[Multidimensional geriatric assessment before transcatheter aortic valve implantation in frail elderly patients with one-year follow-up. Cardio-geriatrician collaboration benefits?]

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is a treatment for high-risk patients with symptomatic severe aortic stenosis. The aim of the study is to assess results of comprehensive geriatric assessment before TAVI and geriatrician advices about TAVI procedure feasibility. We report one-year outcomes after TAVI procedure.

METHODS

All patients who underwent comprehensive geriatric assessment in geriatric day hospital before TAVI were prospectively included in Grenoble. We report characteristics of the patients, geriatrician advices about TAVI procedure feasibility and risks, and one year follow-up.

RESULTS

Twenty-one frail elderly patients underwent geriatric assessment. The mean age was 85.4; demographics included cognitive impairment (76%), renal dysfunction (81%), NYHA functional class III or IV (48%). Eighteen patients were suitable for TAVI according to geriatric assessment, 8 underwent TAVI. None of the 3 patients who were not candidate for TAVI according to geriatricians were implanted. Cardiologists followed geriatrician advices for 56% of cases. Intensive care unit and cardiology stay were prolonged at 3.5 and 7.9days, respectively. Six out of the 8 patients stayed in rehabilitation unit after TAVI. None of the implanted patients died at one-year follow up, despite of the common periprocedural complications: acute kidney injury, ischemic stroke, delirium, pacemaker, hemorrhage.

CONCLUSIONS

Cardiologists follow geriatrician advices about TAVI feasibility in frail elderly patients. Comprehensive geriatric assessment also helps preventing complications and providing quick assessment of occurring periprocedural and postprocedural complications. Optimal management of frail elderly patients undergoing TAVI is a multidisciplinary task involving cardiologists, anaesthetists and geriatricians.

Prevalence of protein-energy malnutrition in hospital patients over 75 years of age admitted for hip fracture

INTRODUCTION

One percent of falls in over-75 years old cause hip fracture (HF). Protein-energy malnutrition (PEM) is associated with falls and fracture. PEM screening and perioperative nutritional management are recommended by the European Society of Parenteral and Enteral Nutrition, yet data on nutritional status in elderly HF patients are sparse. The Mini Nutritional Assessment (MNA) score is presently the most effective screening tool for PEM in over-75 years old.

OBJECTIVE

The principal objective of the present study was to determine the prevalence on MNA of PEM in patients aged over 75 years admitted for HF. Secondary objectives were to identify factors associated with PEM and its role as a factor of evolution.

MATERIALS AND METHODS

A prospective observational epidemiological study included 50 patients aged over 75 years admitted for HF in an 8-bed orthopedic surgery department with a geriatric follow-up unit. PEM was defined by MNA<17/30. Assessment systematically comprised associated comorbidity (Cumulative Illness Rating Scale-Geriatric [CIRS-G]), cognitive status on the Mini Mental State Examination (MMSE), functional status on activities of daily life (ADL), and mean hospital stay (MHS). Scores were compared on quantitative tests (Student t) with the significance threshold set at P<0.05.

RESULTS

Mean age for the 50 patients was 86.1 years (range, 77-94 years). Prevalence of PEM was 28%; a further 58% of patients were at risk for PEM. PEM was associated with elevated CIRS-G (P<0.006), greater numbers of severe comorbidities (P=0.006), more severe cognitive disorder (P=0.005) and functional dependence (P=0.002), and 8 days' longer MHS (P=0.012).

DISCUSSION

The present study confirmed the high prevalence of PEM in HF patients aged over 75 years, supporting longer hospital stay. MNA is a diagnostic gold standard, not to be replaced by albuminemia or body-mass index in this perioperative clinical situation. Given the present economic stakes relating to geriatric trauma patients' hospital stay, it is essential to prevent, diagnose and treat PEM in elderly subjects.

LEVEL OF EVIDENCE

Level IV; prospective cohort study.

[Platypnea-orthodeoxia syndrome: a rare cause of severe hypoxemia]

INTRODUCTION

The platypnea-orthodeoxia syndrome (PO) includes: (i) a dyspnea increasing with orthostatism and decreasing in supine position, (ii) wide positional range in arterial oxygen saturation with tachycardia, (iii) and hypoxemia refractory to oxygen therapy. This syndrome is usually related to a cardiac right-left shunt, and rarely to a pulmonary shunt.

