[Utilité de la tomographie thoraco-abdomino-pelvienne chez les patients âgés hospitalisés pour altération de l'état général]. / Usefulness of thoracic-abdominal-pelvic tomography in older adults hospitalized with alteration of general state.

Alteration of the general state of health is a frequent clinical situation as reason for hospital admission of older adults, although there is no consensus on criteria of the diagnostic approach. Our objective was to study whether thorax, abdomen and pelvis tomography is useful for the diagnosis and determination of a specific care pathway for hospitalized patients over 80 years old with alteration of the general state without identified clinical explanation. retrospective observational monocentric study at a French University Hospital, with the inclusion of all hospitalized patients who had a tomography following for alteration of general state without identified clinical explanation between January 2019 and June 2020. The primary endpoint was the presence of a diagnosis on the tomography report. We studied 48 files of patients (aged 86.2 ± 3.4 years on average). Tomography provided a diagnosis in 60.4% of cases. Factors significantly related to usefulness of tomography were weight loss and duration of weight loss. Among the diagnosed patients, specific actions were taken for 86.2% of them. Our study suggests that thoracic-abdominal-pelvic tomography is useful to examine the alteration of general state in older patients without identified clinical explanation, particularly for those presenting with unintentional weight loss. That suggests that it is probably preferable to use the correct symptoms description instead of alteration of general state.

Safety of subcutaneous versus intravenous ceftriaxone administration in older patients: A retrospective study.

BACKGROUND: Antibiotics play a central role in infection management. In older patients, antibiotics are frequently administered subcutaneously. Ceftriaxone pharmacokinetics after subcutaneous administration is well documented, but little data are available on its safety. METHODS: We compared the occurrence of adverse events associated with ceftriaxone administered subcutaneously versus intravenously in ≥75-year-old patients. We used data from a single-center, retrospective, clinical-administrative database to compare the occurrence of adverse events at day 14 and outcome at day 21 in older patients who received ceftriaxone via the subcutaneous route or the intravenous route at Rennes University Hospital, France, from May 2020 to February 2023. RESULTS: The subcutaneous and intravenous groups included 402 and 3387 patients, respectively. Patients in the subcutaneous group were older and more likely to receive palliative care. At least one adverse event was reported for 18% and 40% of patients in the subcutaneous and intravenous group, respectively (RR = 2.21). Mortality at day 21 was higher in the subcutaneous route group, which could be linked to between-group differences in clinical and demographic features. CONCLUSIONS: In ≥75-year-old patients, ceftriaxone administered by the subcutaneous route is associated with less-adverse events than by the intravenous route. The subcutaneous route, which is easier to use, has a place in infection management in geriatric settings.

Inside the Black Box: A Narrative Review on Comprehensive Geriatric Assessment-Driven Interventions in Older Adults with Cancer.

There is a consensus that the use of comprehensive geriatric assessment (CGA) is good clinical practice for older patients with solid tumors or hematological malignancies. To be complete, a CGA must include a geriatric assessment and an intervention plan. According to the SIOG consensus, a CGA should assess several domains: functional status, comorbidity, cognition, mental health status, fatigue, social status and support, nutrition, and the presence of geriatric syndromes. Progress has been made in the definition of the best way to detect problems, but the benefits are mostly based on prognosis stratification and on the adaptation of cancer treatment. The present review aims to evaluate the level of evidence regarding geriatric interventions proposed following the detection of a problem in cancer patients in each domain mentioned in the SIOG consensus. An online search of the PubMed database was performed using predefined search algorithms specific for each domain of the CGA. Eligible articles had to have well-defined interventions targeting specific domains of the CGA. We screened 1864 articles, but only a few trials on single-domain interventions were found, and often, these studies involved small groups of patients. This review highlights the scarcity of published studies on this topic. The specific impacts of CGA-based interventions have not yet been demonstrated. Multi-domain interventions seem promising, especially when they are based on global assessments. However, standardization seems difficult considering the lack of evidence for each domain. New studies are necessary in multiple care contexts, and innovative designs must be used to balance internal and external validity. An accurate description of the intervention and what "usual care" means will improve the external validity of such studies.

Structural and Managerial Risk Factors for COVID-19 Occurrence in French Nursing Homes.

BACKGROUND: Nursing home (NH) residents accounted for half of the deaths during the 2020 spring wave of the coronavirus disease 2019 (COVID-19) epidemic in France. Our objective was to identify structural and managerial factors associated with COVID-19 outbreaks in NHs. METHODS: We conducted in July 2020 a retrospective study by questionnaire addressed to NH directors in the Brittany region of France. The questions related to structural characteristics of the establishment, human resources, and crisis management decisions. The primary endpoint was the occurrence of at least one confirmed case of COVID-19 among residents between March 1, 2020 and May 31, 2020. The secondary endpoint was total mortality during this period. We used multivariate regressions to identify factors associated with these outcomes. RESULTS: Responses were collected from 231 NHs hosting 20,881 residents, representing a participation rate of 47%. In 24 (10%) NHs, at least one resident presented confirmed COVID-19. NHs often implemented stringent protective measures, with 65% of them choosing to confine residents to their rooms. In multivariate analysis, factors associated with a reduced risk of case occurrence were in-room meal service, early ban of family visits, and daily access to an outdoor space. No association was found between mortality and the factors studied. Our results show an early and strict implementation of lockdown measures, with good epidemiological results in a context of shortage of personal protective equipment (PPE) and non-vaccination. Nevertheless, it raises ethical questions concerning respect of residents' wellbeing and rights. CONCLUSION: Cessation of communal dining seems to be the main measure likely to be effective in preventive terms. It does not seem that room lockdown and cessation of group activities should be recommended, particularly if mask wearing is possible.

