Improved oral hygiene and Candida species colonization level in geriatric patients.

OBJECTIVES: This work consists in improving oral hygiene (OH) for elderly dependent people in long-term hospital care, in order to decrease the degree of colonization and the associated risk of developing oral candidiasis. As this population frequently suffers from such colonization and because it is difficult to install and practice OH care, a study protocol was designed at the request of geriatricians. The objective of the present study was to set up a programme of OH, applied by the care staff, and to monitor oral colonization of by Candida spp. BASIC RESEARCH DESIGN: We compared the levels of hygiene and Candida spp. colonization for a group of 110 long-term patients in geriatric departments at T1, when clinical data were collected and oral mycological samples taken before the OH protocol was applied, and at T2, during the postprotocol phase after 3 months of application, when the clinical data and sample collection were repeated. RESULTS: During these 3 months 11 patients died. These patients were excluded from the results, which are presented for matched series of the 99 patients still present at T2. Statistical analysis comparing the clinical and biological parameters at T1 and T2 established that there had been an improvement in OH: the 'adequate' level was reached for 72.4% of patients at T2 compared with 41.8% at T1 (P < 0.001) and the 'very inadequate' level was observed for 9.2% at T2 compared with 27.9% at T1 (P < 0.01). A reduction was observed in the number of patients showing the highest degree of C. albicans and C. glabrata colonization (> 50 colony forming units) from 41.9% at T1 to 24.9% at T2 (P < 0.05) and from 56.4% at T1 to 13.0% at T2 (P < 0.05) respectively. The number of patients with candidiasis fell significantly from 43.2% at T1 to 10.2% at T2. CONCLUSIONS: The OH protocol led to an overall decrease in Candida spp. colonization, a significant reduction in the number of candidiasis and an improvement in the level of oral and denture hygiene but vigilance is still necessary concerning OH care and the initial training of staff in specific care of the mouth.

Changes in informal care over one year for elderly persons with Alzheimer's disease.

BACKGROUND: Informal caregivers play a major role in all types of assistance for elderly persons with Alzheimer's disease but few longitudinal studies reports change in this role over time. OBJECTIVE: The aim of our research was to describe the objective and subjective burden of informal caregivers of elderly persons with dementia of Alzheimer type, and to follow its evolution during one year. METHODS: A multicentre prospective study of 333 principal caregivers of patients with Alzheimer's disease, followed for one year. RESULTS: At inclusion, the majority of caregivers were involved in most tasks of assistance (activities of daily living, handling money, supervision, organisation of support services) but only 13.4% were involved in basic activities of daily living. As expected, during follow-up, the involvement of caregivers increased and extended to all tasks: whereas at inclusion 11.0% regularly assisted in all tasks, after only 12 months follow-up this figure rose to 28.9% (P < 0.001). Whereas 45.9% of caregivers became involved in carrying out new tasks (mainly organisation of support services and help with basic activities of daily living), 8.9% no longer carried out certain tasks (essentially supervision and organisation of support services), 7.3% replaced one task by another, and for 37.8% there was no change. During the same time, the mean burden experienced by the caregiver showed a very slight change (increasing from a mean score of 21.08 +/- 14.65 to 22.68 +/- 16.45, P = 0.044) with great variation between caregivers. Those who increased their involvement also had a significant increase in caregiver burden. CONCLUSION: While home caregiving appeared to follow an even course, the needs of the care recipient changed rapidly over time and caregivers differed in their response to these changes, indicating that regular follow-up is required.

[Dynamics of interdisciplinary around a health care network: simultaneous programme design and evaluation planning]. / Dynamique interdisciplinaire autour d'un réseau de soins: evaluer et construire en même temps.