OBSERVATION

We report a case of a patient presenting with a post-lung infection dyspnea associated with severe hypoxemia and shunt effect at blood gas. Contrast-enhanced CT-scan showed no pulmonary embolism. PO syndrome was suspected given the transcutaneous blood oxygen saturation variation from 90% in supine position to 60% in standing position, tachycardia, and absence of response to the intensive oxygen therapy.

CONCLUSION

This syndrome should be known by physicians as a possible differential diagnose for refractory dyspnea to oxygen since effective treatment is available.

Cyclodextrin curcumin formulation improves outcome in a preclinical pig model of marginal kidney transplantation

Decreasing organ quality is prompting research toward new methods to alleviate ischemia reperfusion injury (IRI). Oxidative stress and nuclear factor kappa beta (NF-κB) activation are well-described elements of IRI. We added cyclodextrin-complexed curcumin (CDC), a potent antioxidant and NF-κB inhibitor, to University of Wisconsin (UW) solution (Belzer's Solution, Viaspan), one of the most effective clinically approved preservative solutions. The effects of CDC were evaluated on pig endothelial cells and in an autologous donation after circulatory death (DCD) kidney transplantation model in large white pigs. CDC allowed rapid and lasting uptake of curcumin into cells. In vitro, CDC decreased mitochondrial loss of function, improved viability and lowered endothelial activation. In vivo, CDC improved function recovery, lowered histological injury and doubled animal survival (83.3% vs. 41.7%). At 3 months, immunohistochemical staining for epithelial-to-mesenchymal transition (EMT) and fibrosis markers was intense in UW grafts while it remained limited in the UW + CDC group. Transcriptional analysis showed that CDC treatment protected against up-regulation of several pathophysiological pathways leading to inflammation, EMT and fibrosis. Thus, use of CDC in a preclinical transplantation model with stringent IRI rescued kidney grafts from an unfavorable prognosis. As curcumin has proved well tolerated and nontoxic, this strategy shows promise for translation to the clinic.

What are key factors influencing malnutrition screening in community-dwelling elderly populations by general practitioners? A large cross-sectional survey in two areas of France

BACKGROUND/OBJECTIVES

Malnutrition is associated with a high morbi-mortality in elderly populations and their institutionalization at an early stage. The incidence is well known despite being often under-diagnosed in primary care. General practitioners (GPs) have a key role in home care. What are the factors affecting malnutrition-screening implementation by French GPs?

SUBJECTS/METHODS

We conducted a cross-sectional survey in two areas in the southeast of France (Savoie and Isère). In May 2008, an anonymized survey was sent by e-mail and/or post to all GPs with a large clinical practice. Two months later, reminder letters were sent. Potential barriers were measured by dichotomous scale. On GPs' characteristics (socio-demographic, medical training, geriatric practice and knowledge), multiple regression logistic was performed to identify others factors affecting malnutrition screening.

RESULTS

In all, 493 GPs (26.85%) answered and 72.2% felt that malnutrition screening was useful although only 26.6% implemented it each year and 11.9% every 2-5 years. The main barriers to the implementation were patient selection (60.4%) and forgetting to screen (26.6%). Minor barriers were lack of knowledge (19.5%) or time (15%). New factors were identified: unsuitable working conditions (19.1%), insufficient motivation (6.8%) or technical support (7.2%). The quality of malnutrition information received was found to be the only promoter of annual screening (odds ratio=1.44 (1.087-1.919); P=0.011).

CONCLUSIONS

This survey is the first in France to reveal GPs' factors affecting malnutrition implementation. New obstacles were identified in this survey. The hope of implementing regular malnutrition screening by GPs seems to lie with the quality of malnutrition information received.

Impact of functional status on the onset of nosocomial infections in an acute care for elders unit

OBJECTIVE

To assess the role of functional status as a risk factor for nosocomial infections in the elderly.

DESIGN

Prospective study.

SETTING

Acute care for elders units of university hospital of Grenoble.

