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The ageing of the population induces situations of large vulnerability and dependence. Home care usually remains the best response to comply with the person's wish, the family's desire, and the civil society's interest. However, there are circumstances where patient management in a nursing home (EHPAD) is the only solution. The present pandemic of coronavirus COVID-19 has highlighted the issue of EHPAD and their limitations to provide high quality care. To analyze the current position of EHPAD into the care chain and to understand difficulties to their functioning, it seems essential to seek out accelerated changes in the EHPAD since their establishment in 1999 and then in the light of the current crisis, propose possible solutions with a positive view of the role which each EHPAD will have to ensure for future., (© 2022 Published by Elsevier Masson SAS on behalf of l'Académie nationale de médecine.)

An interlaboratory comparison study was conducted by the Vitamin D Standardization Program (VDSP) to assess the performance of liquid chromatography - tandem mass spectrometry (LC-MS/MS) assays used for the determination of serum total 25-hydroxyvitamin D (25(OH)D), which is the sum of 25-hydroxyvitamin D 2 (25(OH)D 2 ) and 25-hydroxyvitamin D 3 (25(OH)D 3 ). A set of 50 single-donor samples was assigned target values for concentrations of 25(OH)D 2 , 25(OH)D 3 , 3-epi-25-hydroxyvitamin D 3 (3-epi-25(OH)D 3 ), and 24R,25-dihydroxyvitamin D 3 (24R,25(OH) 2 D 3 ) using isotope dilution liquid chromatography - tandem mass spectrometry (ID LC-MS/MS). VDSP Intercomparison Study 2 Part 1 includes results from 14 laboratories using 14 custom LC-MS/MS assays. Assay performance was evaluated using mean % bias compared to the assigned target values and using linear regression analysis of the test assay mean results and the target values. Only 53% of the LC-MS/MS assays met the VDSP criterion of mean % bias ≤ |±5%|. For the LC-MS/MS assays not meeting the ≤ |±5%| criterion, four assays had mean % bias of between 12 and 21%. Based on multivariable regression analysis using the concentrations of the four individual vitamin D metabolites in the 50 single-donor samples, the performance of several LC-MS/MS assays was found to be influenced by the presence of 3-epi-25(OH)D 3 . The results of this interlaboratory study represent the most comprehensive comparison of LC-MS/MS assay performance for serum total 25(OH)D and document the significant impact of the lack of separation of 3-epi-25(OH)D 3 and 25(OH)D 3 on assay performance, particularly with regard to mean % bias., (© 2021. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

The Vitamin D External Quality Assessment Scheme (DEQAS) distributes human serum samples four times per year to over 1000 participants worldwide for the determination of total serum 25-hydroxyvitamin D [25(OH)D)]. These samples are stored at -40 °C prior to distribution and the participants are instructed to store the samples frozen at -20 °C or lower after receipt; however, the samples are shipped to participants at ambient conditions (i.e., no temperature control). To address the question of whether shipment at ambient conditions is sufficient for reliable performance of various 25(OH)D assays, the equivalence of DEQAS human serum samples shipped under frozen and ambient conditions was assessed. As part of a Vitamin D Standardization Program (VDSP) commutability study, two sets of the same nine DEQAS samples were shipped to participants at ambient temperature and frozen on dry ice. Twenty-eight laboratories participated in this study and provided 34 sets of results for the measurement of 25(OH)D using 20 ligand binding assays and 14 liquid chromatography-tandem mass spectrometry (LC-MS/MS) methods. Equivalence of the assay response for the frozen versus ambient DEQAS samples for each assay was evaluated using multi-level modeling, paired t-tests including a false discovery rate (FDR) approach, and ordinary least squares linear regression analysis of frozen versus ambient results. Using the paired t-test and confirmed by FDR testing, differences in the results for the ambient and frozen samples were found to be statistically significant at p < 0.05 for four assays (DiaSorin, DIAsource, Siemens, and SNIBE prototype). For all 14 LC-MS/MS assays, the differences in the results for the ambient- and frozen-shipped samples were not found to be significant at p < 0.05 indicating that these analytes were stable during shipment at ambient conditions. Even though assay results have been shown to vary considerably among different 25(OH)D assays in other studies, the results of this study also indicate that sample handling/transport conditions may influence 25(OH)D assay response for several assays., (© 2021. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

