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Abstract Background Postoperative delirium is common in the elderly and is associated with a significant increase in mortality, complications, length of hospital stay and admission in long care facility. Although several interventions have proved their effectiveness to prevent it, the Cochrane advises an assessment of multifaceted intervention using rigorous methodology based on randomized study design. Our purpose is to present the methodology and expected results of the CONFUCIUS trial, which aims to measure the impact of a multifaceted program on the prevention of postoperative delirium in elderly. Method/Design Study design is a stepped wedge cluster randomized trial within 3 surgical wards of three French university hospitals. All patients aged 75 and older, and admitted for scheduled surgery will be included. The multifaceted program will be conducted by mobile geriatric team, including geriatric preoperative consultation, training of the surgical staff and implementation of the Hospital Elder Life Program, and morbidity and mortality conference related to delirium cases. The primary outcome is based on postoperative delirium rate within 7 days after surgery. This program is planned to be implemented along four successive time periods within all the surgical wards. Each one will be affected successively to the control arm and to the intervention arm of the trial and the order of program introduction within each surgical ward will be randomly assigned. Based on a 20% reduction of postoperative delirium rate (ICC = 0.25, α = 0.05, β = 0.1), three hundred sixty patients will be included i.e. thirty patients per service and per time period. Endpoints comparison between intervention and control arms of the trial will be performed by considering the cluster and time effects. Discussion Better prevention of delirium is expected from the multifaceted program, including a decrease of postoperative delirium, and its consequences (mortality, morbidity, postoperative complications and length of hospital stay) among elderly patients. This study should allow better diagnosis of delirium and strengthen the collaboration between surgical and mobile geriatric teams. Should the program have a substantial impact on the prevention of postoperative delirium in elderly, it could be extended to other facilities. Trial registration ClinicalTrials.gov: NCT01316965

Defines the novel isoforms of the fragile X related protein FXR1P during myogenesis. Causes of the fragile X mental retardation syndrome; Amino acid homologies at the C-terminal ends of FXR1P short and long isoforms; Localization of FXR1P in muscle; Differential sedimentation properties of FXR1P.

Introduction. – Candidemia, principally affecting neutropenic patients in departments of onco-haematology and frail patients in intensive care units, can also be observed in frail elderly people in geriatrics.Exegesis. – Authors report four observations of candidemia diagnosed in elderly dependant patients having several different diseases. Clinical sign was a persistent or recurrent fever after a wide-spectrum antibiotic therapy. Patients were treated by fluconazole leading to negative blood cultures in several days. Three out of four patients died within the weeks following antifungal therapy due to severity of associated diseases.Conclusion. – These observations show that a diagnosis of candidemia should be made when a persistent fever is observed in a frail elderly person. Fluconazole, as efficient as amphotericin B and well tolerated by elderly people, should be the first treatment of candidemia in non-neutropenic patients. [ABSTRACT FROM AUTHOR]

Objective: Frailty has been extensively studied in end-stage kidney disease (ESKD) and kidney transplant (KT) patients. The identification of frailty is useful to predict adverse outcomes among ESKD and KT patients. The recent concept of intrinsic capacity (IC) appears as a good and easy-to-understand tool to screen for and monitor frailty in older adults with ESKD. This study aims to assess the relationships between frailty and IC in older adults with ESKD awaiting KT., Design: Cross-sectional study SETTING AND PARTICIPANTS: 236 patients from a day-care geriatric unit undergoing pre-KT geriatric assessment between 2017 and 2022 were included in the main sample, and 151 patients in an independent multicentric replication sample., Measurements: Frailty was evaluated using the physical frailty phenotype (PFP) and IC measures using the World Health Organization's screening (step 1) and diagnostic (step 2) tools for five IC domains (vitality, locomotion, audition, cognition, psychology). Multivariate regressions were run to assess relationships between PFP and IC domains, adjusted for age, sex, and comorbidities. Analyses were replicated using another independent multicenter cohort including 151 patients with ESKD to confirm the results., Results: Impairments in the locomotion, psychology, and vitality IC domains according to WHO screening tools were associated with frailty (odds ratio 9.62 [95% CI 4.09-24.99], 3.19 [95% CI 1.11-8.88], and 3.11 [95% CI 1.32-7.29], respectively). When IC were measured linearly with z-scores, all IC domains except hearing were inversely associated with frailty. In the replication cohort, results were overall similar, with a greater association between psychology domain and frailty., Conclusion: This study highlights the relationship between frailty and IC in ESKD patients. We assume that IC may be assessed and monitored in ESKD patients, to predict and prevent future frailty, and post-KT adverse outcomes., (Copyright © 2024 The Author(s). Published by Elsevier Masson SAS.. All rights reserved.)

Objective: Mammographic screening and management of breast cancer (BC) in elderly women are controversial and continue to be an important health problem. To investigate, through members of the Senologic International Society (SIS), the current global practices in BC in elderly women, highlighting topics of debate and suggesting perspectives., Materials and Methods: The questionnaire was sent to the SIS network and included 55 questions on definitions of an elderly woman, BC epidemiology, screening, clinical and pathological characteristics, therapeutic management in elderly women, onco-geriatric assessment and perspectives., Results: Twenty-eight respondents from 21 countries and six continents, representing a population of 2.86 billion, completed and submitted the survey. Most respondents considered women 70 years and older to be elderly. In most countries, BC was often diagnosed at an advanced stage compared to younger women, and age-related mortality was high. For this reason, participants recommended that personalized screening be continued in elderly women with a long life expectancy.In addition, this survey highlighted that geriatric frailty assessment tools and comprehensive geriatric evaluations needed to be used more and should be developed to avoid undertreatment. Similarly, multidisciplinary meetings dedicated to elderly women with BC should be encouraged to avoid under- and over-treatment and to increase their participation in clinical trials., Conclusion: Due to increased life expectancy, BC in elderly women will become a more important field in public health. Therefore, screening, personalized treatment, and comprehensive geriatric assessment should be the cornerstones of future practice to avoid the current excess of age-related mortality. This survey described, through members of the SIS, a global picture of current international practices in BC in elderly women., Competing Interests: Conflict of Interest: No conflict of interest was declared by the authors., (©Copyright 2023 by the the Turkish Federation of Breast Diseases Societies / European Journal of Breast Health published by Galenos Publishing House.)

The dataset contains Eulerian velocity and pressure fields, and Lagrangian particle trajectories of the wake flow downstream of a smooth cylinder at a Reynolds number equal to 3900. An open source Direct Numerical Simulation (DNS) flow solver named Incompact3d was used to calculate the Eulerian field around the cylinder. The synthetic Lagrangian tracer particles were transported using a fourth-order Runge-Kutta scheme in time and trilinear interpolations in space. Trajectories of roughly 200,000 particles for two 3D sub-domains are available to the public. This dataset can be used as a test case for tracking algorithm assessment, exploring the Lagrangian physics, statistic analyses, machine learning, and data assimilation interests., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2021 The Authors. Published by Elsevier Inc.)

