Comparison of the prognostic value of eight nutrition-related tools in older patients with cancer: A prospective study

OBJECTIVES

The primary objective of the present study was to evaluate and compare the ability of eight nutrition-related tools to predict 1-year mortality in older patients with cancer.

DESIGN, SETTING AND PARTICIPANTS

We studied older patients with cancer from the ELCAPA cohort and who had been referred for a geriatric assessment at one of 14 participating geriatric oncology clinics in the greater Paris area of France between 2007 and 2018.

MEASUREMENTS

The studied nutrition-related tools/markers were the body mass index (BMI), weight loss (WL) in the previous 6 months, the Mini Nutritional Assessment, the Geriatric Nutritional Risk Index (GNRI), the Prognostic Nutritional Index, the Glasgow Prognostic Score (GPS), the modified GPS, and the C-reactive protein/albumin ratio.

RESULTS

A total of 1361 patients (median age: 81; males: 51%; metastatic cancer: 49%) were included in the analysis. Most of the tools showed a progressively increase in the mortality risk as the nutrition-related risk category worsened (overall p-values <0.02 for all) after adjustment for age, outpatient status, functional status, severe comorbidities, cognition, mood, cancer treatment strategy, tumour site, and tumour metastasis. All the models were discriminant, with a C-index ranging from 0.748 (for the BMI) to 0.762 (for the GPS). The concordance probability estimate ranged from 0.764 (WL) to 0.773 (GNRI and GPS)).

CONCLUSION

After adjustment for relevant prognostic factors, all eight nutrition-related tools/markers were independently associated with 1-year mortality in older patients with cancer. Depending on the time or context of the GA, physicians do not always have the time or means to perform and assess all the tools/markers compared here. However, even when some information is missing, each nutritional tool/marker has prognostic value and can be used in the evaluation.

Evaluation of a delayed liver transplantation strategy for patients with HCC receiving bridging therapy: the DELTA-HCC study

INTRODUCTION

To maximize utility and prevent premature liver transplantation (LT), a delayed LT strategy (DS) was adopted in France in 2015 in patients listed for any single HCC treated with resection or thermal-ablation during waiting phase, postponing LT until recurrence. The purpose of this study was to evaluate DS to make sure that it did not hamper pre and post-LT outcomes in DS patients.

PATIENTS AND METHODS

Patients listed for HCC in France between 2015 and 2018 were studied. After data extraction from the national LT database, 2,025 patients were identified and classified according to 6 groups: single tumor entering DS, single tumor not entering DS, multiple tumors, no curative treatment, untreatable HCC or T1 tumors. 18-months Kaplan-Meier estimates of drop-out for death, too sick to be transplanted or tumor progression before LT, 5-year post-LT HCC recurrence and post LT-survival rates were compared.

RESULTS

Median waiting-time in DS group was 910 days. Pre-LT drop-out probability was significantly lower in DS compare to other groups (13% vs 19%, p=0.0043) and significantly higher in the T1 group (25.4%, p=0.05). Post-LT HCC-recurrence rate in multiples nodules group was significantly higher (19.6%, p= 0.019) and post-LT 5-year survival did not differ among groups with 74% in DS group (p=0.22).

CONCLUSION

The DELTA HCC study shows that DS does not negatively impact neither pre- nor post-LT patients 'outcomes, and has the potential to redistribute organs to patients in more urgent need of LT. It can reasonably be proposed and pursued. The unexpected high risk of drop out in T1 patients seems related to the MELD-based driving rules underserving this subgroup, calling for revision of allocation rules.

IMPACTS AND IMPLICATIONS

To maximize utility and prevent premature liver transplantation (LT), a delayed LT strategy (DS) was adopted in France in 2015. It consists in postponing LT until recurrence in patients listed for any single HCC curatively treated by surgical resection or thermal ablation. The DELTA HCC study was conducted to evaluate this nationwide strategy. It shows in a non-US, European LT program that DS:- does not negatively impact pre- nor post-LT patients 'outcome,- concerns up to 20% of LT candidates-has therefore the potential to redistribute organs to patients in more urgent need of LT. Such a delayed strategy can reasonably be pursued and extended to other LT programs. Of note, an unexpected high risk of drop out in T1 patients, seemingly related to MELD-based offering rules which underserve these patients, calls for further scrutinization and revision of allocation rules in this subgroup.

Prognosis of hospitalized adult patients with respiratory syncytial virus infection: a multicenter retrospective cohort study

OBJECTIVES

Respiratory syncytial virus (RSV) is a common agent of viral respiratory infections with significant morbidity and mortality in adults. The objective of this study is to determine risk factors for mortality, invasive mechanical ventilation and to describe the characteristics of patients who received ribavirin.

METHODS

Retrospective multicenter observational cohort study conducted in Great Paris area hospitals, including patients hospitalized between January 1, 2015 and December 31, 2019 for documented RSV infection. Data were extracted from the AP-HP Health Data Warehouse. The primary endpoint was in-hospital mortality.

RESULTS

1168 patients were hospitalized for RSV infection, including 288 (24.6%) patients who required ICU admission. The median [interquartile range] age of patients was 75 [63-85] years, 54% (n=631/1168) of them were women. In-hospital mortality was 6.6% (n=77/1168) in the whole cohort and 12.8% (n=37/288) in ICU patients. Factors associated with hospital mortality were age>85 years (adjusted odds ratio (aOR)=6.29 95% confidence interval [2.47-15.98]), acute respiratory failure (aOR=2.83 [1.19-6.72]), non-invasive (aOR=12.60 [1.41-112.36]) and invasive mechanical ventilation support (aOR=30.13 [3.17-286.27]) and neutropenia (aOR=13.19 [3.27-53.27]). Factors associated with invasive mechanical ventilation were chronic heart (aOR=1.98 [1.20-3.26]) or respiratory failure (aOR=2.83 [1.67-4.80]), and co-infection (aOR=2.62 [1.60-4.30]). Patients who were treated with ribavirin were significantly younger than others (62 [55-69] vs 75 [63-86] years; p<0.001), more frequently males (n=34/48 (70.8%) vs n=503/1120 (44.9%); p=0.001), and almost exclusively immunocompromised (n=46/48 (95.8%) vs n=299/1120 (26.7%); p<0.001).

