Prescription of Blood Lymphocyte Immunophenotyping in the Diagnosis of Lymphoid Neoplasms in Older Adults

Lymphoid neoplasms are a heterogeneous group of lymphoid neoplastic diseases with multiple presentations, and varying prognoses. They are especially frequent in older patients (OPs) and the atypism of this frail elderly population can make the diagnostic process even more difficult. Blood lymphocyte immunophenotyping (BLI) is essential in rapid noninvasive diagnosis orientation and guides complementary investigations. To our knowledge, BLI prescription has never been evaluated in OPs. We hypothesized that, when there is a suspicion of lymphoid neoplasm in the geriatric population, a BLI is performed in view of various clinical or biological abnormalities. This study aimed to: (1) describe the characteristics of hospitalized OPs having undergone BLI for suspected lymphoid neoplasm, (2) identify the causes leading to BLI prescription, and (3) identify the most profitable criteria for BLI prescription. This was a descriptive retrospective study on 151 OPs aged ≥75 years who underwent BLI over a 2-year period. Regarding BLI prescriptions, eight had lymphocytosis, constituting the “lymphocytosis group” (LG+), while the 143 others had BLI prescribed for reasons other than lymphocytosis (LG−), mainly general weakness and anemia. In the LG−, we compared OPs with positive and negative BLI results. The criteria found to be profitable for BLI prescription were lymphadenopathy, splenomegaly, lymphocytosis, and thrombocytopenia. BLI identified circulating lymphoid neoplasms (positive BLI) in 21/151 OPs, mainly marginal zone lymphoma and chronic lymphocytic leukemia. In polymorbid OPs, as per our study population, the diagnostic and therapeutic complexity explained in part the sole use of indirect and minimally invasive diagnostic techniques such as BLI.

Criteria for taking an advance decision to limit the transfer to intensive care of patients aged 75 and over, hospitalised in an acute geriatric unit

OBJECTIVE

Due to the diversity of the elderly population and medical practices, the decision to transfer elderly patients to an intensive care unit is complex. This study aimed to identify the criteria used to take an advance decision to limit transfer to an intensive care unit of patients hospitalised in an acute geriatric unit.

METHODS

This retrospective study included, over a ten-month period, patients >75 years and hospitalised in an acute geriatric unit. They were divided into two groups according to whether or not an advanced decision to limit transfer to an intensive care unit had been taken.

RESULTS

In total, 906 elderly patients were included in the study. Of them, 446 had no advance decision to limit transfer to an ICU. Univariate analysis showed a correlation between an advance decision to limit transfer to an ICU and a Mini Mental State Examination (MMSE) score of less than 20/30. Malnutrition had no impact on the advance decision. In multivariate analysis, the factors associated with an advance decision to limit transfer to an ICU were an age > 85 years, a hospitalisation in the last six months (Odds Ratio (OR) = 1.72, Confidence Interval (CI) 95% [1.23-2.39]), residence in a nursing home (OR = 1.93, 95% CI [1.18-0.16]) and the presence of bedsores (OR = 2.44, 95% CI [1.20-0.98]). A zero Charlson score was associated with the absence of an advance decision to limit transfer to an ICU (OR = 0.42, 95% CI [0.26-0.67]).

CONCLUSION

Some criteria are common to geriatricians, intensive care doctors and emergency physicians, while others are discordant, illustrating differences in physicians' practices.

