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Summary Background Shortening the duration of antibiotic therapy for patients admitted to hospital with community-acquired pneumonia should help reduce antibiotic consumption and thus bacterial resistance, adverse events, and related costs. We aimed to assess the need for an additional 5-day course of β-lactam therapy among patients with community-acquired pneumonia who were stable after 3 days of treatment. Methods We did this double-blind, randomised, placebo-controlled, non-inferiority trial (the Pneumonia Short Treatment [PTC]) in 16 centres in France. Adult patients (aged ≥18 years) admitted to hospital with moderately severe community-acquired pneumonia (defined as patients admitted to a non-critical care unit) and who met prespecified clinical stability criteria after 3 days of treatment with β-lactam therapy were randomly assigned (1:1) to receive β-lactam therapy (oral amoxicillin 1 g plus clavulanate 125 mg three times a day) or matched placebo for 5 extra days. Randomisation was done using a web-based system with permuted blocks with random sizes and stratified by randomisation site and Pneumonia Severity Index score. Participants, clinicians, and study staff were masked to treatment allocation. The primary outcome was cure 15 days after first antibiotic intake, defined by apyrexia (temperature ≤37·8°C), resolution or improvement of respiratory symptoms, and no additional antibiotic treatment for any cause. A non-inferiority margin of 10 percentage points was chosen. The primary outcome was assessed in all patients who were randomly assigned and received any treatment (intention-to-treat [ITT] population) and in all patients who received their assigned treatment (per-protocol population). Safety was assessed in the ITT population. This study is registered with ClinicalTrials.gov, NCT01963442, and is now complete. Findings Between Dec 19, 2013, and Feb 1, 2018, 706 patients were assessed for eligibility, and after 3 days of β-lactam treatment, 310 eligible patients were randomly assigned to receive either placebo (n=157) or β-lactam treatment (n=153). Seven patients withdrew consent before taking any study drug, five in the placebo group and two in the β-lactam group. In the ITT population, median age was 73·0 years (IQR 57·0–84·0) and 123 (41%) of 303 participants were female. In the ITT analysis, cure at day 15 occurred in 117 (77%) of 152 participants in the placebo group and 102 (68%) of 151 participants in the β-lactam group (between-group difference of 9·42%, 95% CI −0·38 to 20·04), indicating non-inferiority. In the per-protocol analysis, 113 (78%) of 145 participants in the placebo treatment group and 100 (68%) of 146 participants in the β-lactam treatment group were cured at day 15 (difference of 9·44% [95% CI −0·15 to 20·34]), indicating non-inferiority. Incidence of adverse events was similar between the treatment groups (22 [14%] of 152 in the placebo group and 29 [19%] of 151 in the β-lactam group). The most common adverse events were digestive disorders, reported in 17 (11%) of 152 patients in the placebo group and 28 (19%) of 151 patients in the β-lactam group. By day 30, three (2%) patients had died in the placebo group (one due to bacteraemia due to Staphylococcus aureus, one due to cardiogenic shock after acute pulmonary oedema, and one due to heart failure associated with acute renal failure) and two (1%) in the β-lactam group (due to pneumonia recurrence and possible acute pulmonary oedema). Interpretation Among patients admitted to hospital with community-acquired pneumonia who met clinical stability criteria, discontinuing β-lactam treatment after 3 days was non-inferior to 8 days of treatment. These findings could allow substantial reduction of antibiotic consumption. Funding French Ministry of Health.

Resume Introduction L’infection urinaire (IU) constitue la deuxieme cause d’infection bacterienne communautaire chez le sujet âge. Ce diagnostic est difficile car les symptomes sont souvent atypiques. Nous presentons les caracteristiques des patients ayant une IU parmi une population geriatrique (signes fonctionnels urinaires et/ou syndrome infectieux). Nous avons egalement evalue la sensibilite et la specificite de la bandelette urinaire (BU) pour le diagnostic d’IU dans cette population. Patients et methode Nous avons realise une etude observationnelle, prospective, monocentrique, d’avril 2017 a janvier 2018, incluant tous les patients hospitalises en geriatrie, presentant des signes fonctionnels urinaires et/ou un syndrome infectieux sans point d’appel, pour lesquels un examen cytobacteriologique des urines (ECBU) a ete demande. Une BU etait systematiquement realisee pour tous ces patients. Les caracteristiques cliniques et biologiques des patients ont ete etudiees selon le diagnostic definitif. En outre, les resultats des BU ont ete compares a ceux des ECBU en cas de diagnostic final d’IU. Resultats Au total, 165 patients ont ete inclus. Parmi eux, 67 (40,6 %) avaient une IU et 98 (59,4 %) avaient un autre diagnostic. Il y avait significativement plus de femmes ( p p La BU presentait une sensibilite elevee (92 %) et une VPN elevee (91 %) interessantes dans notre population. Conclusion En cas d’IU chez le sujet âge, peu de criteres sont discriminants avec une autre origine. Par ailleurs, une BU negative suggere l’absence d’IU en raison de sa bonne valeur predictive negative.

