Orthogeriatric care pathway: a prospective survey of impact on length of stay, mortality and institutionalisation.

INTRODUCTION: Care pathways for elderly hip fracture patients are increasingly implemented but there has been only limited evaluation of their use. Our objective was to investigate the impact of such a care pathway on the use of healthcare resources and on patients' outcomes. MATERIALS AND METHODS: The prospective survey covered 493 hip fracture patients 65 years of age or older that were treated either before "Usual Care = (UC)" or after "Co-Managed-Care = (CMC)" implementation of the care pathway. Primary outcome was length of stay (LoS). Secondary outcomes were 1-year mortality and change in residential status from prefracture baseline to 1-year after surgery. Data were analysed by descriptive and interferential statistics and adjustment for baseline differences amongst the two patient groups was done. RESULTS: Patients in the CMC sample had more preexisting comorbidities (CCI 2.5 versus 2.1). Prior to the fracture, a larger proportion amongst them needed help in ADL (49 versus 26%), and they were more likely to reside in a nursing home (36 versus 29%). Prefracture mobility status was equal in both samples. In the CMC sample LoS was significantly shorter (LoS 8.6 versus 11.3 days, p < 0.01) and patients were less likely to experience a complication (59 vs 73%, p < 0.01) while being in the hospital. There was no significant difference in 1-year mortality or in change of residential status. CONCLUSIONS: A care pathway for elderly hip fracture patients allowed decreased LoS without affecting mortality or change of residential status 1 year after fracture compared to prefracture baseline.

["Smoke smarts": how to help patients to stop smoking?]. / "Fumer futé". Comment aider son patient à se libérer du tabac?

Smoking cessation advice must be part of each medical consultation, because smoking is a disease. Smokers wish to stop, and clinically tested drugs for smoking cessation exist. The success depends on the motivation of the patient and the ability of the doctor to behave as a coach, to improve the desire to stop even in patients heavily addicted to nicotine. In this situation it is proposed to proceed by steps, diminishing gradually the number of smoked cigarettes with the help of nicotine containing preparations. The patient tries to avoid the cigarette by boosting his serum nicotine level with the inhaler or the nicotine gum as often as possible and seeks to understand the reasons why he is a smoker. The drugs bupropion and vareniclin may then help the patient to reinforce their motivation to stop smoking completely.

Influence of the quality of nursing on the duration of weaning from mechanical ventilation in patients with chronic obstructive pulmonary disease.

OBJECTIVE: To evaluate the influence of nursing on the duration of weaning from mechanical ventilation in patients with chronic obstructive pulmonary disease. DESIGN: Data were collected prospectively over a 1-yr period (study year) and compared with previously collected prospective data recorded in our chronic obstructive pulmonary disease database during a 5-yr period. SETTING: The medical intensive care unit (ICU) of a university hospital. PATIENTS: Eighty-seven patients with chronic obstructive pulmonary disease. Fifteen patients had chronic obstructive pulmonary disease that required mechanical ventilation for acute exacerbation of their disease (study year), and 72 were patients with chronic obstructive pulmonary disease from the previously collected data. INTERVENTIONS: The ICU course (duration of mechanical ventilation, mortality) was recorded, as well as several respiratory parameters (pulmonary function tests and arterial blood gases in stable conditions, and nutritional status), and they were compared with an "index of nursing." MEASUREMENTS AND MAIN RESULTS: We developed an "index of nursing", comparing the effective workforce of the nurses (number and qualifications) with the ideal workforce required by the number of patients and the severity of their diseases. A value of 1.0 represented a perfect match between the needed and the effectively present nurses, whereas a lesser value signified a diminished available workforce. This index was compared with the complications and duration of weaning from mechanical ventilation. During the first 5 yrs, the duration of mechanical ventilation increased progressively from 7.3 +/- 8.0 to 38.2 +/- 25.8 days (p = .006). A significant inverse correlation between the duration of mechanical ventilation and the nursing index (p = .025) was found. In the sixth comparative year, the number of nurses increased (nursing index = 1.05) and the duration of mechanical ventilation decreased to 9.9 +/- 13 days (p < .001, yr 5 vs. yr 6). CONCLUSIONS: The quality of nursing appears to be a measurable and critical factor in the weaning from mechanical ventilation of patients with chronic obstructive pulmonary disease. Below a threshold in the available workforce of ICU nurses, the weaning duration of patients with chronic obstructive pulmonary disease increases dramatically. Therefore, very close attention should be given to the education and number of ICU nurses.

Retroperitoneal silicosis mimicking pancreatic carcinoma in an Alpine miner with chronic lung silicosis.

A miner, known to have had lung silicosis for 30 years, was investigated for abdominal pain. A retroperitoneal mass was found, in which histological examination showed an inflammatory reaction to silica.

The glycosaminoglycan composition of the lung with acute and chronic pathology and in senescence.