Analysis of COVID-19 in Professionals Working in Geriatric Environment: Multicenter Prospective Study

Healthcare workers (HCWs) are exposed to a higher risk of coronavirus disease (COVID-19) contamination. This prospective multicenter study describes the characteristics of HCWs tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) while working in a geriatric environment. We also compared HCWs with a positive reverse transcription polymerase chain reaction (RTPCR) assay (RTPCR+ group) and those with a negative test result (RTPCR− group). Between 15/5/2020 and 15/9/2020, 258 HCWs, employed in the acute geriatric unit (AGU), geriatric rehabilitation unit (GRU) or nursing home of three hospitals in Burgundy (France) were invited to complete an online survey. Among the 171 respondents, 83 participants, with mean age 42 years and 87.9% female, were tested for SARS-CoV-2 infection. Among these 83 participants, COVID-19 was confirmed in 38 cases (RTPCR+ group) of which 36 were symptomatic, and the RTPCR assay was negative in 45 cases (RTPCR− group) of which 20 participants were symptomatic. A total of 22.9% (of 83) had comorbidities, 21.7% were active smokers, and 65.1% had received the flu vaccine. A total of 37.3% worked in AGU, 19.3% in GRU and 16.9% in nursing homes. The most common symptom described was headache (23.2%), followed by fatigue or cough (12.5% each), and fever or myalgia (10.7% each). There were more participants with normal body mass index (p = 0.03) in the RTPCR+ group. In contrast, there were more users of non-steroidal anti-inflammatory drugs (p = 0.01), active smokers (p = 0.03) and flu vaccinated (p = 0.01) in the RTPCR− group. No difference was found between the two groups for the type of work (p = 0.20 for physicians and p = 0.18 for nurses). However, acquiring COVID-19 was significantly associated with working in AGU (p < 0.001) and nursing homes (p = 0.001). There were significantly more users of surgical masks (p = 0.035) in the RTPCR+ group and more filtering facepiece-2 mask users (p = 0.016) in the RTPCR− group. Our results reflect the first six months of the COVID-19 pandemic in France. Further studies are needed to evaluate and track the risks and consequences of COVID-19 in HCWs.

[Criteria of early limitation of transfer in intensive care unit of patients aged 75 and over hospitalized in an acute geriatric unit]

Because of heterogeneity of the elderly population and medical practices, the decision of admission of elderly patients (EP) in intensive care unit is more complex. This study aimed to determine the decision criteria for an early limitation of transfer in intensive care unit (ELTICU) of patients hospitalized in an acute geriatric unit. This retrospective study included, over a 10-month period, patients ≥75 years and hospitalized in an acute geriatric unit. They were divided into 2 groups according to whether or not an ELTICU decision was taken. In total, 906 EP were included among them 446 with no ELTICU decision. Univariate analysis showed a correlation between ELTICU and a Mini Mental Status score of less than 20/30. Malnutrition had no impact on ELTICU decision. In multivariate analysis, the factors associated with an ELTICU decision were an age ≥ 85 years, an hospitalization in the last 6 months (Odds Ratio (OR) = 1.72, Confidence Interval (CI) 95% [1.23-2.39]), life in a nursing home (OR = 1.93, 95% CI [1.18-3.16]) and the presence of bedsore(s) (OR = 2.44, 95% CI [1.20-4.98]). A null Charlson score was associated with the absence of an ELTICU decision (OR = 0.42, 95% CI [0.26-0.67]). Some criteria are shared between geriatricians, resuscitators and emergency physicians, while others are discordant, illustrating differences in physicians' practices.

Level of Medical Intervention in Geriatric Settings: Decision Factors and Correlation With Mortality

OBJECTIVES

Level of medical intervention (LMI) has to be adapted to each patient in geriatric care. LMI scales intend to help nonintensive care (NIC) decisions, giving priority to patient choice and collegial discussion. In the present study, we aimed to assess the parameters associated with the NIC decision and whether these parameters differ from those associated with in-hospital mortality.

DESIGN

Prospective observational study.

SETTING AND PARTICIPANTS

All consecutive patients from a French 62-bed acute geriatric unit over 1 year.

METHODS

Factors from the geriatric assessment associated with the decision of NIC were compared with those associated with in-hospital and 1-year mortality, in univariate and multivariate analyses.