An interlaboratory study was conducted through the Vitamin D Standardization Program (VDSP) to assess commutability of Standard Reference Materials® (SRMs) and proficiency testing/external quality assessment (PT/EQA) samples for determination of serum total 25-hydroxyvitamin D [25(OH)D] using ligand binding assays and liquid chromatography-tandem mass spectrometry (LC-MS/MS). A set of 50 single-donor serum samples were assigned target values for 25-hydroxyvitamin D 2 [25(OH)D 2 ] and 25-hydroxyvitamin D 3 [25(OH)D 3 ] using reference measurement procedures (RMPs). SRM and PT/EQA samples evaluated included SRM 972a (four levels), SRM 2973, six College of American Pathologists (CAP) Accuracy-Based Vitamin D (ABVD) samples, and nine Vitamin D External Quality Assessment Scheme (DEQAS) samples. Results were received from 28 different laboratories using 20 ligand binding assays and 14 LC-MS/MS methods. Using the test assay results for total serum 25(OH)D (i.e., the sum of 25(OH)D 2 and 25(OH)D 3 ) determined for the single-donor samples and the RMP target values, the linear regression and 95% prediction intervals (PIs) were calculated. Using a subset of 42 samples that had concentrations of 25(OH)D 2 below 30 nmol/L, one or more of the SRM and PT/EQA samples with high concentrations of 25(OH)D 2 were deemed non-commutable using 5 of 11 unique ligand binding assays. SRM 972a (level 4), which has high exogenous concentration of 3-epi-25(OH)D 3 , was deemed non-commutable for 50% of the LC-MS/MS assays., (© 2021. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

Background: In France, emergency departments (EDs) are the fastest and most common means for general practitioners (GPs) to cope with the complex issues presented by elderly patients with multiple conditions. EDs are overburdened, and studies show that being treated in EDs can have a damaging effect on the health of elderly patients. Outpatient care or planned hospitalizations are possible solutions if appropriate geriatric medical advice is provided. In 2013, France's regional health authorities proposed creating direct telephone helplines, "geriatric hotlines," staffed by geriatric specialists to encourage interactions between GP clinics and hospitals. These hotlines are designed to improve health care pathways and the health status of the elderly., Objective: This study aims to describe the health care pathways and health status of patients aged 75 years and older hospitalized in short-stay geriatric wards following referral from a geriatric hotline., Methods: The study will be conducted over 24 months in seven French university hospital centers. It will include all patients aged 75 and older, living in their own homes or nursing homes, who are admitted to short-stay geriatric wards following hotline consultation. Two questionnaires will be filled out by medical staff at specific time points: (1) after conducting the telephone consultation and (2) on admitting the patient to a short-stay geriatric medical care. The primary endpoint will be mean hospitalization duration. The secondary endpoints will be intrahospital mortality rate, the characteristics of patients admitted via the hotline, and the types of questions asked and responses given via the hotline., Results: The study was funded by the National School for Social Security Loire department (École Nationale Supérieure de Sécurité Sociale) and the Conference for funders of prevention of autonomy loss for the elderly of the Loire department in November 2017. Institutional review board approval was obtained in April 2018. Data collection started in May 2018; the planned end date for data collection is May 2020. Data analysis will take place in the summer of 2020, and the first results are expected to be published in late 2020., Conclusions: The results will reveal whether geriatric hotlines provide the most effective management of elderly patients, as indicated by shorter mean hospitalization durations. Shorter hospital durations could lead to a reduced risk of complications-geriatric syndromes-and the domino chain of geriatric conditions that follow. We will also describe different geriatric hotlines from different cities and compare how they function to improve the health care of the elderly and pave the way toward new advances, especially in the organization of the care path., Trial Registration: ClinicalTrials.gov NCT03959475; https://clinicaltrials.gov/ct2/show/NCT03959475., International Registered Report Identifier (irrid): DERR1-10.2196/15423., (©Laure Martinez, Noémie Lacour, Régis Gonthier, Marc Bonnefoy, Luc Goethals, Cedric Annweiler, Nathalie Salles, Nathalie Jomard, Jérôme Bohatier, Magali Tardy, Etienne Ojardias, Romain Jugand, Bienvenu Bongué, Thomas Celarier. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 13.02.2020.)

