Transmission and effect of multiple clusters of seasonal influenza in a Swiss geriatric hospital.

OBJECTIVES: To investigate a nosocomial outbreak of influenza. DESIGN: Prospective outbreak investigation with active case finding and molecular typing. SETTING: A large academic geriatric hospital in Switzerland. PARTICIPANTS: Elderly hospitalized adults. MEASUREMENTS: Based on syndromic surveillance, a nosocomial influenza outbreak was suspected in February 2012. All suspected cases were screened for respiratory viruses using real-time reverse transcription polymerase chain reaction of nasopharyngeal swabs. Infection control procedures (droplet precautions with single room isolation whenever possible) were implemented for all suspected or confirmed cases. Specimens positive for influenza viruses were processed and sequenced whenever possible to track transmission dynamics. RESULTS: Respiratory samples from 155 suspected cases were analyzed during the outbreak period, of which 69 (44%) were positive for influenza virus, 26 (17%) were positive for other respiratory viruses, and 60 (39%) were negative. Three other cases fulfilled clinical criteria for influenza infection but were not sampled, and one individual was admitted with an already positive test, resulting in a total of 73 influenza cases, of which 62 (85%) were classified as nosocomial. Five distinct clusters of nosocomial transmission were identified using viral sequencing, with epidemiologically unexpected in-hospital transmission dynamics. Seven of 23 patients who experienced influenza complications died. Sixteen healthcare workers experienced an influenza-like illness (overall vaccination rate, 36%). CONCLUSION: Nosocomial influenza transmission caused more secondary cases than repeated community importation during this polyclonal outbreak. Molecular tools revealed complex transmission dynamics. Low healthcare worker vaccination rates and gaps in recommended infection control procedures are likely to have contributed to nosocomial spread of influenza, which remains a potentially life-threatening disease in elderly adults.

[Introduction of acenocoumarol using an algorithm for prescription]. / Introduction de l'acénocoumarol à l'aide d'un algorithme de prescription.

Anticoagulant therapy is indicated in many clinical situations. The handling of vitamin K antagonists (VKA) is difficult and their therapeutic range is narrow, requiring close biological monitoring of INR. Introduction of VKA is a particularly critical period. Algorithms for initiation of oral anticoagulant therapy have been proposed but they are generally designed for warfarin, which has a longer half life as compared to acenocoumarol. In this article, algorithms for the prescription of acenocoumarol are proposed, taking into account the patient's age, weight and initial Quick value. The goal of these algorithms, combined with frequent monitoring of INR, is to limit the bleeding risk during the introduction of anticoagulant therapy.

Preferences of elderly cancer patients in their advance directives.

Efforts to improve the quality of end-of-life decision-making have emphasized the principle of individual autonomy to better ensure that patients receive care consistent with their preferences. Advance directives (ADs) can be vehicles for in-depth and ongoing discussions among health care professionals, patients, and families. The aim of our study was to identify preferences and values expressed in ADs of 50 elderly patients with cancer. Main concerns of the patients were resuscitation and introduction of artificial nutrition. Very few patients had unrealistic expectation. Preferences about patient's symptom management were quite different from one to another. Content of ADs not only involved life-sustaining technology, but also psychosocial items and religious beliefs and values. All patients designated at least one surrogate. In conclusion, ADs should not be considered simply as another questionnaire, but more as a process to improve communication.

A systematic review of existing data on long-term lithium therapy: neuroprotective or neurotoxic?

Lithium is an efficacious agent for the treatment of bipolar disorder, but it is unclear to what extent its long-term use may result in neuroprotective or toxic consequences. Medline was searched with the combination of the word 'Lithium' plus key words that referred to every possible effect on the central nervous system. The papers were further classified into those supporting a neuroprotective effect, those in favour of a neurotoxic effect and those that were neutral. The papers were classified into research in humans, animal and in-vitro research, case reports, and review/opinion articles. Finally, the Natural Standard evidence-based validated grading rationale was used to validate the data. The Medline search returned 970 papers up to February 2006. Inspection of the abstracts supplied 214 papers for further reviewing. Eighty-nine papers supported the neuroprotective effect (6 human research, 58 animal/in vitro, 0 case reports, 25 review/opinion articles). A total of 116 papers supported the neurotoxic effect (17 human research, 23 animal/in vitro, 60 case reports, 16 review/opinion articles). Nine papers supported no hypothesis (5 human research, 3 animal/in vitro, 0 case reports, 1 review/opinion articles). Overall, the grading suggests that the data concerning the effect of lithium therapy is that of level C, that is 'unclear or conflicting scientific evidence' since there is conflicting evidence from uncontrolled non-randomized studies accompanied by conflicting evidence from animal and basic science studies. Although more papers are in favour of the toxic effect, the great difference in the type of papers that support either hypothesis, along with publication bias and methodological issues make conclusions difficult. Lithium remains the 'gold standard' for the prophylaxis of bipolar illness, however, our review suggests that there is a rare possibility of a neurotoxic effect in real-life clinical practice even in closely monitored patients with 'therapeutic' lithium plasma levels. It is desirable to keep lithium blood levels as low as feasible with prophylaxis.

Structured assessment of mental health status in psychogeriatrics: validity of the French HoNOS65+.

OBJECTIVE: To assess the reliability, validity, and feasibility of a French version of the Health of the Nation Outcome Scales for Elderly People (HoNOS65+). METHOD: Twenty mental health professionals completed the scale for 126 elderly patients. We assessed interrater reliability in inpatient and outpatient settings, together with construct and discriminant validity, as well as concurrent validity compared with several widely used clinical instruments. RESULTS: Excellent agreement among raters was observed in the outpatient subgroup (kappa range 0.77 to 1.00), whereas interrater reliability was modest in the inpatient subgroup (kappa values < 0.55). In cases where the patient-caregiver relationship lasted more than 1 month, the reliability of the scale improved. Construct validity analysis revealed no subscale structure. All items except "self-injury" displayed high concurrent validity (significant Spearman correlations with 8 other questionnaires). In terms of discriminant validity, the "cognitive impairment" (area under the curve [AUC] 0.91) and "depressive symptoms" (AUC 0.79) items showed high sensitivity and specificity values. CONCLUSION: Our results indicate that the French version of HoNOS65+ is a promising clinical assessment tool to evaluate mental disorders in the elderly in outpatient settings. We support its use in routine clinical practice, with the condition that a relatively long and individualized patient-caregiver relationship has been established.