CONCLUSIONS

The mortality rate of patients hospitalized with RSV infections was 6.6%. Twenty-five percent of patients required ICU admission.

The Relative Contributions of Occupational and Community Risk Factors for COVID-19 among Hospital Workers: The HOP-COVID Cohort Study

The relative contributions of occupational and community sources of COVID-19 among health-care workers (HCWs) are still subject to debate. In a cohort study at a 2814-bed tertiary medical center (five hospitals) in the Paris area of France, we assessed the proportion of hospital-acquired cases among staff and identified risk factors. Between May 2020 and June 2021, HCWs were invited to complete a questionnaire on their COVID-19 risk factors. RT-PCR and serology test results were retrieved from the virology department. Mixed-effects logistic regression was used to account for clustering by hospital. The prevalence of COVID-19 was 15.6% (n = 213/1369 respondents) overall, 29.7% in the geriatric hospitals, and 56.8% of the infections were hospital-acquired. On multivariable analyses adjusted for COVID-19 incidence and contact in the community, a significantly higher risk was identified for staff providing patient care (especially nursing assistants), staff from radiology/functional assessment units and stretcher services, and staff working on wards with COVID-19 clusters among patients or HCWs. The likelihood of infection was greater in geriatric wards than in intensive care units. The presence of significant occupational risk factors after adjustment for community exposure is suggestive of a high in-hospital risk and emphasizes the need for stronger preventive measures-especially in geriatric settings. Clinicaltrials.gov NCT04386759.

Impact of the COVID-19 pandemic and associated lockdown measures on the management, health, and behavior of the cystic fibrosis population in France during 2020 (MUCONFIN)

Background

Most of the studies on cystic fibrosis (CF) focused on SARS-CoV-2 prevalence and suggested a low incidence of infection in this population. We aimed to assess the impact of the pandemic and related lockdown measures implemented in May 2020 in response to the first wave of SARS-CoV-2 infection on healthcare access, health, and behavior in CF patients.

Methods

A national questionnaire opened online from May 15th, 2020 to June 11^th, 2020 was completed by 751 CF-patients, aged 14 years and over. It comprised questions about access to healthcare, anxiety and depression, smoking, alcohol, drug and psychotropic drug consumption, adherence to CF treatment, and constraints. A semi-structured comprehensive interview was performed no later than 1 month after the end of the lockdown in 16 CF-patients.

Results

The mean age of the population was 28.0 [interquartile range (IQR) 20.0-37.0] years old. More than 75% of in-person consultations scheduled during the lockdown were canceled. Alternatively, 27% were postponed, and telehealth consultations were proposed and accepted in almost 40% of cases. More than 75% of the scheduled physiotherapy sessions were canceled and replaced mainly by self-drainage. Annual follow-up clinic visits were consistently postponed whereas required hospitalizations at CF centers for exacerbation were maintained in most cases. While 43.2% CF-patients had signs of anxiety, 51.0% presented symptoms of depression, both associated with increased use of psychotic medications and inversely correlated to COVID-19 prevalence. Among the lower and lower middle classes, very little medical information was obtained or requested by the patient, participation to sports or other activities was low, while excessive home confinement and isolation were more frequent. In contrast, in the upper middle and upper classes, individuals solicitated help to their CF centre, had more physical activities, and maintained contact with friends or families.

Conclusion

The first lockdown in France had only minimal impact on the management care of CF-patients but was associated with increased symptoms of anxiety and depression, together with behavioral changes that varied with social class.

Trial registration

NCT04463628.

More than a third of middle-aged adults (50-65) have understated executive dysfunction

OBJECTIVES

Understated executive dysfunction (UED) is predictive of cognitive decline and death. We aimed to assess the prevalence of UED, assessed with the clock-drawing test (CDT) and the Frontal Assessment Battery (FAB) in middle-aged adults and to investigate associated characteristics.

METHODS

Cross-sectional analysis of data on 516 community-dwellers aged 50-65, lacking cognitive complaints, who were included prospectively (2010-2017) after a multidimensional geriatric assessment at a "healthy ageing" outpatient clinic. Age- and educational-level-adjusted logistic models were used to assess factors associated with UED.

RESULTS

The CDT and FAB were impaired in 27.7% and 14.7% of the participants (median age: 59.7 years). The prevalence [95% confidence interval (CI)] of UED was 36.2% [32.2-40.5%]. After adjustment for age and education, participants with UED were more likely to be obese (odds ratio [95%CI] = 1.89 [1.12-3.19], P = 0.02), and to have a metabolic syndrome (1.98 [1.06-3.72], P = 0.03).

CONCLUSION

More than one third of middle-aged adults without cognitive complaints have UED, which was linked to obesity and metabolic syndrome. Cognitive screening tests targeting executive functions might be useful for early detection of UED and the initiation of multidomain interventions improving cognitive performance.

Mycotic/Infective Native Aortic Aneurysms: Results After Preferential Use of Open Surgery and Arterial Allografts

OBJECTIVE

Mycotic/infective native aortic aneurysms (INAA) are managed heterogeneously. In the context of disparate literature, this study aimed to assess the outcomes of INAA surgical management and provide comprehensive data in alignment with recent suggestions for reporting standards.