The Trigger Tool Method for Routine Pharmacovigilance: A Retrospective Cohort Study of the Medical Records of Hospitalized Geriatric Patients.

OBJECTIVE: The main objective was to assess the feasibility of the trigger tool method for the retrospective detection of adverse drug reactions (ADRs) in the Rennes University Hospital. The secondary objective was to describe the performance of the method in terms of positive predictive values (PPVs) and severity or preventability of ADRs. METHODS: Using the Rennes University Hospital clinical data warehouse, pharmacovigilance experts performed a retrospective review of a random sample of 30 inpatient hospital medical records per month using the triggers "fall" and "delirium" to identify related ADRs among patients 65 years and older in 2018 in the geriatrics department. Using the Z test, we compared the proportion of medical records with a positive (identified) trigger related to an ADR, which were reviewed within 20 minutes using the reference of 50% reviewed within 20 minutes. RESULTS: Among the 355 medical records reviewed, 222 had at least 1 trigger and 98 at least 1 related ADR. Among the 222 positive trigger medical records, 99.6% were reviewed in under 20 minutes (P < 0.001). The pharmacovigilance assessment took 3 months. The PPVs reached 53.9% (46.0%-61.7%) for falls and 21.0% (14.3%-27.5%) for delirium. Among the ADRs, 80% were serious and 53% were preventable. CONCLUSIONS: Given the low PPV of the triggers used and the considerable need for technical and human resources, the trigger tool method cannot be used as a routine tool at the pharmacovigilance center. However, it could be implemented occasionally for specific purposes such as monitoring the impact of risk minimization measures to prevent ADRs.

A Reliable Fall Detection System Based on Analyzing the Physical Activities of Older Adults Living in Long-Term Care Facilities.

Fall detection systems are designed in view to reduce the serious consequences of falls thanks to the early automatic detection that enables a timely medical intervention. The majority of the state-of-the-art fall detection systems are based on machine learning (ML). For training and performance evaluation, they use some datasets that are collected following predefined simulation protocols i.e. subjects are asked to perform different types of activities and to repeat them several times. Apart from the quality of simulating the activities, protocol-based data collection results in big differences between the distribution of the activities of daily living (ADLs) in these datasets in comparison with the actual distribution in real life. In this work, we first show the effects of this problem on the sensitivity of the ML algorithms and on the interpretability of the reported specificity. Then, we propose a reliable design of an ML-based fall detection system that aims at discriminating falls from the ambiguous ADLs. The latter are extracted from 400 days of recorded activities of older adults experiencing their daily life. The proposed system can be used in neck- and wrist-worn fall detectors. In addition, it is invariant to the rotation of the wearable device. The proposed system shows 100% of sensitivity while it generates an average of one false positive every 25 days for the neck-worn device and an average of one false positive every 3 days for the wrist-worn device.

Why choose geriatric medicine? A national survey among French postgraduate medical students.

Since 2017, geriatric medicine has been available as a postgraduate specialty to French year 7 medical students. We investigated the incentives of the 171 French medical students who opted for geriatric medicine as a postgraduate specialty subsequent to year 6 national qualifying examinations in 2017. A prospective quantitative survey-based study was conducted by means of a questionnaire compiled online and sent by email between December 2017 and May 2018. The questionnaire comprised 43 questions, including 14 single or multiple choice questions, 28 scaled questions evaluating factors of influence using a 5-point Likert scale, and one open-ended contingency question. Of the 171 students, 139 responses were received. The national response rate to this questionnaire was 81.2%. One hundred fourteen students (82.6%) had previous experience of training in geriatric medicine, which for 95 (84.0%) students took place between years 3 and 6 of medical training. This training influenced the choice of 102 respondents (90.2%). Factors reported as having exerted a strong or very strong influence were in particular the rewards of working with older adults; positive personal encounters with older adults in the past; the appeal of interprofessional teamwork; the challenge of cases involving complex diagnostic and therapeutic decisions; the challenge of patients with chronic conditions. The present study is the first to focus on the reasons why French students choose to specialise in geriatric medicine. The results emphasise the importance of training programs in geriatric medicine to promote enthusiasm for this specialty.

Blood transfusion in elderly patients with chronic anemia: a qualitative analysis of the general practitioners' attitudes.

BACKGROUND: Blood transfusion in chronic anemia is not covered by guidelines specific to older adults. When they consider that this treatment is necessary in elderly patients, French general practitioners (GPs) contact a hospital specialist to plan a transfusion. METHODS: Twenty French GPs were questioned individually regarding their approach to blood transfusion using semi-structured interviews. Each interview was recorded, typed up verbatim and then coded using an inductive procedure by theme, in a cross-over design (two researchers) in two phases: analysis and summary, followed by grouping of the recorded comments. RESULTS: The criteria for transfusion were hemoglobin level < 8 g/dL and cardiac comorbidities. Some geriatric issues, such as cognitive disorder or dependence, were considered, either as aspects of frailty favoring transfusion or as markers of reduced life expectancy that limit care. Falls and fear of an unpleasant death from anemia prompted GPs to order blood transfusion. The patient's family provided guidance, but the patient was not routinely consulted. The specialists were rarely asked to participate in decision making. GPs' perceptions were ambivalent: they considered transfusion to be extraordinary and magical, but also pointless since its effects are transient. CONCLUSION: The decision to give a transfusion to an elderly patient with chronic anemia is deemed complex, but GPs seem to take it alone, sometimes guided by the patient's family. The drawing up of an advance care plan could help involve the patient in decision making.