Effect of a multimodal training on the ability of medical students to administer the MMSE: a comparative study

BACKGROUNDS

The Mini-Mental State Examination (MMSE) is the main screening and follow-up test for neurocognitive disorders. In France, it is often administered by medical students. Conditions allowing to administer the MMSE are strict but not well known by students, leading to mistakes in scoring. Our objectives were to assess the effect of a multimodal training on medical students' ability to administer the MMSE and to describe their previous training.

METHODS

75 medical students between the 4th and 6th year of study were included. Previous MMSE training was assessed by a standardized questionnaire. The teaching material used for our training was the article validating MMSE in French, a video explaining the steps on how to administer the MMSE test, and MMSE's scoring exercises. The ability to administer the MMSE was assessed by a Standardized practical exam (SPE). Students were self-selected and then assigned in two groups, one benefiting from all the training before SPE, and the other receiving only the article before SPE.

RESULTS

41 students were included in the training group and 34 in the control group. There was no difference between groups regarding previous training. 71% of the students had already administered a MMSE test and only 17% had received specific training. Students considered their previous training as insufficient in most cases. The overall score and scores of each subpart of the SPE were significantly higher in the training group than in the control group (overall score: median [IQR]: 71 [62-78] vs. 52 [41-57], p < 0.001). The rate of students able to complete the MMSE was higher in the training group compared to the control (85% vs. 44%, p < 0.001). Quality of the training and its usefulness were judged to be good or very good by all participants.

CONCLUSIONS

A multimodal training improves the ability of medical students to administer the MMSE.

[Minimal geriatric assessment by an advanced practice nurse]

The prevalence of haematological malignancies increases in elderly patients. The complexity of therapeutic management makes it necessary to evaluate them using a global approach, namely bio-psycho-environmental. Identifying and assessing their weaknesses are part of the roles of advanced practice nurse (APN). Various tools are used to do this, including the G8 questionnaire, which directs patients towards a comprehensive geriatric assessment, or the Geriatric core dataset, designed to be used during clinical trials and which is more detailed and faster. Could an APN use the latter?

Changes in carotid arterial wall viscosity and carotid arterial stiffness in type 2 diabetes patients

BACKGROUND AND AIMS

Changes in arterial wall viscosity (AWW) and stiffness during type 2 diabetes (T2D) have been little investigated. We explored changes in carotid AWV considering change in arterial stiffness and loading conditions, in patients with T2D.

METHODS

This cross-sectional, monocentric study compared 19 middle-aged patients with T2D to 30 non-diabetic (ND) controls. The absolute viscosity (WV) was determined as the area of the pressure-lumen cross-sectional area (P-LCSA) loop obtained by carotid tonometry and contralateral echo-tracking. The relative viscosity was determined as the ratio between WV and the elastic energy stored within the arterial wall (WV/WE). Carotid geometry, midwall stress, distensibility and elastic modulus were also compared between groups.

RESULTS

T2D patients were older and more frequently had hypertension. Internal diameter, mean central and pulse blood pressure were higher in T2D patients but midwall stress was similar compared to ND controls. WV and WV/WE were higher in T2D patients when compared with ND controls (23 [16-41] vs. 11 [7-18] mm Hg.mm2, p=0.007 and 21% [17-25] vs. 12% [8-17], p < 0.001 respectively) even after adjustment on confounding factors. Carotid arterial stiffness was higher in T2D patients, but after adjustment this difference was only observed for the highest levels of midwall stress.

CONCLUSIONS

Carotid AWV and stiffness are increased in T2D patients but only AWV is significantly increased after considering loading conditions. Whether this increase in energy dissipation within the arterial wall contributes to alter cardiovascular coupling in T2D remains to be established.

[Deliberate intoxication with Datura Stramonium, a rare cause of confusion]

Many drugs can be responsible for this syndrome. Although it remains rare, poisoning by Datura Stramonium should be considered in the event of anticholinergic syndrome in the elderly, particularly in the event of anticholinergic manifestations.

[The proper use of carboxymaltose iron and its economic impact in the geriatric wards of a French university hospital]

The proper use and economic impact of carboxymaltose iron were evaluated for patients hospitalized in the geriatric wards of a French university hospital from November 2019 to April 2020. Martial supplementation was recommended for 75.7% of the 173 patients who received carboxymaltose iron: 43.4% had a real indication for carboxymaltose iron, while 14.4% could have received sucrose iron and 17.9% could have received per os iron. Compliance with the recommendations would have generated savings of 10,345.80 euros (32.1%).

