%), compared to 13% (specificity 96%) for TIBC and 20% (specificity 100%) for serum ferritin. The FEP assay thus emerges as being highly suitable for the diagnosis of iron-deficiency anemia in the elderly subject, particularly when bone marrow is not examined.

[Allergic angiitis with granulomatosis: Churg-Strauss syndrome. Retrospective study of 16 cases]. / L'angéite allergique avec granulomatose: syndrome de Churg et Strauss. Etude rétrospective de 16 observations.

Sixteen patients with Churg-Strauss syndrome (CSS), a disorder characterized by hypereosinophilia and systemic vasculities which complicate preexisting asthma, were analyzed. The mean duration of asthma before CSS was 8 years; peripheral blood eosinophilia was always greater than 1,900/microliters and exceeded 5,000/microliters in 14 cases. The clinical manifestations were the following: 16 in generally poor condition with fever; 12 peripheral neuropathies; 11 cutaneous lesions; 9 pericardial or myocardial involvement; 9 digestive disorders; 9 muscular or articular diseases; 5 renal involvement, all associated with the vasculitis; 7 upper respiratory tract disorders. Chest radiographs showed pleuropulmonary or cardiac anomalies in 11 patients. The diagnosis was confirmed histologically in 11 cases, however, no clinical, biological or evolutive differences were observed between these patients and those with negative biopsies (5). Follow-up for 6.35 +/- 5.55 years was characterized by relapses always preceded by increased eosinophilia. Fourteen patients were successfully treated with corticosteroids, associated with cyclophosphamide in 7 of them. Five-year survival was 87%. Four deaths occurred, all CSS-associated, two because of a poorly adapted therapeutic regimen. The need for rapid and effective treatment must be stressed. The diagnosis can be made based on clinical manifestations alone before histological confirmation can be obtained.

[Magnetic resonance imaging in the diagnosis of pheochromocytoma]. / L'imagerie par résonance magnétique dans le diagnostic des phéochromocytomes.

The diagnosis of pheochromocytoma is biological. If ultrasound enables the visualization of certain adrenal tumours or hepatic metastasis, in fact two tests enable the topographic diagnosis, the screening of ectopic localizations and metastasis. They are IMBG scintigraphy and tomographic scanning. The place of magnetic resonance imaging is not yet specified. However, it has many advantages: absence of irradiations, good anatomic precision, meticulous screening of ectopic forms, of metastases and of adenopathies, study of the tissue characterization, good definition of the tumour relation with the vascular pedicles and the neighbouring structures.

[False and true hypertension in the aged subject. Diagnostic errors and potential solutions]. / Fausses et vraies hypertensions artérielles du sujet âgé. Les erreurs diagnostiques et leurs solutions potentielles.

Arterial hypertension has the same definition in elderly people as in young adults. Epidemiologically, it has clearly been demonstrated that in the elderly it is a risk factor of morbidity and cardiovascular mortality. The international reference method for measuring blood pressure is by auscultation and mercury manometer. However, this indirect measurement is the source of many errors due to the material or the observer, or inherent in the method. A typical example of this is pseudohypertension in the elderly. Several solution are offered to improve the reliability of indirect blood pressure measurement, the most convincing one being the use of scientifically validated autonomous instruments relying on the oscillometry system. Ambulatory blood pressure measurement is interesting, being of diagnostic, therapeutic and probably prognostic value, but all this has to be confirmed in elderly subjects.

[Mycotic aneurysms]. / Les anévrysmes mycotiques.

Mycotic aneurysms are aneurysms infected by bacteria or fungi. These may be secondary to an endocarditis, or they may be primary, and then are developed from a septicemia or bacteremia. The diagnosis, often difficult, is sometime only made during complications, the most severe of which is rupture. This diagnosis must be aided by new imaging techniques such as ultrasonography, tomodensitometry, magnetic resonance imaging. The treatment is medical (antibiotics) and surgical.

[Bronchial cancer with extension into the heart. Apropos of a case with magnetic resonance imaging]. / Cancer bronchique avec extension intracardiaque. A propos d'une observation avec imagerie par résonance magnétique.