Background: The prognostic assessment of older cancer patients is complicated by their heterogeneity. We aimed to assess the prognostic value of routine inflammatory biomarkers., Methods: A pooled analysis of prospective multicenter cohorts of cancer patients aged ≥70 was performed. We measured CRP and albumin, and calculated Glasgow Prognostic Score (GPS) and CRP/albumin ratio. The GPS has three levels (0 = CRP ≤ 10 mg/L, albumin ≥ 35 g/L, i.e., normal values; 1 = one abnormal value; 2 = two abnormal values). One-year mortality was assessed using Cox models. Discriminative power was assessed using Harrell's C index (C) and net reclassification improvement (NRI)., Results: Overall, 1800 patients were analyzed (mean age: 79 ± 6; males: 62%; metastases: 38%). The GPS and CRP/albumin ratio were independently associated with mortality in patients not at risk of frailty (hazard ratio [95% confidence interval] = 4.48 [2.03-9.89] for GPS1, 11.64 [4.54-29.81] for GPS2, and 7.15 [3.22-15.90] for CRP/albumin ratio > 0.215) and in patients at risk of frailty (2.45 [1.79-3.34] for GPS1, 3.97 [2.93-5.37] for GPS2, and 2.81 [2.17-3.65] for CRP/albumin ratio > 0.215). The discriminative power of the baseline clinical model (C = 0.82 [0.80-0.83]) was increased by adding GPS (C = 0.84 [0.82-0.85]; NRI events (NRI+) = 10% [2-16]) and CRP/albumin ratio (C = 0.83 [0.82-0.85]; NRI+ = 14% [2-17])., Conclusions: Routine inflammatory biomarkers add prognostic value to clinical factors in older cancer patients.

Background: Nutritional impairment is common in cancer patients and is associated with poor outcomes. Only few studies focused on cachexia. We assessed the prevalence of cachexia in older cancer patients, identified associated risk factors, and evaluated its impact on 6 month overall mortality., Methods: A French nationwide cross-sectional survey (performed in 55 geriatric oncology clinics) of older cancer patients aged ≥70 referred for geriatric assessment prior to treatment choice and initiation. Demographic, clinical, and nutritional data were collected. The first outcome was cachexia, defined as loss of more than 5% of bodyweight over the previous 6 months, or a body mass index below 20 kg/m 2 with weight loss of more than 2%, or sarcopenia (an impaired Strength, Assistance with walking, Rise from chair, Climb stairs and Falls score) with weight loss of more than 2%. The second outcome was 6 month overall mortality., Results: Of the 1030 patients included in the analysis [median age (interquartile range): 83 (79-87); males: 48%; metastatic cancer: 42%; main cancer sites: digestive tract (29%) and breast (16%)], 534 [52% (95% confidence interval: 49-55%)] had cachexia. In the multivariate analysis, patients with breast (P < 0.001), gynaecologic (P < 0.001), urinary (P < 0.001), skin (P < 0.001), and haematological cancers (P = 0.006) were less likely to have cachexia than patients with colorectal cancer. Patients with upper gastrointestinal tract cancers (including liver and pancreatic cancers; P = 0.052), with previous surgery for cancer (P = 0.001), with metastases (P = 0.047), poor performance status (≥2; P < 0.001), low food intake (P < 0.001), unfeasible timed up-and-go test (P = 0.002), cognitive disorders (P = 0.03) or risk of depression (P = 0.005), were more likely to have cachexia. At 6 months, 194 (20.5%) deaths were observed. Cachexia was associated with 6 month mortality risk (adjusted hazard ratio = 1.49; 95% confidence interval: 1.05-2.11) independently of age, in/outpatient status, cancer site, metastatic status, cancer treatment, dependency, cognition, and number of daily medications., Conclusions: More than half of older patients with cancer managed in geriatric oncology clinics had cachexia. The factors associated with cachexia were upper gastrointestinal tract cancer, metastases, poor performance status, poor mobility, previous surgery for cancer, cognitive disorders, a risk of depression, and low food intake. Cachexia was independently associated with 6 month mortality., (© 2021 The Authors. Journal of Cachexia, Sarcopenia and Muscle published by John Wiley & Sons Ltd on behalf of Society on Sarcopenia, Cachexia and Wasting Disorders.)

Objective: High-flow nasal cannula use in the PICU continues to increase; however, a protocol for weaning patients has yet to be published. This study aimed to create an efficient and safe protocol for weaning high-flow nasal cannula., Design: A Respiratory Assessment Score was created using two validated scoring systems. A protocol was established for set "holidays" off high-flow nasal cannula, where nasal cannula flow was reduced to age-based low-flow nasal cannula rates if Respiratory Assessment Scores met certain criteria., Setting: The PICU at Children's Healthcare of Atlanta at Egleston, a quaternary level hospital affiliated with Emory University., Patients: Patients treated in the PICU with high-flow nasal cannula from August 2013 to March 2014. Exclusions included apnea, heliox therapy, oxygen saturations less than 92% with a FIO2 greater than 50%, admitted to PICU less than 6 hours, progression to intubation prior to scoring, or those ordered by physician to not receive holidays based on clinical status., Interventions: Patients who qualified for a "holiday" based on Respiratory Assessment Score were trialed off high-flow nasal cannula and rescored afterwards to assess tolerance., Measurements and Main Results: One hundred thirty-three patients were treated with high-flow nasal cannula, with the most common diagnosis being bronchiolitis (43%). Of these 133 patients, 119 (89.5%) successfully weaned to low-flow nasal cannula within four holiday attempts. Eighty-three patients (70%) weaned with only one attempt. Fourteen patients (10.5%) failed to wean. Reasons for failure were reintubation, increasing flow on high-flow nasal cannula, too high of Respiratory Assessment Score to meet weaning criteria, or slow weaning after failed attempts. Holidays did not precipitate clinical deterioration or lead to immediate intubation., Conclusions: Our study suggests that a high-flow nasal cannula "holiday" protocol is a safe and effective way to successfully wean PICU patients off high-flow nasal cannula. Additional investigation including validation of the scoring system used is warranted.

A practical protocol for the synthesis of N -arylated methyl 2-aminothiophene-3-carboxylate has been developed via Chan-Lam cross-coupling. The desired products were synthesized by cross-coupling of methyl 2-aminothiophene-3-carboxylate with both arylboronic acids and potassium aryltrifluoroborate salts in moderate to good yields. A broad range of functional groups was well tolerated.