This article reports on the evaluation experience of a multiple sclerosis care network in the Midi-Pyrénées region (MIPSEP). It shows how an evaluation team composed of public health doctors and sociologists progressively and naturally evolved from having a purely external observation role towards having a collaborative role actively working with the network's members and partners. A qualitative method was chosen for the data collection through interviews with the network's actors, and the frameworks for reference were constituted from official texts which defined the networks and their missions. Coming from a curative and healing culture, the network's actors were concerned primarily about how to organise themselves in order to better respond to the needs expressed by the patients. The various professional backgrounds and cultures, faced with different perspectives from innovation and confronted with the related difficulties, participated in a collective expertise exercise and collaborated in the construction process. This example supports an open, qualitative, evolutionary evaluation approach which is done in close proximity to the field and work on the ground. The study is timely given the current explosion of debate on evaluation methods. With a great deal of exchange and reflection on suitable tools and indicators as well as the respective roles of researchers, care givers and decision-makers, the results of this study advocate to favour multidisciplinary approaches, including opening up this process to funders and planning authorities rather than over-theorising about it, which only serves to enclose and paralyse a process that, on the contrary, should aim to be more inclusive. This could be a useful way to decompartmentalise and break down existing barriers within the health system.

[Adverse cutaneous reaction to celecoxib: 6 cases]. / Toxidermies au célécoxib: 6 cas.

INTRODUCTION: Our objective was to characterize adverse cutaneous reactions to celecoxib, a new non steroidal anti-inflammatory drug. PATIENTS AND METHODS: A retrospective study of 6 consecutive patients. RESULTS: The average delay before the onset of the reaction was 10.2 days for patients taking the medication for the first time and 48 hours for one patient taking the drug for the second time. Two patients had fever. Patients presented with an exanthema and in most cases an edema of the face. Buccal mucosa was involved in two patients, and one patient had minimal blister lesions. In five of the six patients, minor and transitory biological abnormalities were found. The intrinsic imputability of the celecoxib was I3 (C3S2) in all the cases. DISCUSSION: Our cases are similar to those reported by the French drug regulatory agency (Pharmacovigilance). Usually the adverse cutaneous reactions were not too severe, with maculo-papulo exanthema and edema of the face. The reactions due to celecoxib are more frequent than those due to other non steroidal anti-inflammatory drugs (7.5% versus 4.1%), but severe cases are rarely reported. Besides, an allergic history to sulphonamide contraindicates celecoxib. However celecoxib does not have the aromatic amine common to antibacterial sulphonamides, and there is no proof of cross reactions between these two families. Furthermore, this amine is usually associated with drug reaction severity, which could explain why severe cases due to celecoxib are rare.

[Medical activity in a emergency outpatient department dermatology]. / Intérêt d'une consultation hospitalière d'urgences dermatologiques.

BACKGROUND: The aim of this study was to characterize the medical activity of a dermatology emergency room and to compare it with 1) outpatients, scheduled visits to the same department and 2) visits to community dermatologists in private practice. METHODS: All the 500 patients who attended the emergency room in one month and all the 411 patients with scheduled appointments during one week within the same period were included prospectively. The clinical diagnoses were recorded and compared between the two groups using chi square and linear correlation tests. Data on the diagnoses made by community dermatologists in private practice were obtained from another study. RESULTS: In the emergency room, 4 diagnoses accounted for 71.4 of all visits: infections (29 p. 100), dermatitis (23.8 p. 100), rashes (11 p. 100) and urticaria (7.6 p. 100). In scheduled visits the 4 leading diagnosis were cancer and precancerous lesions (28.7 p. 100), dermatitis (11.7 p. 100), fungal infections (8.3 p. 100) and acne (7.1 p. 100). There was no correlation (r=0.14; p=0.6) between the 16 more prevalent diagnoses in the emergency room and the prevalence of the same diagnoses in scheduled visits in the hospital department. The emergency diagnosis were also not correlated with those seen in private practice (r=0.21; p=0.4). Seven percent of emergency room consultants were hospitalized. COMMENTS: Skin disorders encountered in the dermatology emergency room differ from those seen both in the outpatient hospital department and in community private practice.