In this study, a one-step method for liquid-liquid extraction has been compared against a two-step procedure for testosterone assays in terms of accuracy, specificity, recovery, lipid removal and baseline noise, using QCs and unknown samples. The difference in accuracy was less than 5% for adult sera, while it was less than 10% for prepubescent sera. To compare specificity, the ion ratio transition of 289 → 97 to 289 → 109 was monitored for all QCs and unknown samples; no interference in the testosterone peak was observed for any tested sample prepared by either the one-step or two-step procedure. The baseline comparison of LC-MS/MS chromatograms of samples indicated that samples prepared by the one-step procedure were of the same quality as those prepared by the two-step procedure; however, recovery in unaltered serum using the one-step procedure was approximately 15% greater across the low to high concentration range. Furthermore, recovery using the one-step procedure was more consistent between stripped and unstripped serum. Lipids were removed efficiently in the two-step procedure as verified by monitoring the typical phospholipid MRM transition of m/z 496 → 184. For every sample processed by the one-step procedure, a one-minute online column wash with 95% methanol was able to remove 95% of the bound lipids, thereby providing a column life-time approximately equivalent to that for the two-step procedure. The presented data indicate that the one-step procedure could replace the two-step procedure while maintaining accuracy, saving time, increasing recovery, and minimizing the potential for errors with the fewer steps required., (© 2018 The Association for Mass Spectrometry: Applications to the Clinical Lab (MSACL). Published by Elsevier B.V.)

Background: This study compares the performance of four frailty screening tools in predicting relevant adverse outcome (disability, institutionalization and mortality) in community-dwelling elderly., Methods: Our study involved a secondary analysis of data from the FréLE cohort study. We focused on the following four frailty screening tools: the abbreviated Comprehensive Geriatric Assessment (aCGA), the Groningen Frailty Indicator (GFI), the Vulnerable Elders Survey-13 (VES-13) and the Fried scale. We used the Barberger-Gateau scale to assess disability. For comparison, we determined the capacity of these tools to predict the occurrence of disability, institutionalization or death using the receiver operating characteristic (ROC) curve. We also determined the threshold at which an optimal balance between sensitivity and specificity was reached. Odds ratios (ORs) were calculated to compare the risk of adverse outcome in the frail versus non-frail groups., Results: In total, 1643 participants were included in the mortality analyses; 1224 participants were included in the analyses of the other outcomes (74.5% of the original sample). The mean age was 77.7 years, and 48.1% of the participants were women. The prevalence of frailty in this sample ranged from 15.0% (Fried) to 52.2% (VES-13). According to the Barberger-Gateau scale, 643 (52.5%) participants were fully independent; 392 (32.0%) were mildly disabled; 118 (9.6%) were moderately disabled; and 71 (5.8%) were severely disabled. The tool with the greatest sensitivity for predicting the occurrence of disability, mortality and institutionalization was VES-13, which showed sensitivities of 91.0%, 89.7% and 92.3%, respectively. The values for the area under the curve (AUC) of the four screening tools at the proposed cut-off points ranged from 0.63 to 0.75. The odds (univariate and multivariate analysis) of developing a disability were significantly greater among the elderly identified as being frail by all four tools., Conclusion: The multivariate analyses showed that the VES-13 may predict the occurrence of disability, mortality and institutionalization. However, the AUC analysis showed that even this tool did not have good discriminatory ability. These findings suggest that despite the high number of frailty screening tools described in the literature, there is still a need for a screening tool with high predictive performance.