Objectives: Patients with borderline personality disorder (BPD) show various psychopathological symptoms and suffer especially from disturbance in their identity. The purpose of the study was to investigate changes-particularly in affective BPD symptoms and identity diffusion-during a structured, disorder-specific inpatient treatment (DST) that combined a psychodynamic transference-focused psychotherapy approach with modules of dialectical behavioural skills training., Method: In a prospective, two-group comparison trial, 44 patients with BPD were assessed with questionnaires addressing identity diffusion and state, as well as trait affective psychopathology, before and after 12 weeks of inpatient treatment. Thirty-two patients received DST, whereas 12 patients were given inpatient treatment-as-usual (TAU). The patients were allocated in a non-random procedure for two groups, in order of admission and availability of treatment options in the DST unit., Results: In the pre-post-comparison, the DST group showed a significant decrease in identity diffusion (p < 0.001) and improvements in instability of the image of self and others (p < 0.008), as well as in pathological (trait and state) symptoms. However, there was no significant improvement in the TAU group., Conclusions: After a 12-week inpatient treatment, the findings indicate significant improvements in the DST group in typical affective borderline symptomatology and in the personality structure feature of identity diffusion. This highlights the significance of a short-term specific inpatient therapy for BPD., Key Practitioner Message: A structured, disorder-specific inpatient treatment of patients diagnosed with borderline personality disorder (BPD) combined a psychodynamic transference-focused psychotherapy treatment approach (focusing on pathological features in personality organization, particularly on non-integrated images of self and others) with modules of dialectical behavioural skills training. This treatment is associated with a decrease in identity diffusion of these patients after 12 weeks of treatment. The treatment is also related to a significant decrease in borderline typical psychopathological symptoms such as depressive symptoms, as well as an improvement in state anger. The outcomes of this structured, disorder-specific inpatient treatment of severely ill BPD patients indicated the relevance of intensive short-term inpatient psychotherapy in terms of psychopathological improvements as well as initial changes in structural personality organization., (Copyright © 2014 John Wiley & Sons, Ltd.)

Background: Guidelines recommend re-excision if resection margins are positive in lumpectomy for breast cancer. However, residual disease (RD) is not always found. The aim of our study was to develop a score to predict RD in re-excision specimens., Materials and Methods: We carried out a multicenter, retrospective study with two population groups. The 'modeling' group was composed of 148 patients treated in the Centre Hospitalier Poissy-St-Germain or the Georges Pompidou European Hospital and the 'validation' group was composed of 67 patients treated in Curie Institute. The score was built with a logistic regression model., Results: Factors independently associated with RD were: a cumulative length of all positive margins>5 mm, invasion by ductal carcinoma in situ only, a pathological tumor size>30 mm and a pathological tumor size<30 mm with a discrepancy of >50% between pathological and radiological tumor size. The 7-point score allowed the classification of patients into three risk groups for RD: low (16% of patients experienced RD), moderate (65%) and high (100%). The areas under the ROC curve of the score and the logistic model were 0.72(95%CI:0.68-0.75,p = 0.60). The proportion of RD in each group of the validation population (25%, 48%, and 100% in the low, moderate and high group, respectively) confirmed the accuracy of the score in an independent population., Conclusions: This score enables the identification of patients at high risk of RD but it cannot provide guidance for the decision to undertake re-excision surgery in the low-risk group. Further studies are needed to test the score in extensive datasets and better identify low-risk patients., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objective: We report the long-term results of the SENTI-ENDO study evaluating the impact of sentinel lymph node (SLN) biopsy on management and survival in patients with early stages of endometrial cancer (EC)., Methods: Patients with FIGO stage I-II EC underwent pelvic SLN biopsy after cervical dual injection (technetium and patent blue) and systematic pelvic node dissection. This study is a secondary endpoint reporting the long-term recurrence free survival (RFS) and the impact of the SLN procedure on adjuvant therapies., Results: The median follow-up was 50 months (range: 3-77 months). Eighteen of the 125 patients (14.4%) experienced a recurrence. The 50-month recurrence-free survival (RFS) was 84.7% with no difference between patients with and without detected SLN (p = 0.09). Among patients with detected SLN (111), no difference in RFS was observed between those with and without positive SLN (p = 0.5). In the whole population, adjuvant therapy was performed in low-, intermediate- and high-risk groups in 31 of 64 patients (48.4%), 28 of 37 patients (75.7%) and 14 of 17 patients (82.3%), respectively (p = 0.0001). For the 111 patients with detected SLN, EBRT was performed in 27 of the 89 with negative SLN and in 11 of the 14 with positive SLN (p = 0.001). Chemotherapy was performed more frequently in patients with positive SLN (6/12, 50%) than in patients with negative SLN (7/56, 12.5%) (p = 0.009)., Conclusions: Our results support the impact of SLN biopsy on surgical management and indications for adjuvant therapies. Further studies are required to assess the clinical impact of the SLN biopsy in early stage EC., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Geriatric Assessment is an appropriate method for identifying older cancer patients at risk of life-threatening events during therapy. Yet, it is underused in practice, mainly because it is time- and resource-consuming. This study aims to identify the best screening tool to identify older cancer patients requiring geriatric assessment by comparing the performance of two short assessment tools the G8 and the Vulnerable Elders Survey (VES-13)., Patients and Methods: The diagnostic accuracy of the G8 and the (VES-13) were evaluated in a prospective cohort study of 1674 cancer patients accrued before treatment in 23 health care facilities. 1435 were eligible and evaluable. Outcome measures were multidimensional geriatric assessment (MGA), sensitivity (primary), specificity, negative and positive predictive values and likelihood ratios of the G8 and VES-13, and predictive factors of 1-year survival rate., Results: Patient median age was 78.2 years (70-98) with a majority of females (69.8%), various types of cancer including 53.9% breast, and 75.8% Performance Status 0-1. Impaired MGA, G8, and VES-13 were 80.2%, 68.4%, and 60.2%, respectively. Mean time to complete G8 or VES-13 was about five minutes. Reproducibility of the two questionnaires was good. G8 appeared more sensitive (76.5% versus 68.7%, P =  0.0046) whereas VES-13 was more specific (74.3% versus 64.4%, P<0.0001). Abnormal G8 score (HR = 2.72), advanced stage (HR = 3.30), male sex (HR = 2.69) and poor Performance Status (HR = 3.28) were independent prognostic factors of 1-year survival., Conclusion: With good sensitivity and independent prognostic value on 1-year survival, the G8 questionnaire is currently one of the best screening tools available to identify older cancer patients requiring geriatric assessment, and we believe it should be implemented broadly in daily practice. Continuous research efforts should be pursued to refine the selection process of older cancer patients before potentially life-threatening therapy.