[Burden experienced by informal caregivers assisting Alzheimer's patients in the REAL.FR study]. / Charge ressentie par les aidants informels de patients atteints de la maladie d'Alzheimer au sein de l'étude REAL.FR: méthode de mesure et facteurs associés.

BACKGROUND: Most AD patients are cared for at home by informal caregivers. The effect of different kind of stressors on caregivers has been referred to as caregiver burden. OBJECTIVE: To determine (1) the level of burden of informal caregivers of Alzheimer's patients in a French national sample; (2) the factors associated with a high level of burden. METHODS: Cross-sectional study of informal caregivers of the demented elderly referred to a psychogeriatric, geriatric or neurological service. The principal caregivers of 531 patients with mild to moderate dementia attending an outpatient cognitive assessment clinic were interviewed via a structured questionnaire that focused upon caregiver-related characteristics such as whether they were living with the patients, their feelings of burden assessed by the Zarit Burden Interview and patients were examined at baseline to evaluate their cognitive, behavioral and functional limitation. RESULTS: Logistic regression analysis showed that patients' characteristics (MMSE, behavioral problems, nutritional problems), caregiver's characteristics (female gender, number of tasks involved in caregiving, cohabitation) and the provision of medical services were independently associated with a high level of burden. In this study increased caregiver burden was related independently to increased levels of patient behaviour disturbance and cognitive impairment. However, neither the illness duration nor the functional disabilities in activities of daily living affected the level of burden. This may have relevance to appropriate interventions for informal caregivers.

Toxic epidermal necrolysis and Stevens-Johnson syndrome: does early withdrawal of causative drugs decrease the risk of death?

BACKGROUND: Withdrawal of the drug(s) that cause severe cutaneous adverse reactions is usually recommended without proof that it alters the course of those reactions. OBJECTIVE: To determine whether the timing of causative drug withdrawal is related to the prognosis of patients with toxic epidermal necrolysis (TEN) or Stevens-Johnson syndrome (SJS). DESIGN: A 10-year observational study (January 1, 1987, through October 30, 1997) of patients admitted to a dermatological intensive care unit, using binary logistic regression analysis. SETTING: A single referral unit in a university hospital. PATIENTS: Consecutive sample of 203 patients with TEN or SJS. Exclusion criteria included causative drug undetermined, lack of information on disease evolution, the date of causative drug(s) withdrawal, or the date when the first definite sign of TEN or SJS appeared. MAIN OUTCOME MEASURE: Death before hospital discharge. RESULTS: One hundred thirteen patients were included; 74 had TEN and 39 had SJS; 20 died. The drug causing TEN or SJS was withdrawn early in 64 patients and late (after the first definite sign of TEN or SJS) in 49 patients. After adjustment for confounding variables (age, maximum extent of detachment, admission year, human immunodeficiency virus status), our model showed that the earlier the causative drug was withdrawn, the better the prognosis (odds ratio, 0.69 for each day; 95% confidence interval, 0.53-0.89). Patients exposed to causative drugs with long half-lives had an increased risk of dying (odds ratio, 4.9; 95% confidence interval, 1.3-18.9). The variables did not interact. CONCLUSIONS: Prompt withdrawal of drug(s) that are suspected to cause SJS or TEN may decrease mortality. Prompt withdrawal of causative drugs should be a priority when blisters or erosions appear in the course of a drug eruption.

Alarm communication network to help carers of the elderly for safety purposes: a survey of a project.

Over years, radical changes in engineering technology have taken place due to greatly improved instrumentation, enhanced computing power, new sensors and upgraded transmission mediums making it possible to achieve in the field what once could only be done on laboratory models. In daily life, the use of an active self-testing instrumentation endowed with a self-diagnostic capability built into the structural fabric of a machine permits us to monitor the initiation of breakdown, corrosion and erosion. This has become particularly important in such means of transportation as planes, boats and automobiles where advanced instrumentation, signal processing and pattern recognition systems operate in fairly conventional structures. By capitalizing on the technological progress in the field of instrumentation and data processing, help can be contemplated for elderly people in nursing homes through detection of abnormal situations. The continued assistance to elderly people is achieved by utilizing a technological system respectful of the elderly's privacy and operating without their active participation.

