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Abstract: Introduction: Heart manifestations of Churg–Strauss syndrome (CSS) are varied. In the early stages of the disease, it is difficult to distinguish between lesions that are specific to CSS and those of other etiologies. The aim of our work was to compare the characteristics of patients with heart manifestations linked or not to Churg–Strauss syndrome. Material and methods: We recorded all clinical symptoms of patients with CSS hospitalized between 1998 and 2008 in Burgundy, France, and determined the possible relationships between heart symptoms and CSS. Results: From a cohort of 31 patients, we found 20 with heart lesions. When heart lesions were present, we noted fewer initial symptoms of digestive disorders (p <0.05), lower levels of lung infiltrates and fewer anti-MPO pANCA (p <0.05). Heart lesions were linked to CSS in 75% of cases. Their patients were thus younger than those in the other cardiac patients (p <0.05), were more likely to have clinical manifestations of heart involvement at diagnosis, were less likely to have lung infiltrates on the X-ray at diagnosis and during flare-ups and less likely to have lung abnormalities on X-rays during flare-ups (p <0.05) and higher level of leucocytes and eosinophils at diagnosis. Conclusion: Heart lesions directly attributable to CSS are frequent, severe and probably underestimated. A specific physiopathology that is not mediated by ANCA seems to be involved in the genesis of CSS-related heart lesions. [Copyright &y& Elsevier]

Only few studies have investigated the use of HA in elderly subjects and there are no data in very elderly subjects. We assessed the prescription of HA and analyzed the relationship between such prescriptions and frailty markers among persons aged 80 and more in an observational study. We recorded the prescriptions for 13,211 patients aged 80-109 years and affiliated to the "Mutualité-Sociale-Agricole (MSA)" of Burgundy over a 1-month period. The prescription of a HA among all included patients, and the existence of serious long-term disease(s) (LTD), polypharmacy or a prescription of cardiovascular drugs among patients receiving a HA were recorder. Among the 13,211 patients, 3412 aged 80-98 years were treated with an HA. The main HA were statins (70.4%), and fibrates were used in 27.3% of cases. Of these 3412 patients, 2250 had one or several LTD mainly coronaropathy, hypertension, diabetes mellitus or peripheral artery disease. The mean number of drugs per prescription was 6.37. Among subjects treated with HA, 40% also received antiplatelets, 35.6% β-blockers and 30% inhibitors of the renin-angiotensin system. For 99% of the patients, the prescription of HA was a renewal. Prescribers were mainly general practitioners (96.8%). Statins are the most widely prescribed HA even among very elderly subjects. However, after 80 years the prescription of HA, mainly statins, decreases with aging. This could be explained by polypathology, polypharmacy and the deterioration in metabolic functions which are markers of frailty. This study should encourage research into the use of statins in very elderly subjects., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objective: The aim of this study was to identify the factors associated with differences between how Alzheimer's disease (AD) patients and their caregivers rate the patient's health-related quality of life (QoL)., Methods: Cross-sectional, multicentre study. Patients were 65 years or more, suffering from mild to moderate AD, native French speakers, with a main caregiver. Interrater agreement of the QoL-AD was assessed using the intraclass coefficient. A generalised linear model was used to identify factors related to the difference in health-related QoL scores between patients and their caregivers., Results: The 122 patients of the study were 82 ± 6 years old and mainly women (69%). Independent factors related to the difference between patients and caregivers were: Mini Mental State Exam score (β = 0.32; 95% CI = 0.05-0.59); instrumental activities of daily living score (β = -0.61; 95% CI = -1.14 to -0.07); total Neuropsychiatric Inventory score (β = 0.10; 95% CI = 0.05-0.59), and Zarit's burden score (β = 0.09; 95% CI = 0.01-0.17)., Conclusion: Practitioners must take into account the trend towards underestimation when health-related QoL is rated by caregivers or proxies., (Copyright © 2012 S. Karger AG, Basel.)