Due to the high risk of infection, the geriatric population is regularly subjected to antibiotics. Faced with bacterial resistance, particularly among elderly dependent patients, it is essential to promote proper use and correct prescription of antibiotics. A study evaluated antibiotic prescription in a geriatric hospital with 598 beds and highlighted the importance of collaboration between geriatricians and infectious disease specialists.

Octogenarians are considered at high surgical risk for the treatment of abdominal aortic aneurysms (AAA). The laparoscopic aortic surgery (LAS) and the endovascular treatment (EVAR) are 2 minimum invasive techniques whose objective is to limit the operative traumatism. The objective of this study was to compare our results with short- and medium-term results with these 2 techniques in the octogenarians.Between January 2002 and December 2012, the data of 674 operated consecutive AAA (315 LAS, 172 EVAR, and 187 open surgeries) were collected prospectively. Eighty-seven patients aged ≥80 years presenting a favorable anatomy were treated by LAS or EVAR. Twenty-five patients aged ≥85 years with a favorable anatomy were excluded because we generally did not propose LAS to them. Statistical analysis compared the demographic data and the results of the 2 groups. The principal criterion of judgment (PCJ) was the combined rate of mortality and severe systemic complications (MSSC) at 30 days. An uni/multivariate model was used to determine the factors associated with the occurrence of the PCJ. The data were expressed as means and standard deviations. A P value ≤0.05 was considered significant.Sixty-two patients (90% men, age 81.8 ± 1.4 years) were included. There were 31 EVAR and 31 LAS. The 2 groups were comparable concerning the demographic data, the comorbidities, and the aneurysmal anatomies. There was a nonsignificant tendency to higher rates of mortality (9.7 vs. 3.2%, P = 0.3) and MSSC at 30 days (16.1 vs. 3.2%, P = 0.09) in the LAS group. During the operation, LAS was associated with a longer operative time (289 ± 85 vs. 152 ± 57 min, P 0.0001), more blood losses (1,073 ± 763 vs. 148 ± 194 mL, P 0.0001), and more transfusions (2.0 ± 3.0 vs. 0.9 ± 1.1 units, P = 0.048). In the postoperative period, the patients operated by LAS had longer reanimation and hospitalization stays (12.9 ± 13.1 vs. 7.0 ± 2.5 days, P = 0.02; and 3.3 ± 4.4 vs. 0.6 ± 0.7 days, P = 0.002; respectively). However, in multivariate analysis, an operative duration300 min was the only variable associated with the PCJ (P = 0.05). With a follow-up of 9.0 ± 10.7 month, there were 2 reinterventions in the EVAR group, whereas with a follow-up of 38.0 ± 23.9 month, no reintervention was observed in the LAS group.In the short run, EVAR significantly reduces the operative traumatism in comparison with LAS in the octogenarian presenting an AAA with a favorable anatomy. However, the choice of the technique is not independently predictive of MSSC at 30 days. When a durable repair is desirable, LAS remains a possible option in the octogenarian with a good general condition presenting a favorable aneurysmal anatomy.

