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Geriatric oncology is based on the synergy between several professionals whose common goal is to improve care for older patients with cancer. This requires sharing a common core of knowledge to facilitate collaboration between them. To date, training in geriatric oncology has been limited in scope and difficult to access for caregivers, particularly nurses and healthcare aides. To meet this need, a massive open online course (MOOC), in geriatric oncology has been developed in France. This kind of course aims to provide simultaneous access for a large number of participants and to foster communication with the pedagogical team through discussion forums. The first session of the MOOC, which has been set up in the Occitania region of France, went online nationwide from March 6 to June 23, 2020. Despite the SARS CoV-2 global health crisis, 1020 people subscribed to the first session and 417 (40.9%) were certified at the end of the course. Most are nurses (35.2%) and work outside Occitania (56.3%). A survey revealed a high satisfaction level regarding relevance of lessons (97.9%), pedagogical quality of teaching team (97.9%), knowledge acquisition (93.6%), meeting learners' needs (90.4%) and practical value of the course (88.3%). This preliminary experience demonstrates the ability of this MOOC to spread the culture of geriatric oncology and the educational potential of this new type of online training.

Resume Introduction Parmi les themes abordes par un Massive Open Online Course (MOOC) en oncogeriatrie, le syndrome confusionnel aigu (SCA) etait une priorite du fait de sa frequence, sa gravite et des difficultes diagnostiques et therapeutiques rencontrees par les professionnels de sante. Notre etude evalue des pratiques dans le domaine de la pedagogie, concernant l’evaluation du contenu d’un module de MOOC sur le SCA. Methodes Constitution d’un groupe pluri-professionnel pour definition du contenu scientifique et des objectifs pedagogiques, ecriture du script, developpement du module de formation. Evaluation des qualites pedagogiques du module selon onze principes de design de MOOC favorisant l’apprentissage. Description de la participation au module. Resultats Sept des onze criteres d’evaluation de la qualite pedagogique etaient documentes. Sur 1020 inscrits, 455 participants (44,6 %) ont repondu au questionnaire de fin de formation sur le SCA : 417 (40,8 % de l’ensemble des inscrits) ont valide l’evaluation, et parmi les 406 ayant renseigne leur profession et region d’exercice, les infirmieres (n = 146, 32 %) etaient majoritaires, les medecins/pharmaciens nombreux (n = 103, 22,6 %), confirmant la couverture du public cible comme l’interet pluri-professionnel du module, avec une repartition sur l’ensemble du territoire national. Discussion L’investissement dans un projet pedagogique d’une equipe pluri-professionnelle a renforce la cohesion de groupe et la valorisation de ses competences. Le developpement de ressources pedagogiques accessibles par internet doit s’accompagner d’une evaluation de la qualite du contenu scientifique, des objectifs et de la methode pedagogiques, avant de pouvoir en apprecier sur le terrain, l’impact reel sur les acquisitions et pratiques des participants.

Fabrice Ferré,1,* Marie-Léa Piel-Julian,2,* Francis Tincres,1 Cyndie Ba,1 Rémi Menut,1 Anne Ferrier,1 Laetitia Bosch,1 Charlotte Martin,1 François Labaste,1 François Montastruc,3 Agnès Sommet,3 Laurent Balardy,2,* Vincent Minville1,4,* 1Département d’Anesthésie-Réanimation et de Médecine Péri Opératoire, Centre Hospitalo-universitaire (CHU) de Toulouse, Toulouse, France; 2Service d’Oncogériatrie, Centre Hospitalo-universitaire (CHU) de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole (IUCT-O), Toulouse, France; 3Laboratoire de Pharmacologie Médicale et Clinique, Centre Midi-Pyrénées de Pharmacovigilance, de Pharmacoépidémiologie et d’Informations sur le Médicament, Pharmacopôle Midi-Pyrénées, INSERM UMR 1027, CIC INSERM 1436, CHU Toulouse, Toulouse, France; 4RESTORE, UMR 1301 Inserm - 5070 CNRS - Université Paul Sabatier, Université de Toulouse, Toulouse, France*These authors contributed equally to this workCorrespondence: Fabrice Ferré, Hôpital Pierre-Paul Riquet, CHU Purpan, place du Dr Baylac, Toulouse, 31059, France, Tel +33 5 61 77 99 88, Email ferre.f@chu-toulouse.frBackground: Postoperative delirium frequently occurs in the elderly after hip fracture surgery and is associated with poor outcomes. Our aim was to identify a correlation between the atropinic burden (AB) due to drugs with clinical antimuscarinic effect and the occurrence of postoperative delirium.Methods: We carried out a prospective, monocentric, observational study including 67 patients over 65 years of age who underwent hip fracture surgery. The addition of the anticholinergic weight of each drug was calculated at different time points to distinguish the prehospital, intra- and postoperative part of the AB. A multivariate analysis was carried out to identify the explanatory variables associated with postoperative delirium.Results: Patients were 78 [71– 86] years old. The time from admission to surgery was 12 [12– 24] hours. The ADL and CIRS scores were 6 [5.5– 6] and 6 [4– 9], respectively. The total (prehospital plus intraoperative plus postoperative) AB was 5 [3– 9]. The incidence of postoperative delirium was 54% (36/67). The demographic characteristics were comparable between delirium and no delirium groups. Univariate analysis showed statistically significant differences between no delirium and delirium groups concerning the number of prehospital atropinic drugs, prehospital AB, the number of postoperative atropinic drugs, postoperative AB, in-hospital AB and the MMSE calculated on postoperative day 5. Using multivariate analysis, postoperative AB, but not pre- and in-hospital ABs, was associated with postoperative delirium with an odds ratio of 1.84 (95% CI: 1.25– 2.72; p = 0.002). A postoperative AB > 2 was associated with a postoperative delirium with an area under ROC curve of 0.73 (95% CI: 0.61– 0.83; p = 0.0001).Conclusion: Contrary to a prior exposure to atropinic drugs, a postoperative atropinic burden > 2 was associated with postoperative delirium in elderly patients with hip fracture. Postoperative administration of (new) antimuscarinic drugs is a precipitating factor of delirium that could be avoided.Keywords: post-operative, anesthesia, atropinic burden, hip fracture, delirium