PARTICIPANT

All patients over 75 years old consecutively hospitalized between January and April 2007.

MEASUREMENT

The main judgement criteria was the rate of nosocomial infection during the hospital stay, defined according to the French technical comity against nosocomial infections. Other data included functional status at baseline and admission (Katz' ADL), usual risk factors for nosocomial infections, demographic and geriatric assessment data.

RESULTS

The study included 223 patients. The mean age was 86.7±6.5 years. A nosocomial infection was diagnosed for 17.0% of the patients. In univariate analysis, the number of medicines, pressure sore, pneumonia diagnosis, illness severity, indwelling bladder catheter, IADL at baseline, and all disability parameters (ADL at baseline, ADL at admission, recent functional decline) were significantly associated with nosocomial infection (p<0.05). In multivariate analysis considering functional status at admission, indwelling bladder catheter (OR=4.43), severe disability at admission (OR=4.42) and illness severity (OR=2.68) were independently associated with nosocomial infection (p<0.05). In a second analysis considering functional status at baseline, only disability at baseline was independently associated with the onset of a nosocomial infection (OR=2.21).

CONCLUSION

Our results suggest a significant impact of functional impairment on the incidence of nosocomial infections in hospitalized elderly population. Disability is a higher risk factor for nosocomial infections than the usual and well-known other parameters. Larger prospective studies are needed to examine the power of this relationship.

Six-month outcome of elderly people hospitalized via the emergency department: the SAFES cohort

BACKGROUND

The objective of the study was to identify factors predictive of 6-month institutionalization or mortality in frail elderly patients after acute hospitalization.

METHODS

A prospective cohort of elderly subjects 75 years and older was set up in nine French teaching hospitals. Data obtained from a comprehensive geriatric assessment were used in a Cox model to predict 6-month institutionalization or mortality. Institutionalization was defined as incident admission either to a nursing home or other long-term care facility during the follow-up period.

RESULTS

Crude institutionalization and death rates after 6 months of follow-up were 18% and 24%, respectively. Independent predictors of institutionalization were: living alone (HR=1.83; 95% CI=1.27-2.62) or a higher number of children (HR=0.86; 95% CI=0.78-0.96), balance problems (HR=1.72; 95% CI=1.19-2.47), malnutrition or risk thereof (HR=1.93; 95% CI=1.24-3.01), and dementia syndrome (HR=1.88; 95% CI=1.32-2.67). Factors found to be independently related to 6-month mortality were exclusively medical factors: malnutrition or risk thereof (HR=1.92; 95% CI=1.17-3.16), delirium (HR=1.80; 95% CI=1.24-2.62), and a high level of comorbidity (HR=1.62; 95% CI=1.09-2.40). Institutionalization (HR=1.92; 95% CI=1.37-2.71) and unplanned readmission (HR=4.47; 95% CI=3.16-2.71) within the follow-up period were also found as independent predictors.

CONCLUSION

The main factors predictive of 6-month outcome identified in this study are modifiable by global and multidisciplinary interventions. Their early identification and management would make it possible to modify frail elderly subjects' prognosis favorably.

Rapid cognitive decline, one-year institutional admission and one-year mortality: analysis of the ability to predict and inter-tool agreement of four validated clinical frailty indexes in the SAFEs cohort

OBJECTIVES

To evaluate the predictive ability of four clinical frailty indexes as regards one-year rapid cognitive decline (RCD - defined as the loss of at least 3 points on the MMSE score), and one-year institutional admission (IA) and mortality respectively; and to measure their agreement for identifying groups at risk of these severe outcomes.

DESIGN

One-year follow-up and multicentre study of old patients participating in the SAFEs cohort study.

SETTING

Nine university hospitals in France.

PARTICIPANTS

1,306 patients aged 75 or older (mean age 85±6 years; 65% female) hospitalized in medical divisions through an Emergency department.

MEASUREMENTS

Four frailty indexes (Winograd; Rockwood; Donini; and Schoevaerdts) reflecting the multidimensionality of the frailty concept, using an ordinal scoring system able to discriminate different grades of frailty, and constructed based on the accumulation of identified deficits after comprehensive geriatric assessment conducted during the first week of hospital stay, were used to categorize participants into three different grades of frailty: G1 - not frail; G2 - moderately frail; and G3 - severely frail. Comparisons between groups were performed using Fisher's exact test. Agreement between indexes was evaluated using Cohen's Kappa coefficient.

