Glomerular filtration rate estimated by Cockcroft-Gault formula better predicts anti-Xa levels than modification of the diet in renal disease equation in older patients with prophylactic enoxaparin

OBJECTIVES

Older people have an increased risk of low molecular weight heparin accumulation leading to an increased bleeding risk. The objective of this study was to assess whether reduced glomerular filtration rate (GFR), estimated by the Cockcroft-Gault or modification of the diet in renal disease (MDRD) equations, indicates drug accumulation by increased anti-Xa levels in older subjects receiving prophylactic enoxaparin treatment.

DESIGN

Cohort study.

SETTING

Acute geriatric units in Nancy Hospital.

PARTICIPANTS

Ninety-two consenting consecutive patients, 65 and older, confined to bed for an acute medical condition requiring enoxaparin for prevention of venous thromboembolism, and hospitalized for at least six days were enrolled.

MEASUREMENTS

Serum creatinine and peak plasma anti-Xa levels 3 to 4 hours after the daily injection of enoxaparin were measured at days 3, 6, 9 and 12 (first dose of enoxaparin at day one). Analyses of variance for repeated measures were used to evaluate significant predictors of peak anti-Xa activity in univariate and multivariate analyses.

RESULTS

A significant correlation was observed between anti-Xa activity and GFR estimated with the Cockcroft formula r=0.43. Following univariate analysis, the three factors associated with higher anti-Xa levels were a lower Cockcroft-Gault GFR (p=0.0002), female gender (p=0.0003) and a lower bodyweight (p<.0001). No significant association between anti-Xa levels and MDRD GFR (p=0.33) was observed. Following multivariate analysis, female gender (p=0.02), bodyweight (p=0.04) and Cockcroft GFR (p=0.05) remained independent determinants of anti-Xa levels.

CONCLUSION

In hospitalized patients older than 65 years old, the Cockcroft-Gault equation, in contrast to the MDRD equation, is able to predict the risk of higher anti-Xa levels.

Study of Mini-Mental State Exam evolution in community-dwelling subjects aged over 60 years without dementia

OBJECTIVE

In recent years, the Mini-Mental State Examination (MMSE) has been widely used and has been proposed for cognitive decline screening in the framework of a systematic geriatric evaluation in health centers. The aim of the present longitudinal study was to identify the potential determinants of MMSE score and its evolution over a 4-year period in a population aged over sixty years with good general health without dementia and consulting for a health check-up.

DESIGN

Longitudinal study.

SETTING

The preventive medical center (CMP) in Nancy.

PARTICIPANTS

687 subjects over 60 years of age (mean age 65.6 ± 5.07 years) were included from the Senior health examination study.

MEASUREMENTS

All subjects underwent 2 visits over a period of 4 years. MMSE measurement and a self-administered questionnaire of emotional and psychological state were evaluated at baseline and at the follow-up visit.

RESULTS

The major components of total variance of baseline MMSE were represented by education level, practice of regular physical activity, nervousness and despair. Multivariate analysis identified 3 variables at baseline visit that independently predicted annual changes in MMSE: MMSE score, education level and "Difficulty in social relations" (r= -0.222, 0.154 and -0.255 respectively).

CONCLUSIONS

Education level and several psychological factors may influence MMSE score and its evolution over time in community-dwelling subjects aged over 60 years without dementia. In these subjects, a low MMSE score does not predict cognitive decline over a period of 4 years. Therefore, the reliability of MMSE in this type of population is questionable.

[Prevention of venous thromboembolism. Survey of in-hospital medical practice]

OBJECTIVES

In an effort to improve the prevention of venous thromboembolism, the Nancy University Hospitals conducted a survey of medical practice concerning indications for preventive therapy and surveillance of platelet counts and anti Xa activity.

METHODS

The survey involved 163 medical files. Questionnaires were filled out in 6 units (3 medical wards and 3 intensive care units).

