Propos: Le but de cette etude prospective etait d'identifier chez des malades âges de plus de 70 ans hospitalises pour une syncope, a partir d'un questionnaire standardise, les signes cliniques permettant de differencier sur les seules donnees de l'anamnese les syncopes d'origine cardiaque ou neurologique. Methodes: 131 malades âges de plus de 70 ans consecutivement hospitalises pour une syncope ont ete inclus. Chaque malade a ete interroge sur ses symptomes presents avant, durant et apres la syncope. Quand cela a ete possible, un temoin (de l'entourage le plus souvent) ayant assiste a la syncope etait interroge pour comparer ses reponses a celles fournies par le malade. Une comparaison statistique des reponses obtenues entre 3 groupes de malades definis par le mecanisme de leur syncope: cause cardiaque, cause neurologique et perte de connaissance inexpliquee apres explorations complementaires appropriees, ainsi qu'une etude de concordance entre les reponses fournies par les malades et leurs temoins a ete realisee. Resultats: Une sensation imminente de perte de connaissance, une oppression thoracique, le souvenir precis des faits avant la perte de connaissance et un antecedent d'arythmie cardiaque etaient independamment et significativement discriminants entre les 3 groupes. Le souvenir des faits precedant la syncope (OR = 7,5; 95 %; intervalle de confiance IC = 2,2 - 25,3) et un antecedent d'arythmie (OR = 4,8; 95 %; IC = 1,.6-14,2) etaient discriminants entre les syncopes d'origine cardiaque et neurologique, tous deux en faveur d'une origine cardiaque. Une concordance entre les reponses des patients et des temoins etait retrouvee pour les questions se rapportant aux antecedents medicaux et aux circonstances de survenue de la syncope. Conclusion: Une memoire precise des faits precedant la syncope et un antecedent d'arythmie sont dans cette etude, en faveur d'une syncope d'origine cardiaque plutot qu'en faveur d'une syncope de cause neurologique. L'interrogatoire des temoins ayant assiste a la syncope du malade n'est pas contributif pour ameliorer la performance de l'anamnese obtenue directement aupres du malade pour envisager la cause ou le mecanisme de sa syncope.

OBJECTIVES:To identify signs and symptoms to differentiate cardiac from neurological syncope in patients over 70 using a standardized questionnaire.DESIGN:Prospective cohort study.SETTING:Five short-stay units in a French university hospital.PARTICIPANTS:One hundred thirty-one in-patients with syncope aged 70 and older.MEASUREMENTS:Patients were interviewed about the signs and symptoms that had been present before, during or after syncope. When possible, a witness who had been present during syncope was also interviewed to compare theirs and the patients' answers. The sensitivity and specificity of 35 questions were calculated among 3 groups defined according to the cause of syncope: cardiac (n = 58), neurological (n = 31) and syncope of unknown origin (n = 42). Statistical analyses were performed to determine discriminating signs and symptoms among the causes and crude agreement was calculated for answers from patients and witnesses.RESULTS:Only 8 and 3 of 35 questions had a sensitivity of at least 0.5 for cardiac and neurological causes respectively. A feeling of impending syncope, thoracic oppression, recall of events preceding syncope and a history of arrhythmia were independently and significantly discriminant among groups. Recall of events preceding syncope (Odds Ratio (OR) = 7.5; 95% confidence interval (CI) = 2.2-25.3) and a personal history of arrhythmia (OR = 4.8; 95% CI = 1.6-14.2) were discriminant between cardiac and neurological causes suggesting mostly a cardiac cause. Agreement between patients and witnesses was only found for questions on the patient's medical history or the circumstances surrounding the onset of syncope.CONCLUSIONS:Recall of events preceding syncope and a history of arrhythmia are strongly suggestive of a cardiac rather than a neurological cause of syncope. Interviews of witnesses are not helpful in suggesting a cause for syncope.