RESULTS

All patients were classified as frail by at least one of the four indexes. The Winograd and Rockwood indexes mainly classified subjects as G2 (85% and 96%), and the Donini and Schoevaerdts indexes mainly as G3 (71% and 67%). Among the SAFEs cohort population, 250, 1047 and 1,306 subjects were eligible for analyses of predictability for RCD, 1-year IA and 1-year mortality respectively. At 1 year, 84 subjects (34%) experienced RCD, 377 (36%) were admitted into an institutional setting, and 445 (34%) had died. With the Rockwood index, all subjects who experienced RCD were classified in G2; and in G2 and G3 when the Donini and Schoevaerdts indexes were used. No significant difference was found between frailty grade and RCD, whereas frailty grade was significantly associated with an increased risk of IA and death, whatever the frailty index considered. Agreement between the different indexes of frailty was poor with Kappa coefficients ranging from -0.02 to 0.15.

CONCLUSION

These findings confirm the poor clinimetric properties of these current indexes to measure frailty, underlining the fact that further work is needed to develop a better and more widely-accepted definition of frailty and therefore a better understanding of its pathophysiology.

Predictors of institution admission in the year following acute hospitalisation of elderly people

OBJECTIVES

The aim of the study was to identify factors related to institutionalisation within one-year follow up of subjects aged 75 or over, hospitalised via the emergency department (ED).

DESIGN

Prospective multicentre cohort.

SETTING

Nine French university teaching hospitals.

PARTICIPANTS

One thousand and forty seven (1 047) non institutionalised subjects aged 75 or over, hospitalised via ED. A sub-group analysis was performed on the 894 subjects with a caregiver.

MEASUREMENTS

Patients were assessed using Comprehensive Geriatric Assessment (CGA) tools. Cox survival analysis was performed to identify predictors of institutionalisation at one year.

RESULTS

Within one year after hospital admission, 210 (20.1%) subjects were institutionalised. For the overall study population, age >85 years (HR 1.6; 95%CI 1.1-2.1; p=0.005), inability to use the toilet (HR 1.6; 95%CI 1.1-2.4; p=0.007), balance disorders (HR 1.6; 95%CI 1.1-2.1; p=0.005) and presence of dementia syndrome (HR 1.9; 95%CI 1.4-2.6; p<0.001) proved to be independent predictors of institutionalisation; while a greater number of children was inversely linked to institutionalisation (HR 0.8; 95%CI 0.7-0.9; p<0.001). Bathing was of borderline significance (p=.09). For subjects with a caregiver, initial caregiver burden was significantly linked to institutionalisation within one year, in addition to the predictors observed in the overall study population.

CONCLUSIONS

CGA performed at the beginning of hospitalisation in acute medical wards is useful to predict institutionalisation. Most of the predictors identified can lead to targeted therapeutic options with a view to preventing or delaying institution admission.

Predicting early mortality among elderly patients hospitalised in medical wards via emergency department: the SAFES cohort study

OBJECTIVES

The aim of the study was, by early identification of deleterious prognostic factors that are open to remediation, to be in a position to assign elderly patients to different mortality risk groups to improve management.

DESIGN

Prospective multicentre cohort.

SETTING

Nine French teaching hospitals.

PARTICIPANTS

One thousand three hundred and six (1 306) patients aged 75 and over, hospitalised after having passed through Emergency Department (ED).

MEASUREMENTS

Patients were assessed using Comprehensive Geriatric Assessment (CGA) tools. A Cox survival analysis was performed to identify prognostic variables for six-week mortality. Receiver Operating Characteristics analysis was used to study the discriminant power of the model. A mortality risk score is proposed to define three risk groups for six-week mortality.

