Thirty-day hospital readmission predictors in older patients receiving hospital-at-home: a 3-year retrospective study in France.

OBJECTIVE: This study described older patients receiving hospitalisation-at-home (HaH) services and identified factors associated with 30-day hospital readmission. DESIGN: 3-year retrospective study in 2017-2019 in France. PARTICIPANTS: 75 108 patients aged 75 years and older who were discharged from hospital medical wards (internal medicine and geriatric units) and admitted to HaH. PRIMARY OUTCOME MEASURE: 30-day hospital readmission. RESULTS: The mean age of patients was 83.4 years (SD 5.7), 52.3% were male and 88.4% lived in a private household. Patients were primarily discharged from the internal medicine unit (85.3%). The top four areas of care in the HaH were palliative care, complex dressing, intravenous therapy and complex nursing care. Overall, 23.5% of patients died during their HaH stay and 27.8% were readmitted to the hospital at 30 days. In the multivariate model, male (OR 1.19, 95% CI 1.16 to 1.23), supportive cancer HaH care (OR 1.78, 95% CI 1.51 to 2.11) and very high intensity care during the previous in-person hospitalisation (OR 1.45, 95% CI 1.34 to 1.57) increased the risk of hospital readmission at 30 days. Older age (OR 0.97, 95% CI 0.97 to 0.98), living in a nursing home (OR 0.51, 95% CI 0.48 to 0.54), postsurgery HaH care (OR 0.49, 95% CI 0.41 to 0.58) and having been previously hospitalised in a geriatric unit (OR 0.81, 95% CI 0.77 to 0.85) decreased the risk of hospital readmission at 30 days. CONCLUSIONS: HaH provides complex care to very old patients, which is associated with high mortality. Several factors are associated with rehospitalisation within 30 days that could be avoided with better integration of different services with higher geriatric skills. TRIAL REGISTRATION NUMBER: CNIL:2228861.

[Hypophosphatemia after injectable iron treatments in adults: Comparison between ferric carboxymaltose and iron sucrose]. / Hypophosphorémie après traitement par fer injectable chez l'adulte : comparaison entre le carboxymaltose ferrique et l'hydroxyde ferrique-saccharose.

Hypophosphatemia is a recognized side effect of treatment of iron deficiency anemias with injectable iron. We analyzed 35 clinical trials that used ferric carboxymaltose (FCM) or iron sucrose (IS). Hypophosphatemia prevalence ranged from 0 to 91.7%. FCM-induced a significant (P<0.001) greater hypophosphatemia prevalence and phosphatemia decrease than IS (52.0% [95% CI: 42.2-61.8%] vs. 7.7% [95% CI: -2.8 to 18.2%] and -1.12mmol/L [95% CI: -1.36 to -0.89mmol/L] vs. -0.13mmol/L [95% CI: -0.59 to 0.32mmol/L]). FCM-induced hypophosphatemia was dose-dependent. The nadir of hypophosphatemia was reached in almost all studies after 7 and 14days. Hypophosphatemia persisted at the end of the study in 53.8% of the reported studies that used FCM and lasted up to 6months. FCM-induced an increase in intact circulating fibroblast growth factor 23 and in renal phosphorus excretion while serum 1-25 dihydroxyvitamin D was decreased. Risk factors for hypophosphatemia after FCM therapy were low basal circulating phosphate or ferritin, low body weight, high glomerular filtration rate, serum parathyroid hormone or hemoglobin and age, whereas renal insufficiency was associated with a lower risk. In conclusion, hypophosphatemia is common after treatment with injectable iron, FCM being associated with a higher risk than IS and with disorders of phosphocalcium metabolism. Monitoring of blood phosphate and 1-25 dihydroxyvitamin D could be considered during FCM therapy.

Vitamin A deficiency during the perinatal period induces changes in vitamin A metabolism in the offspring. The regulation of intestinal vitamin A metabolism via ISX occurs only in male rats severely vitamin A-deficient.