Background: The core features of borderline personality disorder (BPD) are affective instability, unstable relationships and identity disturbance. Axis I comorbidities are frequent, in particular affective disorders. The concept of atypical depression is complex and often underestimated. The purpose of the study was to investigate the comorbidity of atypical depression in borderline patients regarding anxiety-related psychopathology and interpersonal problems., Methods: Sixty patients with BPD were assessed with the Structured Clinical Interviews for DSM-IV Axis I and II Disorders (SCID I, SCID II) as well as the Atypical Depression Diagnostic Scale (ADDS). Additionally, patients completed a questionnaire (SCL-90-R, BDI, STAI, STAXI, IIP-C)., Results: Forty-five BPD patients (81.8%) had a comorbid affective disorder of which 15 (27.3%) were diagnosed with an atypical depression. In comparison to patients with major depressive disorder or no comorbid depression, patients with atypical depression showed significant higher scores in psychopathological symptoms regarding anxiety and global severity as well as interpersonal problems., Conclusions: The presence of atypical depression in borderline patients is correlated with psychopathology, anxiety, and interpersonal problems and seems to be of clinical importance for personalized treatment decisions., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Purpose: This study analyzed the current approaches for rectal cancer treatment in elderly patients., Methods: We retrospectively studied 240 rectal cancer patients who had undergone radiotherapy from 2000 to 2008. The ages of the patients ranged from 65 and 75 years (group A, n = 127) and older than 75 years (group B, n = 113). The distribution of the Charlson comorbidity index was similar between the two groups, but the ECOG performance status (PS) differed between the groups (66 % of the patients of group A were PS 0, and 40 % were PS 0 in group B (p < 0.0001)). The tumor stages were comparable between groups., Results: The median age of the patients was 74.3 years (range 65-90.6). Treatment was discussed during a multidisciplinary cancer team meeting before treatment for 55 % of the cases in group A and 73 % of the cases in group B (p < 0.001), and treatment proposals were in accordance with guidelines in 96 % of the cases in group A and 76 % of the cases in group B (p < 0.001). Group B patients received slightly less concurrent chemotherapy (35 vs. 30 % for group A; p = 0.54), more hypofractionated radiotherapy (41 vs. 54 % for group A; p = 0.064), less surgery (92 vs. 80 % for group A; p = 0.014), and less adjuvant chemotherapy (34 vs. 10 % for group A; p < 0.001). Finally, 80 % of the patients in group A and 60 % of the patients in group B received treatment in accordance with guidelines (p = 0.007) and in the logistic regression model. Non-metastatic patients who were aged below 75 years were predicted for conformal management (HR = 0.323; 95 % CI = 0.152-0.684) irrespective of their performance status, comorbidity, or disease stage., Conclusions: Treatment proposals and administered therapy differed according to age.

Based on physical laws describing the multiscale structure of turbulent flows, this paper proposes a regularizer for fluid motion estimation from an image sequence. Regularization is achieved by imposing some scale invariance property between histograms of motion increments computed at different scales. By reformulating this problem from a Bayesian perspective, an algorithm is proposed to jointly estimate motion, regularization hyperparameters, and to select the most likely physical prior among a set of models. Hyperparameter and model inference are conducted by posterior maximization, obtained by marginalizing out non--Gaussian motion variables. The Bayesian estimator is assessed on several image sequences depicting synthetic and real turbulent fluid flows. Results obtained with the proposed approach exceed the state-of-the-art results in fluid flow estimation.

Background: Children with severe bronchospasm requiring mechanical ventilation may become refractory to conventional therapy. In these critically ill patients, isoflurane is an inhaled anesthetic agent available in some centers to treat bronchospasm. We hypothesized that isoflurane is safe and would lead to improved gas exchange in children with life-threatening bronchospasm refractory to conventional therapy., Methods: A retrospective review was conducted and included mechanically ventilated children treated with isoflurane in a quaternary pediatric ICU for life-threatening bronchospasm, from 1993 to 2007. Demographic, blood gas, ventilator, and outcome data were collected., Results: Thirty-one patients, with a mean age of 9.5 years (range 0.4-23 years) were treated with isoflurane, from 1993 to 2007. Mean time to initiation of isoflurane after intubation was 13 hours (0-120 h), and the mean maximum isoflurane dose was 1.1% (0.3-2.5%). Mean duration of isoflurane administration was 54.5 hours (range 1-181 h), with a total mean duration of mechanical ventilation of 252 hours (range 16-1,444 h). Isoflurane led to significant improvement in pH and P(CO(2)) within 4 hours of initiation (P ≤ .001). Complications during isoflurane administration included hypotension requiring vasoactive infusions in 24 (77%), arrhythmia in 3 (10%), neurologic side effects in 3 (10%), and pneumothorax in 1 (3%) patient., Conclusions: Isoflurane led to improvement in pH and P(CO(2)) within 4 hours in this series of mechanically ventilated patients with life-threatening bronchospasm. The majority of patients in this series developed hypotension, but there was a low incidence of other side effects related to isoflurane administration. Isoflurane appears to be an effective therapy in patients with life-threatening bronchospasm refractory to conventional therapy. However, further investigation is warranted, given the uncertain overall impact of isoflurane in this context.

Background: In early-stage endometrial cancer, intraoperative examination of sentinel lymph nodes (SLNs) can predict nodal involvement and avoid a second surgical procedure. Our goal was to determine the diagnostic accuracy (DA) of intraoperative examination in diagnosing metastatic pelvic SLNs., Methods: This was a retrospective study, including 125 patients with early stage endometrial cancer. Results of intraoperative examination by frozen section (FS) or imprint cytology (IC) were compared with final histology (serial sectioning and immunohistochemistry (IHC)). The diagnostic value of intraoperative examination was calculated., Results: Of the 111 patients with SLNs detected (89%), 87 (78.5%) had an intraoperative examination (30 with FS and 57 with IC). Intraoperative examination detected SLN metastases in 9 of 16 patients with metastatic SLN at definitive histology (sensitivity = 56.3%): macrometastasis in 8 and micrometastasis in 1. Seven false-negative cases were found (43.7%; micrometastases in 6 and isolated tumor cells in 1). The DA of intraoperative examination was 92% (95% confidence interval (CI), 84-96.7). For FS and IC, DA was 97.3% (95% CI, 85.8-99.9) and 88% (95% CI, 75.7-95.5), respectively., Conclusions: FS has better DA than IC for intraoperative examination of SLNs in endometrial cancer. The main limitation of both techniques is in detecting micrometastasis and isolated tumor cells.

Objectives: The aim of this study was to identify factors predictive of nursing home admission (NHA) over a period of 1 year among elderly subjects with dementia., Methods: The study population was drawn from the SAFES cohort that was formed within a national research program into the recruitment of emergency departments in 9 teaching hospitals. Subjects were to have been hospitalized in a medical ward in the same hospital as the emergency department to which they were initially admitted. Subjects who experienced NHA before emergency department admission were excluded. Those with a confirmed diagnosis of dementia were considered in the present analysis. NHA has been defined as the incident admission into either a nursing home or other long term care facility within the follow-up period. Data obtained from a Comprehensive Geriatric Assessment were used in a Cox model to predict 1-year NHA., Results: The 425 subjects of the study were 86 ± 6 years old, and were mainly women (63%). NHA rate was 40% (n = 172). Four factors were identified to increase NHA risk: age 85 or older (hazard ratio [HR] = 1.5; 95% confidence interval [CI] = 1.1-2.1), inability to use the toilet (HR = 2.5; 95% CI = 1.5-4.2), balance disorders (HR = 1.5; 95% CI = 1.1-2.1), and living alone (HR = 1.5; 95% CI = 1.1-2.1). Three factors decreased this risk significantly: inability to transfer (HR = 0.5; 95% CI = 0.3-0.8), increased number of children (HR = 0.88; 95% CI = 0.96-0.99), and increased initial Mini-Mental State Examination score (HR = 0.97; 95% CI = 0.8-0.9)., Conclusion: NHA determinants in dementia are strongly linked to the patient's own characteristics but also to his or her physical or social environment. Interventions should target both members of the dyad "patient-caregiver" because both are affected by the disease., (Copyright © 2012 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Patients with borderline personality disorder (BPD) suffer from instability in their relationships, their affectivity, and their identity. However, the associations between these dimensions are not clear. The purpose of the present study was to investigate the relation between identity diffusion and psychopathology in BPD., Methods: In the second week of inpatient treatment, 52 patients with BPD were assessed with the Inventory of Personality Organization (IPO) and questionnaires measuring general psychiatric symptoms, mood states, and negative affects (SCL-90-R, BDI, STAI, and STAXI). A median split was examined to differentiate BPD patients with high identity diffusion from those with low identity diffusion., Results: BPD patients with high identity diffusion did not differ in their social data from BPD patients with low identity diffusion. However, BPD patients with high identity diffusion showed significantly higher levels of psychiatric symptoms, as well as higher anxiety, anger, and depression scores (p < 0.01). Moreover, they suffered more frequently from concurrent personality disorders (p < 0.05)., Conclusions: These findings indicate an association of identity diffusion with psychopathological symptoms and features of personality disorder and emphasize the clinical significance of identity diffusion for patients with BPD., (Copyright © 2011 S. Karger AG, Basel.)