METHODS

A retrospective review of patients presenting with INAA from September 2002 to March 2020 at two institutions was conducted. In hospital mortality, 90 day mortality, overall mortality, and infection related complications (IRCs) were the study endpoints. Overall survival and IRC free survival were estimated, and predictors of mortality tested using uni- and multivariable analyses.

RESULTS

Seventy patients (60 men [86%], median age 68 years [range 59 - 76 years]) were included. Twenty (29%) were ruptured at presentation. INAA location was thoracic in 11 (16%) cases, thoraco-abdominal in seven (10%), and abdominal in 50 (71%). Half of the abdominal INAAs were suprarenal. Two INAAs were concomitantly abdominal and thoracic. Pathogens were identified in 83%. The bacterial spectrum was scattered, with rare Salmonella species (n = 6; 9%). Open surgical repair was performed in 66 (94%) patients, including five conversions of initially attempted endovascular grafts (EVAR), three hybrid procedures, and one palliative EVAR. Vascular substitutes were cryopreserved arterial allografts (n = 67; 96%), prosthesis (n = 2), or femoral veins (n = 1). Kaplan-Meier estimates of overall survival at 30 and 90 days were 87% (95% confidence interval [CI] 76.6 - 93.0) and 71.7% (95% CI 59.2 - 80.9), respectively. The overall in hospital mortality rate was 27.9% (95% CI 1.8 - 66.5). IRCs occurred in seven (10%) patients. The median follow up period was 26.5 months (range 13.0-66.0 months). Chronic kidney disease (CKD) was independently related to in hospital mortality (odds ratio [OR] 20.7, 95% CI 1.8 - 232.7). American Society of Anesthesiologists score of 3 (OR 6.0, 95% CI 1.1 - 33.9), 4 (OR 14.9, 95% CI 1.7 - 129.3), and CKD (OR 32.0, 95% CI 1.2 - 821.5) were related to 90 day mortality.

CONCLUSION

Surgical INAA management has significant mortality and a low re-infection rate. EVAR necessitated secondary open repair, but its limited use in this report did not allow conclusions to be drawn.

Exercise Interventions With Trained Home Helpers for Preventing Loss of Autonomy and Falls in Community-Dwelling Older Adults Receiving Home Heath Physical Therapy T4H: A Randomized Controlled Pilot Study

BACKGROUND AND PURPOSE

Older adults at risk for falls live independently in the community in their own home and have rehabilitation needs. However, little is known about whether home coaching of older adults can decrease falls at home. We sought to determine whether a novel program for preventing falls and a loss of exercise capacity, the T4H program, in which home helpers act as exercise coaches by using an information technology (IT) device, was acceptable and feasible.

METHODS

Between February 2015 and October 2015, we performed a cluster randomized controlled trial in which home helpers either assisted older adults 75 years and over, to participate in the T4H program, or provided standard home help over 3 months. We assessed levels of acceptability and satisfaction among the older adults and home helpers with regard to the exercise program and the technologies used. To measure efficacy, the main outcome measures for the older adults were the absence of falls requiring medical or paramedical care, unplanned hospitalizations, walking ability in a Timed Up and Go test (TUG), and self-care ability by the Barthel Index at the 3-month follow-up visit.

RESULTS AND DISCUSSION

Overall, 35 older adults were included, aged 89 years and with 68.6% women. Eighty-five percent of the respondents were pleased or very pleased to have participated in the T4H exercise program, 70% were satisfied with the IT devices, and 92% were satisfied with their home helper's level of involvement. Two of the 4 home helper respondents were satisfied or very satisfied with the exercise program, and 2 were moderately satisfied. The proportions of older adult participants with no falls or no unplanned hospitalizations were higher in the T4H group (92.3% and 85.7%, respectively) than in the control group (81.8% and 71.4%, respectively), although these intergroup differences were not statistically significant. The T4H and control groups did not differ significantly with regard to the TUG time (median [IQR]: 27.6 seconds [17.9-58.6] vs 30.7 seconds [19.7-57.2], respectively) or the Barthel Index (median [IQR]: 90 [75-95] and 90 [75-95], respectively).

CONCLUSIONS

The novel T4H home help model was feasible and was associated with a high level of participant satisfaction. We observed a trend toward fewer falls and hospitalizations and better quality of life in the older adults.

Several frailty parameters highly prevalent in middle age (50-65) are independent predictors of adverse events

Although frailty can arise in middle age, very few studies have investigated frailty before 65 years. Our objectives were to assess the prevalence of frailty parameters in middle-aged individuals and probe the association with future adverse events. We performed cross-sectional and longitudinal analyses of community-dwelling individuals aged 50 to 65 (n = 411, median age: 59.0) having undergone a multidomain geriatric assessment (2010–2015) in an outpatient clinic in the greater Paris area of France (SUCCEED cohort). The primary outcome was a composite measure of adverse events (non-accidental falls, fractures, unplanned hospitalizations, death), recorded in 2016/2017. Multivariable logistic regression models were built to identify independent predictors. Six frailty parameters were highly prevalent (> 20%): low activity (40.1%), exhaustion (31.3%), living alone (28.5%), balance impairment (26.8%), weakness (26.7%), and executive dysfunction (23.2%). Female sex (odds ratio: 2.67 [95% confidence interval: 1.17–6.11]), living alone (2.39 [1.32–4.33]), balance impairment (2.09 [1.16–3.78]), executive dysfunction (2.61, [1.18–5.77]), and exhaustion (2.98 [1.65–5.39]) were independent predictors of adverse events. Many frailty parameters are already altered in middle-aged individuals and are predictive of adverse health events. Our findings highlight a possible need for frailty screening and preventive programs targeting middle-aged individuals.