RESULTS

Crude mortality rate after a six week follow-up was 10.6% (n=135). Prognostic factors identified were: malnutrition risk (HR=2.1; 95% CI: 1.1-3.8; p=.02), delirium (HR=1.7; 95% CI: 1.2-2.5; p=.006), and dependency: moderate dependency (HR=4.9; 95% CI: 1.5-16.5; p=.01) or severe dependency (HR=10.3; 95% CI: 3.2-33.1; p < .001). The discriminant power of the model was good: the c-statistic representing the area under the curve was 0.71 (95% IC: 0.67 - 0.75; p < .001). The six-week mortality rate increased significantly (p < .001) across the three risk groups: 1.1% (n=269; 95% CI=0.5-1.7) in the lowest risk group, 11.1% (n=854; 95% CI=9.4-12.9) in the intermediate risk group, and 22.4% (n=125; 95% CI=20.1-24.7) in the highest risk group.

CONCLUSIONS

A simple score has been calculated (using only three variables from the CGA) and a practical schedule proposed to characterise patients according to the degree of mortality risk. Each of these three variables (malnutrition risk, delirium, and dependency) identified as independent prognostic factors can lead to a targeted therapeutic option to prevent early mortality.

Evaluation of postural stability by means of a single inertial sensor

Human posture control during standing is a combination of many complicated control processes. Physical therapists perform different clinical balance tests to either assess postural control or identify balance disorders that can ultimately cause a patient to fall. In this article, several standardized clinical exercises for balance assessment are executed together with an orientation tracker strapped onto the volunteer's sternum. The tracker estimates the 3-D orientation of the trunk in real-time using an efficient attitude determination algorithm. The device is fully portable and sensitive to anteroposterior and mediolateral sways. Analysis of the resulting angles provides several parameters that are useful in assessing and quantifying balance function. This approach could be a valuable tool for a therapist for patient's follow-up and could be combined with existing procedures such as force platforms or optical motion analysis systems. Also, statistical analysis on these parameters could help to characterize normal and pathological performances in a population.

ACTIDOM--a microsystem based on MEMS for activity monitoring of the frail elderly in their daily life

A "ambulatory activity recorder" was developed, with 3 accelerometers and 3 magnetometers, to detect and qualify the elementary activities of a person, such as walking and transfers. The signal processing is explained, along with the preliminary results obtained on young and older healthy subjects. This work open the way to continuous and automatic monitoring of the level of mobility.

Téléassistance en hospitalisation à domicile

OBJECTIVE

The purpose of this project was to study the clinical feasibility of videophone-based communication between patients in their homes, and the care teams who work in the Home Hospitalization department (HH).

METHODS

This pilot study of videophone users compared them with a group of control patients also in HH. They came from either the adult, maternity or pediatric departments. Patients who met the inclusion criteria and consented to participate in the study were randomly assigned to one of two groups: those who had a videophone installed in their homes (telemedicine group), and those who received the standard HH care (control group). Sixteen patients in the telemedicine group were matched with 16 from the control group, according to age, Karnofsky Index score, and the reason for HH admission.

RESULTS

The mean videophone call lasted six minutes, and patients averaged 23 calls each over the study period (0.7 calls per patient per working day). The videophone enabled better follow-up of wounds: for example, the nurse could transmit photos from the patient's home for real-time coordination. It was also useful for following patients suffering from pain, for technical nursing care, and for educating patients and their caregivers. Anxiety (measured with the Hospital Anxiety and Depression Scale) diminished during the study period for the telemedicine patients, compared with the control group (p=0.048). Within the telemedicine group, all patients and their families were very satisfied or satisfied with their care and with the communication (15/15), although the staff's level of satisfaction was slightly lower (14/16); there were no significant differences between groups.

CONCLUSION

The ViSaDom program indicates that videophone communication is feasible and acceptable and could be a useful tool for improving the quality, efficiency and effectiveness of care.

A double-blind placebo-controlled evaluation of sublingual immunotherapy with a standardized ragweed extract in patients with seasonal rhinitis. Evidence for a dose-response relationship

BACKGROUND

There is a growing consensus on the benefits of sublingual-swallow immunotherapy in the treatment of allergic diseases.