The content and distribution of GAGs in the anatomic structures of pathological (pneumoconiosis, pneumonia, pulmonary embolism) and senescent lungs have been measured. The total GAG content of the lung structures, except central bronchi is generally lower than normal in the pathological lungs. The GAG distribution in the pleura (DS predominant), central bronchi (C6S predominant), arteries, veins and 'total lung' is similar to the corresponding normal distribution. The other notable observations are: the concentration of HA in peripheral bronchi and alveoli is increased possibly in response to the high local concentration of coal dust; an age related GAG switch from DS in the arteries of the young to C6S in the arteries of the mature lung is confirmed; the arterial GAG content generally increases with age up to age 103 in the male; the arteries of a female smoker display the mature male pattern of GAG composition. The data suggest that gender, smoking and age, more than acute pathology, determine the GAG composition of the anatomic structures of the lung.

[Continuous oxygen therapy at home. Observations of oxygen users after an instruction program]. / Oxygénothérapie continue à domicile. Etude de l'observance des extracteurs d'oxygène après un programme d'enseignement.

The benefit of continuous domiciliary oxygen therapy (OCD) directly depends on the number of hours the oxygen is used daily. The observance of a correct regime is rarely met at present. For this reason we have done a prospective study for 24 months, assessing the compliance of 64 patients from 28 to 82 years of age. All these patients received a systematic and personal programme of education for 2 days in hospital. We subsequently measured, without the knowledge, either of the patient or the person caring from them, the quarterly oxygen usage. The mean duration of oxygen therapy was 14.7 +/- 3.6 hours. It remained stable during the 2 years of observation: 51% of the patients achieved a treatment of 15 hours or more and 10%, 10 hours or less. We did not find a significant correlation between the hours of compliance and the age, sex, FEV1, FVC and PaO2 or haemoglobin saturation. A significant statistical correlation with the PaCO2 was obtained. The more educated patients had better compliance levels than those of lesser education. The results obtained were better than those found in the literature at the present time. Perhaps it is explained by the level of education given. It cannot be excluded, however, that our severe criteria for the prescription of OCD has selected a population which was more susceptible to achieving good compliance. However, these results encourage the initiation of another prospective study using a control group to make a better assessment of the impact of education on the patient and his carers by the improved compliance in OCD.

Bronchial granular-cell tumor. Report of a case with preoperative cytologic diagnosis on bronchial brushings and immunohistochemical studies.

A 42-year-old man presented with a polypoid endobronchial mass of the right apical segmental bronchus. Bronchial brushing smears contained clusters of cells exhibiting abundant diffusely granular cytoplasm with indistinct borders. A cytologic diagnosis of granular-cell tumor was rendered. Histologic examination of the upper right lobectomy specimen provided confirmation. Immunohistochemically, the granular cells strongly reacted with the S-100 protein antibody. This case demonstrates that the cytologic diagnosis of bronchial granular-cell tumor is possible if this lesion is considered in the differential diagnosis of lung tumors.

Diffuse interstitial lung disease associated with hydrogen peroxide inhalation in a dairy worker.

A 41-yr-old dairy worker, smoker of 40 cigarettes daily, presented with severe gas exchange impairment caused by interstitial lung disease, as shown by transbronchial biopsy. He was exposed chronically to an aerosol of hydrogen peroxide (41 mg/mm3; upper legal limit: 1.5 mg/mm3) which must be incriminated as the etiologic agent, since withdrawal from exposure resulted in improvement, and no other etiology could be identified.

Failure to predict six-month survival of patients with COPD requiring mechanical ventilation by analysis of simple indices. A prospective study.

We analyzed the outcome of 39 consecutive acute exacerbations of chronic obstructive pulmonary disease (COPD) in 35 patients requiring mechanical ventilation, in order to identify the features related to survival. Patients were divided into those surviving less (group A; n = 14) and more (group B; n = 24) than six months. Pulmonary function tests, arterial blood gas levels either on admission or while in a steady state, and nutritional parameters were similar in both groups. Only the duration of mechanical ventilation was longer in group A when compared to group B. In patients dying while being ventilated or surviving less than ten days after extubation, only the forced vital capacity (FVC) was different when compared to the rest of group A. The duration of mechanical ventilation was not related to age or the forced expiratory volume in one second (FEV1). Only a multivariate analysis accounting simultaneously for eight parameters could separate with 78 percent accuracy the different groups of patients; however, following this analysis, 23 percent of the patients in group B could have been falsely classified as nonsurvivors and perhaps rejected for mechanical ventilation. We conclude that the six-month survival of patients with COPD who required mechanical ventilation for an acute exacerbation of their disease cannot be predicted from simple data generally available to the physician in charge at the time of intubation.

Production of lymphocyte chemokinetic activity by stimulated alveolar macrophages.