Risk factors for poor outcome in older patients admitted in a surgical intensive care unit

BACKGROUND

The benefit of a stay in an intensive care unit (ICU) is not certain for older patients, particularly in the surgical context.

AIMS

The objective of this study was to identify the factors associated with an unfavourable outcome in this population.

DESIGN

Prospective, descriptive, monocentric study conducted in the surgical ICU of a French university hospital.

METHODS

Patients aged ≥75 years admitted in the surgical ICU for a predicted length of stay ≥48 hours were included. Patients received an initial and a 6-months nutritional and functional assessment performed by physicians and nurses. The outcome was considered as favourable if the Katz Activities of Daily Living (ADL) variation (ADL delta = 6-months ADL - ICU admission ADL) was between 0 and -0.5 point 6 months after ICU discharge and unfavourable if the ADL delta decreased by more than 0.5 points or if the patient had died 6 months after ICU discharge.

RESULTS

Fifty-six patients-32 (57%) male-aged 79 [77; 83] y were included. ICU mortality was 19%; 6-month mortality was 22%. Median ADL delta was -0.5 [-0.5-0] points. A low ADL score (P = .0438) and a low albumin level (P = .0213) at admission were the two independent factors associated with an unfavourable outcome.

CONCLUSION

Mortality and loss of independence were high in this elderly population during and after their surgical ICU stay. The benefit of a systematic collaboration between intensive care specialists, ICU nurses, and geriatricians, to assess and manage nutritional and functional problems and to prevent a pejorative outcome in patients over 75 years old admitted in surgical ICU needs to be studied.

RELEVANCE TO CLINICAL PRACTICE

There should be systematic screening for objective markers of undernutrition and frailty on ICU admission of older patients as they are associated with a poor prognosis.

Clinical Pharmacist Intervention Reduces Potentially Inappropriate Prescriptions in a Geriatric Perioperative Care Unit Dedicated to Hip Fracture

<b><i>Introduction:</i></b> Clinical pharmacist (CP) intervention improves drug prescription by identifying potentially inappropriate prescriptions (PIPs). Geriatric perioperative care units (UPOGs) provide enhanced care for patients with hip fracture, including drug prescription. However, it is not known whether adding a CP intervention in a UPOG decreases the number of PIPs. This study aimed to evaluate the effect of a CP intervention, combining an implicit and an explicit method, on the number of PIPs in a UPOG. <b><i>Methods:</i></b> This single centre before-after-control-impact study recruited patients aged over 75 years admitted to a UPOG for a hip fracture. The “control group” (“before period”) received usual care including two medication reconciliations, one at admission and one at discharge. The “intervention group” (“after period”) received usual care and a CP intervention including two medication reconciliations, a medication review with two tools, STOPP/START and Medication Appropriateness Index, and a meeting between a CP and geriatricians. PIPs were assessed in both groups by STOPP/START and Medication Appropriateness Index and compared from hospital admission to discharge. <b><i>Results:</i></b> A total of 209 patients were included, 150 in the control group and 59 in the intervention group (mean age: 87.2 ± 5.9 years). The number of PIPs decreased in both groups from hospital admission to discharge (<i>p</i> &#x3c; 0.001). The number of PIPs, potentially inappropriate medications, and potential prescribing omissions decreased more in the intervention group than in the control group (adjusted intervention effect: −2.46 (95% CI: −2.63; −2.24); −1.13 (95% CI: −1.27; −0.98); and −1.35 (95% CI: −1.52; −1.18), respectively, <i>p</i> &#x3c; 0.001 for all). <b><i>Discussion/Conclusion:</i></b> A CP intervention with an explicit and implicit method improved prescriptions in a UPOG. Further randomized studies are necessary to evaluate the effect of a CP intervention on adverse drug events, health costs, and mortality.

Adaptation of Arterial Wall Viscosity to the Short-Term Reduction of Heart Rate: Impact of Aging