RESULTS

In total, 1654 consecutive patients (median age 87 years) were included. Collegial reflection led to NIC decision for 532 patients (32%). In-hospital and 1-year mortality were 22% and 54% in the NIC group vs 2% and 27% in the rest of the cohort (P < .001 for both). In multivariable analysis, high Charlson Comorbidity Index [odds ratio (OR) 1.15, 95% confidence interval (CI) 1.06-1.23, per point], severe neurocognitive disorders (OR 2.78, 95% CI 1.67-4.55), dependence (OR 1.92, 95% CI 1.45-2.59), and nursing home residence (OR 2.38, 95% CI 1.85-3.13) were highly associated with NIC decision but not with in-hospital mortality. Conversely, acute diseases had little impact on LMI despite their high short-term prognostic burden.

CONCLUSIONS AND IMPLICATIONS

Neurocognitive disorders and dependence were strongly associated with NIC decision, even though they were not significantly associated with in-hospital mortality. The decision-making process of LMI therefore seems to go beyond the notion of short-term survival.

Not COVID-19, Don't Overlook Pneumocystis in Patients on Gefitinib!

Simple Summary

COVID-19 pneumonia can be confused with Pneumocystis jirovecii pneumonia (PJP) on computed tomography and is a source of misdiagnosis. This can lead to mistreatment and an increased risk of mortality. Gefitinib, a tyrosine kinase inhibitor anti-EGFR used in cancer therapy and corticosteroids, could increase the risk of PJP.

Abstract

An 82-year-old woman treated for advanced lung cancer with gefitinb was admitted to the emergency unit complaining of dyspnea. Chest computed tomography found abnormalities classified as possible diffuse COVID-19 pneumonia. RT-PCR for Sars-Cov-2 was twice negative. PCR for Pneumocystis jirovecii was positive on bronchoalveolar lavage. The final diagnosis was Pneumocystis jirovecii pneumonia. Therefore, physicians must be careful not to misdiagnose COVID-19, especially in cancer patients on small-molecule therapeutics like gefitinib and corticosteroids.

Iron in the General Population and Specificities in Older Adults: Metabolism, Causes and Consequences of Decrease or Overload, and Biological Assessment

Iron is involved in many types of metabolism, including oxygen transport in hemoglobin. Iron deficiency (ID), ie a decrease in circulating iron, can have severe consequences. We provide an update on iron metabolism and ID, highlighting the particularities in older adults (OAs). There are three iron compartments in the human body: 1) the functional compartment, which consists of heme proteins including hemoglobin, myoglobin and respiratory enzymes; 2) iron reserves (IR), which consist mainly of liver stocks and are stored as ferritin; and 3) transferrin. There are two types of ID. Absolute ID is characterized by a decrease in IR. Its main pathophysiological mechanism is bleeding, which is often digestive and can be due to neoplasia, frequent in OAs. Biological assessment shows low serum ferritin and transferrin saturation (TS) levels. Furthermore, hypochromic microcytic anemia is frequent, and the serum-soluble transferrin receptor (sTfR) level is high. Functional ID, in which IR are high or normal, is due to inflammation, which is also frequent in OAs, particularly in its chronic form. Biological assessments show high serum ferritin, normal or low TS, and normal sTfR levels. Moreover, C-reactive protein is elevated, and there is moderate non-regenerative non-macrocytic anemia. The main characteristics of iron metabolism anomalies in the elderly are the high frequency of ID (20% of ID with anemia in adults ≥85 years) and the severity of its consequences, which include cognitive impairment in case of ID or iron overload and decrease of physical activity in case of ID. In conclusion, causes of ID are frequently intertwined in OAs as a result of the polymorbidity that characterizes them. ID can have dramatic consequences, especially in frail OAs. Thus, measuring the appropriate biological markers prevents errors in the positive diagnosis of ID type, clarifies etiology, and informs treatment-related decision-making.