While the presence of a lymphocytic parenchymal infiltrate is characteristic of several lung diseases, the mechanisms responsible for the focal accumulation of lymphocytes within the lungs remain unclear. Since alveolar macrophages secrete several substances that affect lymphocyte function, we examined supernatants of stimulated, cultured guinea pig alveolar macrophages for their ability to alter lymphocyte motility. Guinea pigs were immunized by footpad injection of ovalbumin (OVA) emulsified in complete Freund's adjuvant. Fourteen days later, alveolar macrophages were obtained by bronchial lavage or teasing the lung parenchyma, enriched by adherence to plastic, and incubated for 3 and 24 hours in culture medium alone or medium containing either latex beads, OVA, or human serum albumin (HSA). Conditioned medium was harvested and assayed for chemoattractant activity against rat splenic lymphocytes in modified Boyden chambers. Regardless of stimulus, there was no evidence of enhanced lymphocyte motility above control values in supernatants harvested at 3 hours. At 24 hours, alveolar macrophages from OVA-sensitized guinea pigs stimulated with latex or OVA generated significant amounts of lymphocyte migration stimulating activity (LCA) (250 +/- 25 and 247 +/- 24 percent of control migration, respectively) compared to cells incubated in medium alone or with HSA (162 +/- 23 and 147 +/- 14 percent, respectively). Antigen recognition appears to be related to the presence of cytophilic anti-OVA antibody on the surfaces of alveolar macrophages of sensitized guinea pigs. LCA is resistant to neuraminidase, chymotrypsin, and heating to 56 degrees C, and was chemokinetic for T-lymphocytes. it elutes from Sephadex G-100 in two regions: one at approximately 67,000 d, and a second at approximately 15,000 d. These studies indicate that following systemic immunization, the guinea pig alveolar macrophage can react to specific antigen or phagocytosis of inert particulates by secreting a chemokinetic factor for T-lymphocytes, and may play a role in the pathogenesis of some types of antigen-induced lung disease.

Single photon emission computed tomography study of human cancer: utilization of 57Co-labelled bleomycin.

The sensitivity and specificity of single photon emission tomography with 57Co-labelled bleomycin (57Co-BLM) for the detection of cancer was determined from a prospective study involving a large group of patients selected to investigate roentgenographic abnormalities. Eighty-four of the 104 patients studied had malignant disease, of whom 76 had a positive scintigram. Eighteen of the 20 patients with benign disorders had a negative scintigram. The sensitivity and specificity was therefore 90.5 and 90% respectively. For the subset of patients who underwent investigation below the diaphragm, the sensitivity was 85.7%, while for investigation above the diaphragm, it reached 95.2% (this excluded reconstructions on the bladder level, because it produced large artifacts). This study leads to the conclusion that SPECT can be used specifically to investigate unidentified X-ray abnormality and diagnose malignancy using 57Co-BLM. In addition, we propose further investigation to evaluate the usefulness of this method in staging cancer.

Influence of ethanol on human T-lymphocyte migration.

Because ethanol consumption is associated with increased susceptibility to infection, we examined the effects of ethanol and its metabolite acetaldehyde on human T-lymphocyte migration, an important functional component of cellular inflammatory responses. With a modified Boyden chamber system, ethanol at 0.25% and 0.50% (vol/vol) inhibited spontaneous motility of human T-lymphocytes, in a noncytotoxic manner, to 65% +/- 7% (mean +/- SEM) and 62% +/- 7% of control values of migration, respectively. When T-lymphocyte migration was stimulated by colchicine (10(-5) mol/L), incubation with ethanol (0.25% and 0.50%, vol/vol) decreased migration to 80% +/- 4% and 66% +/- 8% of control values, respectively. Similar degrees of inhibition of migration were obtained with acetaldehyde at concentrations five to 10 times less than ethanol. Ethanol was similarly capable of inhibiting T cell migration induced by dibutyryl cyclic guanosine monophosphate, but it had no effect on stimulated migration induced by a human chemokinetic lymphokine. Our study demonstrates that ethanol, at concentrations achievable in vivo, is capable of depressing T-lymphocyte migration. This effect might contribute to the immunosuppression associated with ethanol consumption.

[Immunologic study of pleural neoplastic effusions: Detection of immune complexes and complement activation]. / Etude immunologique des épanchements pleuraux néoplasiques: détection de complexes immuns et activation du complément.

Occurrence of immune complexes in malignant pleural effusions has been investigated by the 125I-c1q binding test. 55% of the pleural effusions had C1q binding activity levels higher than those found in transudates used as controls. The levels of C1q binding activity in effusions were significantly higher than those found in the serum of the same cancer patients. High levels of C1q binding activity were found in malignant effusion independently of type or differentiation of the tumors involved. The C1q binding material had properties of immune complexes. The levels of CH50 and C3d, i.e. the degradation product of C3, in malignant effusion were similar to those of transudates. These observations show a high incidence of immune complexes in malignant effusions and a slight activation of complement inadequate for its local consumption. The persistence in major quantity of immune complexes in malignant effusion suggests local formation or decreased clearance.