METHODS

This randomized, double-blind placebo-controlled study was undertaken to assess the efficacy and safety of sublingual immunotherapy with standardized ragweed pollen extract tablets, in patients with an allergic rhinitis. A total of 110 outpatients were randomized (immunotherapy [I]: 55; placebo [P]: 55), of whom 99 were analyzable for efficacy (I: 48; P: 51) and 106 analyzable for safety (I: 53; P: 53). After a 28-day progression phase, the patients received a maintenance treatment during 6.5 months. Efficacy variables included a global assessment of efficacy (patient/ investigator), symptoms and medication scores as well as the frequency of asthma attacks.

RESULTS

In the active treatment group, 43 patients completed the study, versus 49 on placebo. During the whole period of pollination, the difference favoring immunotherapy was highly significant for the global assessment by the patient (p = 0.004) and by the investigator (p = 0.005). Adverse reactions were reported more often in the active treatment but mild or moderate, and they abated after dose adjustment. A subgroup analysis of those patients receiving the highest dose of immunotherapy (3 tablets 3 times a week) showed a highly significant response for rhinitis and conjunctivitis total scores by comparison to lower dosages.

CONCLUSION

This study confirms the efficacy and safety of sublingual immunotherapy and strongly suggests a dose-response relationship.

Telesurveillance of elderly patients by use of passive infra-red sensors in a 'smart' room

We have developed an automated surveillance system based on passive infra-red sensors. Eight sensors were installed in a hospital room. A computer automatically captured data from the sensors every night from 21:00 until 06:00 the following morning. The sensors were polled twice per second and when a sensor was activated by movement, the event and time were recorded in a data file. At the end of the surveillance period the program analysed the data and generated a report showing the activities taking place in the room and their times. Four elderly patients were observed for a total of 97 nights. A total of 1637 possible sequences of movements by the patient and the hospital staff were detected. The computer was able to identify 1450 sequences (89%) correctly, in comparison with manual analysis. Only 10 movements (0.6%) were undetected by the system; all were very short sequences (five or six activations of the sensors). The system was generally capable of detecting and classifying all major movements in the room.

[The use of exit questionnaires, a survey at 7 hospital centers]

Measuring the satisfaction of hospitalised patients has been mandatory in France since 1996. The most common tool for assessing the level of satisfaction is the use of self-administered questionnaires given to the patient upon his/her release from the hospital. A survey was conducted among seven public hospitals to appraise the development and use of such questionnaires, their results and the way in which these results are taken into account in order to improve the quality of care. The survey's results illustrate that the policy with respect to their construction varies between hospitals, without any evaluation of the validity of the questionnaires produced. In most cases, the questionnaires are passively distributed to the patient at the time of discharge. The response rates are low (ranging from 4 to 18%), and the analysis of the collected questionnaires, to the extent to which it is done, is not necessarily used to improve the quality of care. An appropriate evaluation strategy, one capable of effecting change and improving hospital care, still remains to be established in the hospitals which participated in the survey.

A preliminary study of the feasibility of wound telecare for the elderly

We have developed a method for remote wound assessment in the elderly. Wound images were taken with a digital camera at a resolution of 640x480 pixels. JPEG compression was then used to produce images of about 100 kByte. Selected clinical data were transmitted by email, together with standardized digital images of wounds. The remote physician then read the clinical data and viewed the digital images on a 38 cm colour display monitor, at a resolution of 800x600 pixels, in 16-bit colour, using standard software. Three elderly inpatients with pressure sores or leg ulcers had both bedside and remote examinations, by different physicians. The diagnosis and therapeutic recommendations proposed after each of the two examinations were compared qualitatively. There was reasonable agreement between the two physicians in the assessment of wound size, anatomical classification, wound bed and status of infection. However, the lack of palpation represented a major limitation to remote wound assessment, despite the use of probes to delineate the depth of any opening in the wound bed.

[Thoracic empyema in very old patients: two types of clinical presentation]

INTRODUCTION

Primitive thoracic empyema or empyema secondary to pneumonia represents a significant medical problem necessitating prolonged hospitalizations and increasing the rates of morbidity and mortality. Average patient age is 55 years and remains rare in very old patients (> 85). We report here two observations in very old patients, pointing out the diversity of the clinical presentation.

EXEGESIS

Empyema thoracis is classically associated with underlying diseases. It is often polymicrobial but Gram-positive bacteria and anaerobes are more frequent than Gram-negative bacteria. The clinical presentation may be aspecific without any parameters in favor of infectious disease: the rapidity of pleural drainage and antibiotic therapy are the main prognostic factors.