The Prescription of Vitamin K Antagonists in a Very Old Population: A Cross-Sectional Study of 8696 Ambulatory Subjects Aged Over 85 Years

We compared very elderly people taking vitamin K antagonists (VKA) and those not taking VKA (noVKA). Individuals were included in the noVKA group if there was no VKA on their reimbursed prescriptions during the study period. We also compared three subgroups, constituted by VKA type (fluindione, warfarin, or acenocoumarol). We included individuals aged over 85 years, affiliated to Mutualité Sociale Agricole of Burgundy, who were refunded for prescribed VKA in September 2017. The VKA and noVKA groups were compared in terms of demographic conditions, registered chronic diseases (RCD), number of drugs per prescription and cardiovascular medications. The three VKA subgroups were compared for the same items plus laboratory monitoring, novel and refill VKA prescriptions, and prescriber specialty. Of the 8696 included individuals, 1157 (13.30%) were prescribed VKA. Mean age was 90 years. The noVKA group had fewer women (53.67 vs 66.08%), more RCD (93.43 vs. 71.96%) and more drugs per prescription (6.65 vs. 5.18) than the VKA group (all p < 0.01). Except for direct oral anticoagulants and platelet aggregation inhibitors, the VKA group took significantly more cardiovascular medications. The most commonly prescribed VKA was fluindione (59.46%). Mean age was higher in the warfarin (90.42) than in the acenocoumarol (89.83) or fluindione (89.71) subgroups (p < 0.01). No differences were observed for sex (women were predominant) or RCD. 13% of subjects in this population had a VKA prescription. Fluindione was the most commonly prescribed VKA.

Changes in Treatment of Very Elderly Patients Six Weeks after Discharge from Geriatrics Department

We assessed the prescriptions of patients hospitalized in a geriatric unit and subsequently discharged. This prospective and observational study was conducted over a two-month period in the geriatrics department (acute and rehabilitation units) of a university hospital. Patients discharged from this department were included over a two-month period. Prescriptions were analyzed at admission and discharge from the geriatrics department (DGD), and six weeks after DGD. We included 209 patients, 63% female, aged 86.8 years. The mean number of medications prescribed was significantly higher at DGD than at admission (7.8 vs. 7.1, p = 0.003). During hospitalization, 1217 prescriptions were changed (average 5.8 medications/patient): 52.8% were initiations, 39.3% were discontinuations, and 7.9% were dose adjustments. A total of 156 of the 209 patients initially enrolled completed the study. Among these patients, 81 (51.9%) had the same prescriptions six weeks after DGD. In univariate analysis, medications were changed more frequently in patients with cognitive impairment (p = 0.04) and in patients for whom the hospital report did not indicate in-hospital modifications (p = 0.007). Multivariate analysis found that six weeks after DGD, there were significantly more drug changes for patients for whom there were changes in prescription during hospitalization (p < 0.001). A total of 169 medications were changed (mean number of medications changed per patient: 1.1): 52.7% discontinuations, 34.3% initiations, and 13% dosage modifications. The drug regimens were often changed during hospitalization in the geriatrics department, and a majority of these changes were maintained six weeks after DGD. Improvements in patient adherence and hospital-general practitioner communication are necessary to promote continuity of care and to optimize patient supervision after hospital discharge.

Impact of Age, Multimorbidity and Frailty on the Prescription of Preventive Antiplatelet Therapy in Older Population