[Symptomatology and markers of the severity of erythematous drug eruptions]. / Sémiologie et marqueurs de sévérité des toxidermies érythémateuses.

OBJECTIVES: Skin reactions to drugs affect about 2.2 percent of inpatients. More often, they are described as morbilliform or maculopapular. The objectives of this study were to characterize these skin reactions and to look for severity markers. METHODS: We retrospectively analyzed 133 cases of drug reactions collected in a Dermatology unit from 1973 to 1995 for whom, photographs and blood cell count were available. Well recognized disorders were excluded (Stevens-Johnson syndrome, Lyell syndrome, TEN, AGEP, vasculitis, phototoxicity, fixed drug eruption). Severity was defined on 3 criteria: hospitalization, skin reaction prolonged more than 21 days and visceral involvement. For each criteria, we studied the association with clinical and laboratory findings, first with univariate analysis, then with multivariate analysis for significant associations. RESULTS: Characteristics of the 133 included cases were: women: 58 p. 100, mean age: 52 years, inpatients: 80 p. 100, mean interval from beginning of drug therapy to reaction: 12 days, mean duration: 26 days, responsible drugs: antibiotics: 41 p. 100, nonsteroidal antiinflammatory drugs: 11 p. 100, anticonvulsants: 10 p. 100. A few reactions showed a monomorphous pattern fitting a single denomination in a classic dermatological nomenclature: maculopapular: 10 p. 100, morbilliform: 6 p. 100, scarlatiniform: 5 p. 100, small papules: 5 p. 100. Polymorphous reactions were observed in 73 p. 100 of cases with 3 different patterns on the average. Nearly half of the cases exhibited maculopapular and scarlatiniform lesions simultaneously. We observed fever (61 p. 100), mucosal lesions (26 p. 100), lymphadenopathy (30 p. 100), eosinophilia (count > 500/mm3: 44 p. 100, > 1500/mm3: 17 p. 100), and visceral involvement (22 p. 100), including hepatitis (18 p. 100). Four severity markers were identified: fever, lymphadenopathy, erythema involving more than 60 p. 100 of the body surface area, eosinophilia. CONCLUSION: This study underlines the polymorphous clinical presentation of skin reactions to drugs and the minority of maculopapular or morbilliform patterns leading us to propose the term of "erythematous drug reactions". Despite several biases (hospital recruitment of more severe reactions, retrospective analysis) this study is the first to show some severity markers. Close to the criteria used to define the "hypersensitivity syndrome" these simple clinical markers may have important practical implications.

[Lyell syndrome and Stevens-Johnson syndrome caused by lamotrigine]. / Syndrome de Lyell et syndrome de Stevens-Johnson à la lamotrigine.

BACKGROUND: Lamotrigine is a new anticonvulsant belonging to the triazine family. Several cases of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) have been described in patients taking this drug. We report 2 cases in children attending the same hospital. CASE REPORTS: Two children, aged 9 and 13 years, developed SJS and TEN respectively, 3 and 28 days after lamotrigine was added to their usual anticonvulsant regimen. In both cases, outcome was favorable despite major decline in psychomotor capacity in one. In the first case, chronological attributability was plausible for lamotrigine and doubtful for sodium valproate, clonazepam and hydrocortisone. In the second case, chronological attributability was probable for amoxicillin, plausible for lamotrigine and doubtful for sodium valproate, but the numerous previous absorptions of amoxicillin made lamotrigine more suspect. DISCUSSION: The risk of Steven-Johnson syndrome and toxic epidermal necrolysis is high with lamotrigine with an estimated frequency of 1/1000. This risk is probably higher than with other anticonvulsants. Associating lamotrigine with sodium valproate increases the frequency of adverse skin reactions.

Caregiver stress: a failed negotiation? A qualitative study in South West France.