Aims: The issue of leptin as a putative state marker of alcohol use and its role in craving has been raised in the last few years. Recently, a strong GABA-ergic modulation of leptin was postulated. The aim of the pilot study was to examine leptin levels in correlation with the strongly GABA-mimetic active substance clomethiazole. The main hypothesis was that higher doses of the strong GABA-mimetic clomethiazole are positively correlated with higher leptin levels., Methods: Twenty-eight alcohol-dependent patients (3 females, median age 36 years) undergoing alcohol withdrawal were included. In 18 patients with and 10 without clomethiazole, serum leptin was analyzed at day 1 and day 7 of alcohol withdrawal. Both groups did not differ by age, BMI, or alcohol use characteristics., Results: In the clomethiazole group, significant correlations were found between leptin levels at day 1 and clomethiazole dose (p = 0.004), clomethiazole and leptin at day 1/BMI (p = 0.009) and leptin at day 1 and clomethiazole/body surface (p = 0.006). Furthermore, patients with higher clomethiazole doses demonstrated significant higher leptin levels at day 1 (p = 0.044) and day 7 (p = 0.046)., Conclusions: Our pilot data show a strong association between leptin levels and clomethiazole doses, thus supporting further research., (Copyright © 2011 S. Karger AG, Basel.)

Background: Natural orifice translumenal endoscopic surgery is an emerging surgical phenomenon. Although the development of "pure" natural orifice translumenal endoscopic surgical techniques in humans has been slowed by major technical hurdles, "hybrid" or combined variants have been increasingly reported. Laparoscopic sleeve gastrectomy (SG) is a commonly performed treatment of morbid obesity. We have developed a combined variant of SG for patients with morbid obesity. Our aim was to assess the feasibility and safety of such an approach, which could eventually reduce the postoperative pain, preserve the abdominal wall, and enhance cosmesis., Methods: Combined, transvaginal and abdominal SG was attempted in 20 patients. The inclusion criteria were morbid obesity (body mass index <50 kg/m(2)), female gender, an absence of gynecologic disorders, and the absence of major previous abdominal surgery. The local ethical committee approved the present study. The technique was performed using a vaginal incision with 1 or 2 abdominal ports., Results: The procedure was a success in 14 patients (70%). In 6 patients, conversion to a more conventional laparoscopic SG was required, with ≥ 1 abdominal ports added. The mean operative time was 116 minutes (range 54-231). The postoperative complication rate was 5% (1 patient developed pneumonia). No hemorrhage, surgical site infection, or fistula was encountered. The mean length of hospital stay was 72 hours (range 24-144)., Conclusion: Our combined, transvaginal and abdominal variant of laparoscopic SG was sure and feasible in a small series of selected patients with morbid obesity., (Copyright © 2011. Published by Elsevier Inc.)

Objectives: To evaluate the predictive ability of four clinical frailty indexes as regards one-year rapid cognitive decline (RCD - defined as the loss of at least 3 points on the MMSE score), and one-year institutional admission (IA) and mortality respectively; and to measure their agreement for identifying groups at risk of these severe outcomes., Design: One-year follow-up and multicentre study of old patients participating in the SAFEs cohort study., Setting: Nine university hospitals in France., Participants: 1,306 patients aged 75 or older (mean age 85±6 years; 65% female) hospitalized in medical divisions through an Emergency department., Measurements: Four frailty indexes (Winograd; Rockwood; Donini; and Schoevaerdts) reflecting the multidimensionality of the frailty concept, using an ordinal scoring system able to discriminate different grades of frailty, and constructed based on the accumulation of identified deficits after comprehensive geriatric assessment conducted during the first week of hospital stay, were used to categorize participants into three different grades of frailty: G1 - not frail; G2 - moderately frail; and G3 - severely frail. Comparisons between groups were performed using Fisher's exact test. Agreement between indexes was evaluated using Cohen's Kappa coefficient., Results: All patients were classified as frail by at least one of the four indexes. The Winograd and Rockwood indexes mainly classified subjects as G2 (85% and 96%), and the Donini and Schoevaerdts indexes mainly as G3 (71% and 67%). Among the SAFEs cohort population, 250, 1047 and 1,306 subjects were eligible for analyses of predictability for RCD, 1-year IA and 1-year mortality respectively. At 1 year, 84 subjects (34%) experienced RCD, 377 (36%) were admitted into an institutional setting, and 445 (34%) had died. With the Rockwood index, all subjects who experienced RCD were classified in G2; and in G2 and G3 when the Donini and Schoevaerdts indexes were used. No significant difference was found between frailty grade and RCD, whereas frailty grade was significantly associated with an increased risk of IA and death, whatever the frailty index considered. Agreement between the different indexes of frailty was poor with Kappa coefficients ranging from -0.02 to 0.15., Conclusion: These findings confirm the poor clinimetric properties of these current indexes to measure frailty, underlining the fact that further work is needed to develop a better and more widely-accepted definition of frailty and therefore a better understanding of its pathophysiology.

Patients with borderline personality disorder (BPD) suffer from affective instability, impulsivity, and identity disturbance which particularly manifest in an unstable or insecure self-image. One main problem for studies of core psychopathology in BPD is the complex subject of identity disturbance and self-image. The purpose of this study was to investigate the self-image of BPD patients with a qualitative research approach. Twelve patients with BPD were compared to 12 patients with remitted major depressive disorder (MDD) without personality disorder, using the Structured Interview of Personality Organization (STIPO). The transcribed interviews were analyzed using a combination of content analysis and grounded theory. BPD patients described themselves predominantly as helpful and sensitive; reported typical emotions were sadness, anger, and anxiety. MDD patients on the other hand reported numerous and various characteristics and emotions, including happiness, as well as sadness and anxiety. Other persons were characterized by the BPD group as egoistic and satisfied, while the MDD group described others as being balanced and secretive. BPD patients displayed an altruistic, superficial, and suffering self-image. Aggressive tendencies were only seen in other persons. Our findings support the concept of a self and relationship disturbance in BPD which is highly relevant for psychotherapy treatment.