Background Diffuse large B cell lymphoma (DLBCL) is an aggressive disease. The first-line treatment is well defined in young patients, however in oldest old patients treatment remains unclear. Objectives To investigate the impact of therapeutics management and geriatric evaluation on survival in aged patients with DLBCL. Methods We performed a systematic review of PUBMED and COCHRANE databases of published report on elderly patients (median age 80 and above) with DLBCL, from January 2002 to January 2020. Results We included 32 studies (6 prospective and 26 retrospective). Patients treated with anthracyclines-containing chemoimmunotherapy had a two-years overall survival (OS) of 59% to 74.3% in prospective studies, and 48.1 to 64.6% in retrospective studies. With less intensive treatment without anthracyclines, two-years OS was 28% to 53%. Without specific treatment, median OS was two months. History of falls and severe comorbidities were associated with a decrease survival. Conclusions Chemoimmunotherapy with anthracyclines increase survival in selected very elderly patients in compared to less intensive regimen. Geriatric assessment, in particular altered mobility disorders and severe comorbidities, are predictive of survival and should be associated to the therapeutic decision. More comparative studies are needed to guide the management of frailer patients.

Background Pazopanib is a tyrosine kinase inhibitor given at the approved dose of 800 mg orally once daily (OD), but often requiring individual dose adjustment due to toxicity. Limited data is available to guide prescription in older patients especially the unfit according to geriatric assessment. Patients and methods VOTRAGE is a 3 + 3 dose-escalation, open-label phase I trial of continuous OD oral administration of pazopanib to evaluate safety, PK and PD data in unfit older patients with advanced solid tumors. The primary objective was to determine the maximum tolerated dose (MTD). PK data were compared with those obtained in younger adult patients in a population PK analysis. Results Eighteen patients with a median age of 82.5 years (range 75–91) were included in three dosing cohorts (400, 600, and 800 mg daily). Three dose-limiting toxicities (DLT) were observed in five patients at 800 mg and one DLT at 600 mg in six evaluable patients. MTD was defined as level 2 dose (600 mg). Individual oral clearance was not correlated with age. A relationship was observed between the occurrence of DLT and pazopanib plasma exposure. Decreased oral bioavailability of pazopanib when given with proton-pump inhibitors was confirmed in this group of patients. Conclusion We recommend performing geriatric assessment in patients older than 75 and starting pazopanib at 600 mg per day in unfit older patients. Therapeutic drug monitoring appears very helpful in this population.

Objective Hematological treatment decisions in older adults with hematological malignancies are complex. Our objective is to study the impact of a comprehensive geriatric assessment on hematological treatment decision in older patients and the factors associated with change in treatment plan. Methods We conducted a cross-sectional analysis of patients aged 65 years and above with hematological malignancies, hospitalized between 2008 and 2019 at the University Cancer Institute of Toulouse. They were assessed by a geriatrician/nurse team using a comprehensive geriatric assessment (CGA). A penalized logistic regression model with elastic net regularization was used to identify factors associated with change in hematological treatment plan. Results A total of 424 patients were included. Main hematological malignancies were lymphoma (36.1 %), acute myeloid leukemia (26.9 %) and myelodysplastic syndrome (19.8%). Change in hematological treatment plan was suggested after CGA for 92 patients (21.7%). Factors associated with change in treatment plan were functional impairment according to ADL and IADL scale, mobility impairment, the presence of comorbidity defined by the Charlson score > 1 and increasing age. Conclusion A CGA has a significant impact on hematological treatment decision in older patients. Functional and mobility impairment, comorbidities and age are predictive factors of change in treatment plan.

Introduction: Limiting the number of dependent older people in coming years will be a major economic and human challenge. In response, the World Health Organization (WHO) has developed the «Integrated Care for Older People (ICOPE)» approach. The aim of the ICOPE program is to enable as many people as possible to age in good health. To reach this objective, the WHO proposes to follow the trajectory of an individual’s intrinsic capacity, which is the composite of all their physical and mental capacities and comprised of multiple domains including mobility, cognition, vitality / nutrition, psychological state, vision, hearing. Objective: The main objective of the INSPIRE ICOPE-CARE program is to implement, in clinical practice at a large scale, the WHO ICOPE program in the Occitania region, in France, to promote healthy aging and maintain the autonomy of seniors using digital medicine. Method: The target population is independent seniors aged 60 years and over. To follow this population, the 6 domains of intrinsic capacity are systematically monitored with pre-established tools proposed by WHO especially STEP 1 which has been adapted in digital form to make remote and large-scale monitoring possible. Two tools were developed: the ICOPE MONITOR, an application, and the BOTFRAIL, a conversational robot. Both are connected to the Gerontopole frailty database. STEP 1 is performed every 4-6 months by professionals or seniors themselves. If a deterioration in one or more domains of intrinsic capacity is identified, an alert is generated by an algorithm which allows health professionals to quickly intervene. The operational implementation of the INSPIRE ICOPE-CARE program in Occitania is done by the network of Territorial Teams of Aging and Prevention of Dependency (ETVPD) which have more than 2,200 members composed of professionals in the medical, medico-social and social sectors. Targeted actions have started to deploy the use of STEP 1 by healthcare professionals (physicians, nurses, pharmacists,…) or different institutions like French National old age insurance fund (CNAV), complementary pension funds (CEDIP), Departmental Council of Haute Garonne, etc. Perspective: The INSPIRE ICOPE-CARE program draws significantly on numeric tools, e-health and digital medicine to facilitate communication and coordination between professionals and seniors. It seeks to screen and monitor 200,000 older people in Occitania region within 3 to 5 years and promote preventive actions. The French Presidential Plan Grand Age aims to largely implement the WHO ICOPE program in France following the experience of the INSPIRE ICOPE-CARE program in Occitania.

The implementation of cross-functional measures along the care pathway of cancer patients in France is globally lower in the elderly. However, age is not a criterion for excluding curative treatment, and the evaluation of physical, psychological and social resources and comorbidities is particularly significant in this population. Identifying needs in terms of support care which influences the patient's quality of life as well as the efficacy of treatments is also essential. The objective of geriatric oncology coordination is to offer elderly cancer patients global treatment, curative or otherwise, through the putting in place of a personalised care programme.

