[The contribution of teleconsultation and isolation of symptomatic cases in control of the COVID-19 outbreak a military base]. / Apport de la téléconsultation et de l'isolement des cas symptomatiques dans la maîtrise de l'épidémie COVID-19 au sein d'une base militaire.

BACKGROUND: The first wave of COVID-19 swept over France during the first quarter of 2020, leading to saturation of the health care system. We wished to study, in a French military medical unit assisting one of the country's largest armed forces populations, the impact of teleconsultation and the systematic isolation of all possible, probable and confirmed cases of COVID-19. METHODS: This is a retrospective study carried out from March 9 to May 31, 2020 on the basis of our activity register. The variables collected included type of medical consultation procedure, occupational status, classification of cases and date of onset of first symptoms. We have paralleled our activity with that of SOS Médecins and the emergency departments of the Île-de-France region. RESULTS/DISCUSSION: During this period, 1719 episodes of care (teleconsultations or physical consultations) were recorded, of which 91% (n=1561) were linked to COVID-19. We identified 598 "suspected" (possible and probable) and confirmed cases. "Isolated" teleconsultations (not followed by a face-to-face medical consultation, sample taking or necessitating the dispatch of prompt assistance) represented 86% of episodes of care (n=1482). Comparison of our activity and the number of new cases with the databases of SOS Médecins and the Île-de-France emergency services suggests that our isolation strategy was timely and effective. CONCLUSION: The contribution of teleconsultation was substantial and reassuring. Teleconsultation makes it possible to absorb a large volume of patients, is easy to implement, and entails no nosocomial risk. Isolation of infected patients should be a priority during an outbreak. Once it has become a priority to rapidly bring an epidemic under control, this attitude must be extended to all symptomatic patients.

Adherence to fracture liaison service programs in patients over 70: the hidden part of the iceberg.

Significant dropout rates have been observed throughout Fracture Liaison Service (FLS) programs, especially for elderly patients. In an FLS program set up specifically for patients over 70, the non-initiation of osteoporosis treatment was the only factor associated with poor adherence to the program. Neither age nor frailty factors affected adherence. INTRODUCTION: FLS programs are considered the most effective interventions for secondary prevention of osteoporotic fractures. Our objective was to identify risk factors for non-adherence to an FLS program set up specifically for patients over 70. METHODS: Our multifaceted, intensive program included five appointments over a 2-year period. One hundred sixty-seven patients (mean age 83.5 years) who presented with a recent fragility fracture were enrolled. Multivariable analysis was conducted to determine whether the demographic, clinical, frailty, and osteoporotic risk factors of the patients influenced their adherence to the program. RESULTS: About half of the patients did not attend the follow-up visits. According to the regression analysis, non-initiation of osteoporosis treatment was associated with poor adherence to the program (aHR 3.66). Demographic, clinical, dwelling, frailty factors, osteoporotic risk factors, fracture type, or densitometric scores were not associated with adherence. The first self-reported reason for withdrawal was the difficulty of attending several follow-up visits, and the second was the feeling of not being concerned. CONCLUSION: We observed that non-initiation of osteoporosis treatment was the only factor correlated with non-adherence to an FLS program. Thus, neither age nor frailty factors should result in patients not being included in FLS. Beyond the necessity of the osteoporosis treatment, good patient understanding of the relevance of all the interventions included in the program is the key.

[Medication reconciliation: Interests and limits]. / Conciliation médicamenteuse : intérêts et limites.

Admission to hospital is a critical transition point for the continuity of care in medication management. Medication reconciliation can identify and resolve errors due to inaccurate medication histories. The practice of medication reconciliation is securing for the patient because of the medication errors detected with significant clinical impact. Its implementation must comply with the recommendations of the French National Authority for Health (HAS) and its deployment is now integrated into the contract for improving the quality and efficiency of care (CAQES). However, although it allows to intercept medication errors, its impact on the length of hospitalization, the rate of readmission and/or death following discharge seems limited. Given the limited human resources to carry out this time-consuming activity, patient prioritization should be considered. Studies on the fate of patients and on the medico-economic issues are also necessary in order to make this activity sustainable.