Pneumonia amongst elderly people living in institutions is common and is a frequent cause of mortality and hospital admission. It is important to distinguish between prevention of viral pneumonia, which primarily consists of influenza vaccination programmes, and prevention of bacterial pneumonia. Prevention of influenza infection in institutions requires the vaccination of as many as possible of both residents and caregivers. In the event of a declared epidemic then amantadine can be used to reduce the severity of, and complication rate of, influenza infection. The indications for giving this therapy need to be balanced against potential side-effects, especially neurological ones. For the prevention of bacterial pneumonia risk factors such as immobility or impaired swallowing should be first identified and dealt with as necessary. Anti-pneumoncoccal vaccination may be considered, but on current evidence, the value of systematic vaccination of residents has not yet been established.

In clinical practice the will to find out the cause of normocytic anemia (NA) in elderly patients is preferentially based on individual physician's background rather than on objective data such as their hemoglobin level. However, it could be postulate that this clinical performance depends on this "cut off" of hemoglobin (more this value is decreased more it could be easy to find the cause of anemia). The aim of this study was to investigate the relationship between the number of cases with defined cause of NA (after a standardized procedure) and the level of hemoglobin.Methods.-In this prospective study 211 inpatients aged 70 years or more with NA disclosed on admission or during hospitalization have been selected. In 162 of them finally included, a standardized procedure with complementary explorations was performed.Results.-In 134 patients, the cause of NA was established amongst inflammatory diseases and chronic renal failure was the most frequently identified. In 20%, anemia was multifactorial. Despite investigations anemia remained unexplained in 17.3% of studied patients. For a decrease of at least 10% below the normal range of hemoglobin level, sensitivity of diagnosis was 70% and specificity 60%. Positive predictive value to make the diagnosis when hemoglobin level was below 20% from normal value was 100%.Conclusion.-The cause of NA in elderly patients after basic explorations may be assessed in up to 80% of cases. We found a significant relationship between the value of hemoglobin level and the number of anemia with confirmed diagnosis. More hemoglobin level is decreased better is clinical performance. (C) 2003 Elsevier SAS. Tous droits reserves.

Les pneumopathies du sujet âgé vivant en institution sont fréquentes, graves en terme de mortalité et à l’origine d’un recours fréquent à l’hospitalisation. Il faut distinguer la prévention des pneumopathies virales justifiant essentiellement de programmes de vaccination antigrippale de la prévention des pneumopathies bactériennes. La prévention des infections grippales doit se faire en vaccinant le plus largement possible les résidents mais aussi les personnels soignants. En cas d’épidémie déclarée, le recours à l’amantadine est efficace pour diminuer la gravité et les conséquences de l’infection. La posologie de ce médicament doit tenir compte de ses effets secondaires potentiels notamment neurologiques.

UNLABELLED:In clinical practice the will to find out the cause of normocytic anemia (NA) in elderly patients is preferentially based on individual physician's background rather than on objective data such as their hemoglobin level. However, it could be postulate that this clinical performance depends on this "cut off" of hemoglobin (more this value is decreased more it could be easy to find the cause of anemia). The aim of this study was to investigate the relationship between the number of cases with defined cause of NA (after a standardized procedure) and the level of hemoglobin.METHODS:In this prospective study 211 inpatients aged 70 years or more with NA disclosed on admission or during hospitalization have been selected. In 162 of them finally included, a standardized procedure with complementary explorations was performed.RESULTS:In 134 patients, the cause of NA was established amongst inflammatory diseases and chronic renal failure was the most frequently identified. In 20%, anemia was multifactorial. Despite investigations anemia remained unexplained in 17.3% of studied patients. For a decrease of at least 10% below the normal range of hemoglobin level, sensitivity of diagnosis was 70% and specificity 60%. Positive predictive value to make the diagnosis when hemoglobin level was below 20% from normal value was 100%.CONCLUSION:The cause of NA in elderly patients after basic explorations may be assessed in up to 80% of cases. We found a significant relationship between the value of hemoglobin level and the number of anemia with confirmed diagnosis. More hemoglobin level is decreased better is clinical performance.

