FRAILTY, SARCOPENIA AND LONG TERM CARE UTILIZATION IN OLDER POPULATIONS: A SYSTEMATIC REVIEW.

This systematic literature review documents the link between frailty or sarcopenia, conceptualized as dimensions of physical health, and the use of long-term care services by older individuals. Long-term care services include formal and informal care provided at home as well as in institutions. A systematic review was performed according to PRISMA requirements using the following databases: PubMed-Medline, Embase, CINAHL, Web of Science, and Academic Search Premier. We included all quantitative studies published in English between January 2000 and December 2018 focusing on individuals aged 50 or more, using a relevant measurement of sarcopenia or physical frailty and a long-term care related outcome. A quality assessment was carried out using the questionnaire established by the Good Practice Task Force Report of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Five subsets of long-term care outcome were considered: 1/ nursing home placement (NHP), 2/ nursing home short stay (NHSS), 3/ formal personal care (FPC), 4/ formal home help (FHH), 5/ informal care (IC). Out of 1943 studies, 17 were finally included in the review. With some studies covering several LTC outcomes, frailty and / or sarcopenia were associated with increased LTC use in 17 out of 26 cases (NHP: 5/6, NHSS: 3/4, FPC: 5/7, FHH: 1/4, IC: 3/5) The association was not consistent in 5 cases (NHP: 1/6, NHSS: 1/4, FPC: 2/7, FHH: 0/4, IC: 1/5) and the association was either not significant or the results inconclusive in the remaining 9 cases. Overall, while results on sarcopenia are scarce, evidence support a positive association between frailty and LTC use. The evidence is stronger for the association of physical frailty with nursing home placement / short stay as well as on FPC. There is less (more heterogeneous) evidence regarding the correlation between physical frailty and FHH or IC use. Results need to be confirmed by more advanced statistical methods or design based on longitudinal data.

[Contract for improving professional practices: What is the impact perceived by GPs?]. / Le contrat d'amélioration des pratiques individuelles (CAPI) : quels impacts perçus par les médecins généralistes sur leurs pratiques ?

BACKGROUND: The CAPI (contract for improving professional practices) is a voluntary pay for performance scheme for primary care physicians introduced in France in 2009. Our objective was to analyze general practitioners' (GPs) perceptions of the impact of the CAPI on their healthcare practices. METHOD: The methodology was both qualitative, using thematic analysis of responses to three items of a questionnaire mailed to GPs in 2011, and quantitative using thematic multiple correspondence analysis of responses together with cluster analysis based on the ward aggregation criterion. RESULTS: A total of 1050 general practitioners answered, 31% had signed a CAPI. For CAPI-participating GPs, the contract was mostly related to changing practices for drug prescription. GPs who did not participate in the CAPI focused on ethical issues. They denounced a conflict of interest between the doctor and the patient and also the risk of patient selection. They connected these concepts to selected indicators. Due to their relationship with the health insurance fund, they feared their freedom of practice would be restricted. CONCLUSION: GP involvement in designing indicators would favor better balance between economic goals and values of care. The patients' viewpoint should be studied. Pay for performance has been renewed in the 2011. Further studies will analyze the impact of this new scheme in a medical and economic perspective.

Gastric mucosal oxygen delivery decreases during cardiopulmonary bypass despite constant systemic oxygen delivery.

UNLABELLED: Previous studies report a decrease in gastric mucosal oxygen delivery during cardiopulmonary bypass (CPB). However, in these studies, CPB was associated with a reduction in systemic oxygen delivery (DO2). Conceivably, this decrease in DO2 could have contributed to the observed decrease in gastric mucosal oxygen delivery. Thus, in the present study, we assessed the effects of the maintenance of DO2 (at pre-CPB values) during hypothermic (30-32 degrees C) CPB on the gastric mucosal red blood cell flux (GMRBC flux) using laser Doppler flowmetry. In 11 patients requiring cardiac surgery, the pump flow rate during CPB was initially set at 2.4 L x min(-1) x m(-2) and was adjusted to maintain DO2 at pre-CPB values (flow 2.5-2.7 L x min[-1] x m[-2]). Despite a constant DO2, the GMRBC flux was decreased during CPB. These decreases averaged 50% +/- 16% after 10 min, 50% +/- 18% after 20 min, 49% +/- 21% after 30 min, and 49% +/- 19% after 40 min of CPB. The rewarming period was associated with an increase in GMRBC flux. Thus, maintaining systemic DO2 during CPB seems to be an ineffective strategy to improve gastric mucosal oxygen delivery. IMPLICATIONS: In the present study, we tested the hypothesis that gastric mucosal red blood cell flux assessed by laser Doppler flowmetry could be improved by maintaining baseline systemic flow and oxygen delivery during hypothermic cardiopulmonary bypass. Despite this strategy, gastric mucosal red blood cell flux decreased by 50% during hypothermic cardiopulmonary bypass.

[Morphine in cesarean section and postoperative analgesia]. / Les morphiniques dans les césariennes et en analgésie postopératoire.

Epidural opioids for caesarean section are routinely used by many anaesthesists. Combined epidural injection of a local anaesthetic and an opioid provides a more rapid onset of profound analgesia. No side effects are observed in either the mother or the neonate with epidural "microdoses" of sufentanil or fentanyl, but the postoperative analgesia is of short duration. Combined intrathecal injection on 0.1-0.2 mg morphine and 0.5% hyperbaric bupivacaine provides a better intra- and postoperative analgesia. Opiates used during anaesthesia in toxemic women before delivery imply strict subsequent paediatric care. Good postoperative analgesia can be obtained with intrathecal morphine or patient-controlled analgesia. Using other techniques depends on care and surveillance facilities. Opiates by spinal or intravenous route are not dangerous for breast-fed newborns.

[Cardiorespiratory management of severe injured patients in intensive care units]. / Prise en charge cardio-respiratoire des traumatisés graves en réanimation.

Late mortality of severely injured patients could be prevented by the quality of early cardiorespiratory management. Indeed traumatized patients with high risk of multiple organ failure (according to age, ISS, amount of blood transfused, and/or metabolic acidosis) need a pulmonary artery catheterization as soon as possible (postdefinitive phase: during the surgical period or at the admission in the ICU). Such a procedure allows the intensivist to determine therapeutic goals in term of O2 delivery (DO2) and O2 uptake (VO2) in front of a frequent increased peripheral O2 demand, These goals (usually DO2 > or = 600 ml.min-1m-2 and VO2 > or = 150 ml.min-1.m-2) may be reached by the combination of prolonged mechanical ventilation (adapted to the pulmonary status), subnormal O2 carrying capacity (hematocrite between 30 and 35% in the absence of persistent bleeding), and increased cardiac output through an additional volume loading (without an excessive positive cumulated fluid balance on the second posttraumatic day) and the early administration of inotropic drugs (dobutamine). Reaching these goals usually permits a 61% reduction in the posttraumatic incidence of organ failure.