Context: Some men who use finasteride for hair loss report persistent sexual and other symptoms after discontinuing finasteride therapy., Objective: To determine whether these persistent symptoms after discontinuation of finasteride use are due to androgen deficiency, decreased peripheral androgen action, or persistent inhibition of steroid 5α-reductase (SRD5A) enzymes., Participants: Finasteride users, who reported persistent sexual symptoms after discontinuing finasteride (group 1); age-matched finasteride users who did not report sexual symptoms (group 2); and healthy men who had never used finasteride (group 3)., Outcomes: Sexual function, mood, affect, cognition, hormone levels, body composition, functional magnetic resonance imaging (fMRI) response to sexually and affectively valenced stimuli, nucleotide sequences of androgen receptor (AR), SRD5A1, and SRD5A2; expression levels of androgen-dependent genes in skin., Setting: Academic medical center., Results: Symptomatic finasteride users were similar in body composition, strength, and nucleotide sequences of AR, SRD5A1, and SRD5A2 genes to asymptomatic finasteride users and nonusers. Symptomatic finasteride users had impaired sexual function, higher depression scores, a more negative affectivity balance, and more cognitive complaints than men in groups 2 and 3 but had normal objectively assessed cognitive function. Testosterone, dihydrotestosterone, 5α-androstane-3α,17β-diol-glucuronide, testosterone to dihydrotestosterone and androsterone glucuronide to etiocholanolone glucuronide ratios, and markers of peripheral androgen action and expression levels of AR-dependent genes in skin did not differ among groups. fMRI blood oxygen level-dependent responses to erotic and nonerotic stimuli revealed abnormal function in brain circuitry linked to sexual arousal and major depression., Conclusions: We found no evidence of androgen deficiency, decreased peripheral androgen action, or persistent peripheral inhibition of SRD5A in men with persistent sexual symptoms after finasteride use. Symptomatic finasteride users revealed depressed mood and fMRI findings consistent with those observed in depression.

Objective: Obstructive sleep apnea syndrome (OSA) leads to a deterioration in cognitive functions, with regard to memory and executive functions. However, few studies have investigated the impact of treatment on these cognitive functions in elderly subjects., Methods: The study was conducted in a large cohort of subjects aged 65 years or older (the PROOF cohort). Subjects were not diagnosed or treated for OSA. Subjects underwent a polygraphic recording. Cognitive performance was assessed in all OSA subjects at baseline and 10 years later, whether or not they were receiving continuous positive airway pressure (CPAP) therapy., Results: A group of 126 patients were analyzed. Only 26% of them were treated, with therapy initiated at the discretion of the primary care physician. Among treated subjects, self-reported compliance with therapy was good (> 6 h/night on average), and 66% of them reported an improvement in their quality of life. Patients receiving CPAP treatment had a higher apneahypopnea index (p = 0.006), a higher oxygen desaturation index (p < 0.001), and experienced more pronounced daytime repercussions (p = 0.004). These patients showed a statistically significant improvement in mental agility (similarities test; p < 0.0001) and memory performance (Grober and Buschke delayed free recall; p = 0.02)., Conclusion: CPAP treatment is associated with the maintenance of memory performance over time., (© 2015 American Academy of Sleep Medicine.)

The number of nonagenarian people in the world is steadily growing. This phenomenon will increase in future years: in 2050, world population prospects estimate 71.16 million people aged 90 years or older. The two main causes of death among people aged 85 years or more in Europe in 2003 were cardiovascular and cerebrovascular diseases and cancers. However, the elderly are often excluded from clinical trials; they are underrepresented in clinical registries and especially nonagenarians. Care (medical, surgical, oncology) of these very elderly is currently insufficiently based on scientific recommendations. For the physician, the choice to treat or not to treat very elderly patients (for fear of side effects) is difficult. Oncology is particularly affected by this problem. Here we review these different fields of internal medicine management of nonagenarian patients with a special focus on oncology and on comprehensive geriatric assessment as a base for all care decision taking.