Most randomized controlled trials for psoriasis used placebo comparators despite the availability of effective treatments

BACKGROUND

The availability of effective treatments for psoriasis raises ethical questions about the use of a placebo group in therapeutic trials. We evaluated the use of the placebo over time in such trials.

METHODS

From trials in a living Cochrane review and network meta-analysis for psoriasis, we included trials comparing a biologic to a placebo or other systemic treatment. First, we tested the changes in placebo rate from 2001 to 2019 by linear regression, then constructed networks for 2004-2019 and evaluated the contribution of the placebo to the network meta-analysis estimates per trial and per comparison.

RESULTS

We included 81 trials (36,774 patients). The placebo rate did not decrease significantly over time. The proportion contribution of trials with a placebo decreased from 100% in 2004 to 86% in 2008 and 75% in 2019. However, the proportion contribution of trials without a placebo remained low (from 0% in 2004 to 25% in 2019).

CONCLUSION

The design of future psoriasis trials should be reviewed to improve the number of patients to be included in a placebo group.

Individual red blood cell fetal hemoglobin quantification allows to determine protective thresholds in sickle cell disease

Polymerization of the sickle hemoglobin (HbS) is a key determinant of sickle cell disease (SCD), an inherited blood disorder. Fetal hemoglobin (HbF) is a major modulator of the disease severity by both decreasing HbS intracellular concentration and inhibiting its polymerization. However, heterocellular distribution of HbF is common in SCD. For HbS polymerization inhibition, the hypothesis of an "HbF per red blood cell (HbF/RBC) threshold" requires accurate measurement of HbF in individual RBC. To date, HbF detection methods are limited to a qualitative measurement of RBC populations containing HbF - the F cells, which are variable. We developed an accurate method for HbF quantification in individual RBC. A linear association between mean HbF content and mean RBC fluorescence by flow cytometry, using an anti-Human-HbF antibody, was obtained from non-SCD subjects presenting homogeneous HbF distribution. This correlation was then used to measure HbF/RBC. Hydroxyurea (HU) improves SCD clinical manifestations, mainly through its ability to induce HbF synthesis. The HbF distribution was analyzed in 14 SCD patients before and during HU treatment. A significant decrease in RBC population containing less than 2 pg of HbF/RBC was observed. Therefore, we tested associations for %RBC above different HbF/RBC thresholds and showed a decrease in the pathognomonic vaso-occlusive crisis incidence from the threshold of 4 pg. This quantity was also correlated with the level of sickle RBC after in vitro deoxygenation. This new method allows the comparison of HbF/RBC distributions and could be a useful tool to characterize baseline patients HbF distribution and therapeutic response to HbF inducers.

Functional decline in geriatric rehabilitation ward; is it ascribable to hospital acquired infection? A prospective cohort study

BACKGROUND

In some European countries, including France, older patients with functional decline in acute units are transferred to geriatric rehabilitation units. Some patients may not benefit from their stay in a geriatric rehabilitation unit and paradoxically worsened their functional status. Previous prognostic models of functional decline are based on only baseline parameters. However, some events can occur during rehabilitation and modify the association between baseline parameters and rehabilitation performance such as heart failure episode, falls or hospital-acquired infection (HAI). The incidence of functional decline in these units and factors associated with this decline have not been clearly identified.

METHODS

We used a prospective cohort of consecutive patients aged ≥75 years admitted to a geriatric rehabilitation unit in a French university hospital. The main endpoint was functional decline defined by at least an one-point decrease in Activities of Daily Living (ADL) score during the stay. Baseline social and geriatric characteristics were recorded and comorbidities were sought by the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). During follow-up, hospital-acquired infection (HAI) was recorded, as was ADL score at discharge. Multivariate logistic regression and mediation analyses were used to identify factors associated with ADL decrease.

RESULTS

Among the 252 eligible patients, 160 (median age 84 years [interquartile range (IQR) 80-88] had available ADL scores at baseline (median score 7 [IQR 4-10]) and at discharge (median 9 [6-12]). Median CIRS-G score was 11 [8-13], 23 (14%) had a pulmonary HAI; 28 (17.5%) showed functional decline. On multivariable analysis, functional decline was associated with comorbidities (global CIRS-G score, P = 0.02, CIRS-G for respiratory disease [CIRS-G-R] ≥2, P = 0.02, or psychiatric disease, P = 0.02) and albumin level < 35 g/l (p = 0.03). Significant associations were found between functional decline and CIRS-G-R (OR 3.07 [95%CI 1.27-7.41], p = 0.01), between functional decline and pulmonary HAI (OR 3.12 [1.17-8.32],p = 0.02), and between CIRS-G-R and pulmonary HAI (OR 12.9[4.4-37.7], p = 0.0001). Theses associations and the reduced effect of CIRS-G-R on functional decline after adjusting for pulmonary HAI (OR 2.26 [0.83-6.16], p = 0.11) suggested partial mediation of pulmonary HAI in the relation between CIRS-G-R and functional decline.

CONCLUSION

Baseline comorbidities were independently associated with functional decline in patients hospitalized in a geriatric rehabilitation unit. Pulmonary HAI may have mediated this association. We need to better identify patients at risk of functional decline before transfer to a rehabilitation unit and to test the implementation of modern and individual programs of rehabilitation outside the hospital for these patients.