Recent European Society of Parenteral and Enteral Nutrition guidelines highlighted the interest of prevention, diagnosis and treatment of malnutrition in the management of coronavirus disease 19 (COVID-19) patients. The aim of our study was to evaluate the prevalence of malnutrition in patients hospitalised for COVID-19. In a prospective observational cohort study malnutrition was diagnosed according to the Global Leadership Initiative on Malnutrition (GLIM) two-step approach. Patients were divided into two groups according to the diagnosis of malnutrition. Covariate selection for the multivariate analysis was based on P n 46, 57·5 %) was similar in the two groups. Three patients who died (3·75 %) were malnourished. Multivariate analysis exhibited that low BMI (OR 0·83, 95 % CI 0·73, 0·96, P = 0·0083), dyslipidaemia (OR 29·45, 95 % CI 3·12, 277·73, P = 0·0031), oral intake reduction P = 0·0422) and glomerular filtration rate (Chronic Kidney Disease Epidemiology Collaboration; CKD-EPI) at admission (OR 0·979, 95 % CI 0·96, 0·998, P = 0·0297) were associated with the occurrence of malnutrition. We demonstrate the existence of a high prevalence of malnutrition in a general cohort of COVID-19 inpatients according to GLIM criteria. Nutritional support in COVID-19 care seems an essential element.

Among the themes to be addressed by a Massive Open Online Course (MOOC) on geriatric oncology, one of the priorities was delirium, due to its frequency, complications and difficulties encountered by healthcare professionals in diagnosing and managing delirium. Our study aims to evaluate professional practices in the area of education, regarding the evaluation of the content of a MOOC module about delirium syndrome in geriatric oncology.We created a multidisciplinary group to define the scientific content, the pedagogical objectives, the scriptwriting and the development of a training module. The quality of instructional design was then evaluated according to eleven MOOC design principles to promote learning. Participants were studied.Seven of the eleven criteria for evaluating pedagogical quality were documented. Among the 1020 participants, 455 (44.6%) completed the final test concerning delirium: 417 (40.8%) passed the final test; 406 documented their profession and the region of France where they worked: 146 (32%) nurses (confirming the participation of the targeted audience), 103 (22.6%) doctors/pharmacists (illustrating the multi-professional interest of the thematic), with a wide distribution of the participants over the national territory.The multidisciplinary team's investment in developing these teaching materials strengthened the group's cohesion and valuated its professional skills. All teaching resources developed for access via the internet must be accompanied by an evaluation of the quality of the scientific content, objectives and teaching methods, before being able to appreciate its use in the field and assess its real impact on the participants' learning and practice.

BACKGROUND The effects of SARS-CoV-2 (COVID-19) on the myocardium and their role in the clinical course of infected patients are still unknown. The severity of SARS-CoV-2 is driven by hyperinflammation, and the effects of SARS-CoV-2 on the myocardium may be significant. This study proposes to use bedside observations and biomarkers to characterize the association of COVID-19 with myocardial injury. OBJECTIVE The aim of the study is to describe the myocardial function and its evolution over time in patients infected with SARS-CoV-2 and to investigate the link between inflammation and cardiac injury. METHODS This prospective, monocentric, observational study enrolled 150 patients with suspected or confirmed SARS-CoV-2 infection at Toulouse University Hospital, Toulouse, France. Patients admitted to the intensive care unit (ICU), regular cardiologic ward, and geriatric ward of our tertiary university hospital were included during the pandemic period. Blood sampling, electrocardiography, echocardiography, and morphometric and demographic data were prospectively collected. RESULTS A total of 100 patients were included. The final enrolment day was March 31, 2020, with first report of results at the end of the first quarter of 2021. The first echocardiographic results at admission of 31 patients of the COCARDE-ICU substudy population show that biological myocardial injury in COVID-19 has low functional impact on left ventricular systolic function. CONCLUSIONS A better understanding of the effects of COVID-19 on myocardial function and its link with inflammation would improve patient follow-up and care. CLINICALTRIAL Clinicaltrials.gov NCT04358952; https://clinicaltrials.gov/ct2/show/NCT04358952 INTERNATIONAL REGISTERED REPORT DERR1-10.2196/24931

Background The effects of SARS-CoV-2 (COVID-19) on the myocardium and their role in the clinical course of infected patients are still unknown. The severity of SARS-CoV-2 is driven by hyperinflammation, and the effects of SARS-CoV-2 on the myocardium may be significant. This study proposes to use bedside observations and biomarkers to characterize the association of COVID-19 with myocardial injury. Objective The aim of the study is to describe the myocardial function and its evolution over time in patients infected with SARS-CoV-2 and to investigate the link between inflammation and cardiac injury. Methods This prospective, monocentric, observational study enrolled 150 patients with suspected or confirmed SARS-CoV-2 infection at Toulouse University Hospital, Toulouse, France. Patients admitted to the intensive care unit (ICU), regular cardiologic ward, and geriatric ward of our tertiary university hospital were included during the pandemic period. Blood sampling, electrocardiography, echocardiography, and morphometric and demographic data were prospectively collected. Results A total of 100 patients were included. The final enrolment day was March 31, 2020, with first report of results at the end of the first quarter of 2021. The first echocardiographic results at admission of 31 patients of the COCARDE-ICU substudy population show that biological myocardial injury in COVID-19 has low functional impact on left ventricular systolic function. Conclusions A better understanding of the effects of COVID-19 on myocardial function and its link with inflammation would improve patient follow-up and care. Trial Registration Clinicaltrials.gov NCT04358952; https://clinicaltrials.gov/ct2/show/NCT04358952 International Registered Report Identifier (IRRID) DERR1-10.2196/24931

(1) Background: COVID-19 has become a global pandemic and older patients present higher mortality rates. However, studies on the characteristics of this population set are limited. The objective of this study is to describe clinical characteristics and outcomes of older patients hospitalized with COVID-19. (2) Methods: This retrospective cohort study was conducted from March to May 2020 and took place in three acute geriatric wards in France. Older patients hospitalized for COVID-19 infections were included. We collected clinical, radiological, and laboratory outcomes. (3) Results: Ninety-four patients were hospitalized and included in the final analysis. Mean age was 85.5 years and 55% were female. Sixty-four (68%) patients were confirmed COVID-19 cases and 30 (32%) were probable. A majority of patients were dependent (77%), 45% were malnourished, and the mean number of comorbidities was high in accordance with the CIRS-G score (12.3 &plusmn, 25.6). The leading causes of hospitalization were fever (30%), dyspnea (28%), and geriatric syndromes (falls, delirium, malaise) (18%). Upon follow-up, 32% presented acute respiratory failure and 30% a geriatric complication. Frailty and geriatric characteristics were not correlated with mortality. Acute respiratory failure (p = 0.03) and lymphopenia (p = 0.02) were significantly associated with mortality. (4) Conclusions: Among older patients hospitalized with COVID-19, clinical presentations were frequently atypical and complications occurred frequently. Frailty and geriatric characteristics were not correlated with mortality.

