[Emergency intervention of hospitalisation at home in nursing home during the pandemic period of Covid-19]. / Intervention en urgence de l'hospitalisation à domicile en établissement d'hébergement pour personnes âgées dépendantes pendant la période pandémique de la Covid-19.

BACKGROUND: In the context of the pandemic Covid-19, the Hospitalization A Home (HAH) of the Assistance Publique - Hôpitaux de Paris (APHP) has implemented a new organisation with emergency interventions to meet the needs of residents in palliative care in nursing home. The objective of the study was to describe their clinical characteristics, the modalities of the intervention and their care pathways during the HAH intervention. METHODS: This is a descriptive study on the emergency intervention of the HAH in 74 nursing home in the area of Ile-de-France during one month (April 2020) with a sample of 132 residents. The data collection included the socio-demographic and clinical characteristics of residents and on data about nursing home included. RESULTS: Emergency intervention of the HAH in nursing home involved very elderly residents with severe functional disabilities and with signs of respiratory failure linked to the Covid 19. The intervention took place mainly during the day and the week with a territorial heterogeneity and with a double medical validation between the prescribers and the HAH physician. Seventy per cent of the residents died at their living place. Among nursing home included, they were of medium size, mainly with private status and a large majority had already collaborated with the APHP's HAH. DISCUSSION/CONCLUSION: Emergency intervention of the HAH in nursing home was feasible and responded to an unmeet need for palliative care residents. These results should allow the ongoing development of this new organization for elderly population living in private homes.

Recommendations for bowel obstruction with peritoneal carcinomatosis.

This article reports on the clinical practice guidelines developed by a multidisciplinary group working on the indications and uses of the various available treatment options for relieving intestinal obstruction or its symptoms in patients with peritoneal carcinomatosis. These guidelines are based on a literature review and expert opinion. The recommended strategy involves a clinical and radiological evaluation, of which CT of the abdomen is a crucial component. The results, together with an analysis of the prognostic criteria, are used to determine whether surgery or stenting is the best option. In most patients, however, neither option is feasible, and the main emphasis, therefore, is on the role and administration of various symptomatic medications such as glucocorticoids, antiemetic agents, analgesics, and antisecretory agents (anticholinergic drugs, somatostatin analogues, and proton-pump inhibitors). Nasogastric tube feeding is no longer used routinely and should instead be discussed on a case-by-case basis. Recent studies have confirmed the efficacy of somatostatin analogues in relieving obstruction-related symptoms such as nausea, vomiting, and pain. However, the absence of a marketing license and the high cost of these drugs limit their use as the first-line treatment, except in highly selected patients (early recurrence). When these medications fail to alleviate the symptoms of obstruction, venting gastrostomy should be considered promptly. Rehydration is needed for virtually every patient. Parenteral nutrition and pain management should be adjusted according to the patient needs and guidelines.

End of life care in adolescents and young adults with cancer: experience of the adolescent unit of the Institut Gustave Roussy.

BACKGROUND: Cancer is the third leading cause of death in adolescents and young adults (AYA). Little is known, however, about how end-of-life unfolds for those who die of progressive disease. In order to better evaluate the specific needs of these patients, we performed this study providing baseline information about end-of-life care patterns for AYA in our department. PATIENTS: A standardised form was used to collect data concerning all 45 patients treated for a malignancy in the Paediatric and Adolescent Oncology Department at the Gustave Roussy Institute, and who had died of progressive disease above 13 years of age, over a two-year period. RESULTS: The main diagnoses were sarcomas and brain tumours. Previous cancer-directed treatment included a median of 3 different chemotherapy regimens, high-dose chemotherapy with haematopoietic stem cell support for 13% and radiotherapy for 40%. One in every four patients had been enrolled in a clinical trial at diagnosis. Median survival was 18 months after the diagnosis and 7 months after the first relapse/progression. During the last week of life, the median number of physical symptoms was 4, mostly pain and dyspnoea. Frequent psychological symptoms were sadness, anxiety, fear and guilt. End-of-life care included transfusions, artificial nutrition, corticosteroids, pain control, sedation but also palliative chemotherapy. The median time spent in hospital during the last month of life was 16 days. Most patients had died in hospital. CONCLUSIONS: The terminally ill adolescent displays notable challenges to care providers and requires a holistic approach with the help of a multidisciplinary team.

Misdiagnosis of chronic thrombocytopenia in childhood.

PURPOSE: Children ultimately diagnosed with nonimmune chronic thrombocytopenia are often referred to pediatric hematology clinics with a provisional diagnosis of autoimmune thrombocytopenic purpura (AITP). The authors' aim was to establish in these patients the features characterizing the mechanism of thrombocytopenia. PATIENTS AND METHODS: The authors performed a retrospective review of the case records of seven children (three boys and four girls, aged 5 months to 7 years) with misdiagnosed chronic AITP referred to a single pediatric hematology center between 1990 and 2000. RESULTS: In the seven children, the suspected diagnosis on referral was AITP and the final diagnosis was inherited thrombocytopenia. Abnormalities of platelets and/or leukocyte morphology were present in all of them. Other features suggestive of inherited thrombocytopenia included a history of familial thrombocytopenia (2/7), failure of steroids and/or intravenous immunoglobulins to raise the platelet count to normal levels (5/7), and moderate increase of Indium-111 platelet turnover in the two patients tested. Platelet-associated IgG (PaIgG) was above the normal threshold in the four children tested; the direct monoclonal antibody immobilization of platelet antigens (MAIPA) test was negative in the four children tested and the serum test was positive in two boys. Bone marrow examination revealed either a normal (4/7) or an elevated (3/7) number of megakaryocytes. CONCLUSIONS: Family history and blood cell morphology analysis in experienced hands are the first steps in discriminating AITP from inherited thrombocytopenia in children with isolated chronic thrombocytopenia. In contrast, bone marrow examination and search for specific autoantibodies using the MAIPA test are of little help. An isotopic platelet life span study, when available, should be performed before considering splenectomy to exclude the diagnosis of inherited thrombocytopenia, especially when steroids and/or IgG IV administration failed to raise the platelet count.