Falls are the leading cause of accidental death among the elderly, accounting for about 12 000 deaths per year. The risk of falls increases with age: one-third of subjects over 65 years old living in the community and half of those over 85 fall at least once a year. Despite their frequency, falls should not be trivialized, as they are associated with significant morbidity and care expenditure: 10% of falls have severe traumatic consequences, and30 % of hospital admissions for traumatic injury among elderly individuals are due to falls. Even when they have no physical repercussions, falls can have psychological effects (anxiety while walking, fear of falling), and can be complicated by a psychomotor disadaptation syndrome with voluntary restriction of activities of daily living in 30% of cases. Risk factors for falls are numerous, and falls are rarely due a single, precise reason. Recurrent falls are associated with balance and gait impairment and decreased muscle strength, sometimes due to a latent pathological condition. Factors that may favor falls in the home must be taken into account through targeted prevention actions. Among institutionalized populations, the risk of falls increases with the severity of dementia, the use of certain drugs (particularly psycho tropics) and the existence of wasting, which leads to a decline in quadriceps strength. About 1.5% of all health expenditure is related to falls. The majority of these costs are due to hospitalization, fractures of the proximal femur being the most costly complication. In recent years, thanks to the prevention of both osteoporosis and falls, the annual number of hip fractures has been stable at about 79,500 cases per year, standardized hospitalization rates have declined, and the average length of stay has decreased. With the increasing number of elderly people, one priority to reduce healthcare costs is to identify and correct factors of frailty in midlife, using a preventive approach.

Background: preservation of cognitive abilities is required to have a good quality of life. The predictive value of cognitive functioning at 65 years old on successful ageing 6 years later is not established., Methods: nine hundred and seventy-six questionnaires were sent by mail to a sample of healthy and voluntary French pensioners. Successful ageing was defined through health status and well-being. Cognitive abilities had been assessed 6 years earlier according to an objective method (Free and Cued Selective Recall Reminding Test (FCSRT), the Benton visual retention test and the similarities subtest of the Wechsler Adult Intelligence Scale-Revised) and a subjective one (Goldberg's anxiety scale, Mac Nair's scale and a Visual Analogue Scale to evaluate memory abilities change in the last 5 years)., Results: six hundred and eighty-six questionnaires could be analysed. The mean age was 72.9 ± 1.2 years old with 59% of women and 99% lived at home. Well-being was negatively correlated with the FCSRT (r = -0.08, P = 0.0318) but positively related with the Benton (r = 0.09, P = 0.0125) and the similarities tests (r = 0.09, P = 0.0118). There is a negative correlation between anxious and cognitive complaints measured at baseline, and successful ageing indicators 6 years later., Conclusion: preservation of cognitive abilities at the age of retirement can predict a successful ageing 6 years later. ClinicalTrials.gov Identifier: NCT00759304.

Quality of life is a concept describing the aptitude of an individual to function in a given environment and to draw satisfaction from it. It is associated with the notions of good health and well-being. Quality of life is first and foremost a subjective concept. When confronted with the problems of a chronic disease, the elderly subject him/herself must evaluate its repercussions and the effectiveness of medical interventions. Preventive measures and specific geriatric care have increased the longevity and quality of life of old people. It is important to stress that specific geriatric care does not weigh heavily on health-care expenditure and is profitable in the long term. However, this extra longevity is accompanied in a significant minority of people by multiple sensory and/or cognitive disabilities, loneliness and dependency, with a negative impact on people's view of this period of life.