Platelet aggregation inhibitors (PAI) have widely proven their efficiency for the prevention of ischemic cardiovascular events. We aimed to describe PAI prescription in an elderly multimorbid population and to determine the factors that influence their prescription, including the impact of age, comorbidities and frailty, evaluated through a comprehensive geriatric assessment. This cross-sectional study included all patients admitted to the acute geriatric department of a university hospital from November 2016 to January 2017. We included 304 consecutive hospitalized patients aged 88.7 ± 5.5 years. One third of the population was treated with PAI. A total of 133 (43.8%) patients had a history of cardiovascular disease, 77 of whom were on PAI. For 16 patients, no indication was identified. The prescription or the absence of PAI were consistent with medical history in 61.8% of patients. In the multivariate analysis, among the 187 patients with an indication for PAI, neither age (odds ratio (OR) = 1.00; 95% confidence interval (CI): [0.91-1.08], per year of age), nor comorbidities (OR = 0.97; 95% CI: [0.75-1.26], per point of Charlson comorbidity index), nor cognitive disorders (OR = 0.98; 95% CI [0.91-1.06] per point of Mini Mental State Examination), nor malnutrition (OR = 1.07; 95% CI [0.96-1.18], per g/L of albumin) were significantly associated with the therapeutic decision. PAI were less prescribed in primary prevention situations, in patients taking anticoagulants and in patients with a history of bleeding. In conclusion, a third of our older comorbid population of inpatients was taking PAI. PAI prescription was consistent with medical history for 61.8% of patients. Age, multimorbidity and frailty do not appear to have a significant influence on therapeutic decision-making. Further research is needed to confirm such a persistence of cardiovascular preventive strategies in frail older patients from other settings and to assess whether these strategies are associated with a clinical benefit in this specific population.

The prescription of direct oral anticoagulants in the elderly: An observational study of 19 798 Ambulatory subjects

OBJECTIVE

Direct oral anticoagulants (DOACs) are increasingly prescribed to elderly people, but the epidemiologic data for this population remains scarce. We compared the elderly population taking DOACs and those not taking DOACs (noDOAC).

METHOD

We included individuals over 75 years old, affiliated to Mutualité Sociale Agricole of Burgundy (a French regional health insurance agency), who had been refunded for a prescribed DOAC between 1st and 30th September 2017. The DAOC group (DAOCG) and noDOAC group (noDOACG) were compared in terms of demographic conditions, registered chronic diseases (RCD), and number and types of prescribed drugs. In the DOACG, we compared the type of prescribing physician and laboratory monitoring for novel prescriptions (initial) and prescription refills (≥ 3 months).

RESULTS

Of the 19 798 included patients, 1518 (7.7%) were prescribed DAOCs and 18 280 (92.3%) were not. Mean and median age was 85 years in the 2 groups (DOACG and noDOACG). In the DOACG, there were more men (50% vs 40.2%), more RCD (88.9% vs 68.7%) and more drugs per prescription (6 ± 2.8 vs 5 ± 2.9) (All P < .01). The DOACG also took more antihypertensive drugs. The most commonly prescribed DOACs were apixaban (42.9%) followed by rivaroxaban (38.4%) and dabigatran (18.6%). Complete blood count, serum creatinine and coagulation function tests were requested for 69.4%, 75% and 22.2%, respectively, of patients prescribed DAOCs.

CONCLUSIONS

The DOACG had more RCD and drugs per prescription than the noDOACG; routine laboratory monitoring was insufficient. What's known Platelet aggregation inhibitors (low-dose) are recommended for secondary prevention of cardiovascular events in patients suffering from symptomatic atherosclerosis. The main risk of this treatment is bleeding. What's new A prescription for platelet aggregation inhibitors was found in 34% of geriatric inpatients in this prospective study. Compliance to guidelines was better for symptomatic peripheral artery disease than for primary prevention in accordance with recent publications. Geriatric comorbidities had no impact on the prescription of platelet aggregation inhibitors. Underuse of platelet aggregation inhibitors was observed in 11.3% of cases and overuse in 13.7% of cases.

[Study of the element secretory glands of a tubicolous polychaete (Pectinaria (= Lagis) koreni) with the help of electron microprobe and ion microanalyzer (author's transl)]

Two histophysical methods (electron microprobe and ion microanalyzer) were used on sections of Annelids in order to study the inorganic composition of cement secretory glands. Mg, Ca and P were demonstrated in large amounts in the secretions, associated with organic matter. Traces, or no, Fe, Al and Si were found. Possibilities of artifacts are discussed, and these results are compared with biochemical methods. A hypothesis is proposed in order to explain the differences observed between biochemical and present results, which suggest, for the hardening of cements a different chemical mechanism to that suggested by Vovelle in annelid Sabellaria alveolata.