Background Changes in arterial wall viscosity, which dissipates the energy stored within the arterial wall, may contribute to the beneficial effect of heart rate (HR) reduction on arterial stiffness and cardiovascular coupling. However, it has never been assessed in humans and could be altered by aging. We evaluated the effect of a selective HR-lowering agent on carotid arterial wall viscosity and the impact of aging on this effect. Methods and Results This randomized, placebo-controlled, double-blind, crossover study performed in 19 healthy volunteers evaluated the effects of ivabradine (5 mg BID, 1-week) on carotid arterial wall viscosity, mechanics, hemodynamics, and cardiovascular coupling. Arterial wall viscosity was evaluated by the area of the hysteresis loop of the pressure-lumen cross-sectional area relationship, representing the energy dissipated (W_V), and by the relative viscosity (W_V/W_E), with W_E representing the elastic energy stored. HR reduction by ivabradine increased W_V and W_E whereas W_V/W_E remained stable. In middle-aged subjects (n=11), baseline arterial stiffness and cardiovascular coupling were less favorable, and W_E was similar but W_V and therefore W_V/W_E were lower than in youth (n=8). HR reduction increased W_V/W_E in middle-aged but not in young subjects, owing to a larger increase in W_V than W_E. These results were supported by the age-related linear increase in W_V/W_E after HR reduction (P=0.009), explained by a linear increase in W_V. Conclusion HR reduction increases arterial wall energy dissipation proportionally to the increase in W_E, suggesting an adaptive process to bradycardia. This mechanism is altered during aging resulting in a larger than expected energy dissipation, the impact of which should be assessed. Registration URL: https://www.clinicaltrials.gov; Unique identifier: 2015/077/HP. URL: https://www. eudract.ema.europa.eu; Unique identifier: 2015-002060-17.

[A rare but increasing aetiology of febrile dyspnea in the elderly]

Pneumocystis jirovecii pneumonia (PJP) is an opportunistic infectious disease well described in patients living with HIV (PLHIV) but that can occur in other immunosuppressed patients. Currently, its incidence decreases in PLHIV but increases in non-HIV immunosuppressed patients, particularly in case of hematological diseases. Thus, in elderly, the diagnosis of PJP should be evoked in case of subacute pneumonia rapidly evolving to an acute respiratory distress, with or without interstitial pneumonia at chest radiography, and a context of immunosuppression.

Predictive Value for Outcome and Evolution of Geriatric Parameters after Transcatheter Aortic Valve Implantation

OBJECTIVES

To identify parameters of comprehensive geriatric assessment (CGA) CGA including ABCDEF score, a multidomain frailty assessment, associated with poor outcome after TAVI and to assess the evolution of CGA parameters at 6-months follow-up.

DESIGN

one-year monocentric prospective cohort study.

SETTING

Departments of geriatric medicine and cardiology in Rouen University Hospital, Normandy, France.

PARTICIPANTS

all patients over 70, selected for TAVI by a multidisciplinary "heart team".

MEASUREMENTS

8-areas CGA was performed before TAVI and at 6-months follow-up. Poor outcome was defined as decrease in 1 BADL or unplanned readmission at 6 months or death within the first year after TAVI. Geriatric characteristics associated with poor outcome were assessed by logistic regression with surgical scores as bivariable. Geriatric characteristics were compared between baseline and 6-months follow-up.

RESULTS

114 patients (mean age 85.8±5.3 years) were included. Mean EuroSCORE was 19.1±10.6%. Poor outcome occurred in 57(50.0%) patients. Loss of one BADL (OR:1.66, 95CI[1.11-2.48]), decrease in IADL (OR:1.41, 95CI[1.14-1.74]), in plasmatic albumin (OR:1.10, 95CI[1.01-1.20]), in MMSe (OR:1.13, 95CI[1.02-1.26]), low walking speed (OR:1.53, 95CI[1.01-2.33]) and ABCDEF score ≥2 (OR:1.63, 95CI[1.09-2.42]) were independently associated with poor outcome. In survivors with complete follow-up (n=80), most geriatric parameters were maintained 6 months after TAVI, but IADL decreased (5.6±1.9 to 4.9±2.2, p<0.001). MMSe increased in patients with previous cognitive impairments whereas it decreased in those without (p<0.001).

CONCLUSION

CGA parameters are independently associated with poor outcome after TAVI. These parameters, but IADL, are maintained at 6 months and course of the MMSe depends on previous cognitive status.

Feasibility and Determinants of Orthostatic Hypotension Self-measurement at Home in an Elderly Community-Dwelling Population

BACKGROUND

Orthostatic hypotension (OH) measurement reproducibility is poor. Our objectives were to assess feasibility of self-detection home-measured OH (HOH) and HOH determinants.

METHODS

Subjects older than 65 years, attending a geriatric outpatient clinic, able to understand the HOH protocol: 3 blood pressure (BP) measures after 5 minutes of seating and BP measures after 1 and 3 minutes of standing, each morning and evening for 3 consecutive days were lent a validated digital automatic sphygmomanometer. Reports containing at least 4 correct measurements were deemed a success. Factors associated with HOH were studied.