Churg-Strauss Syndrome (SCS) is a systemic vasculitis associated with asthma and eosinophilia. The aim of our work is to describe this pathology in the Burgundian population in France. We counted from the hospitalisation data-processing summaries, the whole of the SCS hospitalised in Burgundy between 1998 and 2008. During the follow-up, the clinical and paraclinical characteristics of every patient were collected. The average prevalence is of 11.3 per million inhabitants and the incidence is of 1.2 new cases per million inhabitants per annum. There exists however, a great prevalence disparity and incidence amongst the various departments of the area. The patient's average follow-up is of 7.7 years. In 23% of the cases one finds a starting factor for vasculitis. The delay between the first signs and the diagnostic is an average of 61 months. The ANCA are positive in 26% of cases and of anti-myeloperoxidase specificity in 83% of cases (P < 0.001). The most profitable biopsies are essentially cutaneous and neuromuscular. At the diagnostic, two-third of the patients have had a treatment adapted according to the current recommendations based on the Five Factor Score. The remission rate within a 1-year period is of 77%. The remission is strongly correlated to the therapeutic protocol associating corticoids and cyclophosphamide (P < 0.05). In conclusion, the prevalence of SCS in our area is similar to that observed in other European regions. However, this vasculitis remains a difficult and often a tardive diagnostic pathology.

Background: There is currently a lack of consensus for the diagnosis, investigations and treatments of acute bacterial prostatitis (AP)., Methods: The symptoms, investigations and treatments of 371 inpatients diagnosed with AP were analyzed through a retrospective study conducted in four departments - Urology (U), Infectious Diseases (ID), Internal Medicine (IM), Geriatrics (G) - of two French university hospitals., Results: The cause of admission, symptoms, investigations and treatments depended markedly on the department of admission but not on the hospital. In U, patients commonly presented with a bladder outlet obstruction, they had a large imaging and functional check-up, and received alpha-blockers and anti-inflammatory drugs. In ID, patients were febrile and received longer and more appropriate antibiotic treatments. In G, patients presented with cognitive disorders and commonly had post-void urine volume measurements. In IM, patients presented with a wide range of symptoms, and had very diverse investigations and antibiotic regimen.Overall, a 3:1 ratio of community-acquired AP (CA-AP) to nosocomial AP (N-AP) was observed. Urine culture isolated mainly E. coli (58% of AP, 68% of CA-AP), with venereal agents constituting less than 1%. The probabilistic antibiotic treatments were similar for N-AP and CA-AP (58% bi-therapy; 63% fluoroquinolone-based regimen). For N-AP, these treatments were more likely to be inadequate (42% vs. 8%, p < 0.001) and had a higher rate of bacteriological failure (48% vs. 19%, p < 0.001). Clinical failure at follow-up was more common than bacteriological failure (75% versus 24%, p < 0.001). Patients older than 49 had more underlying urinary tract disorders and a higher rate of clinical failure (30% versus 10%, p < 0.0001)., Conclusion: This study highlights the difficulties encountered on a daily basis by the physicians regarding the diagnosis and management of acute prostatitis.

Ionized calcium (Ca(2+)) seems to be the best measure of active serum calcium but, in France, numerous laboratories do not have Ca(2+) analyzers so that numerous clinicians use Payne's formula to obtain adjusted calcium (Ca(Ad)) values. In frail very elderly patients with protein/energetic malnutrition and very low concentrations of albumin, "correction" with Payne's formula usually gives false hypercalcemic results, so that hypocalcemia may be seriously underdiagnosed. Two hundred and ninety-four patients of 80 years and older with serum albumin level < 35 g/l were included in four French hospitals for elderly people. Biological measurements were standardized in order to determine Ca(2+) and total calcium (Ca(T)) in accordance with approved guidelines. Ca(Ad) was calculated with Payne's formula whereas the dependence of Ca(2+) with serum protein, albumin and Ca(Ad) was investigated by linear regression, the goodness-of-fit of each equation with the measure of Ca(2+) being studied. Taking into account serum protein and albumin levels, multiple linear regression gave the equation: Ca(2+) (mmol/l)=0.188-0.00469 protein (g/l)+0.0110 albumin (g/l)+0.401 Ca(Ad) with r(2)=0.442. The relative difference between the measure and the value given by the equation did not depend upon the center, and the correlation between measured and computed values of Ca(2+) was better, for any group, with our formula than with Payne's formula. When Ca(2+) was expressed with Ca(T) instead of Ca(Ad), albumin term was no longer significant and the new equation was: Ca(2+) (mmol/l)=0.592-0.00449 protein (g/l)+0.410 total calcium (mmol/l) with r(2)=0.438. We propose an alternative to direct measurement of Ca(2+) with a simple formula usable in geriatric units, which are often deprived of high-performance equipment.