Background: Recent ESPEN guidelines highlighted the interest of prevention, diagnosis and treatment of malnutrition in the management of coronavirus disease 19 (COVID-19) patients. The aim of our study was to evaluate the prevalence of malnutrition in patients hospitalized for COVID-19. Methods: Prospective observational cohort study on COVID-19 inpatients admitted to a tertiary hospital. Malnutrition was diagnosed according to the Global Leadership Initiative on Malnutrition two-step approach. Patients were divided in two groups according to the diagnosis of malnutrition. Covariate selection for the multivariate analysis was based on P value Results: 80 patients were prospectively enrolled in the study. Thirty patients (37.5%) had criteria for malnutrition. The need for ICU admission (n=46, 57.5%) was similar in the two groups. Three patients who died (3.75%) were malnourished. Multivariate analysis exhibited that low BMI (OR=0.83, 95% CI [0.73-0.96], p=0.0083), dyslipidemia (OR=29.45, 95% CI [3.12-277.73], p=0.0031), oral intakes reduction Conclusions: We demonstrate the existence of a high prevalence of malnutrition (37.5%) in a general cohort of COVID-19 inpatients according to GLIM criteria. Considering this high prevalence, nutritional support in COVID-19 care seems an essential element. Trial registration: Ethical Committee No 2020-A01237-32)(RC31/20/0165 NUTRI-COV

International audience; Frailty is known to predict dementia. However, its link with neurodegenerative alterations of the central nervous system(CNS) is not well understood at present. We investigated the association between the biomechanical response of the CNS and frailty in older adults suspected of normal pressure hydrocephalus (NPH) presenting with markers of multiple co-existing pathologies. The biomechanical response of the CNS was characterized by the CNS elastance coefficient inferred from phase contrast magnetic resonance imaging and intracranial pressure monitoring during a lumbar infusion test. Frailty was assessed with an index of health deficit accumulation. We found a significant association between the CNS elastance coefficient and frailty, with an effect size comparable to that between frailty and age, the latter being the strongest known risk factor for frailty. Results were independent of CSF dynamics, showing that they are not specific to the NPH neuropathological condition. The CNS biomechanical characterization may help to understand how frailty is related to neurodegeneration and detect the shift from normal to pathological brain ageing.

Objectives To examine frailty determinants differences in patients with a recent diagnosis of cancer compared to non-cancer patients among older adult. Revealing those differences will allow us to individualize the exact frailty management in those patients diagnosed with cancer. Design This is an observational cross-sectional, monocentric study. Setting Patients were evaluated at the Geriatric Frailty Clinic (GFC), in the Toulouse University Hospital, France, between October 2011 and February 2016. Participants 1996 patients aged 65 and older were included (1578 patients without cancer and 418 patients with solid and hematological cancer recently diagnosed). Measurements Frailty was established according to the frailty phenotype. The frailty phenotype measures five components of frailty: weight loss, exhaustion, low physical activity, weakness and slow gait. Frailty phenotype was categorized as robust, pre-frail and frail. Results In a multinomial logistic regression, cancer, compared to the non-cancer group, is not associated with an increased likelihood of being classified as pre frail (RRR 0.9, 95% CI [0.5; 1.6], p 0.9) or frail (RRR 1.2, 95% CI [0.7; 2.0], p 0.4) rather than robust. When considering each Fried criterion, a significant higher odd of weight loss was observed in older patients with cancer compared to the non-cancer patients (OR 2.3, 95% CI [1.8; 3.0], p Conclusion In this real-life study evaluating elderly patients with and without cancer, we didn’t confirm our hypothesis, in fact we found that cancer was not associated with frailty severity using both a phenotypic model and a deficit accumulation approach. Cancer may contribute, at least additively, to the development of frailty, like any other comorbidity, rather than a global underlying condition of vulnerability.

Background Half of cancer cases occur in patients aged 70 and above. Majority of older patients are eligible for chemotherapy but evidence for treating this population is sparse and severe toxicities affect more than half of them. Determining prognostic biomarkers able to predict poor chemotherapy tolerance remains one of the major issues in geriatric oncology. Ageing is associated with body composition changes (increase of fat mass and loss of lean mass) independently of weight-loss. Previous studies suggest that body composition parameters (particularly muscle mass) may predict poor chemotherapy tolerance. However, studies specifically including older adults on this subject remain sparse and the majority of them study body composition based on computed tomography (CT) scanner (axial L3 section) muscle mass estimation. This method is to date not validated in elderly cancer patients. Methods This trial (Fraction) will evaluate the discriminative ability of appendicular lean mass measured by dual-energy X-ray absorptiometry (DXA) to predict severe toxicity incidence in older cancer-patients treated with first-line chemotherapy. DXA is considered the gold standard in body composition assessment in older adults. Patient’s aged ≥70 diagnosed with solid neoplasms or lymphomas at a locally advanced or metastatic stage treated for first-line chemotherapy were recruited. Patients completed a pre-chemotherapy assessment that recorded socio-demographics, tumor/treatment variables, laboratory test results, geriatric assessment variables (function, comorbidity, cognition, social support and nutritional status), oncological risk scores and body composition with DXA. Appendicular lean mass was standardized using evidence based international criteria. Participants underwent short follow-up geriatric assessments within the first 3 months, 6 months and a year after inclusion. Grade 3 to 5 chemotherapy-related toxicities, as defined by the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE) were assessed at each chemotherapy cycle. Discussion The finding that body composition is associated with poor tolerance of chemotherapy could lead to consider these parameters as well as improve current decision-making algorithms when treating older adults. Trial registration ClinicalTrials.gov Identifier: NCT02806154 registered on October 2016.

