Malnutrition: a highly predictive risk factor of short-term mortality in elderly presenting to the emergency department.

OBJECTIVES: To identify independent risk factors of mortality among elderly patients in the 3 months after their visit (T3) to an emergency department (ED). DESIGN: Prospective cohort study. SETTING: University hospital ED in an urban setting in France. PARTICIPANTS: One hundred seventy-three patients aged 75 and older were admitted to the ED over two weeks (18.7% of the 924 ED visits). Of these, 164 patients (94.8%) were included in our study, and 157 (95.7%) of them were followed three months after their ED visit. MEASUREMENTS: During the inclusion period (T0), a standardized questionnaire was used to collect data on socio-demographic and environmental characteristics, ED visit circumstances, medical conditions and geriatric assessment including functional and nutritional status. Three months after the ED visits (T3), patients or their caregivers were interviewed to collect data on vital status, and ED return or hospitalization. RESULTS: Among the 157 patients followed at T3, 14.6% had died, 19.9% had repeated ED visits, and 63.1% had been hospitalized. The two independent predictive factors for mortality within the 3 months after ED visit were: malnutrition screened by the Mini Nutritional Assessment short-form (MNA-SF) (OR=20.2; 95% CI: 5.74-71.35; p<.001) and the Cumulative Illness Rating Scale for Geriatrics (CIRS-G) score (OR=1.1; 95% CI: 1.01-1.22; p=.024). CONCLUSION: Malnutrition is the strongest independent risk factor predicting short-term mortality in elderly patients visiting the ED, and it was easily detected by MNA-SF and supported from the ED visit.

[Immune profile of elderly patients admitted in a geriatric short care unit]. / Étude du profil immunitaire de sujets âgés hospitalisés en unité de court séjour gériatrique.

INTRODUCTION: Immunosenescence embraces the whole of age-induced changes observed in the immunomodulatory functions of a living organism, and is mostly characterized by a decrease in cell-mediated immunity and important modifications of the immunological repertoire. The impact of the pathology on ageing immunity is poorly understood and few data are available on the immunological status of old polypathological patients. METHODS: We report the results of a prospective study aiming at characterizing several established immunological parameters in patients of 75 years old or more, and admitted for diverse pathologies in a unit of acute geriatric ward. RESULTS: Among the 51 included patients (35 women and 16 men), 90% displayed poly-pathologies. We found a prevalence of 86% of immunological abnormalities, with lymphopenia among 41% of the patients (<1500/mm(3)) and abnormal lymphocytes phenotypes among 95% of the oldest patients (>85 years). A strong skewing towards memory T lymphocytes (CD45RO+) over naive T lymphocytes (CD45RA+) was found in 80% of the cases and inverted CD4/CD8 T cells ratio was observed in 12% of our patients. Vitamin D insufficiency (<30ng/ml), which is frequent among the patients (94%), is a predictive factor for T and B cell lymphopenia. CONCLUSION: Immunological abnormalities are frequent in this frail population and lymphopenia, in particular, could constitute a reinforcing factor of fragility. Vitamin D deficiency could also affect elderly patients' immunity.

[Immunosenescence and infections, myth or reality?]. / Immunosénescence et infections, mythe ou réalité?

The susceptibility of elderly people to infectious diseases is usually associated to increasing risk factors found in young adults. However, the role of immune function ageing is associated with the decline of immune function but this decline is not homogenous. Some functions such as the cellular immune system are altered but others are enhanced such as innate immunity. The important events of immune ageing are modifications of lymphocyte subsets with accumulation of memory cells, decrease in proliferative response, and a chronic inflammatory state. The chronic antigenic load throughout life is responsible for gaps in the antigenic system with a greater sensitivity to new antigens. These immune system changes are all the more important that diseases are severe and that denutrition is associated. These diseases will speed up the ageing process. The interaction between immunosenescence and pathology is an important phenomenon to consider. This review outlines the immune system changes due to ageing, their relationship with diseases of the aged patient, and the consequences of these modifications on vaccination effectiveness.

Early contacts between T lymphocytes and activating surfaces.

Cells continually probe their environment to adapt their behaviour. A current challenge is to determine how they analyse nearby surfaces and how they process information to take decisions. We addressed this problem by monitoring human T lymphocyte attachment to surfaces coated with activating anti-CD3 or control anti-HLA antibodies. Interference reflection microscopy allowed us to monitor cell-to-surface apposition with a few nanometre vertical resolution during the first minutes following contact. We found that (i) when a cell fell on a surface, contact extension was preceded by a lag of several tens of seconds. (ii) During this lag, vertical membrane undulations seemed to generate transient contacts with underlying surfaces. (iii) After the lag period, the contact area started increasing linearly with a rate of about 1.5 µm(2) s(-1) on activating surfaces and about 0.2 µm(2) s(-1) on control surfaces. (iv) Concomitantly with lateral surface extension, the apparent distance between cell membranes and surfaces steadily decreased. These results are consistent with the hypothesis that the cell decision to spread rapidly on activating surfaces resulted from the integration of information yielded by transient contacts with these surfaces generated by membrane undulations during a period of about 1 min.