Prediction of overall survival in patients with hepatocellular carcinoma treated with Y-90 radioembolization by imaging response criteria

PURPOSE

To evaluate the potential of imaging criteria in predicting overall survival of patients with hepatocellular carcinoma (HCC) after a first transcatheter arterial yttrium-90 radioembolization (TARE) MATERIALS AND METHODS: From October 2013 to July 2017, 37 patients with HCC were retrospectively included. There were 34 men and 3 women with a mean age of 60.5±10.2 (SD) years (range: 32.7-78.9 years). Twenty-five patients (68%) were Barcelona Clinic Liver Cancer (BCLC) C and 12 (32%) were BCLC B. Twenty-four primary index tumors (65%) were>5cm. Three radiologists evaluated tumor response on pre- and 4-7 months post-TARE magnetic resonance imaging or computed tomography examinations, using Response Evaluation Criteria in Solid Tumors (RECIST) 1.1, modified RECIST (mRECIST), European Association for Study of the Liver (EASL), volumetric RECIST (vRECIST), quantitative EASL (qEASL) and the Liver Imaging Reporting and Data System treatment response algorithm. Kaplan-Meier survival curves were used to compare responders and non-responders for each criterion. Univariate and multivariate Cox proportional hazard ratio (HR) analysis were used to identify covariates associated with overall survival. Fleiss kappa test was used to assess interobserver agreement.

RESULTS

At multivariate analysis, RECIST 1.1 (HR: 0.26; 95% confidence interval [95% CI]: 0.09-0.75; P=0.01), mRECIST (HR: 0.22; 95% CI: 0.08-0.59; P=0.003), EASL (HR: 0.22; 95% CI: 0.07-0.63; P=0.005), and qEASL (HR: 0.30; 95% CI: 0.12-0.80; P=0.02) showed a significant difference in overall survival between responders and nonresponders. RECIST 1.1 had the highest interobserver reproducibility.

CONCLUSION

RECIST and mRECIST seem to be the best compromise between reproducibility and ability to predict overall survival in patients with HCC treated with TARE.

The obesity paradox for mid- and long-term mortality in older cancer patients: a prospective multicenter cohort study

BACKGROUND

Overweight and obesity are associated with adverse health outcomes. However, substantial literature suggests that they are associated with longer survival among older people. This "obesity paradox" remains controversial. In the context of cancer, the association between overweight/obesity and mortality is complicated by concomitant weight loss (WL). Sex differences in the relation between BMI (in kg/m2) and survival have also been observed.

OBJECTIVES

We studied whether a high BMI was associated with better survival, and whether the association differed by sex, in older patients with cancer.

METHODS

We studied patients aged ≥70 y from the ELCAPA (Elderly Cancer Patients) prospective open cohort (2007-2016; 10 geriatric oncology clinics, Greater Paris urban area). The endpoints were 12- and 60-mo mortality. We created a variable combining BMI at cancer diagnosis and WL in the previous 6 mo, and considered 4 BMI categories-underweight (BMI < 22.5), normal weight (BMI = 22.5-24.9), overweight (BMI = 25-29.9), and obesity (BMI ≥ 30)-and 3 WL categories-<5% (minimal), 5% to <10% (moderate), and ≥10% (severe). Univariate and multivariate Cox proportional hazards analyses were conducted in men and women.

RESULTS

A total of 2071 patients were included (mean age: 81 y; women: 48%; underweight: 30%; normal weight: 23%; overweight: 33%; obesity: 14%; predominant cancer sites: colorectal (18%) and breast (16%); patients with metastases: 49%). By multivariate analysis, obese women with WL < 5% had a lower 60-mo mortality risk than normal-weight women with WL < 5% (adjusted HR: 0.56; 95% CI: 0.37, 0.86; P = 0.012). Overweight/obese women with WL ≥ 5% did not have a lower mortality risk than normal-weight women with WL < 5%. Overweight and obese men did not have a lower mortality risk, irrespective of WL.

CONCLUSIONS

By taking account of prediagnosis WL, only older obese women with cancer with minimal WL had a lower mortality risk than their counterparts with normal weight.This trial was registered at clinicaltrials.gov as NCT02884375.

Promoting patients' rights at the end of life in a geriatric setting in France: The healthcare professionals' level of knowledge about surrogate decision-makers and advance directives

OBJECTIVE

To assess levels of knowledge about patients' rights, surrogate decision-makers, and advance directives among healthcare professionals at three hospitals in France.

METHODS

A multicenter, cross-sectional study in three geriatric hospitals in the Paris area (France) in 2015. The participants' level of knowledge was assessed via an 18-item self-questionnaire on surrogate decision-makers, advance directives, and end-of-life decision-making. The characteristics associated with a good level of knowledge were assessed using logistic regression.

RESULTS

Among the 301 healthcare professionals (median ± standard deviation age: 40.4 ± 10.2 years; women: 73.4 %), only 15.0 % (95 % confidence interval (CI): [19.7-29.5]) correctly answered at least 75 % of the questions on patients' rights. Respectively 24.6 % [19.7-29.5], 36.5 % [31.1-42.0] and 37.5 % [32.0-43.0] had sufficient knowledge regarding "surrogate decision-maker", "advance directives", and "decision-making at the end of life". In a multivariable analysis, the only factor significantly associated with a good level of knowledge about end-of-life policy was employment in a university hospital, with a non-significant trend for status as a physician.

CONCLUSIONS

Our survey of staff working in geriatric care units highlighted the poor overall level of knowledge about healthcare surrogates and advance directives; the results suggest that additional training in these concepts is required.

PRACTICE IMPLICATIONS

Continuing education of healthcare professionals on advance directives and surrogate decision-maker should be promoted to ensure rights of elderly patients at the end of life.