RESULTS

Indications for preventive therapy were found to be quite variable with the exception of very low risk of thromboembolism where the treat/do not treat ratio was 0.1/1, indicating a clear tendency for abstention. This ratio was 0.77/1 and 0.38/1 respectively for low and moderate risk and 2/1 for high risk. There was undoubtedly a ward effect. The attitudes in practice tended toward non-prevention in patients without limited mobility. For platelet counts, an initial count was performed in 95% of the cases and during treatment in 38% although the specific rates were not the same for different types of units. Anti-Xa activity, which according to prevention recommendations need not to be determined, was not monitored in 88% of the cases. In accordance with prevention recommendations, anti-Xa activity was not determined in 88% of the cases.

CONCLUSION

Further progress is needed in the prevention of venous thromboembolism and should be based on wider use of existing methods.

[Infectious diarrhea in the aged]

Infectious diarrhoea in the elderly is associated with high morbidity and mortality and need early diagnosis and treatment. Polypathology, malnutrition, polytherapy, length of stay in the hospital and residence in nursing-home contribute to the increasing incidence and gravity of these diseases with aging. Viral gastroenteritis is responsible for epidemic in nursing-home residents. Bacterial gastrointestinal infections are primarily caused by enterotoxigenic agents inducing sporadic or epidemic infections food poisoning. Older adults are more particularly exposed to antibiotic-associated diarrhoea. Clostridium difficle has been increasingly recognized as a cause of pseudomembranous colitis in elderly and is associated with increased mortality. The approach to an old patient with suspected infectious diarrhoea should be to eliminate the likely noninfectious causes, to detect immediate complications due to hydroelectrolytic loss, to initiate early appropriated oral rehydration therapy so as to prevent dehydratation, to avoid the use of antimotility drugs, and to evaluate and to take over nutritional consequences of diarrhoea.

[Central pontine myelinolysis: apropos of an oligosymptomatic form]

The authors report a case of paucisymptomatic central pontine myelinolysis (CMP). A 66 years old female had severe hypochloronatremia and hypokaliemia due to diuretic. Despite a slow hydroelectrolytic correction, she presented with dumbness and seizure. CT scan showed hypodensity of protuberance and magnetic resonance imaging (MRI) shown hypersignal of protuberance and undercortex, compatible with central and extra pontine myelinolysis. The long term clinical outcome was good, as MRI's data. Rapid and important correction of severe hyponatremia should be the most important factors of demyelination, secondary to interference with cerebral adaptation mechanisms to hypoosmolality. These factors were not present in this case.

Thymoma with immunodeficiency (Good's syndrome) associated with selective cobalamin malabsorption and benign IgM-kappa gammopathy

We have described the first case, to our knowledge, in which recurrent respiratory tract infections were the primary manifestation of thymoma with immunodeficiency (Good's syndrome) associated with cobalamin malabsorption and immunoglobulin M-kappa (IgM-kappa) M component. The intrinsic factor receptor activity was dramatically decreased in a mucosal homogenate prepared from ileal biopsies. This decreased activity could be the principal cause of the malabsorption of labelled cobalamin which was observed in the presence of intrinsic factor. However, it could be the consequence of the cobalamin deficiency, as it is known that a cobalamin deficiency can affect the assimilation of cobalamin, even in presence of exogenous intrinsic factor.

[Nutritional and trace elements status in cardiomyopathies in the elderly]

Nutritionnal status remain poor in hospitalized elderly for cardiopathy compared to healthy controls, secondary to bad general status. Selenium rate appears significantly lower in ischemic cardiomyopathy than in valvular or hypertension cardiopathy.

[Modalities of detection of abnormal blood level of thyroid hormones in hospitalized aged patients]

In a continuous series of 3836 patients over 60 years old, 24.1% have abnormal tests, 1.28% present hyperthyroidism and 1.98% hypothyroidism. Screening with TSH alone and T4 if abnormality, appears as the most helpful and costless method in order to detect thyroid dysfunction in hospitalised elderly patients.