Background Frailty and hemoglobin concentration, above what would be considered clinical anemia, are two common findings in older patients that lead to an increased risk of negative health outcomes. The objective of this study is to evaluate whether hemoglobin concentration is an independent predictor of frailty and investigate possible causal pathways with a focus on the relationship between inflammation or nutrition and hemoglobin concentration. Methods 1829 community-dwelling participants aged 65 years or older who visited the Toulouse frailty day hospital during 2011 and 2016 were included in this analysis. Patients underwent a comprehensive geriatric assessment and had a blood sample taken. A series of multivariate logistic regression models were performed after minimizing potential influence from age, gender, kidney function, inflammation, cognition, nutritional status and certain socio-economic factors. Results Hemoglobin concentration and frailty are significantly associated after minimizing potential influence from other covariates (p p > 0.005). Conclusions Hemoglobin concentration is strongly associated with frailty in older adults. These results can have potentially important implications for prevention policies targeting frailty by identifying potential patients with high risk of adverse outcomes and functional outcomes.

Consequences of inappropriate prescriptions and polymedication in patients suffering from cancer are beginning to be well documented. However, the methods used to evaluate these consequences are often discussed. Few studies evaluate the risk of interaction with anticancer drugs in elderly patients suffering from cancer. To describe the prevalence (i) of polypharmacy, (ii) of potentially inappropriate drug prescriptions and (iii) of drug interactions involving anticancer treatments, using a multiple reference tools. A retrospective, cross-sectional, multicenter study performed from January to December 2012. Patients aged 65 years or older suffering from cancer presented at the oncogeriatric multidisciplinary meeting. Polymedication (>6 drugs), potentially inappropriate prescriptions and drug interactions involving anticancer treatment were analyzed in combination with explicit and implicit criteria within a global approach. Among the 106 patients included in this study, polypharmacy was present in 60.4% of cases, potentially inappropriate drug prescription in 63.1% and drug interactions in 16% of case, of which 47% involved anti-cancer treatments. Twenty-seven major drug interactions were identified and eight interactions involved chemotherapy. Polymedication, inappropriate prescribing and drug interactions involving anti-cancer drugs are common and largely underestimated in elderly cancer patients.

Introduction La place du myelogramme dans le bilan initial d’une thrombopenie isolee differe selon les referentiels nationaux et internationaux de prise en charge du purpura thrombopenique immunologique (PTI). Alors que la Societe americaine d’hematologie propose pas de maniere systematique, les recommandations internationales (2010) et francaises (2017) l’incluent au diagnostic d’une thrombopenie isolee de facon systematique chez les patients de plus de 60 ans afin d’eliminer une hemopathie, en particulier un syndrome myelodysplasique. Ces recommandations sont issues de consensus d’experts mais il n’existe pas de donnees quant a la rentabilite de cet examen dans ce contexte. L’objectif de cette etude etait d’evaluer la rentabilite du myelogramme au diagnostic de PTI chez les patients âges de plus de 60 ans presentant une thrombopenie isolee. Patients et methodes La source de donnees etait le registre Cytopenies Auto-immunes : Registre Midi-PyreneEN (CARMEN). Tous les patients ayant presente un diagnostic incident de PTI en region Midi-Pyrenees (3 millions d’habitants) ont ete inclus de maniere prospective depuis juin 2013 dans le registre CARMEN. Le PTI etait defini selon les recommandations internationales (numeration plaquettaire 60 ans ; absence de signes cliniques d’hemopathie maligne (adenopathies, hepatomegalie, splenomegalie) ; thrombopenie isolee ; myelogramme realise au diagnostic de PTI. Les caracteristiques initiales et la prise en charge des patients ayant un myelogramme anormal ont ete decrites. Resultats Nous avons identifie114 patients (66 hommes et 48 femmes) repondant a l’ensemble des criteres d’inclusion. L’âge moyen au diagnostic de PTI etait de 76 ans (ecart-type [ET] : 9 ans). La numeration plaquettaire au diagnostic etait de 32,7 × 109/L (ET : 27,7 × 109/L) ; 58 patients ont presente des manifestations hemorragiques au diagnostic : saignements cutanes isoles (n = 33), saignements buccaux (n = 17), epistaxis (n = 10) et hematurie (n = 3). Un seul patient avait un myelogramme anormal, l’examen ayant permis le diagnostic d’un syndrome myelodysplasique. Il s’agissait d’un patient de 62 ans sans antecedent notable, presentant en 2014 des manifestations hemorragiques cutanees isolees revelant une thrombopenie isolee (6 × 109/L). Le reste de l’hemogramme montrait : hemoglobine : 15,2 g/dL ; VGM : 83 fL ; leucocytes : 5,3 × 109/L ; polynucleaires neutrophiles : 3,5 × 109/L ; lymphocytes : 1,0 × 109/L ; monocytes : 0,3 × 109/L. Le myelogramme montrait une cellularite normale. La lignee megacaryocytaire etait en rapport avec la densite medullaire mais presentait des signes de dysplasie (noyaux separes). Il existait egalement une dysgranulopoiese significative avec pelgerisation et degranulation de certains elements. On observait enfin une dysplasie erythroblastique avec la presence de quelques cytoplasmes feuilletes. Ces anomalies etaient compatibles avec le diagnostic de syndrome myelodysplasique avec dysplasie multilignee. L’analyse cytogenetique etait normale. La prise en charge du PTI a consiste initialement a une association de corticoides et d’immunoglobulines intraveineuses (reponse partielle). Le patient a recu par la suite du danazol (reponse complete), de l’eltrombopag (apres une perte de reponse au danazol et la survenue d’hemorragie conjonctivale, avec une reponse complete) et plus recemment du romiplostim (apres une perte de reponse a l’eltrombopag, avec une reponse complete). Il a egalement ete traite en 2019 par du rituximab pour tenter de diminuer l’exposition aux agonistes du recepteur a la thrombopoietine, sans efficacite. Un nouveau myelogramme a ete realise avant la premiere perfusion de rituximab (quatre ans apres le premier) avec les memes resultats cytologiques et cytogenetiques. Conclusion La decouverte d’une hemopathie maligne lors du diagnostic de PTI est rare lorsque la presentation est typique, meme chez les patients de plus de 60 ans. Un seul syndrome myelodysplasique (0,8 %) a ete diagnostique dans notre serie sans repercussion sur la prise en charge therapeutique et l’evolution du PTI avec un recul de 5 ans.