Following a report by the Health Ministry recommending a greater implication of general practitioners (GP) in the diagnosis and care of mistreated older people, we wanted to evaluate what was actually their role in this matter. A study was made of files of mistreated older persons referred to the social services in a Parisian suburb. For each file, we noted who raised the first suspicions of mistreatment, who diagnosed it, what happened next, and what precisely the GP's role was. Out of 600 files, we found 12 cases, concerning 14 persons (two couples). Although all the patients had health problems requiring frequent consultations with their GP, none of these situations were diagnosed by the GP. In all cases, the GP played only a secondary role, if at all. The following points are discussed: The link between family problems and history cannot be ignored in the follow up of such situations. The GP's role is discussed regarding clinical knowledge of mistreatment and the legal rules they have to deal with. Our results bring to light how the balance between the person's autonomy and the necessary direct action is especially delicate in this field.

Background: Acute myocardial infarction (AMI) in elderly patients is often unrecognized and associated with poor prognosis., Objectives: To investigate management and efficacy of reperfusion therapy to the elderly patients with AMI., Methods: From the January 1, 2001 to October 31, 2002, 964 patients with AMI were included in the French regional RICO survey. The patients were divided into three groups: younger (<70 years old), elderly (70-79 years old) and very elderly (>or=80 years old)., Results: Distribution of groups was 56, 27, and 16%, respectively. The longest time delay to first request for medical attention was found in the very elderly group (30 and 55 vs. 90 min, respectively, p < 0.05). Rate of lysis fell significantly with increasing age (35, 22 and 9%, respectively, p < 0.001) but the time delay to lysis was similar for the 3 groups. The proportion of patients who benefited from primary percutaneaous transluminal coronary angioplasty decreased with age (21, 15, 11%, respectively, p < 0.001), but time delay to balloon angioplasty was similar and no difference in mortality rate was observed between the three groups after reperfusion. The incidence of in-hospital cardiovascular events (cardiogenic shock and recurrent myocardial infarction/ischemia) and in-hospital mortality increased with age (5, 13, 17%, respectively, p < 0.001). Moreover, multivariate analysis showed that only ejection fraction and Killip >1 were independent predictive factors for in-hospital cardiovascular mortality, respectively (OR 5.15, 95% CI 2.08-12.74, p < 0.0001 and OR 3.81, 95% CI 1.90-7.65, p < 0.0001), whereas age, sex, diabetes and anterior location were not significant., Conclusion: Our data in an unselected population indicate that very elderly patients were characterized by increased pre-hospital delays and less frequent utilization of reperfusion therapy, although no difference in the mortality in reperfused patients could be observed between the three age groups., ((c) 2005 S. Karger AG, Basel.)