Les macro-ASAT sont une cause reconnue d'élévation isolée et persistante des aspartate aminotransférases (ASAT). Il s'agit de complexes de haut poids moléculaire, associant ASAT et macromolécule, le plus souvent une immunoglobuline. Leur pathogénie est inconnue, et bien qu'elles apparaissent souvent de signification bénigne, leur association à de nombreuses maladies auto-immunes et hépatiques a été décrite.Nous rapportons le cas d'une patiente de 45 ans ayant présenté de façon concomitante une gammapathie monoclonale à IgA et une élévation des ASAT à plus de six fois la normale, isolée au bilan hépatique. En parallèle du diagnostic de myélome multiple, les analyses ont démontré la présence d'un complexe macro-ASAT contenant l'IgA monoclonale. L'évolution du taux d'ASAT a suivi celle du taux de l'immunoglobuline monoclonale lors du traitement du myélome, confirmant la responsabilité du complexe antigène-anticorps dans l'hyper-transaminasémie.Il s'agit du premier cas d'association aussi clairement définie entre macro-ASAT et immunoglobuline monoclonale.Macro-AST is recognized as a classical aetiology of isolated and persistent increase of serum aspartate aminotransferase (AST) levels. Macro-AST are high molecular weight complexes associating AST and a macromolecule, often an immunoglobulin. Although those macroenzymes of unknown pathogenesis are usually non-pathogenic, association with several diseases, including autoimmune diseases and liver diseases has been described.We report here the case of a 45-year-old patient with previously normal liver enzymes in whom an AST elevation and an IgA monoclonal gammopathy were discovered concomitantly. Following the diagnosis of multiple myeloma, we could evidence in the patient's serum a complex between AST and the monoclonal IgA. AST levels course followed closely the progression of monoclonal gammopathy.This is the first report demonstrating a clear link between macro-AST and a monoclonal gammopathy.

Les spondyloarthrites débutent principalement chez l’adulte jeune, cependant un début après 45 ou 50 ans n’est pas exceptionnel. La répartition du type de spondyloarthrite diffère chez le sujet âgé et notamment le rhumatisme psoriasique devient très prépondérant à cet âge. L’expression clinique des spondyloarthrites à début tardif est aussi variée que chez le sujet jeune. La difficulté diagnostique tient au plus grand nombre de diagnostics différentiels et à la difficulté d’interpréter l’imagerie des sacro-iliaques et du rachis à cet âge. Certaines présentations trompeuses sont particulières au début tardif comme le LOPS (late onset peripheral spondyloarthritis) qui se caractérise par une oligoarthrite peu inflammatoire contrastant avec des signes généraux, un important syndrome inflammatoire et parfois des œdèmes asymétriques des membres inférieurs. Le tableau peut aussi évoquer une pseudo polyarthrite rhizomélique mais la cortico résistance doit attirer l’attention. L’âge avancé n’est pas, en soi, un argument suffisant pour récuser le diagnostic de spondyloarthrite. La présence d’antécédents familiaux de spondyloarthrite et du phénotype HLA B27 constitue souvent des arguments essentiels pour le diagnostic.Spondyloarthritis are usually observed in young adults, however an onset after 45 or even 50 years of age are not exceptional. The distribution of the type of spondyloarthritis differs in older subjects and in particular psoriatic arthritis becomes very preponderant at theses ages. The clinical expression of late-onset spondyloarthritis is as varied as in young patients. The diagnostic difficulty lies in the greater number of differential diagnoses and the difficulty of interpreting sacroiliac and spine imaging at this age. Some misleading presentations are common in late-onset disease, such as LOPS (late onset peripheral spondyloarthritis) consisting of mild inflammatory oligoarthritis that contrasts with general signs, severe inflammatory syndrome, and sometimes asymmetrical edema on the legs. Late-onset spondyloarthritis may presenting as polymyalgia rheumatica-like syndrome, but corticosteroid resistance should attract attention. Advanced age is not, in itself, a sufficient argument to reject a diagnosis of spondyloarthritis. A family history of spondyloarthritis and phenotype HLA B27 often constitute essential indicators pointing towards this diagnosis.