CONCLUSION

Because of the diversity of clinical presentation in the elderly population, and because of the efficiency of rapid treatment, geriatric physicians should perform an examination of pleural fluid when pleural effusion is unknown.

[Variation in eosinophilia and measures of pollen counts of grasses (Poaceae) and ragweed (Ambrosia) in the Rhone valley]

Sensitivity to ragweed pollen, along with grasses pollen, is the leading cause of pollen-induced allergy in our region. Our study focuses on the variation of eosinophilia levels in the blood taken from a sample of the general population during both ragweed and grasses pollination periods. The pollen trap located in the central Rhône River Valley region has provided weekly counts since 1995. The Etablissement Français du Sang Rhône-Alpes-Valence routinely checks hypereosinophilia in the blood through systematic analysis after a blood donation. Average cumulative pollen counts for grasses and ragweed present an interesting correlation with the levels of hypereosinophilia measured at the end of the summer.

[A French tool for evaluation of home palliative care: adaptation of the Support Team Assessment Schedule]

The authors describe the utilisation of a quality assessment tool for palliative care administered at home. The questionnaire entitled Support Team Assessment Schedule (STAS) was translated from English for this study. It was then utilised comparatively with different quality of life evaluation instruments. Only the results of the STAS are described here. The approach allows for the unresolved problems in the care to come to the surface week after week. The STAS comprises nine items pertaining to the patient and his/her family, and seven items concerning the services provided. The study exhibits the results of 107 evaluations completed from 50 patients stricken with cancer or AIDS in an advanced phase. The availability of this auto clinical audit tool, employable at home or in a hospital, constitutes an essential initial step in the field of French-speaking clinical evaluation of palliative care.

Teleconsultation in psychology: the use of videolinks for interviewing and assessing elderly patients

Although elderly people are one of the major target groups for telemedicine applications, they remain under-represented in studies of teleconsultation. Videolinks appear to be easily used by many elderly people as a means of communicating with health-care staff, including psychologists and doctors. To date, studies of psychometric teleconsultation have been confined to screening tests, or have used very small numbers of patients. There is a need to examine the reliability of more complex psychometric batteries and to use larger samples of older people. Some recommendations for conducting clinical interviews and psychometric tests are presented, based on clinical experience and a review of the literature. The importance of ergonomic considerations, patient comfort and professional preparation are explained.

A smart room for hospitalised elderly people: essay of modelling and first steps of an experiment

We present a study of modelling and the first steps of an experiment of a smart room for hospitalised elderly people. The system aims at detecting falls and sicknesses, and implements four main functions: perception of patient and environment through sensors, reasoning from perceived events and patient clinical findings, action by way of alarm triggering and message passing to medical staff, and adaptation to various patient profiles, sensor layouts, house fixtures and architecture. It includes a physical multisensory device located in the patient's room, and a multi-agent system for fall detection and alarm triggering. This system encompasses a perception agent, and a reasoning agent. The latter has two complementary capacities implemented by sub-agents: deduction of type of alarm from incoming events, and knowledge induction from recorded events. The system has been tested with a few patients in real clinical situation, and the first experiment provides encouraging results which are described in a precise manner.

Sublingual-swallow immunotherapy (SLIT) with a standardized five-grass-pollen extract (drops and sublingual tablets) versus placebo in seasonal rhinitis

BACKGROUND

Recent studies have demonstrated the efficacy of sublingual-swallow immunotherapy (SLIT) in seasonal and perennial rhinitis. Sublingual administration of solutions is not convenient for all patients. The aim of the study was to evaluate the efficacy and safety of immunotherapy administered sublingually, initially as drops, and then as tablets during maintenance therapy.

METHODS

A total of 126 patients with grass-pollen seasonal rhinitis were included in this double-blind, randomized, placebo-controlled trial. During the progression of doses phase, the five-grass extract was given as sublingual drops from 1 to 100 IR/ml. Once the 100 IR dose was reached, the drops were replaced by a single 100-IR sublingual tablet per day.