The authors report a case of a 64-year-old patient with an adenocarcinoma of the bronchus with mediastinal involvement. The echocardiography and CT scan showed the existence of involvement of the left auricle. Confirmation and the extent of the intra-cardiac involvement were provided by nuclear magnetic resonance imaging which confirmed the diagnosis here and was particularly helpful. The authors further recall that the place of nuclear magnetic resonance as a standard investigation in assessing staging in bronchial cancer remains to be determined in relation to CT scanning.

[Determination of erythrocyte protoporphyrin by a spectrofluorometry method]. / Détermination de la protoporphyrine érythrocytaire par méthode spectrofluorimétrique.

Erythrocyte protoporphyrin (EP) measurement is useful for the diagnosis of protoporphyrin, iron deficiency or lead poisoning. The authors described a manual procedure for the spectrofluorimetric determination of EP. Erythrocytes were used, instead of whole blood. The following steps were performed: treatment with celite suspension, extraction using ethylacetate/acetic acid, estimation of the fluorescence of protoporphyrin IX extracted in HCl. Analytical results are following: a low detection limit (0.045 mumol/l), a linear response up to 2 mumol/l, within run and day-to-day precision respectively better than 3.5 p. cent and 5.8 p. cent. The procedure with predilution led to no significant difference with the spectrophotometric reference method (student t-test, t: 0.85) up to 42 mumol/l. Concentrations of EP according to age were studied for children (0.0470-1.000 mumol/l), middle-aged subjects (0.390-0.880) and elderly subjects (0.340-1.040). The proposed method is accurate, rapid and available for routine measurements.

[Experience at an Internal Medicine service in the postoperative follow-up of 403 patients operated on at a cardiovascular surgery service]. / Expérience d'un service de Médecine Interne dans les suites postopératoires de 403 patients opérés dans un service de Chirurgie Cardio-vasculaire.

Over the last 3 years, 403 patients operated in the Department of Cardiovascular Surgery of Broussais Hospital have been transferred to a Department of Internal Medicine for secondary postoperative care. A total of 245 non-cardiac complications (64%) and 134 cardiac or vascular complications (36%) were observed in 321 of these 403 patients (80%). Infections accounted for 26% of non-cardiac complications (63/245). They included 9 cases of mediastinitis, 2 cases of septicemia, 6 endocarditis, 6 wound infections, and 40 other infections (ENT, gastrointestinal, pulmonary, urogenital). The non-cardiac, non-infectious complications comprised mainly delayed healing (39 cases) and pleuropulmonary (29 cases), ENT (9 cases), gastrointestinal (31 cases), urogenital (12 cases), hematological (17 cases) and neuropsychiatric (9 cases) complications; and, finally, 37 inflammatory syndromes. The cardiac complications were pericarditis with or without tamponade (24 cases), arrhythmias or conduction disturbances (50 cases), haemodynamic (54 cases) and vascular (6 cases complications. These very varied complications sometimes occurred late and could be latent. They resulted in prolongation of the duration of hospitalization, so increasing the overall health costs.

[Spontaneous dissection of the renal artery]. / Dissection spontanée de l'artère rénale.

In this paper we describe a case involving spontaneous dissection of the renal artery (DRA) successfully treated with an aorto-renal venous graft. DRA is a rare disorder which strikes men especially. Hypertension is the most frequent sign of its presence, which is usually of sudden onset, and with major adverse impact on the eye and brain. Arteriography is the key diagnostic examination. The most typical image is that of "cuffing". Treatment is surgical in nearly 50% of cases and should be as conservative as possible since these lesions may be bilateral.

[Infectious complications, delayed wound healing and inflammatory syndromes as late complications of cardiovascular surgery]. / Complications infectieuses, retards de cicatrisation et syndromes inflammatoires dans les suites retardées de la chirurgie cardiovasculaire.

Four-hundred and three patients were admitted to an internal medicine unit for late complications of cardiac or vascular surgery; 321 of these patients (80 per cent) had a total of 379 complications or intercurrent disease, 147 (40 per cent) of which were infections (71 cases), delayed healing of the operative wound (39 cases) or inflammatory syndromes (37 cases). Such complications are notable for their immediate or secondary severity, the diagnostic problems sometimes raised by their latency, their repercussions on the length of hospitalization and cost of surgery, and the thoughts they inspire concerning the minimal stay in hospital required after this type of surgery.