Objective: To assess, in a population of elderly patients, the circumstances clinical and progressive characteristics and form of management of an acute colonic pseudo-obstruction (ACPO)., Method: Retrospective study of the files of 40 patients aged 70 and more having presented an acute colonic pseudo-obstruction and hospitalised in the university hospital in Dijon from January 1995 to June 2000., Results: The population was composed of 24 men (60%) and 16 women (40%) with a mean age of 80.8 years. The reasons for hospitalisation were varied: only 15 patients had been referred for an occlusive syndrome. 39 patients presented with abdominal distension, 30 suffered from abdominal pain. In this population, 17 patients exhibited reduced or clearly limited mobility, 20 patients had altered cognitive capacity with an MMS < 20. Thirty-eight patients suffered from a progressive heart disease and 8 patients presented with advanced dementia. The usual treatment of these patients to help the intestinal transit included diuretics in 25 cases and agents slowing the transit in 19 cases. Biologically speaking, hypokalaemia was observed in 21 cases and increased thyroid stimulating hormone (TSH) in 3 cases. An image was obtained of the abdomen without preparation in all patients: the mean caecum diameter was of 9.8 cm. A colon aspiration was performed in 20 patients and molecules to improve peristaltism were administered in 21 cases, with neostigmine prescribed for 9 patients. Surgery was required for 7 patients and 3 of them subsequently died. In terms of progression, 20 patients were cured after treatment, 13 relapsed and 7 patients worsened. Unfortunately, 10 patients died in our series., Discussion: In our study, the clinical profiles of acute colonic pseudo-obstruction were similar to those described in the literature: they occurred in varying circumstances, in medical or surgical settings ina predominantly male population of elderly, heavily dependent,patients. Treatment of this affection is not clearly codified for fragile patients with multiple diseases and the mortality rate observed should stimulate further studies, notably on pharmacological level.

Unlabelled: THE EXTENT OF THE PROBLEM: Because of the costs of intensive care, there is a possibility that access to this sector may be limited for those above a certain age. It would therefore appear necessary to develop an ethical clinical strategy in order to assess as precisely as possible and on individual level, the benefits and risks of these techniques, since age itself is simply a criterion among so many others. Among the elements that are important for the decision is the respect of the patient's wish, when it can be obtained since this is a fundamental point. In studies conducted in the United States, 50 to 90% of the elderly persons interviewed did not wish to be resuscitated in the case of cardiac arrest. CRITERIA FOR ADMISSION: The decision to admit an elderly patient in an intensive care unit must take into account the functional state of the patient, appreciated on daily activity and mobility scores and the neuro-psychological assessment, before hospitalization. In parallel, the severity of the underlying disease and the impact on visceral failures, assessed by the severity scores on admission appear to be more reliable prognostic elements than the patients' age itself. FOLLOWING RESUSCITATION: The quality of life of elderly patients within the months following resuscitation is difficult to assess, but is considered as acceptable in the majority of surviving patients., In Practice: The choice of admission in intensive care of an elderly patient requires a multidisciplinary approach that takes into account the patient's and/or family's wishes, the benefit/risk ratio of the technical act but which also, in certain cases, bears in mind the principle of end of life and the patient's dignity.

Objective: To have an overview of the French population concerning palliative care., Method: French opinion poll, based on a questionnaire submitted to 302 persons recruited at random in the street, in several regions of France. It included questions concerning the representation of pain, the sick body, death, the end of life and palliative care., Results: Regarding the management of pain, the majority of persons surveyed (59.6%) felt that the general practitioner was the appropriate referent to treat pain. The population's experience with regard to the death of a close relative revealed that death had occurred in hospital in 58.3% of cases. Nevertheless, the majority (57%) of the population wished to die in their own home. The concept of palliative care centres is increasing in the public's mind, but remains vague in its practical aspects for 60.9% of the population surveyed. For 29.5% of the population surveyed, information and training of health professionals in palliative care was considered as a priority., Conclusion: The end of life and death is a source of fear for most of the population. This motivates a transfer towards the medical corps for the professional and technical management of this period of life, and the health professionals must be prepared to respond appropriately to this specific demand.