Understated Cognitive Impairment Assessed with the Clock-Drawing Test in Community-Dwelling Individuals Aged ≥50 Years

OBJECTIVES

To estimate the prevalence of understated cognitive impairment by administering the Clock-Drawing Test (CDT) to community-dwelling individuals aged ≥50 years and to investigate the associated clinical phenotype.

DESIGN

A cross-sectional analysis of baseline data on community-dwelling individuals assessed at an outpatient clinic in the Paris region of France.

SETTING AND PARTICIPANTS

Participants aged ≥50 years (n = 488, median age: 62.1 years) prospectively included in the SUCCessful agEing outpatiEnt's Department survey between 2010 and 2014.

METHODS

A multidimensional geriatric assessment, including cognition [7-point CDT, Mini-Mental State Examination (MMSE), the 5-word screening test (5-WT), and the Frontal Assessment Battery (FAB)], gait speed in dual tasks, mood [the Geriatric Depression Scale (GDS)], balance, physical functions (gait speed and handgrip strength), nutrition, bone density, and comorbidities; major cardiovascular risk factors, and Scheltens and Fazekas scores on brain magnetic resonance imaging. Baseline characteristics were analyzed as a function of the CDT score (<7 vs 7), using age-adjusted logistic models.

RESULTS

The prevalence of impairment in the CDT was 23.6%; higher than the values for the MMSE (12.7%), 5-WT (2.3%), and FAB (16.6%). In age-adjusted analyses, a lower educational level (odds ratio [95% confidence interval] = 0.72 [0.58‒0.89]), diabetes (2.57 [1.14‒5.79]), metabolic syndrome (1.93 [1.05‒3.56]), lower gait speed in the cognitive dual task (1.27 [1.05‒1.53]), a poorer Geriatric Depression Scale score (1.86 [1.04‒3.32]), a poorer MMSE score (2.56 [1.35‒4.88]), a poorer FAB score (1.79 [1.01‒3.16]), impaired episodic memory in the 5-WT (4.11 [1.12‒15.02]), and a higher Scheltens score (P = .001) were significantly associated with CDT impairment.

CONCLUSIONS AND IMPLICATIONS

Understated cognitive impairment is common among young seniors and is associated with factors known to be linked to a higher risk of cognitive decline and dementia. These findings suggest that the CDT may be of value for identifying high-risk individuals who may then benefit from targeted multidomain prevention actions (diet, exercise, cognitive training, and vascular risk factor management).

CBCT-Based Image Guidance for Percutaneous Access: Electromagnetic Navigation Versus 3D Image Fusion with Fluoroscopy Versus Combination of Both Technologies-A Phantom Study

PURPOSE

We set out to compare three types of three-dimensional CBCT-based imaging guidance modalities in a phantom study: image fusion with fluoroscopy (IF), electromagnetic navigation (EMN) and the association of both technologies (CEMNIF).

MATERIALS AND METHODS

Four targets with a median diameter of 11 mm [first quartile (Q1): 10; third quartile (Q3): 12] with acute angle access (z-axis < 45°) and four targets of 10 mm [8-15] with large angle access (z-axis > 45°) were defined on an abdominal phantom (CIRS, Meditest, Tabuteau, France). Acute angle access targets were punctured using IF, EMN or CEMNIF and large angle access targets with EMN by four operators with various experiences. Efficacy (target reached), accuracy (distance between needle tip and target center), procedure time, radiation exposure and reproducibility were explored and compared.

RESULTS

All targets were reached (100% efficacy) by all operators. For targets with acute angle access, procedure times (EMN: 265 s [236-360], IF: 292 s [260-345], CEMNIF: 320 s [240-333]) and accuracy (EMN: 3 mm [2-5], IF: 2 mm [1-3], CEMNIF: 3 mm [2-4]) were similar. Radiation exposure (EMN: 0; IF: 708 mGy.cm² [599-1128]; CEMNIF: 51 mGy.cm² [15-150]; p < 0.001) was significantly higher with IF than with CEMNIF and EMN. For targets with large angle access, procedure times (EMN: 345 s [259-457], CEMNIF: 425 s [340-473]; p = 0.01) and radiation exposure (EMN: 0, CEMIF: 159 mGy.cm² [39-316]; p < 0.001) were significantly lower with EMN but with lower accuracy (EMN: 4 mm [4-6] and CEMNIF: 4 mm [3, 4]; p = 0.01). The operator's experience did not impact the tested parameters regardless of the technique.

CONCLUSION

In this phantom study, EMN was not limited to acute angle targets. Efficacy and accuracy of puncture for acute angle access targets with EMN, IF or CEMNIF were similar. CEMNIF is more accurate for large angle access targets at the cost of a slightly higher procedure time and radiation exposure.

Identification of five frailty profiles in community-dwelling individuals aged 50-75: A latent class analysis of the SUCCEED survey data

OBJECTIVES

We sought to identify frailty profiles in individuals aged 50-75 by considering frailty as an unobservable latent variable in a latent class analysis (LCA).

STUDY DESIGN

589 prospectively enrolled community-dwelling individuals aged 50-75 (median: 61.7 years) had undergone a standardized, multidomain assessment in 2010-2015. Adverse health outcomes (non-accidental falls, fractures, unplanned hospitalizations, and death) that had occurred since the assessment were recorded in 2016-2017.

MAIN OUTCOME MEASURES

The LCA used nine indicators (unintentional weight loss, relative slowness, weakness, impaired balance, osteoporosis, impaired cognitive functions, executive dysfunction, depression, and hearing impairment) and three covariates (age, gender, and consultation for health complaints). The resulting profiles were characterized by the Fried phenotype and adverse health outcomes.