Purpose of the Study: Elderly breast cancer (EBC) patients are often denied adjuvant chemotherapy because of age. Breast cancer is among the most frequent cancer in Western Countries and recent data suggest that adjuvant chemotherapy could be active in selected elderly patients. We investigated the impact of age and comprehensive geriatric assessment (CGA) among other variables taken into account in tumor boards to recommend adjuvant chemotherapy in EBC patients., Method(s): We retrospectively reviewed breast cancer tumor board records of all consecutive EBC patients (over 70 years old) discussed from July 2006 to July 2009 in our institution. The recorded variables included age, comorbidities, tumor stage, grade, ER/PR and HER2 status, treatment characteristics and CGA conclusions. Agreement with breast cancer treatment guidelines was verified. Reasons for deviations were recorded., Result(s): A total of 192 early EBC patients files (mean age 76.7 years, range 70-98) were analyzed. Elderly patients were less likely to receive adjuvant chemotherapy even when deemed appropriate by guidelines (p<.001). Out of 118 patients with ≥1 risk factors (pT2-4, N+, RH-, SBR III), 70 were proposed adjuvant chemotherapy. In multivariate analysis, age >80 years, but not CGA result, was an independent variable associated with a decreased likelihood to receiving adjuvant chemotherapy. Moreover, 93 patients (48.4%) underwent CGA, of whom no Balducci's class III patient received adjuvant chemotherapy. An appropriate treatment was administered in only 69% and 42% of Balducci's class I and II patients, respectively., Conclusion(s): Our results suggest that age remains an independent variable associated with a decreased use of adjuvant chemotherapy. However, in our series systemic adjuvant chemotherapy was probably underused in "fit" patients. Further efforts are needed to better integrate CGA into tumor boards proposals for early EBC patients., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Even though the efforts in research have detailed further the physiopathology and the dynamics of the frailty process an operational definition of frailty is still far from being unequivocal. Studies carried out from the SAFEs cohort study allowed a pragmatic approach in the identification of the at-risk groups for the lost of independency during the hospital stay and factors influencing their future at short-, mid- and long-term. Based upon these results, we propose to discuss the relevance of the current operational indicators of frailty in order to show that clinical markers or indicators are insufficient to differentiate the frailty process from normal ageing. Finally we give rise to the imperative necessity to detect frailty at a preclinical stage with the help of biological and more particularly inflammatory markers.

Objectives: The aim of the study was to identify factors related to institutionalisation within one-year follow up of subjects aged 75 or over, hospitalised via the emergency department (ED)., Design: Prospective multicentre cohort., Setting: Nine French university teaching hospitals., Participants: One thousand and forty seven (1 047) non institutionalised subjects aged 75 or over, hospitalised via ED. A sub-group analysis was performed on the 894 subjects with a caregiver., Measurements: Patients were assessed using Comprehensive Geriatric Assessment (CGA) tools. Cox survival analysis was performed to identify predictors of institutionalisation at one year., Results: Within one year after hospital admission, 210 (20.1%) subjects were institutionalised. For the overall study population, age >85 years (HR 1.6; 95%CI 1.1-2.1; p=0.005), inability to use the toilet (HR 1.6; 95%CI 1.1-2.4; p=0.007), balance disorders (HR 1.6; 95%CI 1.1-2.1; p=0.005) and presence of dementia syndrome (HR 1.9; 95%CI 1.4-2.6; p<0.001) proved to be independent predictors of institutionalisation; while a greater number of children was inversely linked to institutionalisation (HR 0.8; 95%CI 0.7-0.9; p<0.001). Bathing was of borderline significance (p=.09). For subjects with a caregiver, initial caregiver burden was significantly linked to institutionalisation within one year, in addition to the predictors observed in the overall study population., Conclusions: CGA performed at the beginning of hospitalisation in acute medical wards is useful to predict institutionalisation. Most of the predictors identified can lead to targeted therapeutic options with a view to preventing or delaying institution admission.

Background: Retrospective single-centre series have shown the feasibility of sentinel lymph-node (SLN) identification in endometrial cancer. We did a prospective, multicentre cohort study to assess the detection rate and diagnostic accuracy of the SLN procedure in predicting the pathological pelvic-node status in patients with early stage endometrial cancer., Methods: Patients with International Federation of Gynecology and Obstetrics (FIGO) stage I-II endometrial cancer had pelvic SLN assessment via cervical dual injection (with technetium and patent blue), and systematic pelvic-node dissection. All lymph nodes were histopathologically examined and SLNs were serial sectioned and examined by immunochemistry. The primary endpoint was estimation of the negative predictive value (NPV) of sentinel-node biopsy per hemipelvis. This is an ongoing study for which recruitment has ended. The study is registered with ClinicalTrials.gov, number NCT00987051., Findings: From July 5, 2007, to Aug 4, 2009, 133 patients were enrolled at nine centres in France. No complications occurred after injection of technetium colloid and no anaphylactic reactions were noted after patent blue injection. No surgical complications were reported during SLN biopsy, including procedures that involved conversion to open surgery. At least one SLN was detected in 111 of the 125 eligible patients. 19 of 111 (17%) had pelvic-lymph-node metastases. Five of 111 patients (5%) had an associated SLN in the para-aortic area. Considering the hemipelvis as the unit of analysis, NPV was 100% (95% CI 95-100) and sensitivity 100% (63-100). Considering the patient as the unit of analysis, three patients had false-negative results (two had metastatic nodes in the contralateral pelvic area and one in the para-aortic area), giving an NPV of 97% (95% CI 91-99) and sensitivity of 84% (62-95). All three of these patients had type 2 endometrial cancer. Immunohistochemistry and serial sectioning detected metastases undiagnosed by conventional histology in nine of 111 (8%) patients with detected SLNs, representing nine of the 19 patients (47%) with metastases. SLN biopsy upstaged 10% of patients with low-risk and 15% of those with intermediate-risk endometrial cancer., Interpretation: SLN biopsy with cervical dual labelling could be a trade-off between systematic lymphadenectomy and no dissection at all in patients with endometrial cancer of low or intermediate risk. Moreover, our study suggests that SLN biopsy could provide important data to tailor adjuvant therapy., Funding: Direction Interrégionale de Recherche Clinique, Ile-de-France, Assistance Publique-Hôpitaux de Paris., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Purpose: To describe the patterns of care of elderly cancer patients (ECPs) (>70 years old) and the factors affecting the referral by general practitioners (GPs) of patients to cancer specialists (SPs), in Alsace France., Methods: A postal mail questionnaire was sent to a total of 2818 physicians including primary care physicians and specialists. The factors possibly responsible for a poor referral rate of ECPs and the factors affecting treatment implementation by specialists were explored. We also searched for unmet needs such as the incorporation of geriatric assessment into routine practice and continuous medical education (CME) programs., Results: A total of 1217 questionnaires were returned (46.9%) from 1053 GPs and 214 SPs. Patients' age did not negatively impact referral to SPs as opposed to patients' performance status, wishes, and co-morbidities. Conversely, a significant decrease in patients' file presentation by SPs to tumor boards was observed for patients over 80 years old. Neither reimbursement nor SPs' waiting lists were an issue. The need for CME programs in geriatric oncology was emphasized by both GPs and SPs., Conclusions: Age was not the governing variable that impacted patient referral. The need for CME in geriatrics was highlighted for both GPs and SPs., (Copyright (c) 2009 Elsevier Ireland Ltd. All rights reserved.)