PURPOSE: 1) To test the hypothesis of the existence of a perinatal vitamin A (VA) programming of VA metabolism and to better understand the intestinal regulation of VA metabolism. METHODS: Offspring from rats reared on a control (C) or a VA-deficient (D) diet from 6 weeks before mating until offspring weaning, i.e., 7 weeks after mating, were themselves reared on a C or D diet for 19 weeks, resulting in the following groups: C-C (parents fed C-offspring fed C), D-C, C-D and D-D. VA concentrations were measured in plasma and liver. ß-Carotene bioavailability and its intestinal conversion rate to VA, as well as vitamin D and E bioavailability, were assessed after gavages with these vitamins. Expression of genes involved in VA metabolism and transport was measured in intestine and liver. RESULTS: C-D and D-D had no detectable retinyl esters in their liver. Retinolemia, hepatic retinol concentrations and postprandial plasma retinol response to ß-carotene gavage were higher in D-C than in C-C. Intestinal expression of Isx was abolished in C-D and D-D and this was concomitant with a higher expression of Bco1, Scarb1, Cd36 and Lrat in males receiving a D diet as compared to those receiving a C diet. ß-Carotene, vitamin D and E bio-availabilities were lower in offspring receiving a D diet as compared to those receiving a C diet. CONCLUSION: A VA-deficient diet during the perinatal period modifies the metabolism of this vitamin in the offspring. Isx-mediated regulation of Bco1 and Scarb1 expression exists only in males severely deficient in this vitamin. Severe VA deficiency impairs ß-carotene and vitamin D and E bioavailability.

A pragmatic trial testing a tailored non pharmacologic therapies on nocturnal behavioral and psychological symptoms associated with dementia.

We compared the efficacy of tailored non pharmacological therapies (NPT) on specific nocturnal behavioral and psychological symptoms of dementia (BPSD). This retrospective 1-year study included 84 older dependent patients institutionalized in 7 long-term care home. Dedicated assistants, who were taught by experts how to use NPT, were asked to record the occurrence of each BPSD episode, to choose a given NPT on the basis of their knowledge of the patient and the type of BPSD and to estimate its efficacy. Wandering was the most prevalent BPSD followed by agitation/aggression and screaming. The most used therapy was cognitive stimulation, followed by multisensory stimulation, reminiscence and Montessori-based. Regarding wandering, multisensory stimulation was found to be the most efficacious NPT significantly different from Montessori-based, cognitive stimulation or reminiscence. With regards to agitation/aggression or screaming, Montessori-based was found to be the most efficacious NPT significantly different from multisensory stimulation, reminiscence and cognitive stimulation.

A description of dry oral forms of medication administration modifications by nurses in home settings.

Modifying the galenic of dry oral forms (DOF) to be administered to patients with swallowing or behavioral disorders is frequent in long term care homes. The objective was to investigate the practice of modifying DOF galenic by nurses in home settings (NHS). A 14-question electronic survey was distributed to 1977 NHS. Almost 3/4 of respondents reported crushing tablets or opening capsules, with 37% on a daily basis. Approximately 22% did not inquire about the feasibility of modifying galenic DOF beforehand. Nearly 75% of NHS were aware about the risk of ineffectiveness after crushing tablets or opening capsules. However, only 14% mentioned the risk of overdosing associated with this practice. More than 60% of NHS never wore protective equipment when changing dosage form. Changing the dosage form of DOF is a widespread practice in home settings. Our present work urges the need to improve collaboration between prescribing physicians, nurses and pharmacists.

ß-Carotene Bioavailability and Conversion Efficiency Are Significantly Affected by Sex in Rats: First Observation Suggesting a Possible Hormetic Regulation of Vitamin A Metabolism in Female Rats.