Identification of Frailty in a Population of Former Immigrant Workers in the South of France.

BACKGROUND: Frailty is unevenly distributed across the world but also within different populations in the same country. OBJECTIVES: This study sought to identify frailty in former immigrant workers, known as Chibanis, living in an immigrant hostel in Marseille. The secondary objective was to describe health care access, as well as any chronic diseases reported. DESIGN, PARTICIPANTS AND SETTING: Our descriptive, observational, monocentric study conducted from January to April 2021 included 67 Chibanis, living in an immigrant hostel in Marseille. MEASUREMENTS AND RESULTS: Almost all this population (97%), with a median age of 77 years, presented at least one frailty criterion: 7.5% were malnourished, 55.2% had a grip strength of < 27 kg, and 41.8% were on multiple drugs. Majority of Chibanis (86.6%) had multimorbidity. CONCLUSION: Identifying frailty in this population of Chibanis must be proposed through a specific, adapted care pathway including referral to a specialist.

HoSAGE: Sarcopenia in Older Patients before and after Treatment with Androgen Deprivation Therapy and Radiotherapy for Prostate Cancer.

BACKGROUND: Sarcopenia is a muscle disease defined by a loss of muscle strength associated to a decrease in skeletal muscle mass. In addition to aging, many factors may contribute to sarcopenia as cancer and/or androgen deprivation therapy (ADT). OBJECTIVES: The aims of this study are to describe the prevalence of sarcopenia in older prostate cancer patients before initiation of treatment with ADT and radiotherapy, and to evaluate the impact of ADT on the occurrence or aggravation of sarcopenia in this population. DESIGN: longitudinal study. PARTICIPANTS AND SETTING: Sarcopenia was prospectively evaluated in 31 consecutive patients aged 70 to 88 years, referred in one hospital unit of south eastern France, for a comprehensive geriatric assessment (CGA) before cancer treatment initiation. MEASUREMENTS AND RESULTS: CGA, measures of muscle strength and physical performances were performed at baseline (T0) and at the end of cancer treatment (T1). Appendicular skeletal muscle mass was measured by Dual-energy X-ray absorptiometry (DXA) at the end of treatment. At T0, 8 patients (among 31) had a probable sarcopenia according to European consensus, and 18 had altered physical performance. At T1, 15 patients (among 19) had abnormal one leg balance test. Finally, only one patient had a sarcopenia confirmed by DXA. CONCLUSION: This preliminary study showed a high prevalence of muscle disorders before initiation of ADT in a population of elderly cancer prostate patients with intermediate frailty status, and an increased risk of falls at the end of ADT. This highlighted the importance of screening for sarcopenia before treatment initiation, to prevent the occurrence or aggravation of sarcopenia by possible adjustment of treatment, and implementation of appropriate exercise and nutrition interventions.

Cyclophosphamide dose adjustment based on body weight and albuminemia in elderly patients treated with R-mini-CHOP.