Background The comprehensive geriatric assessment (CGA) is the gold standard in geriatric oncology to identify patients at high risk of adverse outcomes and optimize cancer and overall management. Many studies have demonstrated that CGA could modify oncologic treatment decision. However, there is little knowledge on which domains of the CGA are associated with this change. Moreover, the impact of frailty and physical performance on change in cancer treatment plan has been rarely assessed. Methods This is a cross-sectional study of older patients with solid or hematologic cancer referred by oncologists for a geriatric evaluation before cancer treatment. A comprehensive geriatric assessment was performed by a multidisciplinary team to provide guidance for treatment decision. We performed a multivariate analysis to identify CGA domains associated with change in cancer treatment plan. Results Four hundred eighteen patients, mean age 82.8 ± 5.5, were included between October 2011 and January 2016, and 384 of them were referred with an initial cancer treatment plan. This initial cancer treatment plan was changed in 64 patients (16.7%). In multivariate analysis, CGA domains associated with change in cancer treatment plan were cognitive impairment according to the MMSE score (p = 0.020), malnutrition according to the MNA score (p = 0.023), and low physical performance according to the Short Physical Performance Battery (p = 0.010). Conclusion Cognition, malnutrition and low physical performance are significantly associated with change in cancer treatment plan in older adults with cancer. More studies are needed to evaluate their association with survival, treatment toxicity and quality of life. The role of physical performance should be specifically explored.

The implementation of cross-functional measures along the care pathway of cancer patients in France is globally lower in the elderly. However, age is not a criterion for excluding curative treatment, and the evaluation of physical, psychological and social resources and comorbidities is particularly significant in this population. Identifying needs in terms of support care which influences the patient's quality of life as well as the efficacy of treatments is also essential. The objective of geriatric oncology coordination is to offer elderly cancer patients global treatment, curative or otherwise, through the putting in place of a personalised care programme.

Supporting patients undergoing chemotherapy is one of the priorities of geriatric oncology care. To this effect, a Toulouse hospital team has developed a telephone follow-up service operated by nurse navigators. In collaboration with the multi-disciplinary team of the hospitalisation service, it provides close support to the patient and their family.

A consensual and operational definition of frailty is necessary in geriatric oncology. While many studies have focused on geriatric syndromes evaluated in the comprehensive geriatric assessment (CGA) to select patients at higher risk of poor outcomes, few have compared CGA data with Fried's phenotype of frailty, the most consensual measurement of frailty in geriatrics. Our objective was to determine a threshold of impaired domains evaluated in CGA associated with Frailty status.A cross-sectional study including all patients with cancer, evaluated from January 2011 to February 2016 at the Geriatric Frailty Clinic, Toulouse. A CGA was performed evaluating seven geriatric domains. Frailty was measured by Fried's phenotype to classify patients into three groups (robust/pre-frail/frail). We plotted a ROC curve to determine the threshold of impaired domains associated with frailty according to Fried.We included 418 patients aged 82.8 years (range 66-100 years). Thirty-three patients (7.9%) were robust, 155 (37.1%) pre-frail and 230 (55%) frail. There was a significant difference in ADL, IADL, nutrition, cognition and polypharmacy between the three groups (p .001 for each domain). Frail patients had more impaired geriatric domains on CGA than pre-frail and robust patients (respectively 4.5 ± 1.5, 2.8 ± 1.6 and 2.1 ± 1.2; p .001). The threshold of 4 impaired geriatric domains associated with Fried's Frailty status was identified (Se 77.39%, Sp 67.55%). Area under the curve was 79.6%.The phenotype of frailty is associated with more impaired geriatric domains and a threshold of 4 altered domains could be used to detect frailty from CGA data.

Background:Making the diagnosis of aortitis may be challenging in the “real life”.18F-FDG PET/CT (PET) has emerged has the gold standard to diagnose aortitis but it is expensive and not always quickly available. Injected CT-scan (CT) can also be used to diagnose aortitis, which is suspected when there is an extended circumferential, non-atherosclerotic increase of the aortic wall thickness (AWT). However, data are lacking on the diagnostic performances of AWT to diagnose aortitis.Objectives:To describe the diagnostic performance of AWT measured by CT to diagnose aortitis in patients over 50 years of age.Methods:We performed a monocentric retrospective study between 2013 and 2018 including 1) all patients over 50 years of age who had performed a PET for inflammation or fever of unknown origin or for suspicion of classical giant cell arteritis (GCA), aortitis or large vessel vasculitis (LVV); 2) with an injected CT-scan performed in the 30 days before or after PET; 3) not diagnosed to have cancer or infection 4) exposed to corticosteroids for less than 3 days at the time of CT and PET. The gold standard for aortitis was PET positivity according to the 2018 European consensus grading criteria (1). AWT was measured at different aortic segments (ascending aorta, descending thoracic aorta and suprarenal abdominal aorta) by a single radiologist unaware of the result of PET and of the previous interpretation of CT-scan.Results:Eighty-nine patients were included (female: 47%; mean age 68.8 (50-93) years; GCA: n=28). Twenty patients had aortitis according to the PET result (GCA: n=16).Mean maximal aortic wall thickening was: 3.25 mm (median: 3.3; range: 2-4.6) in the aortitis group and 2.2 mm (median: 2.1; range 1-3.8) in the negative PET group (p < 0.001).The best ROC curve AUC (85%) was obtained considering the maximal AWT on the thoracic and suprarenal abdominal aorta only. The AUC of the ROC curve at the ascendant thoracic aorta was poor (75%) (Figure).The Youden’s index of the ROC curve was 2.6 mm with a sensitivity of 85 % and specificity of 71 % (Table) for aortitis diagnosis. An AWT ≤ 2.0 mm exclude the diagnosis of aortitis. The 3 mm threshold had a PPV of only 52% and an AWT ≥ 4 mm was fully specific.Conclusion:Aortitis diagnosis using a routine injected CT-scan interpreted by a single radiologist may be certain when showing an AWT ≥ 4 and excluded for an AWT≤ 2.0. The threshold of 3 mm seems not sufficiently specific to diagnose aortitis without a confirmatory PET.References:[1]Riemer H.J.A. Slart et al. FDG-PET/CT(A) imaging in large vessel vasculitis and polymyalgia rheumatica: joint procedural recommendation of the EANM, SNMMI, and the PET Interest Group (PIG), and endorsed by the ASNC. Eur J Nucl Med Mol Imaging. 2018 Jul;45(7):1250–69.Table.Performance of different threshold for maximal thickness of the aortic wall for diagnosis of aortitis using PET positivity as the gold standard*.Thickness (mm)SensitivitySpecificityNPVPPVaccuracy≥ 1.9100 %30.4%100 %29.41 %46 %≥ 2.0100 %31.88 %100 %29.85 %47 %≥ 2.295 %53.62 %97.36 %37.25 %63 %≥ 2.685 %71.01 %94.23 %45.94 %74 %≥ 3.060 %84.05 %87.88 %52.17 %78 %≥ 3.360 %92.75 %88.89 %70.59 %85 %≥ 3.535 %95.65 %83.54 %70 %82 %≥ 3.825 %98.55 %81.92 %83.33 %82 %≥ 4.020 %100 %81.17 %100 %82 %*Made with ROC curve in descendant thoracic and suprarenal segment of the aorta; PET:18F-FDG PET/CT; NPV: negative predictive value; PPV: positive predictive value.Figure.ROC curve of aortic wall thickness, in descendant thoracic and suprarenal abdominal segments for the diagnosis of aortitis.Disclosure of Interests:None declared