The purpose of this work is to analyze the various negotiations involved in setting up and developing a caregiving relationship with a disabled elderly person, to understand the processes inducing caregiver stress. Within the conceptual framework defined by the paradigm of negotiation, this study uses the theoretical contributions of the parallelist theory and the theory of the gift. It is based on a qualitative inquiry including fifty-four caregivers conducted in Toulouse (South West France). The analysis focuses on two undersystems of the caregiver's relationships: 1) the caregiver/cared-for's relationship, which is characterized by the establishment and maintenance of a "tacit contract" and 2) the relationships with other eligible caregivers, which are marked by the "designation" of the principal caregiver. This analysis shows that a failure in the negotiation process can induce a designation and/or a weak tacit contract-the result of which is the caregiver's expression of stress. This expression is closely linked to the caregiver's perception of a negative balance in his/her exchanges with the partners. This study should help break away from the one-way arrow model currently dominating the field of caregiver stress research.

Randomised comparison of thalidomide versus placebo in toxic epidermal necrolysis.

BACKGROUND: Toxic epidermal necrolysis (TEN) is associated with a 30% death rate. Tumour necrosis factor alpha (TNF-alpha) has been implicated in the pathogenesis of TEN. Thalidomide is a potent inhibitor of TNF-alpha action. We did a double-blind, randomised, placebo-controlled study of thalidomide in TEN. METHODS: The patients received a 5-day course of thalidomide 400 mg daily or placebo. The main endpoint was the progression of skin detachment after day 7. Secondary endpoints were the severity of the disease, evaluated with the simplified acute physiology score (SAPS), and the mortality. TNF-alpha and interleukin 6 were measured. FINDINGS: The study was stopped because there was excess mortality in the thalidomide group--ten of 12 patients died compared with three of ten in the placebo group (Fisher's exact test with Katz's approximation, relative risk=2.78, p=0.03). After adjustment for SAPS, mortality remained significantly higher in the thalidomide group than in the placebo group (exact logistic regression mid-p=0.007; 95% CI for odds ratio 2.7 to infinity). Plasma TNF-alpha concentration was higher in the thalidomide group than the placebo group on day 2, though the difference was not significant (Wilcoxon rank-sum test p=0.07). INTERPRETATION: Even though few patients were included, our data suggest that thalidomide is detrimental in TEN, possibly because of a paradoxical enhancement of TNF-alpha production.

Lichenoid erythrodermic bullous pemphigoid of the African patient.

BACKGROUND: Lichen planus (LP) pemphigoides is defined by the concurrence of bullous pemphigoid (BP) and LP lesions. However, other autoimmune bullous skin diseases such as paraneoplastic pemphigus or bullous lupus erythematosus may also be associated with lichenoid eruptions. OBJECTIVE: Our purpose was to describe 3 African patients with a similar form of lichenoid erythrodermic BP. METHODS: Medical records of the 3 patients were reviewed for clinical, histologic, and biologic data. The ultrastructural localization of autoantibody deposits was studied by direct and indirect immunoelectron microscopy. The antigenic specificities recognized by the patients' sera were analyzed by immunoblotting on human epidermal extracts. RESULTS: Three black African men had a severe lichenoid erythroderma associated with BP lesions involving the skin and mucosa. Histologic and direct immunofluorescence examination of skin and mucosal lesions were consistent with the diagnosis of BP associated with a lichenoid dermatitis. Immunoblot analysis of sera detected anti-BPAG1 and anti-BPAG2 antibodies and immunoelectron microscopy showed IgG deposits localized in the lamina lucida and the hemidesmosomes. The 3 patients were natives of an area near the Senegal River and had the common HLA-DR10 haplotype. CONCLUSION: The clinical and histologic features of these 3 patients were distinct from classic LP pemphigoides. Their common geographic origin and the presence of the HLA-DR10 haplotype suggest that these cases represent a particular type of lichenoid erythrodermic BP, which is probably determined by genetic factors.