RESULTS

HOH feasibility was 82.8% (241 subjects) with no difference between participants who failed or succeeded. Among the 241 subjects (mean age (SD) = 78.0 (8.3) years old; 62.1% of women), 139 were free of HOH, 70 had 1 HOH episode and 32 had 2 or more HOH episodes. Hypertension, dementia, atrial fibrillation, diabetes, and heart failure were found in 70.0%, 10.4%, 9.4%, 8.8%, and 3.4% of cases, respectively. Subjects were treated with antihypertensive, benzodiazepine, statin medication in 47.3%, 9.3%, 7.4% of cases, respectively, and 42.4% experienced polypharmacy. HOH episodes were associated with dementia (P = 0.01), presence of OH during the geriatric outpatient clinic assessment (P = 0.0002), statin therapy (P = 0.04), and polypharmacy (P = 0.0002). In multivariate analysis, benzodiazepine (OR (95% CI) = 2.59 (1.10-6.08) and statin medication (OR (95% CI) = 1.92 (1.10-3.33)) remained significantly associated with HOH.

CONCLUSIONS

HOH had a good feasibility and relevant determinants. A study to address the predictive value of HOH will be conducted.

Benefits of a Pre-Treatment Comprehensive Geriatric Assessment in a Rare Case of Gemella Haemolysans Endocarditis in an 86-Year-Old Patient and a Review of the Literature

Infective endocarditis is a serious condition, which is associated with high mortality in elderly patients. Gemella haemolysans (GH) is a microorganism from the Streptococcus family, rarely involved in infective endocarditis. Here, we present a case of Gemella haemolysans endocarditis in an 86-year-old patient, successfully treated by antibiotics and surgery following a pre-treatment comprehensive geriatric assessment (CGA). This case is discussed in the context of a review of all published cases of Gemella haemolysans endocarditis. We illustrate the benefit of a systematic pre-treatment comprehensive geriatric assessment in elderly patients with infective endocarditis.

Chronic neurological disorders and related comorbidities: Role of age-associated physiological changes

Current knowledge indicates that the physiological aging process starts with subclinical changes at the molecular and cellular level, which affect nearly all physiological systems. For example, the age-associated remodeling of the immune system (i.e., immunosenescence) and vascular aging per se can contribute to frailty and vulnerability among older adults. They are also described as being implicated in the pathophysiology of some major chronic comorbid conditions such as age-associated diseases of the central (e.g., stroke, Parkinson's disease, Alzheimer's disease, and related disorders) and peripheral (e.g., polyneuropathy) nervous systems. These neurologic disorders are also among the greatest contributors to geriatric syndromes, which refer to highly prevalent and chronic conditions among aged people of multifactorial origin, such as delirium, falls, incontinence, and frailty. Neurologic disorders can also occur in patients with one or more geriatric syndromes and thus further interfere with the quality of life, physical function, morbidity, and mortality. This chapter presents and discusses in three sections the complex interrelationships between the main determinants of aging with a specific focus on vascular aging, chronic neurologic disorders, and the specific clinical presentation of geriatric syndromes in older people.

Evaluation of the PMMA microlens efficiency for the realization of a solar micro-concentrator array

In order to assess the performance of solar micro-concentrators, specific methods and protocols need to be developed, tested, and applied. In detail, as in conventional concentration modules, one of the fundamental parameters to consider is the efficiency of optical concentrators. In fact, optical concentrators give fundamental information on the current potentially generated from solar microcells that receive the concentrated light radiation. To develop a measurement method for micrometer-size optical components, a suitable optical system was implemented and used. Moreover, the potential application of the printed microstructures in an optical system for solar micro-concentrators was demonstrated.

Silk flow-diverter stent for the treatment of complex intracranial aneurysms: A one-year follow-up multicenter study

Background Flow-diverter stents have been successfully used in the treatment of complex aneurysms with limited therapeutic alternatives. We report our experience using the Silk flow diverter (SFD; Balt Extrusion, Montmorency, France) for the treatment of complex aneurysms in four Argentine centers. Methods We conducted a retrospective review of 246 consecutive patients who were treated with the SFD at four Argentine centers between January 2009 and January 2017. The patient and aneurysm characteristics, as well as the details of the procedure, were analyzed. The angiographic and clinical findings were recorded during and immediately after the procedure and at 12-month follow-up. Results Angiography follow-up at 12 months was possible in 235 patients (95.5%) with 282 aneurysms. A total of 265 aneurysms (93.9%) presented with complete occlusion of the aneurysmal sac (class 1) and 17 aneurysms (6.1%) presented with partial occlusion (class 2). The 12-month clinical follow-up showed 11 patients with major events (seven, scale 2; five, scale 3; and two, scale 4). The morbidity and mortality rates were 4.2% (11/289) and 2.1% (5/289), respectively. Conclusions The treatment of aneurysms with the SFD was associated with a low rate of complications and a high percentage of aneurysmal occlusion. These findings suggest that SFD is an effective and safe alternative in the endovascular treatment of complex aneurysms.