Background: The preservation of autonomy and the ability of elderly to carry out the basic activities of daily living, beyond the therapeutic care of any pathologies, appears as one of the main objectives of care during hospitalization., Objectives: To identify early clinical markers associated with the loss of independence in elderly people in short stay hospitals., Methods: Among the 1,306 subjects making up the prospective and multicenter SAFEs cohort study (Sujet Agé Fragile: Evolution et suivi-Frail elderly subjects, evaluation and follow-up), 619 medical inpatients, not disabled at baseline and hospitalized through an emergency department were considered. Data used in a multinomial logistic regression were obtained through a comprehensive geriatric assessment (CGA) conducted in the first week of hospitalization. Dependency levels were assessed at baseline, at inclusion and at 30 days using Katz's ADL index. Baseline was defined as the dependence level before occurrence of the event motivating hospitalization. To limit the influence of rehabilitation on the level of dependence, only stays shorter than 30 days were considered., Results: About 514 patients were eligible, 15 died and 90 were still hospitalized at end point (n = 619). Two-thirds of subjects were women, with a mean age of 83. At day 30 162 patients (31%) were not disabled; 61 (12%) were moderately disabled and 291 severely disabled (57%). No socio-demographic variables seemed to influence the day 30 dependence level. Lack of autonomy (odds ratio (OR) = 1.9, 95% confidence interval (CI) = 1.2-3.6), walking difficulties (OR = 2.7, 95% CI = 1.3-5.6), fall risk (OR = 2.1, 95% CI = 1.3-6.8) and malnutrition risk (OR = 2.2, 95% CI = 1.5-7.6) were found in multifactorial analysis to be clinical markers for loss of independence., Conclusions: Beyond considerations on the designing of preventive policies targeting the populations at risk that have been identified here, the identification of functional factors (lack of autonomy, walking difficulties, risk of falling) suggests above all that consideration needs to be given to the organization per se of the French geriatric hospital care system, and in particular to the relevance of maintaining sector-type segregation between wards for care of acute care and those involved in rehabilitation.

Aims: The purpose of this study was to evaluate the efficacy, risks, safety, and follow-up of radiofrequency (RF) catheter ablation of atrioventricular nodal re-entrant tachycardia (AVRNT) in patients (pts) > or = 75 years old (n=42) (GpI) compared with pts younger than 75 years (n=234) (GpII)., Methods and Results: The study population consisted of 276 consecutive pts (39.5% men/60.5% women), from 15 to 98-year-old (average 56+/-17 years) with AVRNT referred for RF ablation (RFA) from October 1997 to January 2004. Combined anatomical and electrogram approaches were used to guide RFA. The cumulative risk of AVRNT recurrence was analysed by the Kaplan-Meier method and log-rank test. The average follow-up was 34+/-18 months. GpI (80+/-4 years) differed significantly from GpII (51+/-14 years) regarding: heart rate tachycardia (160+/-20 vs. 180+/-30 bpm; P=0.0001), the slow pathway antegrade refractory period (370+/-70 vs. 340+/-60 ms; P=0.01), the fast pathway antegrade refractory period (360+/-60 vs. 330+/-60 ms; P=0.003), retrograde refractory period (360+/-60 vs. 330+/-60 ms; P=0.0007), left ventricular ejection fraction (60+/-12 vs. 65+/-7%; P=0.0009), and ischaemic ECG signs during tachycardia (76.2% vs. 61%; P=0.09). RFA was successfully obtained in 275/276 (99.6%), 42/42 in GpI (100%), and 233/234 (99.6%) in GpII. Five complications occurred (1.8%): major complications in two pts (0.7%) and minor complications in three pts (1.1%). Major complications were deep venous thrombosis with pulmonary embolus (n=1) and pericardial effusion (n=1), minor complications were groin haematoma (n=3). One complication was observed in GpI (groin haematoma) (2.4%) and four in GpII (deep venous thrombosis with pulmonary embolus in one, groin haematoma in two, and pericardial effusion in one) (1.7%). The number of recurrences was not statistically different between the two groups (0 vs. 3.4%; P=0.5) with a respective average follow-up of 28+/-18 and 35+/-18 months, respectively., Conclusion: Catheter ablation of AVRNT in elderly and very elderly pts appears to be a reasonable approach regarding feasibility and effectiveness without increasing the risk of AV block.