RESULTS

We identified five profiles: "fit" (LC1, 29.7% of the participants; median age: 59 years); "weight loss, relative slowness, and osteoporosis" (LC2, 33.2%; 63 years); "weakness and osteopenia" (LC3, 21.9%; 60 years); "impaired physical and executive functions" (LC4, 11%; 67 years); and "impaired balance, cognitive functions, and depression" (LC5, 4.3%; 70 years). Almost all members of LC3 and LC4 were female, and were more likely than members of other profiles to have a frail or pre-frail Fried phenotype. Non-accidental falls were significantly more frequent in LC4. LC5 (almost all males) had the highest number of comorbidities and cardiovascular risk factors but none was frail.

CONCLUSIONS

Our data-driven approach covered most geriatric assessment domains and identified five frailty profiles. With a view to tailoring interventions and prevention, frailty needs to be detected among young seniors.

Obesity paradox in older cancer patients for middle and long-term mortality: A prospective multicenter cohort study of 2,071 patients

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Background: Overweight and obesity are associated with numerous adverse health outcomes. However, among older adults, substantial literature suggests an improved survival among overweight and obese patients. This phenomenon, referred to as the “obesity paradox” remains controversial. In the context of cancer, the association between overweight/obesity and mortality is complex due to the concomitant weight loss and cachexia. We aim to assess the impact of high Body Mass Index (BMI) on mortality in a large population of older cancer patients. Methods: We studied patients aged ≥70 from the ELCAPA prospective open-cohort (2007-2016; 10 geriatric oncology clinics, Great Paris urban area). Endpoints were 12- and 48-months mortality. A variable combining BMI at cancer diagnosis and weight loss (in the 6 months preceding the diagnosis) was created. BMI categories considered: underweight, (BMI < 22.4kg/m²), normal weight (BMI 22.5-24.9), overweight (BMI 25-29.9), and obese (BMI ≥30); weight loss (WL) categories: < 5%, 5- < 10%, ≥10%. Univariate and multivariate Cox proportional-hazards analysis were conducted in males and females. Results: A total of 2071 patients were included (mean age, 81; female, 48%; metastases, 49%; main localizations: digestive (37%), urinary (26%), breast (16%); underweight (30%), normal weight (23%), overweight (33%), obese (14%)). After adjustment for age, smoking, inpatient status, cancer site, metastasis, performance status and comorbidities, overweight women with < 5% WL were at lower risk of 12- and 48-months mortality compared to normal weight women with < 5% WL (aHR = 0.56; p = 0.043 and 0.65; p = 0.031, respectively). Obese women with < 5% WL had a lower mortality risk only at 48-months (aHR = 0.63; p = 0.036). The obesity paradox was stronger in overweight metastatic women. Overweight or obese women with 5- < 10% or ≥10% WL had no reduced risk of mortality compared to normal weight women. Overweight and obese men had no reduced risk of mortality irrespective of weight loss. Conclusions: By taking into account initial weight loss, we did not found evidence for obesity paradox in older patients with cancer except in the subgroup of women with minimal weight loss. Clinical trial information: NCT02884375.

Prognostic value of routine biomarkers in older patients with cancer: Pooled analysis of three prospective cohorts

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Background: To assess prognostic value of routine biomarkers in older patients with cancer. Methods: A pooled analysis of three prospective multicentre cohorts, ELCAPA, PHRC Aquitaine and ONCODAGE was conducted. Patients aged 70 years or older, with cancer were included. Biomarkers collected were plasmatic C-reactive protein, albumin and a combined score: Glasgow Prognostic Score (GPS). The GPS comprised three categories (0: CRP≤10 mg/L, albumin≥35 g/L; 1: CRP≤10 mg/L and albumin < 35 g/L, or CRP > 10 mg/L and albumin≥35 g/L; 2: CRP > 10 mg/L and albumin < 35 g/L).The primary endpoint was overall survival at 12 months. Multivariable Cox models were used, adjusting for age, sex, localisation, metastatic status, performance status, frailty screening index, the G8. Discriminative properties were assessed using Harrell C index and NRI (Net Reclassification Improvement). Results: Overall 1800 patients were analyzed (ELCAPA: N = 543, PHRC Aquitaine: N = 253, ONCODAGE: N = 1004; mean age: 78.5±5.5 years; 61.7% of men; 37% metastatic; most frequent localisations: breast (34.9%) and colon-rectum (17.7%); 70.7% of patients screened at risk of frailty with G8). Overall survival was 71.1%. GPS was independently associated with death (among normal G8: GPS 1: Hazard Ratio (HR) = 4.48; 95% Confidence Interval (95% CI) = [2.03; 9.89], GPS 2: 11.64 [4.54; 29.81], among abnormal G8: GPS 1: 2.45 [1.79; 3.34], GPS 2: 3.97 [2.93; 5.37]. The addition of GPS to the clinical model (Harell C: 0.82 [0.80; 0.83]) improved discrimination (Harell C: 0.84 [0.82; 0.85], NRI: 11% [5; 19]). Conclusions: GPS could be used in older patients with cancer to help decision-making and prognosis assessment.

Trends in hospitalization rates for psoriasis flares since the introduction of biologics: a time series in France between 2005 and 2015

BACKGROUND

In the late 2000s, the introduction of biologics transformed the prognosis for patients with moderate-to-severe psoriasis. We hypothesized that treatment with biologics may associate with a reduction in the hospitalization rate for psoriasis flares.

OBJECTIVE

To analyse changes over time in the hospitalization rate for psoriasis flares.

METHODS

We included inpatient stays in any of nine French hospitals between 2005 and 2015 for a psoriasis flare, as documented in the national inpatient database. In two centres, we also analysed data from the individual patients' electronic medical records.