SCOPE: To study the effect of variation in dietary vitamin A (VA) content on its hepatic and intestinal metabolism. METHODS AND RESULTS: Adult female and male rats are fed with diets containing 400, 2300, or 9858 IU kg-1 VA for 31-33 weeks. VA concentrations are measured in plasma and liver. Bioavailability and intestinal conversion efficiency of ß-carotene to VA are assessed by measuring postprandial plasma ß-carotene and retinyl palmitate concentrations after force-feeding rats with ß-carotene. Expression of genes involved in VA metabolism, together with concentrations of RBP4, BCO1, and SR-BI proteins, are measured in the intestine and liver of female rats. Plasma retinol concentrations are lower and hepatic free retinol concentrations are higher in females than in males. There is no effect of dietary VA content on ß-carotene bioavailability and its conversion efficiency, but bioavailability is higher and conversion efficiency is lower in females than in males. The expression of most genes exhibited a U-shaped dose response curve depending on VA intake. CONCLUSIONS: ß-Carotene bioavailability and conversion efficiency to VA are affected by the sex of rats. Results of gene expression suggest a hormetic regulation of VA metabolism in female rats.

Hypnotherapy in Treatment of Mastocytosis: A Prospective Study.

Mastocytosis is an orphan disease associated with many systemic symptoms, chronic handicap, and potentially marked social consequences despite improved therapies. In this study, the authors aimed to measure the effect of 2 hypnosis sessions on mastocytosis symptoms in a clinical setting. Questionnaires (pain, flushes, energy, digestive symptoms, quality of life, perceived symptom severity, and global impression of change) were completed pre- and posthypnosis intervention. Data from 20 patients were analyzed (mean age: 53.3 years, 75% female). Compared to baseline assessment, patients exhibited a significant improvement immediately after the first and second hypnosis sessions with regard to the number of days with abdominal pain, abdominal pain intensity and fatigue (p = .03 and p = .005; p = .05 and p = .02; p = .034, and p = .039, respectively). Perceived severity of symptoms was significantly improved throughout the study (p = .0075). Long-term improvement in global impression of change was observed in half the responders (8/16). Patients with mastocytosis had an improvement in disabling symptoms with the impact of hypnotic intervention persisting at 1 month. Several patients experienced long-term improvement.

Vitamin A Deficiency during the Perinatal Period and First Weeks of Life Modifies Vitamin A and Lipid Postprandial Metabolism in Both Female and Male Young Rats.

SCOPE: The effect of vitamin A deficiency on vitamin A and lipid postprandial metabolism in young rats is addressed, considering the effect of sex. METHODS AND RESULTS: Sprague-Dawley rats are fed either 400 UI.kg-1 vitamin A diet (vitamin A-deficient (VAD) diet) or 2300 UI.kg-1 vitamin A (control diet), before being mated. Mothers receive the same VAD or control diet during gestation and lactation. Offspring receive the same diet than mothers until 8 weeks of age. VAD diet-fed female and male offspring display a severe vitamin A deficiency with no body weight or glucose tolerance defects. Fasting plasma triglyceride concentrations are decreased in VAD diet-fed animals compared to controls (p < 0.05). Retinyl ester postprandial responses after vitamin A gavage, expressed as area under the curves, are not different in VAD diet-fed and control animals, although retinyl ester postprandial peak is significantly delayed (p < 0.05) in VAD diet-fed rats. Lipids also accumulate in the distal part of the intestine after gavage and [1-13 C]-oleate postprandial response is decreased in VAD diet-fed males. CONCLUSION: Vitamin A deficiency modulates both vitamin A absorption rate and lipid postprandial metabolism, which can partly explain the altered fasting lipid status observed in VAD diet-fed offspring.

Predicting Chemotherapy Toxicity and Death in Older Adults with Colon Cancer: Results of MOST Study.