[Non necrotizing bacterial cellulitis and bacteriemia due to Shewanella putrefaciens]. / Dermohypodermite bactérienne non nécrosante et bactériémie à Shewanella putrefaciens.

Shewanella putrefaciens is a Gram negative opportunistic pathogen which causes skin and soft tissue infections and bacteriemia in immunocompromized patients. We report a 86-year-old man, who presented with an infectious cellulitis of the leg associated with Shewanella putrefaciens bacteriemia. This patient was treated by mycophenolate mofetil for a bullous pemphigoid resistant to corticotherapy.

[Central nervous system HIV-associated polyarteritis nodosa: long-term outcome]. / Devenir à long terme d'un cas de périartérite noueuse cérébrale associée au VIH.

INTRODUCTION: HIV-associated vasculitis is an infrequent entity, and only few data about its long-term evolution is available. EXEGESIS: We report the long-term outcome of a patient with central nervous system HIV-associated periarteritis nodosa and then discuss the therapeutic options for this class of vasculitis. CONCLUSION: This observation highlights the role of HAART in the treatment of HIV-associated vasculitis. Persistent remission can be obtained when viral replication is under control.

[Thymoma and disseminated lupus erythematosus. Two new cases and review of the literature]. / Thymome et lupus érythémateux disséminé. A propos de deux nouvelles observations et revue de la littérature.

INTRODUCTION: Thymoma is a tumour originating in the epithelial cells of the thymus, associated with several immunologic disorders. The association of thymoma with systemic lupus erythematosus has rarely been described. We report two cases of this association. EXEGESIS: Description of two cases and a review of the literature. Mr T. was 41 years old when the diagnosis of thymoma and lupus was made. The thymectomy did not influence the evolution of his lupus. Mrs G. had been treated because of a lupus for 8 years prior to developing a thymoma. One year later she presented with erythroblastopenia, which was only sensitive to cyclosporin. CONCLUSION: The association between lupus and thymoma has been reported in 36 cases in the literature. Thymoma is benign in 59% of the cases. The clinical presentation of lupus is nonspecific except for age, median 48 years, and sex ratio, 4:3. The clinical outcome of the lupus is not influenced by the thymectomy. Thymoma may precede lupus with a delay of several years or it may be diagnosed concurrently or several years later. This association is not accidental, though the pathogenic link between these conditions remains unknown. One could suppose that the decrease of the thymic function in the course of thymoma could enhance the expression of autoreactive T lymphocytes as well as the activation of B cells. Patients should be followed after thymectomy because autoimmune diseases, particularly lupus, may develop belatedly. On the other hand, thymoma may be suspected mainly when lupus occurs in patients around 50 years of age.

Still's-like disease, breast prosthesis, and collagen implants.

Silicone-induced connective tissue disease raises a controversial issue. We report a case of Still's disease associated with silicone and collagen implants that showed improvement on steroids, but remained steroid-dependent despite removal of the silicone implants. This observation complements four previous cases in the literature and questions the role of breast implants in the pathogenesis of Still's disease. The number of cases studied is insufficient for conclusions, but silicone-implant-associated syndrome may be confused with Still's disease. We consequently propose the use of ferritinemia and its serum glycosylated fraction level as discriminating factors. Collagen has been associated with some inflammatory diseases, but never previously with Still's disease. However, considering this observation and previous data in the literature, its role may be postulated as an exacerbating factor or a pathogenic agent.

[Hemoperitoneum of ovarian origin complicating antivitamin K treatment]. / Hémopéritoines d'origine ovarienne compliquant les traitements par antivitamine K.

INTRODUCTION: Ovarian hemorrhage with hemoperitoneum is a rare but serious complication of ovulation related to rupture of either the corpus luteum or functional cyst. It is due to treatment using oral indirect anticoagulant and specifically affects young women. CURRENT KNOWLEDGE AND KEY POINTS: We review cases that were reported since the initial description by Weseley in 1957. The main indications for oral indirect anticoagulant are thrombophlebitis and valvular cardiac prosthesis. Pelvic pain with peritoneal irritation is the most common symptom in more than one third of the patients. An initial collapse is reported in 22% of the cases. Surgery is the main treatment. Mortality is 3% and recurrences occur in nearly 25% of the patients. FUTURE PROSPECTS AND PROJECTS: Potential ovarian hemorrhage should be investigated when a woman taking oral indirect anticoagulant develops acute abdominal pain. Surgery should be conservative and whenever possible, should include celioscopy. Systematic ovarian blockade should be discussed in women taking long-term oral indirect anticoagulant.