Tracking tool for frailty: ABCDEF

The aging population leads to psychological, medical and social reflection for optimal care of the elderly, especially characterized by a frailty state. The frailty is the cause of morbi-mortality require screening to anticipate these complications. The objective was to evaluate the statistical performance and feasibility of the tool "ABCDEF" to screen frailty defined by Fried's criteria. A prospective multicenter study including 300 ambulatory elderly consultants was conducted. ABCDEF appears feasible without major prior training or special equipment by any doctor or caregiver during an assessment in 98% of consultants. His sensitivity to detect frailty, is of 75% and specificity of 64%. The frailty tracking threshold is 3 criteria (6). Its negative predictive value is interesting because it eliminates the hypothesis of frailty in 91% of cases. This tracking tool requires, when abnormal, further geriatric assessment. It provides a standardized and normative approach to describe frailty whose frequency is high in people older than 80 and whose consequences are major.

[Anaemia and chronic diseases]

The prevalence of anemia in old patients is 20%. Anemia is mostly multifactorial associated with multiple comorbidities that are frequently observed in people of 65 years or older. Chronic renal failure, inflammatory diseases, nutrient deficiencies and especially iron deficiency are the most associated conditions with anemia. Anemia represents a prognosis marker of general health in old people. Thus anemia is associated with higher rates of morbidities (such as unplanned hospitalizations) and greatest mortality. Therefore anemia could be considered either as a consequence of chronic diseases or a prognosis marker of their severity. The prognosis of chronic cardiac failure is for example worst in anemic patients. Finally anemia is listed as a component of the frailty.

Glycation: the angiogenic paradox in aging and age-related disorders and diseases

Angiogenesis is generally a quiescent process which, however, may be modified by different physiological and pathological conditions. The "angiogenic paradox" has been described in diabetes because this disease impairs the angiogenic response in a manner that differs depending on the organs involved and disease evolution. Aging is also associated with pro- and antiangiogenic processes. Glycation, the post-translational modification of proteins, increases with aging and the progression of diabetes. The effect of glycation on angiogenesis depends on the type of glycated proteins and cells involved. This complex link could be responsible for the "angiogenic paradox" in aging and age-related disorders and diseases. Using diabetes as a model, the present work has attempted to review the age-related angiogenic paradox, in particular the effects of glycation on angiogenesis during aging.

Changes in the levels of eicosanoids in cats naturally and experimentally infected with Dirofilaria immitis

Feline heartworm (Dirofilaria immitis) infection is a severe, life-threatening disease. The eicosanoids are lipid mediators derived from the metabolism of the arachidonic acid, involved in the regulation of the immune response and of inflammatory reactions. In this study, naturally infected cats showed significant higher levels of prostaglandin E(2) (PGE2), thromboxane B(2) (TXB(2)) and leukotriene B(4) (LTB4) than uninfected cats. Changes in the levels of eicosanoids during the infection were observed in experimentally infected cats. PGE2 increased significantly during the first 60 days post-infection, then progressively decreased until day 180 post-infection. At this time, PGE2 values are still significantly higher than those observed before the infection. TxB2 and LTB4 increased progressively from the beginning of infection and reached their maximum levels 180 days post-infection. In experimentally infected, ivermectin-treated cats, 15 days after treatment (45 days after infection) both PGE2 and LTB4 levels were similar to those observed in experimentally infected, untreated cats. No significant differences of PGE2 levels were found before the infection and at the end of the experiment (165 days post-treatment, 195 days post-infection). Increased levels of LTB4 were found 15 days post-treatment, afterward they progressively decreased. These data show that D. immitis infection influences the production of intravascular eicosanoids in cats. The high levels of PGE2 observed in the early phase of infection could be related to the survival of the worms, while those of TxB2 and LTB4 detected at the end of the study could mediate the inflammatory reactions and thrombi formation during the feline dirofilariosis.