Background Few data are available on management of very elderly colon cancer patients, especially concerning the parameters of therapeutic decisions and the role of geriatricians. Methods We retrospectively reviewed the charts of patients over 80 years of age who underwent surgery for a localised colon cancer in a French academic hospital. Results A total of 176 patients underwent surgery (postoperative morbidity and mortality rates: 25% and 6.7%). Adjuvant chemotherapy was discussed at a multidisciplinary team meeting for 91% of stage III patients, but only 13.5% of them were treated. Twenty-five patients relapsed: 19 were discussed at the multidisciplinary meeting and 16 were treated (5 had a metastasectomy). Despite their increase with time, geriatric assessments were infrequent, 17% (33% after 2006), and had no impact on postoperative morbi-mortality. Median overall survival and recurrence-free survival were 65.3 months and 65.1 months, respectively. Age, emergency surgery, and Charlson comorbidity index were independent prognostic factors. Conclusion Selected elderly colon cancer patients have significant access to surgery. However, postoperative morbi-mortality rates remain high and adjuvant chemotherapy rarely prescribed. Perioperative geriatric assessment, especially before surgery, should be routinely proposed to these patients to evaluate its impact on postoperative morbi-mortality and prescription of adjuvant treatment.

Hepatitis E is currently diagnosed after all other causes of hepatitis have been excluded. Moreover, HEV testing is not performed to prevent blood transmission in developed countries. We report here on the case of a patient with acute hepatitis while receiving potentially hepatotoxic medications for autoimmune disorders, with low-level autoimmune markers and negative ‘‘standard’’ viral markers; it was finally determined that he was suffering from transfusion-transmitted hepatitis E. 2012 European Association for the Study of the Liver. Published

■ Le theme de la personne de confiance ne s'est pas implante dans la pratique des medecins generalistes ■ Leur relation au long cours avec les patients les place pourtant dans une position privilegiee pour aborder ce sujet ■ La personne de confiance semble pouvoir permettre d'ameliorer la qualite des soins ■ Divers facteurs limitant la designation de la personne de confiance temoignent des insuffisances actuelles du dispositif.

Introduction La conciliation medicamenteuse (CM) est un processus de recueil d’informations permettant d’optimiser la prescription lors de l’entree du patient notamment en reduisant les erreurs medicamenteuses. Les divergences sont le resultat de la comparaison du bilan medicamenteux optimise (BMO) et de l’ordonnance des medicaments a l’admission (OMA). Ces divergences peuvent etre intentionnelles (DI) de la part du prescripteur, ou au contraire non intentionnelles (DNI). L’objectif de ce travail est de presenter les differentes divergences observees 3 mois apres la mise en place de cette activite sur 29 lits de geriatrie aigue de notre etablissement. Materiels et methode L’activite de CM a ete effectuee avec l’aide d’un externe en pharmacie encadre par un pharmacien senior. Dans les 48 h apres l’admission dans le service, une revue exhaustive des traitements pris par le patient avant l’hospitalisation a ete realisee grâce a diverses sources d’informations (dossier patient, entretien patient/pharmacien d’officine, ordonnances …) puis comparee a l’OMA prescrite dans PHEDRA®. Un tableau Excel® nous a permis de compiler pour chaque patient les donnees demographiques, les sources utilisees (nature, nombre), le BMO (nombre de lignes), l’OMA (nombre de lignes) et les divergences observees (nombre, nature et type). Resultats et discussion Sur les 3 mois d’activite, 106 patients ont ete concilies, dont 7 patients concilies deux fois suite a leurs readmissions dans le service. L’âge moyen des patients etait de 88 ± 4,6 ans avec un ratio H/F = 0,41. Les CM ont ete realisees dans les premieres 24 h (87 %) ou dans les 24–48 h (13 %) apres l’admissions des patients. En moyenne, 5 sources d’informations ont permis d’etablir le BMO. Les sources les plus consultees etaient le dossier patient papier et informatise (99 %), le courrier d’hospitalisation externe (93 %), les ordonnances du patient (86 %) et le pharmacien d’officine (65 %). Un total de 875 lignes dans les BMO a ete compare aux 877 lignes retrouvees dans les OMA. Parmi les 553 divergences relevees, 499 etaient intentionnelles (90 %) dont 44 % non documentees et 54 non intentionnelles (10 %). Les DNI detectees entre le BMO et l’OMA etaient reparties de la facon suivante : 42 medicaments omis a l’admission, 11 modifications de posologies (8 posologies infra-therapeutiques et 3 posologies supra-therapeutiques) et 1 substitution d’une association medicamenteuse par une autre contenant un principe actif a action pharmacologique differente. Les therapeutiques les plus concernees par des DNI sont les medicaments a visee digestive et metabolique (27,8 %), cardiovasculaire (20,4 %) et neurologique (14,8 %). Le temps moyen par conciliation a ete de 100 ± 28 minutes par patient. Conclusion La mise en place de la CM a permis une contribution significative de la pharmacie aupres des medecins et des soignants. Au-dela de confirmer l’interet de cette activite dans la prevention de l’iatrogenie medicamenteuse, en particulier chez le sujet âge polypathologique et polymedique, ce travail demontre la necessite d’etendre et de perenniser l’activite au sein de notre etablissement geriatrique.

