[Urinary tract infections in the elderly]

DEFINITIONS

Age over 65 years is generally used to define the elderly population. Urinary tract infections are increasingly frequent after this age. Comorbidity and living conditions in the elderly have a particular incidence on the clinical expression and the bacterial flora involved. Besides these elements, altered cognitive capacity and abnormal urinary function prior to the infection and lead to an atypical clinical presentation.

ASYMPTOMATIC BACTERIURIA

Systematic screening has produced a large body of literature on asymptomatic bacteriuria. Our review of the literature leads to the conclusion that systematic bacteriology tests are not warranted in the elderly population in general due to the subsequent risk of germ selection and erroneous diagnosis.

PRACTICAL ATTITUDE

The diagnosis of urinary infection must be evidence-based, taking into account the patient's history and ruling out other diagnoses. In all cases, antibiotics must be carefully adapted to the patient's situation and titrated to kidney function.

Patients' preferences concerning medical information and surrogacy: results of a prospective study in a French emergency department

OBJECTIVE

To study the wishes of a sample of French patients about medical information and surrogacy, at a time when the French Ministry of Health is supporting increased patient autonomy.

DESIGN

A cohort of competent patients with non-critical illnesses or injuries completed an intention-to-act questionnaire on the amount of medical information they would want to receive should they be hospitalized or in a life-threatening situation. The percentage of patients who would want to have a surrogate if they were in a coma was determined, as well as the identity of the preferred surrogate. The subgroup of patients who were married or living with a partner was evaluated separately to determine how often the spouse/partner was the preferred surrogate. Associations were looked for between patients' wishes and age, sex, educational level, occupation, hierarchical order in the family, and level of confidence in medicine.

SETTING

The emergency room of a teaching hospital in the Paris area (France).

RESULTS

Of the 1089 patients included in the study, 5. 5 % reported that they would not want any information, 25.3 % that they would want to participate actively in all decisions about their care, and 87.3 % that they would want to be fully informed if they were in a life-threatening situation. Slightly less than one-third of the patients (29.6 %) believed they would not want a surrogate if they developed a coma. Among the patients living with a spouse/partner, 40.6 % (229/561) indicated they would want their spouse/partner to be their surrogate. A significant correlation was observed between wanting more information and wanting a surrogate. Younger patients with a higher educational level were significantly more likely to predict a desire for information and for a surrogate than the other patients.

CONCLUSION

Our patients expressed a strong desire to receive extensive information should they become seriously ill, and two-thirds of them reported they would want a surrogate. However, only 40.6 % of the patients living with a spouse/partner would want their spouse/partner to be their surrogate. These data suggest that the time has probably come to propose a nation-wide public hearing on medical information and surrogacy in France.

Malaria chemoprophylaxis of 3,446 French travelers departing from Paris to eight tropical countries

BACKGROUND

Each year more and more French travelers are visiting areas where malaria is endemic. The aim of this study was to assess prophylactic regimens used by French travelers and to determine whether they meet current published recommendations.

METHODS

This 12 month transversal study (May 1, 1995 to April 31, 1996) was conducted in embarkment lounges of Roissy Charles de Gaulle Airport to eight "tropical" destinations.

RESULTS

3,446 French travelers were enrolled. Twenty two and three-fifths percent of travelers had not sought any advice. The percentages of travelers staying less than 3 months (n = 2899) at risk of malaria (i.e., using none or inadequate chemoprophylaxis) were, according to the destination: Brazil (20%), Gabon (83%), Ivory Coast (26%), Kenya (43%), Madagascar (39%), Thailand (22%), Venezuela (41%) and Vietnam (8%). The suitability of the prophylaxis according to the information source for travelers staying less than 3 months varied as follows: specialist physician (OR = 1), travel agent (OR = 1.01, CI = 0.9 - 1. 1), occupational physician (OR = 1.13, CI = 0.6 - 2.1), GP (OR = 1. 58, CI = 1.1 - 2.3), none (OR = 1.95, CI = 1.3 - 2.9), friends (OR = 3, CI = 1.8 - 5) and pharmacist (OR = 3.94, CI = 2.1 - 7.5). Suitability of prophylaxis also varied according to the type of trip: organized tour (OR = 1), business trip (OR = 1.04, CI = 0.8 - 1.4), adventure tourism (OR = 2.1, CI = 1.6 - 2.9) and visit to family or friends (OR = 2.3, CI = 1.7 - 3.1).

CONCLUSIONS

This study shows that the quality of advice on antimalarial chemoprophylaxis varies markedly according to the source, and that nearly one in three French travelers (29.3 %, 850/2899) to tropical areas is at risk of malaria.

Follow-up after primary therapy: management of the symptomatic patient-surgery

The benefit of secondary surgery in patients (pts) recurring after a negative second look is still a matter of controversy. Twenty-seven patients underwent this procedure: 5 were stage I at primary surgery and 22 stage IIIC. All 5 stage I pts had a pelvic recurrence: 3 were left with no visible tumor and were then treated with cisplatin chemotherapy. Two are alive and with no evidence of disease (NED) at 45 and 62 months. In stage IIIC pts, optimal debulking (< 2 cm) was achieved in 59% (13/22), and 8 of them had no macroscopic residual tumor. All pts were then treated with cisplatin chemotherapy. Only 3 pts are still alive and NED at 56, 61, and 67 months. The most important prognostic parameters regarding secondary surgery seem to be residual tumor volume both at primary and secondary surgery, time interval between negative second-look surgery and recurrence, histology (serous) and degree of differentiation, and response to second-line chemotherapy. Finally, surgery can have a true palliative role in pts who present with bowel obstruction; in our center, most patients who had a definitive procedure did benefit from the quality of life viewpoint.

Long-term effects of radiotherapy administered in childhood for the treatment of malignant diseases

BACKGROUND

The use of radiotherapy for the treatment of childhood malignancy has improved long-term survival significantly, and many treated children now survive well into adulthood. As a consequence, long-term effects of childhood irradiation are being seen with increasing frequency.

METHODS

The medical records of 236 patients who had been treated for malignant disease with radiotherapy during childhood were examined to determine the long-term effect of the radiation on their growth and development.

RESULTS

Mean treatment dose was 35.5 Gy; mean age at treatment was 7.2 years; and mean follow-up was 14.5 years. Adjuvant chemotherapy was given to 82%. Some degree of bone deformity (usually with overlying soft-tissue hypoplasia) was seen in 40%; 21% developed some type of endocrine deficiency; 30% developed atrophic skin changes; and 7% developed second malignancies. The incidence of bone deformity and hormonal deficiency increased with the radiation dose; the incidence of second malignancy was independent of dose. Bone deformities were more common when radiation was administered before the age of 2 years.

CONCLUSIONS

The consequences of radiotherapy in childhood are significant and must be considered when planning treatment. Even when treatment is essential, families should be informed of the possibility of growth disturbance to prevent subsequent misunderstanding.