BACKGROUND: Diffuse large B-cell lymphoma (DLBCL) is the most common lymphoma in elderly patients, and R-CHOP chemotherapy is the standard treatment protocol for DLBCL. Elderly patients (often defined as 75 years of age) are treated with anticancer drugs with precaution; however, the pharmacokinetics and pharmacodynamics (PK and PD) of these agents have not been thoroughly investigated in this population. In this study, we investigated the PK of cyclophosphamide (CP) and doxorubicin (DOXO) in elderly patients in order to verify if there is an influence of age on the PK of these anticancer drugs. MATERIALS AND METHODS: This is a prospective multi-center clinical trial investigating the PK of CP and DOXO in elderly and very elderly patients with DLBCL treated by R-mini-CHOP regimen. Dose levels were 25 mg/m2, 0.7-1.4 mg/m2, 750 mg/m2, and 375 mg/m2 for DOXO, Vincristine (VCR), CP, and Rituximab, respectively. For PK analysis, 7 time point samples were collected over 48 h post-administration on cycle 3. CP and VCR plasma concentrations were measured using UPLC-MS/MS validated method. DOX plasma concentrations were measured using UPLC coupled with fluorescence detection-validated method. PK-POP modeling has been performed with a non-linear mixed-effect model program (Monolix). RESULTS: 31 patients (15 males and 16 females), 75 to 96 years old, were treated with R-miniCHOP protocol. Among them, 19 patients were treated with VCR. A one-compartment (1cpt) open model with linear elimination adequately described CP concentration-time courses. The population PK parameters for CP were: CL = 3.58 L/h, Vmale = 32.2 L, and Vfemale = 28.7 L. Body weight (BW), albuminemia, and gender demonstrated a significant impact on CP PK. A 2-compartment (2cpt) open model with linear elimination best described DOXO concentration-time courses. The population PK parameters for DOXO obtained for the structural model were: CL = 51.1 L/h, Q = 49.6 L/h, V1 = 29.4 L, V2 = 1,130 L (clearances: CL, Q, volumes of distribution: V1, V2). The main covariate effects on DOXO PK were related to gender, BW, and VCR administration. VCR increases DOXO V1 from 29.4 L to 57.5 L (p = 0.02). No hematologic and cardiac grade 3 or 4 toxicity were recorded. CONCLUSIONS: Usually, in the absence of specific data, the majority of the physicians empirically reduce anticancer drug dose in the elderly patients (Tourani in J Geriatr Oncol 3(1): 41-48, 2012), or even does not treat these very-old patients. A better knowledge of the pharmacokinetics in very-old patients should allow a better dose adjustment based on the most significant physiological factors that modify the pharmacokinetic parameters. In this study, no serious toxicity was observed in these very elderly patients (84.1 years). This indicates that dose adjustment of chemotherapies should not only be based on age and creatinine clearance, but also, based upon appropriate physiological and biological data. Our findings indicate that, CP dose adjustment should be done according to serum albumin levels and patients BW and gender.

The effect of moisture content and alkalinity on the anaerobic biodegradation of VIP contents.

This study investigated the effect of additional moisture and/or alkalinity on the rate of anaerobic digestion in samples of material obtained from pit latrines. In modified serum bottle tests it was shown that poor gas production rates were observed from all experiments with material collected at the lower part of one pit. Using material from the top layer of a second pit it was shown that experimental bottles produced significant amounts of gas with both the addition of water and the addition of alkalinity. The results supports the motivating hypotheses that moisture content and pH buffering capacity obtained in VIP material are low and may be limiting factors in the rate of stabilisation that may occur in these pits. This implies that increasing the moisture content and alkalinity in the pit has the potential to increase stabilisation rate in the pit when the material is not already well-stabilised.

The effect of moisture content and alkalinity on the anaerobic biodegradation of pit latrine sludge.

This study investigated the effect of additional moisture and/or alkalinity on the rate of anaerobic digestion in samples of material obtained from pit latrines. In modified serum bottle tests it was shown that poor gas production rates were observed from all experiments with material collected at the lower part of one pit. Using material from the top layer of a second pit it was shown that experimental bottles produced significant amounts of gas for all treatments. Analysis of data indicated that treatment with additional alkalinity had no discernible effect on anaerobic gas production rates, but that there was some correlation between moisture content and gas production rate. These results did not support the hypothesis that low pH buffering capacity was a limiting factor in the rate of digestion of pit latrine sludge, but confirmed that low moisture content could reduce the rate of stabilisation. This implies that increasing the moisture content in a pit latrine has the potential to increase biological stabilisation rates in the pit when the material is not already well-stabilised.

[Treatments of steroid-dependent nephrotic syndrome in children]. / Traitements du syndrome néphrotique cortico-dépendant de l'enfant.