Introduction:There are discrepancies across recommendations about the indication of bone marrow smear in adults diagnosed for immune thrombocytopenia (ITP). The 2011 American Society of Hematology guidelines do not recommend bone marrow smear in case of typical ITP. In contrast, the 2010 international consensus and the 2017 French guidelines recommend systematic bone marrow smear in adults aged >60 years even in case of typical ITP to detect a blood cancer, particularly myelodysplastic syndrome. This recommendation is driven from expert consensus. Data are lacking about the positivity rate of this examination in older patients with typical ITP. The aim of this study was to assess the positivity rate of bone marrow smear at ITP diagnosis in >60-year-old patients with no other clinical or biological sign of hematological malignancy. Methods:Data source was theCARMEN (Cytopénies Auto-immunes : Registre Midi-PyréneEN) registry. All adult patients with an incident diagnosis of ITP in the French Midi-Pyrénées region (South of France, 3 million inhabitants) are prospectively enrolled since June 2013 in the multicenter CARMEN registry. ITP is defined by international guidelines (platelet count 60 years; absence of clinical signs of hematological malignancy (lymphadenopathy, hepatomegaly, splenomegaly); isolated thrombocytopenia on blood count; bone marrow smear performed at ITP diagnosis. We described patients with abnormal bone marrow smear and implications for ITP management. Results:We identified 114patients (66 men and 48 women) satisfying all inclusion criteria. Mean age at ITP diagnosis was 76 years (standard deviation - SD: 9 years). Platelet count at diagnosis was 32.7 x 109/L (SD: 27.7 x 109/L) and 58 patients presented with bleeding: skin bleeding only (n=33), oral bleeding (n=17), epistaxis (n=10) and hematuria (n=3). Only one patient had an abnormal bone marrow smear corresponding to a characterized hematological disease: a myelodysplastic syndrome. It was a 62-year-old man without medical history who presented in 2014 with extensive skin bleeding, and isolated thrombocytopenia (6 x 109/L). Other blood count parameters were: hemoglobin: 15.2 g/dL; MCV: 83 fL; leukocytes: 5.3 x 109/L; polynuclear neutrophils: 3.5 x 109/L; lymphocytes: 1.0 x 109/L; monocytes: 0,3 x 109/L . Bone marrow smear revealed normal cellularity. The megakaryocytic lineage was normally represented with significant number of megakaryocytes with multiple separated nuclei. Significant dysgranulopoiesis was also observed with pseudo-Pelger-Huët anomaly and cytoplasmic hypogranulation. Some erythroblasts with defective haemoglobination or cytoplasmic vacuolation were present. This aspect was compatible with the diagnosis of myelodysplastic syndrome with multilineage dysplasia (MDS-MLD). Karyotype was normal. The patient was initially treated for ITP with steroids and intravenous immunoglobulins (with partial response), then with danazol (complete response), eltrombopag (after loss of response to danazol and ocular bleeding, resulting in complete response) and more recently romiplostim (after loss of response to eltrombopag, resulting in complete response). He was treated in 2019 by rituximab to spare exposure to thrombopoietin receptor agonists, without efficacy. Before Rituximab, another bone marrow smear was performed (4 years after the first one) with the same cytologic and cytogenetic features (MLD-MDS with normal caryotype). Conclusions:Diagnosis of hematological malignancy is very uncommon in >60 year-old patients who present with typical ITP. Myelodysplastic syndrome was found in 1 (0.8%) patient in this series, and did not impact the management or the evolution of the patient with a five-year follow-up. Overall, this study sustains guidelines that does not recommend systematic testing for bone marrow examination in >60 year-old patients with typical ITP. Disclosures Comont: BMS: Consultancy, Membership on an entity's Board of Directors or advisory committees. Recher:Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Astellas: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Sunesis: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Incyte: Honoraria; Macrogenics: Consultancy, Membership on an entity's Board of Directors or advisory committees; Astellas: Consultancy, Membership on an entity's Board of Directors or advisory committees; Abbvie: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Jazz: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Amgen: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding. Beyne-Rauzy:Novartis: Research Funding; Cellgene: Research Funding. Moulis:CSL Behring: Research Funding; Amgen pharma: Research Funding, Speakers Bureau; Novartis pharma: Research Funding, Speakers Bureau.