PURPOSE: Older patients with colon cancer (CC) are vulnerable to chemotherapy toxicity and death. Establishing simple scores specific for patients with CC to predict severe chemotoxicity or early death is needed to select the best treatment strategy. SUBJECTS, MATERIALS, AND METHODS: This prospective multicenter study included patients aged ≥70 years with CC receiving adjuvant or first-line metastatic chemotherapy. Frailty markers (nutrition, physical activity, energy, mobility, strength), comprehensive geriatric assessment (functional status, comorbidities, falls, nutrition, cognition, and depression), and usual laboratory parameters were collected. Logistic or Cox regression was used to examine at 500 days the association between frailty markers, comprehensive geriatric assessment, laboratory parameters, and grade 3-4 toxicity or death. RESULTS: A total of 97 patients (median age, 79.0 years) received adjuvant (37.1%) or metastatic (62.9%) chemotherapy. During the first 500 days, grade 3-4 toxicity occurred in 49.5%, and 30% died. The predictive model for grade 3-4 toxicity combined (polychemotherapy × 3) + (hypoalbuminemia <32 g/L × 2) + (abnormal grip strength × 1.5) + C-reactive protein >11 mg/L + Eastern Cooperative Oncology Group performance status (ECOG-PS), cutoff score >3. The predictive model for death combined (metastasis × 5) + (age × 2) + alkaline phosphatase >100 IU/mL + sex (female) + abnormal grip strength + ECOG-PS, cutoff score >6. For chemotoxicity prediction, sensitivity was 81.6% and specificity 71.4%. For death prediction, sensitivity was 89.7% and specificity was 83.6%. CONCLUSION: These simple and efficient "ColonPrediscores" will help to better identify older patients with CC with increased risk of chemotherapy-related toxicity and/or death. IMPLICATIONS FOR PRACTICE: The two scores assessed in this study, called "ColonPrediscores", offer a major advantage in that they do not need a previous complete geriatric assessment, which makes them an easy-to-use tool in oncologic settings.

Platelet CD40 ligand and bleeding during P2Y12 inhibitor treatment in acute coronary syndrome.

Antiplatelet therapy through inhibition of the adenosine diphosphate (ADP)/P2Y12 pathway is commonly used in the treatment of acute coronary syndrome (ACS). Although efficient in preventing platelet activation and thrombus formation, it increases the risk of bleeding complications. In patients with ACS receiving platelet aggregation inhibitors, that is, P2Y12 blockers (n = 923), we investigated the relationship between plasma and platelet-associated CD40L levels and bleeding events (n = 71). Treatment with P2Y12 inhibitors in patients with ACS did not affect plasma-soluble CD40L levels, but decreased platelet CD40L surface expression (pCD40L) and platelet-released CD40L (rCD40L) levels in response to stimulation as compared to healthy controls. In vitro inhibition of the ADP pathway in healthy control platelets reduced both pCD40L and rCD40L levels. In a multivariable analysis, the reduced pCD40L level observed in ACS patients was significantly associated with the risk of bleeding occurrence (adjusted odds ratio = 0.15; 95% confidence interval = 0.034-0.67). P2Y12 inhibitor-treated (ticagrelor) mice exhibited a 2.5-fold increase in tail bleeding duration compared with controls. A significant reduction in bleeding duration was observed on CD40L+/+ but not CD40L-/- platelet infusion. In addition, CD40L blockade in P2Y12 inhibitor-treated blood samples from a healthy human reduced thrombus growth over immobilized collagen under arterial flow. In conclusion, measurement of pCD40L may offer a novel approach to assessing bleeding risk in patients with ACS who are being treated with P2Y12 inhibitors.

A Novel Rapid Method of Red Blood Cell and Platelet Permeabilization and Staining for Flow Cytometry Analysis.

BACKGROUND: Flow cytometry essentially focuses on surface-expressed proteins, with few protocols being devoted to intracellular components. We evaluated a two-step procedure using new formaldehyde-free permeabilization and staining reagents that allow the staining of platelets and red blood cells (RBCs) from whole blood. METHODS: Citrated blood was treated with the new staining protocol (NSP) or control reagent (phosphate-buffered solution bovine serum albumin) and stained with antibodies against surface or intracellular markers. The effects of the NSP on cell integrity, morphology, and content were evaluated. RESULTS: The NSP slightly reduced the cell count (~20%) and changed the RBC morphology with a 42% mean diameter reduction. Conversely, the NSP did not affect platelet discoid morphology and led to a minor size decrease (11%). These morphological changes neither impelled a gating strategy modification nor interfered with the discrimination among populations based on surface markers. The NSP provided intracellular access to all the tested antigens: CD62P, FXIII, and CD63 in platelets and glycated and fetal hemoglobin (HbA1c and HbF) and nucleic acid in RBCs. The NSP gave excellent intra-assay precision with minimal impact on cell morphology and fluorescence labelling over time (up to 24 h). CONCLUSIONS: With the ability to detect surface and intracellular antigens through a rapid preparation protocol without washing steps or toxic formaldehyde treatment, this NSP designed for research offers a marked improvement in the analysis of platelets and RBCs isolated directly from whole blood. Consequently, the NSP opens new avenues to investigate platelet degranulation and erythrocyte subpopulations. © 2019 International Clinical Cytometry Society.