RESULTS

Throughout the grass-pollen season, patients in the active treatment group had significantly lower (P < 0.05) total conjunctivitis and ocular redness scores. Rhinitis symptoms were not significantly different between the two groups. Patients given the active treatment were significantly (P < O.02) less likely to have asthma symptoms. The global medication score showed no significant difference between the two groups. A highly significant difference in favor of the active treatment group was seen in inhaled salbutamol use (P < 0.01).

CONCLUSIONS

Clinical benefits achieved during the present study included significant improvements in conjunctivitis symptoms and prevention of asthma symptoms. The overall safety profile of the active treatment (drops or tablets) was good.

Sublingual-swallow immunotherapy (SLIT) with a standardized five-grass-pollen extract (drops and sublingual tablets) versus placebo in seasonal rhinitis

BACKGROUND

Recent studies have demonstrated the efficacy of sublingual-swallow immunotherapy (SLIT) in seasonal and perennial rhinitis. Sublingual administration of solutions is not convenient for all patients. The aim of the study was to evaluate the efficacy and safety of immunotherapy administered sublingually, initially as drops, and then as tablets during maintenance therapy.

METHODS

A total of 126 patients with grass-pollen seasonal rhinitis were included in this double-blind, randomized, placebo-controlled trial. During the progression of doses phase, the five-grass extract was given as sublingual drops from 1 to 100 IR/ml. Once the 100 IR dose was reached, the drops were replaced by a single 100-IR sublingual tablet per day.

RESULTS

Throughout the grass-pollen season, patients in the active treatment group had significantly lower (P < 0.05) total conjunctivitis and ocular redness scores. Rhinitis symptoms were not significantly different between the two groups. Patients given the active treatment were significantly (P < O.02) less likely to have asthma symptoms. The global medication score showed no significant difference between the two groups. A highly significant difference in favor of the active treatment group was seen in inhaled salbutamol use (P < 0.01).

CONCLUSIONS

Clinical benefits achieved during the present study included significant improvements in conjunctivitis symptoms and prevention of asthma symptoms. The overall safety profile of the active treatment (drops or tablets) was good.

"Telepsychometry": a remote psychometry consultation in clinical gerontology: preliminary study

OBJECTIVE

Evaluation of the clinical feasibility of remote psychometric consultation with elderly patients.

METHODS

Remote consultation with six women and four men (average age 87) was compared with a standard consultation. An interview and two psychometric tests were used: the Mini-Mental Status Examination (MMSE) and the Clock Face Test (CFT), which were administered by a clinical psychologist and controlled by a psychologist observer who remained in the room with the patient. The experimental setting consisted of two rooms linked by a coaxial cable. Each room was equipped with a camera, television screen, and microphone. The clinician was able to operate the mobile camera in the patient's room by remote control. The clinician was assisted by a computer, which helped to focus on standardized points. A video camera recorded the consultation for documentation purposes.

RESULTS

Decreased performance was observed in the remote versus the standard consultation for both tests (MMSE: p = 0.008; CFT: p = 0.006). Physiologic hearing loss may have been responsible for a fall in the patients' attention.

CONCLUSION

Remote psychometric consultation can be applied successfully to the psychological examination of elderly patients provided that communication problems are solved.

Feasibility of orthopaedic teleconsulting in a geriatric rehabilitation service

Fifteen elderly patients participated in a teleconsultation with an orthopaedic surgeon, which was then followed by a conventional, face-to-face consultation. The comparison between the surgeon's ratings for both types of consultation suggested that the telemedicine consultation was satisfactory in terms of the quality of image and sound, the clinical examination and general simplicity. The telemedicine consultations did not generate a need for any additional clinical investigations, although in two cases a face-to-face consultation was necessary to clarify clinical signs (shortening of a limb and scar tissue). The surgeon's rating of his decision level was superior in the face-to-face situation in four cases, and for 11 patients it was equal. Similarly, the surgeon's level of confidence in decision making was superior in the conventional situation for five patients and equal for 10 patients. Patient attitudes towards teleconsulting were favourable. There was a high level of patient satisfaction. Teleconsulting between orthopaedic surgeons and elderly patients therefore appears to be possible, provided that certain technical, clinical and psychological considerations are addressed.