[Hypersensitivity syndrome during Mycoplasma pneumoniae infection]. / Syndrome d'hypersensibilité au cours d'une infection à Mycoplasma pneumoniae.

BACKGROUND: Skin manifestations have been described in 25% of patients with Mycoplasma pneumoniae infection. CASE REPORT: We report a case of Mycoplasma pneumoniae infection in a 29-year-old man who developed a polymorphous erythema-like reaction. Skin manifestations were associated with voluminous lymph node enlargement and high eosinophil levels both in serum and alveolar lavage. Seroconversion against Mycoplasma pneumoniae IgG was documented with ELISA. The clinical course was favorable with erythromycin. DISCUSSION: ELISA IgG seroconversion is sufficient to confirm the diagnosis of Mycoplasma pneumoniae infection as this test has an 80-90% specificity. This case was unusual by its clinical presentation and high eosinophil counts in serum and tissue samples, similar to what is found in drug-induced hypersensitivity.

Reactions and interactions of some commonly used systemic drugs in dermatology.

This article deals with the main interactions and adverse effects of some drugs that are used daily by dermatologists. It includes tetracyclines and Minocycline in the treatment of acne; antimalarials and discoid lupus; dapsone; thalidomine; oral retinoids; methotrexate and cyclosporine. Several of these drugs are discussed.

Increased levels of interleukin 5 are associated with the generation of eosinophilia in drug-induced hypersensitivity syndrome.

Hypersensitivity syndrome (HSS) usually refers to severe drug eruption associated with systemic symptoms and eosinophilia. Interleukin (IL)-5 regulates eosinophil counts with the help of IL-3 and granulocyte-macrophage colony-stimulating factor (GM-CSF). Blood IL-5 levels have been reported to be increased in patients with eosinophilia secondary to parasitic infections or idiopathic eosinophilia, but have never been evaluated in drug-induced eosinophilia. The aim of our study was to determine whether IL-5, IL-3 and GM-CSF are involved in eosinophilia in patients with drug-induced HSS. Plasma levels of IL-3, IL-5 and GM-CSF were assayed by ELISA in seven patients with drug-induced HSS, in eight patients with cutaneous adverse drug reactions not associated with eosinophilia, and in five patients with eosinophilia unrelated to drug treatment. IL-5 levels were normal in all eight patients with drug eruptions without eosinophilia, and increased in five of the seven patients with HSS. In the latter patients, IL-5 levels peaked several days before highest eosinophil counts were noted, and returned to normal within a few days, even when eosinophilia persisted. In patients with eosinophilia unrelated to drug treatment, IL-5 levels, although significantly increased remained lower than in HSS patients. IL-3 and GM-CSF could not be detected in any group, at any time. Our results show that IL-5 is involved in drug-related eosinophilia. As IL-5 production was only involved in the early stages of the reaction, it is suggested that IL-5 mainly derives from activated lymphocytes rather than eosinophils. Our results support the clinical relevance of previous in vitro findings. Further studies are needed to test whether assays of IL-5 production by lymphocytes of patients stimulated by the suspected drug and/or its metabolites, are useful in establishing causality in drug-induced reactions associated with eosinophilia.

Multisensor system and artificial intelligence in housing for the elderly.

To improve the safety of a growing proportion of elderly and disabled people in the developed countries, a multisensor system based on Artificial Intelligence (AI), Advanced Telecommunications (AT) and Information Technology (IT) has been devised and fabricated. Thus, the habits and behaviours of these populations will be recorded without disturbing their daily activities. AI will diagnose any abnormal behavior or change and the system will warn the professionals. Gerontology issues are presented together with the multisensor system, the AI-based learning and diagnosis methodology and the main functionalities.

Prevalence of cancer in the elderly: discrepancies between self-reported and registry data.

Data on self-reported cancer by a sample of 3349 elderly persons in the south-west of France were validated against registry data in the same region: only 21% of the persons on the cancer registry reported occurrence of cancer. Breast cancer was found to be most frequently accurately reported.