International audience; Objective: The aim of our study was to assess major cardiovascular event incidence, predictors, and mortality in ANCA-associated vasculitis (AAV).Methods: We conducted a retrospective cohort study of all GPA or MPA, according to Chapel Hill Consensus Conference classification criteria, diagnosed between 1981 and 2015. Major cardiovascular event was defined as acute coronary artery disease, or ischemic stroke, or peripheral vascular disease requiring a revascularization procedure. We calculated the comparative morbidity/mortality figure (CMF) and we used Cox proportional hazards regression models to assess the risk of coronary artery disease, ischemic stroke associated with AAV, after adjusting for covariates.Results: 125 patients, 99 GPA (79,2%) and 26 MPA (20,8%), were followed 88.4 ± 78.3 months. Ischemic stroke incidence was four times higher than in the general population (CMF 4,65; 95% CI 4,06-5,31). Coronary artery disease incidence was four times higher than in the general population (CMF 4,22; 95% CI 1,52-11,68). Smoking habits and history of coronary artery disease were strongly associated with coronary artery disease occurrence (adjusted HR 8.8; 95% CI 2.12-36.56, and adjusted HR 10.3; 95% CI 1.02-104.5, respectively). ENT flare-up was an independent protective factor for coronary artery disease occurrence. We did not identify factors significantly associated with stroke occurrence. The age-adjusted mortality rate was 22.5 per 1000 person-years. Mortality in AAV was 1.5 times higher than in the general population (CMF 1.56; 95% CI 1.34-1.83).Conclusion: AAV have a significantly increased risk of mortality, ischemic stroke, and coronary artery disease.

Arterial hypertension is among the leading risks for mortality. This burden requires in hypertensive patients the use of single, double or more antihypertensive drugs. The relationship between intracranial pressure (ICP) and arterial blood pressure is complex and still under debate. The impact of antihypertensive drugs on ICP is unknown. We wanted to understand whether the use of antihypertensive drugs has a significant influence on ICP and cerebrospinal fluid (CSF)/brain related parameters.In a cohort of 95 patients with suspected normal pressure hydrocephalus, we prospectively collected drug details according to the Anatomical Therapeutic Chemical (ATC) classification. Lumbar infusion studies were performed. Using ICM+ software, we calculated at baseline and plateau ICP and pulse amplitude, resistance to CSF outflow, elastance, and pressure in the sagittal sinus and CSF production rate. We studied the influence of the administration of 1, 2, 3 or more antihypertensive drugs on ICP-derived parameters. We compared the data using Student's and Mann-Whitney tests or Chi-squared and Fisher's exact test.Elastance is significantly higher in patients with at least one antihypertensive drug compared with patients without medication. On the contrary, pressure volume index (PVI) is significantly decreased in patients with antihypertensive drugs compared with patients not on these medications. However, the number of antihypertensive drugs does not seem to influence other ICP parameters.Patients on antihypertensive drugs seem to have a stiffer brain than those not on them.

Introduction: Cancer in the elderly is a major public issue. However, older patients have long been debarred from clinical trials. There is a high unmet medical need for specific trials addressing oncology strategies adapted to older patients' conditions. While randomised phase III trials remain the gold standard, they usually require large numbers of patients. In this perspective, late single-arm phase II trials assessing treatment feasibility might prove a good alternative. However, it is essential to take into account the heterogeneity in an ageing population characterised by frailty. Standard parallel phase II studies in defined frail and non-frail populations also require a high number of patients. Used in molecular subtyping and treatment effect heterogeneity, stratified adaptive designs can improve statistical performance, but they have never been used in geriatric oncology. This report describes their potential benefits and useful applications as compared with standard designs. Methods: In a heterogeneous population, stratified adaptive designs allowed us to select subgroups of interest in two stages. Operational characteristics were evaluated through simulations of clinical trials under different scenarios. Results: Simulations showed that the use of stratified adaptive designs can efficiently minimise both the number of patients to be included and accrual duration with competitive statistical power and high heterogeneity detection rate at interim analysis. Conclusion: Compared with classical phase II designs, stratified adaptive phase II trial methodology offers a promising approach to improve clinical research in geriatric oncology. These designs may also be efficient in other populations such as children or adolescents and young adults. (C) 2018 Elsevier Ltd. All rights reserved.

Objectives: Arterial hypertension is among the leading risks for mortality. This burden requires in hypertensive patients the use of single, double or more antihypertensive drugs. The relationship between intracranial pressure (ICP) and arterial blood pressure is complex and still under debate. The impact of antihypertensive drugs on ICP is unknown. We wanted to understand whether the use of antihypertensive drugs has a significant influence on ICP and cerebrospinal fluid (CSF)/brain related parameters.

Objective: The amplitude of intracranial pressure (ICP) can be measured by ICP monitoring. Phase-contrast magnetic resonance imaging (PCMRI) can quantify blood and cerebrospinal fluid (CSF) flows. The aim of this work was to investigate intracranial compliance at rest by combining baseline ICP monitoring and PCMRI in hydrocephalus patients.

Introduction A comprehensive geriatric assessment (CGA) evaluating several domains of health is recommended for elderly patients with cancer. Effects of altered domains on the risk of death in this population need to be clarified. The aim of this study was to estimate the independent association of each CGA domain to overall survival (OS). Method Patients included in the ONCODAGE cohort completed a CGA at baseline. Cox models (one per domain) estimated the hazard ratio (HR) of death for each CGA domain. Directed Acyclic Graphs (DAGs) selected specific sets of adjustment factors for each model. Results The analysis included 1264 patients (mean age: 78 years, women: 70%). Median follow-up was 5.2 years, and 446 patients died. Each altered domain had a detrimental effect on survival, sometimes dependent on gender, age, education or time from inclusion. Nutritional status had a time-varying effect, with higher mortality rates if altered only within the first 3 years of follow-up. In case of altered mobility, the risk of death was higher only for the youngest patients and, in case of altered autonomy, only for the youngest women. An altered neurological state led to higher mortality rates; this effect increased with the level of education. Patients with altered psychological status or more than four comorbidities at baseline had also higher mortality rates. Conclusions Patients with an altered CGA domain have a higher risk of death than those without any alteration. The effect of some alterations is different in some subgroups or at a given time of the treatments.

Supporting patients undergoing chemotherapy is one of the priorities of geriatric oncology care. To this effect, a Toulouse hospital team has developed a telephone follow-up service operated by nurse navigators. In collaboration with the multi-disciplinary team of the hospitalisation service, it provides close support to the patient and their family.