Increased levels of the megakaryocyte and platelet expressed cysteine proteases stefin A and cystatin A prevent thrombosis.

Increased platelet activity occurs in type 2 diabetes mellitus (T2DM) and such platelet dysregulation likely originates from altered megakaryopoiesis. We initiated identification of dysregulated pathways in megakaryocytes in the setting of T2DM. We evaluated through transcriptomic analysis, differential gene expressions in megakaryocytes from leptin receptor-deficient mice (db/db), exhibiting features of human T2DM, and control mice (db/+). Functional gene analysis revealed an upregulation of transcripts related to calcium signaling, coagulation cascade and platelet receptors in diabetic mouse megakaryocytes. We also evidenced an upregulation (7- to 9.7-fold) of genes encoding stefin A (StfA), the human ortholog of Cystatin A (CSTA), inhibitor of cathepsin B, H and L. StfA/CSTA was present in megakaryocytes and platelets and its expression increased during obesity and diabetes in rats and humans. StfA/CSTA was primarily localized at platelet membranes and granules and was released upon agonist stimulation and clot formation through a metalloprotease-dependent mechanism. StfA/CSTA did not affect platelet aggregation, but reduced platelet accumulation on immobilized collagen from flowing whole blood (1200 s-1). In-vivo, upon laser-induced vascular injury, platelet recruitment and thrombus formation were markedly reduced in StfA1-overexpressing mice without affecting bleeding time. The presence of CA-074Me, a cathepsin B specific inhibitor significantly reduced thrombus formation in-vitro and in-vivo in human and mouse, respectively. Our study identifies StfA/CSTA as a key contributor of platelet-dependent thrombus formation in both rodents and humans.

Impact of Environmental Modifications to Enhance Day-Night Orientation on Behavior of Nursing Home Residents With Dementia.

OBJECTIVES: To determine whether environmental rearrangements of the long-term care nursing home can affect disruptive behavioral and psychological symptoms of dementia (BPSD) in residents with dementia. DESIGN: Prospective 6-month study. SETTING: The study was conducted before (phase 1) and after (phase 2) environmental rearrangements [skylike ceiling tiles in part of the shared premises, progressive decrease of the illuminance at night together with soothing streaming music, reinforcement of the illuminance during the day, walls painted in light beige, oversized clocks in corridors, and night team clothes color (dark blue) different from that of the day team (sky blue)]. PARTICIPANTS: All of the patients (n = 19) of the protected unit were included in the study. They were aged 65 years or older and had an estimated life expectancy above 3 months. MEASURES: Number and duration of disruptive BPSD were systematically collected and analyzed over 24 hours or during late hours (6:00-12:00 pm) during each 3-month period. RESULTS: There was no significant change in the patients' dependency, risk of fall, cognitive or depression indexes, or treatment between phase 1 and 2. Agitation/aggression and screaming were observed mainly outside the late hours as opposed to wandering episodes that were noticed essentially within the late hours. The number of patients showing wandering was significantly lower over 24 hours during phase 2. The number of agitation/physical aggression, wandering, and screaming and the mean duration of wandering episodes were significantly (P = .039, .002, .025, and .026 respectively) decreased over 24 hours following environmental rearrangements. Similarly, a significant reduction in the number and mean duration of wandering was noticed during the late hours (P = .031 and .007, respectively). CONCLUSIONS: Our study demonstrates that BPSD prevalence can be reduced following plain environmental rearrangements aimed at improving spatial and temporal orientation.