RESULTS

A total of 3572 stays were included. The introduction of biologics was not associated with a decrease in the number of hospitalizations for a psoriasis flare; on the contrary, we observed a non-significant increase in the number of hospitalizations (13 hospitalizations for psoriasis flares per quarter per 10 000 beds). In the two-centre study, the introduction of biologics was associated with a significant increase in the hospitalization of patients receiving topical treatments only (520 hospitalizations per year per 10 000 beds) and those with a first psoriasis flare.

CONCLUSION

The number of hospitalizations for a psoriasis flare tended to increase between 2005 and 2015. The availability of additional treatment options might have increased patient demand and/or broadened the indications in clinical practice.

Screening for frailty in community-dwelling elderly subjects: Predictive validity of the modified SEGA instrument

AIMS

To study the capacity of the SEGAm instrument to predict loss of independence among elderly community-dwelling subjects.

METHODS

The study was performed in four French departments (Ardennes, Marne, Meurthe-et-Moselle, Meuse). Subjects aged 65 years or more, living at home, who could read and understand French, with a degree of autonomy corresponding to groups 5 or 6 in the AGGIR autonomy evaluation scale were included. Assessment included demographic characteristics, comprehensive geriatric assessment, and the SEGAm instrument at baseline. Subjects had follow-up visits at home at 6 and 12 months. During follow-up, vital status and level of independence were recorded. Logistic regression was used to study predictive validity of the SEGAm instrument.

RESULTS

Among the 116 subjects with complete follow-up, 84 (72.4%) were classed as not very frail at baseline, 23 (19.8%) as frail, and 9 (7.8%) as very frail; 63 (54.3%) suffered loss of at least one ADL or IADL at 12 months. By multivariable analysis, frailty status at baseline was significantly associated with loss of independence during the 12 months of follow-up (OR=4.52, 95% CI=1.40-14.68; p=0.01). We previously validated the SEGAm instrument in terms of feasibility, acceptability, internal structure validity, reliability, and discriminant validity.

CONCLUSIONS

This instrument appears to be a suitable tool for screening frailty among community-dwelling elderly subjects, and could be used as a basis to plan early targeted interventions for subjects at risk of adverse outcome.

Risk of Rectal Neoplasia after Colectomy and Ileorectal Anastomosis for Ulcerative Colitis

BACKGROUND AND AIMS

Colectomy can be required in the management of ulcerative colitis [UC]. While ileal-pouch anal anastomosis [IPAA] is the recommended reconstruction technique, ileorectal anastomosis [IRA] is still performed and might present some advantages. However, the risk of rectal neoplasia might limit its indication. The aims of our study were to determine the incidence of rectal neoplasias following IRA for UC and to identify risk factors associated with rectal carcinomas.

METHODS

We performed a multicenter retrospective study including patients who underwent IRA for UC from 1960 to 2014 in 13 centers. Cox-proportional hazard models were used to determine carcinoma-associated risk factors.

RESULTS

A total of 343 patients were included, with a median follow-up of 10.4 years after IRA. At the end of follow-up, 38 rectal neoplasias (including 19 carcinomas) were diagnosed, and 7 patients [2%] had either died from rectal carcinoma or had a metastatic disease. Incidences of rectal carcinoma after IRA for UC were estimated at 3.2% at 10 years and at 7.3% at 20 years, whereas incidences of neoplasia were estimated at 7.1% and 14% at 10 and 20 years, respectively. In multivariate analysis, age at IRA, IBD duration, primary sclerosing cholangitis [PSC] and history of prior colonic carcinoma were independently associated with the risk of rectal carcinoma following IRA.

CONCLUSION

The risk of rectal carcinoma in patients with IRA for UC remains, and this justifies long-term endoscopic surveillance. Either IPAA or end ileostomy should be considered in 'high-risk' patients i.e. those with PSC and/or with prior colonic neoplasia.

Screening for frailty in elderly subjects living at home: validation of the Modified Short Emergency Geriatric Assessment (SEGAm) instrument

OBJECTIVES

To validate the modified version of the Short Emergency Geriatric Assessment (SEGAm) frailty instrument in elderly people living at home.

DESIGN

Longitudinal, prospective, multicentre study.

SETTING

Four departments (Ardennes, Marne, Meurthe-et-Moselle, Meuse) in two French Regions (Champagne-Ardenne and Lorraine).

PARTICIPANTS

Subjects aged 65 years or more, living at home, who could read and understand French, with a degree of autonomy corresponding to groups 5, or 6 in the AGGIR autonomy evaluation scale.

MEASUREMENTS

Assessment included demographic characteristics, comprehensive geriatric assessment, and the SEGAm instrument. Psychometric validation was used to study feasibility and acceptability, internal structure validity, reliability, and discriminant validity of the SEGAm instrument.

RESULTS

Between July 1st 2012 and March 31st 2013, 167 patients were included in the study. Averaged age was 77±7 years, the majority were women (70.7%). Feasibility and acceptability of the SEGAm instrument were excellent: we observed no refusal to participate, no drop-out during administration, no missing items, no ceiling or floor effects, and the administration time was short (5.0±3.5 min). By factor analysis, the instrument proved to be unidimensional. It showed good internal consistency (Cronbach's alpha coefficient: 0.68) and good test-retest (intra-class correlation: 0.88) at 7 days interval. Discriminant validity showed a significant difference, mainly for nutritional status, fall risk, dependency, mood and depression risk, and comorbidities.

CONCLUSION

Based on these psychometric properties, the SEGAm appears to be an easy-to-use instrument that is particularly suitable for use in the community to identify frail elderly people who could benefit from early targeted interventions.