Background: A number of studies have shown that elderly cancer patients were denied optimal anticancer treatment because of age. Colorectal cancer is among the most frequent cancers in Western countries, and adjuvant chemotherapy has proven efficacy and tolerance in this condition. This study was undertaken to explore the current approaches to adjuvant chemotherapy in elderly cancer patients in a single institution., Patients and Methods: We retrospectively analyzed all patients' files that were discussed in the gastro-intestinal tumor board of the Hôpitaux Universitaires de Strasbourg during 3 years (2004-2006). The recorded variables included sex, age, tumor stage, cancer location colon vs rectum, number of comorbidities, occurrence of an oncogeriatric assessment, type and tolerance of chemotherapy. We investigated the reason to not administer adjuvant therapy in patients whom should have received this treatment if guidelines had to be applied., Results: A total of 193 consecutive patients' files were extracted from colorectal cancer patients that had been discussed in the gastro-intestinal tumor board. Among these, we isolated patients over 70 years old who were proposed with either adjuvant chemotherapy (group A, n=65) or follow up (group B, n=128). The median age in group A was 75.3 years old. Tumor board recommendations were in accordance with guidelines in 91% of cases. Chemotherapy was delivered in 44 pts (76%) and completed in 42 (95%). The median age in group B was 78.6 years old, and in this group tumor board proposal met the guidelines in 83% of cases. In the logistic regression model, disease stage was the major variable leading to adjuvant treatment recommendation, age and comorbidities being of lesser importance., Conclusions: In our series, elderly colorectal cancer patients are not undertreated. Efforts should be maintained to educate physicians with regard to feasibility of adjuvant chemotherapy in elderly patients., (Copyright (c) 2009 Elsevier Ireland Ltd. All rights reserved.)

Trocar site hernia is a known complication after laparoscopic surgery, especially at 10-mm and larger port sites. Only a few cases of herniation through 5-mm port sites are reported in the literature. We describe 2 cases of bowel herniation and bowel obstruction through 5-mm port sites. The patients were 63 and 74 years old; both had endometrial cancer and underwent an uncomplicated hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy with peritoneal drains left at the lateral 5-mm port sites. Each patient presented symptoms of small bowel obstruction after which the drains were removed and were found to have evisceration through a laterally placed 5-mm port site. The bowel was reduced locally, and a segmental bowel resection was needed in 1 case. Bowel herniation can occur through the fascial defect after placement of a 5-mm port, especially if drains have been placed at the port site.

Geriatric oncology is increasingly developing in Western countries as it is established that cancer peaks after 60 years of age, and the populations are inexorably aging. Aging is associated with a decrease in the use of chemotherapy, and some patients are therefore exposed to undertreatment. Comprehensive geriatric assessment is a composite of several scores that target the multidimensional aspects of the old person. With the use of comprehensive geriatric assessment, geriatricians and oncologists can tailor treatment to their patients. In this review, we briefly describe the characteristics of elderly cancer patients, and identify the pitfalls of anticancer treatment in elderly patients. In light of our expertise, we describe the benefits that can be awaited from joint efforts from geriatricians and oncologists and suggest future directions to answer unmet needs., (Copyright 2009 S. Karger AG, Basel.)

To identify predictive factors for 2-year mortality in frail elderly patients after acute hospitalisation, and from these to derive and validate a Mortality Risk Index (MRI). A prospective cohort of elderly patients was set up in nine teaching hospitals. This cohort was randomly split up into a derivation cohort (DC) of 870 subjects and a validation cohort (VC) of 436 subjects. Data obtained from a Comprehensive Geriatric Assessment were used in a Cox model to predict 2-year mortality and to identify risk groups for mortality. A ROC analysis was performed to explore the validity of the MRI. Five factors were identified and weighted using hazard ratios to construct the MRI: age 85 or over (1 point), dependence for the ADL (1 point), delirium (2 points), malnutrition risk (2 points), and co-morbidity level (2 points for medium level, 3 points for high level). Three risk groups were identified according to the MRI. Mortality rates increased significantly across risk groups in both cohorts. In the DC, mortality rates were: 20.8% in the low-risk group, 49.6% in the medium-risk group, and 62.1% in the high-risk group. In the VC, mortality rates were respectively 21.7, 48.5, and 65.4%. The area under the ROC curve for overall score was statistically the same in the DC (0.72) as in the VC (0.71). The proposed MRI appears as a simple and easy-to-use tool developed from relevant geriatric variables. Its accuracy is good and the validation procedure gives a good stability of results.

Objectives: The purpose of the study was to compare the postoperative pain of patients who had a hysterectomy through vaginal route according to the process of binding: wire or electrosurgical bipolar vessel sealing., Patients and Methods: Retrospective study carried out in the 60 last patients who underwent a hysterectomy by vaginal route for a benign pathology in the gynaecological service of surgery of the CHI Poissy-Saint-Germain-en-Laye until March 2006. Among these patients, 32 had profited from a binding by wire and 28 of the electrosurgical bipolar vessel sealing. The studied criteria were the post-operative pain, total morphine consumption and the durations of the analgesic treatment, the hospitalisation and intervention time., Results: The postoperative pain in the first 24 hours was twice lower using thermofusion; it was valid in immediate post-operative period and after 24 hours. In addition, total morphine consumption was also significantly lower using thermofusion., Discussion and Conclusion: This pilot study shows that the electrosurgical bipolar vessel sealing allows a reduction in the pain into the immediate postoperative period. Other prospective and randomised studies would allow it and conclude on the duration of hospitalisation, the quality of life from the patients and the cost in terms of public health.

Objectives: The aim of this study was to identify early indicators of prolonged hospital stays by elderly patients., Methods: This prospective pilot study, conducted at Strasbourg University Hospital, included patients aged 75 years or older who were hospitalized via the emergency department (SAFES cohort: Sujet Agé Fragile: Evaluation et suivi, that is, Frail Elderly Subjects: Evaluation and Follow-up). A gerontologic evaluation of these patients during the first week of their hospitalization furnished the data for an exact logistic regression. Two definitions were used for prolonged hospitalization: 30 days and a composite number adjusted for diagnosis-related group according to the French classification (f-DRG)., Results: The analysis examined 137 hospitalizations. More than two thirds of the patients were women (73%), with a mean age of 84 years. Twenty-four hospitalizations (17%) lasted more than 30 days, but only 6 (4%) lasted beyond the DRG-adjusted limit. No social or demographic variables appeared to affect the length of stay, regardless of the definition of prolonged stay. No indicator was associated with the 30-day limit, but clinical markers were linked to prolongation assessed by f-DRG adjustment. A "risk of malnutrition" (OR=14.07) and "mood disorders" (OR=2,5) were both early markers for prolonged hospitalization. Although not statistically significant, "walking difficulties" (OR=2.72) and "cognitive impairment" (OR=5.03) appeared to be associated with prolonged stays. No association was seen with either the variables measured by Katz's Activities of Daily Living Index or its course during hospitalization., Conclusion: Our study shows that when generally recognized indicators of frailty are taken into account, a set of simple items enables a predictive approach to the prolongation of emergency hospitalizations of the elderly.