Primary nephrotic syndrome (NS) is the most common glomerular disease in children. It is characterized by massive proteinuria and hypoalbuminemia. It typically has a sudden onset and more than 70% of patients will experience at least one relapse. An immunological origin has long been postulated, although the precise molecular mechanisms underlying the disease remain debated. Steroids are the first-line therapy with cumulative dose and duration of initial treatment varying among countries. Steroid-sparing agents may be indicated in case of steroid-dependency or frequent relapses. However, no consensus exists regarding the different treatment options. These treatments are mostly suspensive and therefore, need to be prolonged for several months. Levamisole, an antihelminthic drug, also has an immunomodulatory function, and alone or in combination with steroids, it can decrease cumulative steroid dose and relapses. It is usually well tolerated, and its principal side effects are cytopenia and elevated liver enzymes. Mycophenolate mofetil is an immunosuppressive agent whose reported side effects are cytopenia and diarrhea. Calcineurin inhibitors (cyclosporine or tacrolimus) have long been used in steroid-dependent patients. Their major side effects are hirsutism, gum hypertrophy, and nephrotoxicity, leading to interstitial kidney fibrosis and chronic kidney disease. Cyclophosphamide is an efficient treatment but its gonadal toxicity is a major drawback to its use. More recent drugs such as rituximab are very effective but require hospitalization for the infusion and induce an increased risk of opportunistic infection, prolonged neutropenia, and anaphylaxis. In this review, we present the available treatments, their indications, and the side effects.

[Is pure red cell aplasia a new extra digestive manifestation of celiac disease?]. / L'érythroblastopénie: nouvelle manifestation extradigestive de la maladie coeliaque?

INTRODUCTION: Celiac disease is an autoimmune enteropathy that appears on a predisposed genetic background. Its clinical presentation has been extended those last years by varied extradigestive manifestations. EXEGESIS: This is a case report of a twenty-year-old woman who presented simultaneously a celiac disease and pure red cell aplasia. The IgA and IgG antigliadin antibodies as well as antinuclear, anti-DNA, anti-SSA and anti-SSB antibodies were detected, without any clinical symptom supporting the diagnosis of systemic lupus erythematosus or Sjögren syndrome. Thoracic CT-scan reveals a thymus enlargement and biopsy concludes to thymus hyperplasia at histological examination. Pure red cell aplasia regressed after gluten-free diet, corticoid therapy and thymectomy. CONCLUSION: This observation, added to the three others paediatric cases previously published in the literature concern an uncommon association between pure red cell aplasia and celiac disease. However, they are not enough to conclude to a direct link between these two disorders. Pure red cell aplasia could represent un new dysimmune manifestation occurring in celiac disease, but this will need to be confirmed with others cases.

Cobalamin deficiency in the elderly: aetiology and management: a study of 125 patients in a geriatric hospital.

INTRODUCTION: Cobalamin deficiency is frequent in elderly patients and the main aetiologies are food-cobalamin malabsorption and pernicious anaemia. The aim of our retrospective study was to identify the causes and methods of management of cobalamin deficiency at Nice geriatric university hospital. METHODS: A retrospective monocentric study was conducted over 14 months at Nice geriatric hospital, which included patients with cobalamin deficiency having received supplementation. The clinical and paraclinical data, etiological diagnosis, treatment and follow-up modalities were analyzed retrospectively. RESULTS: We studied 125 elderly patients whose median age was 85.5 ± 7 years. The etiological diagnosis was food-cobalamin malabsorption for 72 patients (57.6 %), nutritional cobalamin deficiency for 15 patients (12 %), pernicious anaemia for 12 patients (9.6 %) and there was no etiological diagnosis for 26 patients (20.8 %). Concerning cobalamin therapy, 111 patients (88.8 %) received oral therapy and 14 (11.2 %) intramuscular therapy. Vitamin B12 levels increased significantly after supplementation (p<0.001) but cobalamin administration varied according to the diagnoses (p<0.001) and was less effective in patients with dementia (p=0.04) and food-cobalamin malabsorption. CONCLUSION: Our study showed the importance of food-cobalamin malabsorption in etiological diagnosis in accordance with the literature, but also the non-negligible share of nutritional cobalamin deficiency. Mainly oral cobalamin supplementation was used in our study with a significant increase in vitamin B12 levels. An oral cobalamin regimen is proposed for elderly patients with cobalamin deficiency but with no severe neurological signs.