Objectives: Determine the clinical and etiological features of Clostridium difficile diarrhea in elderly subjects., Patients and Methods: We retrospectively analyzed 21 cases of C. difficile diarrhea observed in patients at the Dijon geriatric center from January 1994 through December 1995. The diagnosis was established on C. difficile toxin evidenced in fecal matter., Results: There were 13 women and 8 men (mean age 85.9 years). All patients had several underlying disease conditions and were highly dependent. Three outbreaks involving 11 patients were observed. In more than half of the patients, the primary clinical signs were colitis with fever, highly elevated erythrocyte sedimentation rate and high white cell count. Eleven patients also had candidiasis of the digestive tract. All patients had received one or several antibiotics during the 15 days prior to diarrhea. The main antibiotic families were aminopenicillins, cephalosporins and fluoroquinolones. Twenty patients were given specific treatment: imidazoles in 15 cases and vancomycin in 9. Diarrhea was successfully controlled in 14 cases. There were 2 cases of recurrence and 6 patients died after a cascade of complications. C. difficile infection persisted in 2 at death., Discussion: Over recent years C. difficile diarrhea has become a serious problem in geriatric units. Antibiotic therapy is the main risk factor as well as protein-calorie malnutrition, immunodeficiency, and colonic stasis. Morbidity and mortality are high in fragile elderly subjects.

Objective: The prevalence of some autoantibodies in the elderly population has been reported to be greater than in younger controls. The prevalence of ANCA has been shown to be low in a generally healthy population, but has not been established in the elderly. Thus, the presence of ANCA in elderly patients might not have the same clinical significance as in younger people. The aim of this study was to evaluate the prevalence of ANCA in elderly subjects., Patients and Methods: Serum samples from 137 subjects (96 females, 41 males; mean age = 82.2 years +/- 6.97 SD) were evaluated. Criteria for exclusion included suspected or established systemic vasculitis, connective tissue or neoplastic diseases, acute infection, HIV infection, current therapy with corticosteroids or cytotoxic drugs, and recent blood transfusion. ANCA were detected by indirect immunofluorescence on ethanol-fixed normal human neutrophils. Fluorescence patterns were classified as c-ANCA, p-ANCA or nuclear. Sera exhibiting p-ANCA or nuclear fluorescence were further tested by IIF on formalin-acetone fixed normal human neutrophils. Sera whose reaction pattern was cytoplasmic were considered as positive for "true" pANCA. Additionally, sera were tested for the presence of antinuclear antibodies (IIF), anti-double-stranded DNA (enzyme immunoassay) and IgM rheumatoid factors (enzyme immunoassay)., Results: The prevalence of c-ANCA was 0% (95% CI = 0-2.66), the prevalence of p-ANCA was 2.2% (95% CI = 0.45-6.3), and the prevalence of "true" p-ANCA was 0.73% (95% CI = 0.02-4). The prevalence of ANA, anti ds-DNA and RF were respectively 38%, 3.6%, and 11.7%., Conclusion: The prevalence of ANCA is not increased in elderly people. Thus, the presence of ANCA in elderly subjects may have the same clinical significance as in younger people.

Objectives: To evaluate the clinical presentation and biological features of primary hyperparathyroidism (pHPT) in very old subjects., Methods: Thirty patients aged 75 years or more, with pHPT were analyzed retrospectively. The diagnosis of pHPT was based on usual biological signs and was always confirmed by the finding of morphological abnormalities with parathyroid imaging or neck surgical exploration., Results: At initial examination, recent general symptoms and neuromuscular symptoms were observed in 87% and 83% of the cases, respectively. Neuropsychiatric manifestations were noted in 73% of the cases. Confusion and depression were the most frequent findings, observed in 30% and 27% of the cases, respectively. In one of two patients with dementia like state, the mental status improved dramatically after surgery of the parathyroid adenoma. Serum calcium levels were in the normal range in 13% of the cases and equal or below 110 mg/L in 47% of the cases. There was no correlation between serum calcium level and the severity of mental changes. Serum parathyroid hormone determinations were abnormal in 93% of the patients. Thirteen patients underwent surgery with biological improvement in all cases. An ultrasonically guided percutaneous ethanol injection of parathyroid adenoma was performed in 10 patients with a biological cure rate of 50%., Conclusion: This study shows the major prevalence and potential severity of neuropsychiatric disorders in pHPT in very old patients. Because neuropsychiatric disturbances can respond favourably to surgical treatment, the clinician must systematically look for pHPT in elderly patients with cognitive impairment.