In the elderly, urinary tract infections are frequent. Diagnosis is not always evident because symptoms are often absent. In doubt, a urinary strip evaluation must be performed. Prevention begins with simple lifestyle and dietary rules, such as good voiding and adequate fluid intake. Asymptomatic bacteriuria is treated only in certain cases. Other urinary tract infections require antibiotics, which must be adapted to renal function.

Management of elderly patients with bronchial cancer should take into account specific factors linked to the patient's age, and the presence of co-morbidities. A geriatric evaluation enables us to use relevant information in the therapeutic decision-making process. However, the Comprehensive Geriatric Assessment described in the literature is tedious and time-consuming. We describe the use of a simplified geriatric evaluation (SGE), in 57 patients aged ≥75 years (mean age: 80.8 years) with thoracic cancer, before discussing therapeutic options with colleagues from various departments. This evaluation enabled us to classify the patients into four groups: group 1 consisted of patients in a good general state; group 2+ comprised patients with no more than two stabilized co-morbidities or one poorly or non-stabilized co-morbidity; group 2− comprised patients with more than two stabilized co-morbidities, or at least two poorly or non-stabilized co-morbidities; group 3 consisted of frail patients. The three patients in group 1 did not have any negative factors that could complicate their management and therefore received anti-tumor therapy. The 15 patients in group 3 were considered to have co-morbidities or functional alterations that were too advanced for them to benefit from anti-tumor therapy, and received symptomatic treatment only. Among the 39 patients in the intermediary groups 2+ and 2−, 24 underwent surgery, chemotherapy or radiotherapy (21 (87.5%) patients in group 2+ and 3 (20.0%) patients in group 2−). These data suggest that the SGE is an important aid to decision-making in the management of elderly patients with bronchial cancer.

The effects of food restriction on liver glucagon and vasopressin V1a receptors, on AGE accumulation and on gene expression were investigated in 10- and 30-month-old WAG/Rij female rats fed ad libitum or chronically food-restricted by 30%. The age-related increase in glucagon and vasopressin V1a receptor density, as well as the rise in glucagon-induced cAMP generation was prevented by the restriction. AGE accumulation, characteristic of the aging process, was normalized in food-restricted animals. Gene expression determined with rat Atlas cDNA Expression Arrays containing 1176 cDNA indicates that a few genes exhibited a greater than twofold change in mRNA ratios with age. Most down-regulated genes were related to oxidative metabolism of lipids, and most of the up-regulated genes were concerned with the cell cycle and transcription factors. Chronic food restriction partially prevents these changes in gene expression and induces up- and down-regulation of several mRNAs which are not modified with age in ad libitum fed rats.

Glucose tolerance is reduced with age. The relationship between this change in glucose homeostasis and signaling of glucagon and vasopressin V1a receptors was investigated in hepatocytes isolated from 10- and 30-month-old female WAG/Rij rats. Binding capacity of hepatocytes for 125I glucagon and 3H vasopressin increased 2- and 1.8-fold, respectively, between 10 and 30 months. Intracellular cAMP accumulation induced by glucagon was 40% greater in hepatocytes of aging rats than of adults, although EC50 were similar in the two groups. Conversely, phosphodiesterases activity and nucleotides leakage out of the cells were unchanged with age. The rise in intracellular calcium consecutive to the stimulation of V1a receptor was comparable in adult and senescent animals. Finally, glucose release by hepatocyte suspensions was greater in senescent than in adult animals in absence as in presence of glucagon. These experiments suggest that increase in glucagon receptor expression and cAMP generation would contribute to the impaired glucose tolerance characteristic of the aging process.

As hospitals' visiting times are extended, patients' families and friends are granted an ever more important place. The nursing team of an acute geriatrics unit open 24/7 examined the place and the role of patients' families and friends and their involvement in care.