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.

Objective: Our aim was to describe the living conditions of disabled elderly subjects aged 75 years and more living at home., Design: This study was conducted in 1996-97 in the Alsace region in France and included two parts. First, a sample survey was mailed to 15,600 subjects randomly selected from a pension funds list. This survey provided with a reliable representation of the study population in terms of disabilities using the Colvez classification. In the second part, the most disabled individuals were selected and, among them, 1,259 subjects were visited at home. Their disabilities and living conditions were noted using a predefined set of questions., Results: An estimated 71,000 subjects aged 75 years and more lived at home in the study region. The vast majority were free of significant disability. Help to wash and dress was needed by 6,000 until 1,500 were bedridden or confined to an armchair. Between 4,350 and 5,400 met the criteria for iso-resource grades (IRG) 1 to 3. Disability was associated with age, female gender, cognitive impairment and some social and professional characteristics. Family support was routine in almost every aspect of everyday life including personal hygiene. Professional support was mostly limited to technical interventions. Professional nursing care concerned only the most dependent persons. Nevertheless, needs for help in home and social activities remained high even in the least dependent individuals and were strongly age-dependent. Only 10% of individuals with IRG 1 to 3 complained of inadequate help. More than 80% of the elderly felt comfortable with their living conditions at home and were not thinking of moving from home to an institution for old people., Conclusion: The present study confirms the important commitment of family members and their close relationships toward their elderly.

Clinical examination (history and physical examination) is not considered to be a useful tool in the diagnosis of ectopic pregnancy (EP). In this systematic review we aimed to evaluate its value when ancillary tests are not readily available or when they are equivocal. Suspicion of EP is based on the presence of one or more of the following signs: vaginal bleeding, acute pelvic pain, or any risk factors for EP occurring in a pregnant woman. Detection of early pregnancy by urinary or serum hCG testing must be systematic because neither medical history nor physical examination can rule out early pregnancy with a high level of confidence. No isolated sign has sufficient diagnostic accuracy to rule out EP. In presence of vaginal bleeding without pain and if abdominal and pelvic examination are normal the risk of EP is very low. The presence of spontaneous pain moderate to severe, peritoneal signs, or definite pain during digital cervical mobilization increase the probability of EP. Absence of these signs does not rule out EP but tend to eliminate tubal rupture. In the presence of these signs one may consider an emergency transfer in a specialized center. In their absence, suspicion of EP may have outpatient diagnosis procedures.

Advances in laboratory tests and transvaginal ultrasound have enabled very early diagnosis of ectopic pregnancy. Expectative management has progressively become a real medical option for ectopic pregnancies as an alternative to surgery or medical treatment. The decision to abstain from treatment must be based on very strict criteria: patients with no symptoms, hematosalpinx<3 cm, no hemoperitoneum, hCG level<1000 mUI/ml and decreasing 48 hours later, a progesterone level<10 ng/ml. Regular surveillance until normalization of clinical, ultrasound and biological results is essential. The rate of success, which reaches 90%, clearly justifies this medical option.

Background: One of the problems of sentinel lymph node (SLN) biopsy is the risk of false negatives. At the Institut Curie, to reduce the false-negative rate, we have developed a histological quality control of the SLN performed by blue dye alone, which consists of verification of the SLN blue stain by the pathologist., Methods: A total of 324 patients underwent an SLN biopsy procedure with patent blue dye only followed by an immediate axillary dissection. Initially, SLNs were checked to ensure that they were blue by macroscopic examination. Finally, a search for immunohistochemistry micrometastasis was performed., Results: In 277 (85.5%) of 324 patients, an SLN was identified by the surgeon. After standard examination, the false-negative rate was 11.1% (10 of 90). After macroscopic checking of the 197 negative SLNs, 167 of the 197 were confirmed blue, and there were 5 false negatives, which brought the false-negative rate down to 5.6% (5 of 90). Sixty SLNs out of the 167 confirmed blue SLNs were then proved to be immunohistochemically micrometastatic, and there were 3 false negatives, giving a final false-negative rate of 2.2% (2 of 90; P =.002)., Conclusions: In this series, the procedure of pathologic analysis of the SLN has resulted in a significant reduction of the false-negative rate.

Objectives: The aim of this study was to specify the characteristics of enterobacterial urinary infections producing wide spectrum beta-lactamase (WSBL) and the management strategies for these patients infected in geriatric wards., Methods: The prevalence, bacteriological characteristics and treatment regimens of enterobacterial urinary infections producing WSBL, diagnosed in a geriatric department of internal medicine from May 1977 to April 2001, were studied retrospectively., Results: Sixty-six enterobacterial urinary infections producing WSBL were diagnosed, with 53 (80%) of them acquired in the ward. They represented 1.6% of admissions and concerned 24 men and 42 women (sex ratio: 0.57), with a mean age of 87 years. Their prevalence was of 20 in the 1st year, 11 in the 2nd, 9 in the third and 26 in the 4th year. The mean duration of hospitalization of infected patients was 4.5-fold longer (90 vs. 20 days) and the mortality rate 2-fold higher (32 vs. 14%). Enterobacter aerogenes were responsible for half (46%) of the WSBL urinary infections. The skin was invaded by enterobacteria in 67% and the feces in 57% of cases. More than one third of the urinary infections treated relapsed, and digestive decontamination was only efficient in half of the patients treated., Conclusion: This 4-year study emphasizes the limits of antibiotherapy in eradicating WSBL-producing enterobacteria and the fact that only the strict respect of hygiene by all caregivers (isolation of patients exhibiting WSBL and washing-disinfection of the hands between each patient) limits the incidence of such infections.

Background: The aim of the study was to evaluate the safety and efficacy of the Musset Poitout surgical procedure consisting in an anterior uterosacral ligament transposition and a cervix amputation. The main indication is an uterovaginal prolapse with an isolated elongation of the cervix., Methods: A retrospective consecutive series of 20 women with an elongation of uterine cervix undergoing Musset Poitout procedure over a 10 year period between 1990 and 2001 with analysis of per and post operative complications and success. Four Kelly urethral plications were performed in the same time. The patient's ages, time under anesthesia, change in hemoglobin, days of hospitalization, medical illnesses, complications and follow-up were assessed. Failure was defined as a symptomatic elongation of the cervix or a third degree hysterocele on examination., Results: and discussion. The median age of Musset Poitout procedure was 43.9 years (range 23-83). General anaesthesia could be performed in all patients. Mean operation time was 67 minutes (range 40-130). No major per or post operative complications occurred. The average of post-operative bladder cathetherisation was 3.65 days, the average hospital stay was 6.3 days. Complications were insignificant: urinary tract infection in 2, voiding dysfunction in 2. All the patients but 2 were followed for a mean 59 months (range 6-127). There was one recurence (5.5%)., Conclusion: In this preliminary assessment the Musset Poitout procedure offered significant avantages in a genital prolapse with elongation of the cervix.