Feasibility and acceptability of a self-measurement using a portable bioelectrical impedance analysis, by the patient with chronic heart failure, in acute decompensated heart failure.

Chronic heart failure (CHF) is a major public health matter. Mainly affecting the elderly, it is responsible for a high rate of hospitalization due to the frequency of acute heart failure (ADHF). This represents a disabling pathology for the patient and very costly for the health care system. Our study is designed to assess a connected and portable bioelectrical impedance analysis (BIA) that could reduce these hospitalizations by preventing early ADHF. METHODS: This prospective study included patients hospitalized in cardiology for ADHF. Patients achieved 3 self-measurements using the BIA during their hospitalization and answered a questionnaire evaluating the acceptability of this self-measurement. The results of these measures were compared with the clinical, biological and echocardiographic criteria of patients at the same time. RESULTS: Twenty-three patients were included, the self-measurement during the overall duration of the hospitalization was conducted autonomously by more than 80% of the patients. The acceptability (90%) for the use of the portable BIA was excellent. Some correlations were statistically significant, such as the total water difference to the weight difference (p=0.001). There were common trends between the variation of impedance analysis measures and other evaluation criteria. CONCLUSION: The feasibility and acceptability of a self-measurement of bioelectrical impedance analysis by the patient in AHF opens up major prospects in the management of monitoring patients in CHF. The interest of this tool is the prevention of ADHF leading to hospitalization or re-hospitalizations now requires to be presented by new studies.

The beta secretase BACE1 regulates the expression of insulin receptor in the liver.

Insulin receptor (IR) plays a key role in the control of glucose homeostasis; however, the regulation of its cellular expression remains poorly understood. Here we show that the amount of biologically active IR is regulated by the cleavage of its ectodomain, by the ß-site amyloid precursor protein cleaving enzyme 1 (BACE1), in a glucose concentration-dependent manner. In vivo studies demonstrate that BACE1 regulates the amount of IR and insulin signaling in the liver. During diabetes, BACE1-dependent cleavage of IR is increased and the amount of IR in the liver is reduced, whereas infusion of a BACE1 inhibitor partially restores liver IR. We suggest the potential use of BACE1 inhibitors to enhance insulin signaling during diabetes. Additionally, we show that plasma levels of cleaved IR reflect IR isoform A expression levels in liver tumors, which prompts us to propose that the measurement of circulating cleaved IR may assist hepatic cancer detection and management.

Diagnostic value of conventional chest radiography in intrathoracic goiters-retrospective analysis of 2570 patients.

PURPOSE: Since intrathoracic goiters (IG), either cervico-mediastinal goiters (CMGs) or mediastinal nodules (MNs), can lead to sternotomies and/or evitable reoperations, their detection is mandatory before thyroid surgery. A systematic screening by CT scan or MRI is not conceivable because of their expensiveness. We tested if conventional chest radiography (CCR) could remain a good screening tool for IG before thyroid surgery. METHODS: In this retrospective study (2554 patients), CCR usefulness was evaluated in relation with patients' complaints, clinical examination, neck US, and anatomical and surgical findings. RESULTS: CMGs (n = 67) and MNs (n = 42) were symptomatic in 10 and 5 patients, respectively. Clinical examination or neck US suspected their existence in 25 and 13 and 45 and 17 patients, respectively. Among the 50 IG detected by CCR (42 CMGs and 8 MNs), 4 CMGs and 2 MNs were missed by clinical examination or neck US. CCR failed to detect IG in 59 patients (54%): 25 CMGs (37%) and 34 MNs (80%). Twenty-eight IG (9 CMGs and 19 MNs) were discovered during surgery. CCR resulted in false positive in 88 out of 2445 patients (3.5%). CCR potentially avoided reoperation in two patients (a maximum saving of 6160 €, whereas the total cost of CCR was 54,895 €). CONCLUSIONS: CCR should not be used routinely for the preoperative detection of IG. Surgeons should preferably use clinical examination or neck US and directly perform CT scan when a mediastinal extension is suspected.