Chassagne, Philippe MD1; Capet, Corinne MD1; Verdonck, Arnaud MD1; Bercoff, Eric MD1; Doucet, Jean MD1; Hellot, Marie-France MD2; Arnaud, Philippe3; Ducrotte, Philippe MD4; Denis, Philippe MD5 Author Information

objectives To control whether prescriptions of curative doses of heparin (non fractioned heparins, enoxaparin, tinzaparin) in the hospital complied with the official recommendations; to provide the physicians with information adapted to the recorded misuse and to evaluate the influence of this information.Methods A prospective study was conducted between May and October 1999 on the prescriptions of 20 residents from 6 services in 3 phases: phase P1 with initial evaluation (particularly on the indications for heparin, the molecule administered, initial dose and monitoring), phase P2 with analysis and diffusion of an adapted information and phase P3 with final evaluation.Results 111 inpatients were included in the phase PI (66,7% aged over 75 years, 18,9% with creatinin clearance below 30 ml/mn) and 101 Inpatients were included in the phase P3 (56,4% aged over 75 years, 10,8% with renal failure). During phase PI: among the prescriptions of low molecular weight heparin (LMWH) 54,3% did not comply with the official vecommendations; initial doses were too high in 15,3% of patents; mean initial doses of LMWH were not adapted to age, weight or creatinin clearance. Only 58,5% of patients had their platelets monitored. On the other hand, 15,3% of patients exhibited helparin side effects. During phase P3, the main modifications in prescriptions were a reduction in inappropriate indications for LMWH, reduction in LMWH prescriptions in patients aged over 75 or with excessive body weight or with renal failure, and increased platelet monitoring, but without significant difference. on the other hand, mean initial doses of each heparin were not modified. Heparin complications decreased but not significantly.Conclusion This study highlights a real context of heparin prescription at curative doses, often differing from clinical studies, particularly with regards toage, renal failure and comorbidity, prescriptions often unadapted to official-recommendations on indications, dose and monitoring; a real but limited influence of appropriate information for the physicians, which partially depends on the accuracy of official recommendations, particularly in patients with increased hemorrhagic risk. (C) 2002, Masson, Paris.

Objective: To ascertain preventable and non-preventable risk factors for adverse drug events (ADEs) in elderly inpatients at hospital admission.Patients and methods: This was a prospective study of 2814 inpatients over 70 years of age who were consecutively admitted from November 1997 to December 1999 to a 60-bed geriatric unit of a French university hospital, and the 500 consecutive ADEs that were present at admission. All drugs administered during the month preceding hospitalisation, signs or symptoms of ADEs, and risk factors related to the drug prescription or patient's diseases were considered: excess drug doses, potential drug-drug interactions (DDIs), interfering chronic disease and acute interfering disease.Results: 66.7% of the ADEs were associated with cardiovascular, metabolic, renal or neuropsychological symptoms. The drugs involved were mainly cardiovascular (43.7%) and psychotropic (31.2.%) drugs. One or more risk factors (mainly DDIs and/or interfering acute diseases) were recorded in 81.2% of ADEs. An interfering acute disorder (usually dehydration) was more frequent in ADEs resulting from drugs or drug combinations administered for 1 month or more (p < 0.05). 41.3% of risk factors were preventable (some DDIs, excess doses, interfering chronic diseases). One risk factor alone or the combination of all risk factors was preventable in 40.2% of ADEs.Conclusions: This study suggests that many ADEs in the elderly may be decreased by removing all the preventable risk factors before a drug is prescribed (mainly DDIs and excess doses) and by reinforcing drug monitoring when an interfering acute disease occurs.

Pneumonia amongst elderly people living in institutions is common and is a frequent cause of mortality and hospital admission. It is important to distinguish between prevention of viral pneumonia, which primarily consists of influenza vaccination programmes, and prevention of bacterial pneumonia. Prevention of influenza infection in institutions requires the vaccination of as many as possible of both residents and caregivers. In the event of a declared epidemic then amantadine can be used to reduce the severity of, and complication rate of, influenza infection. The indications for giving this therapy need to be balanced against potential side-effects, especially neurological ones. For the prevention of bacterial pneumonia risk factors such as immobility or impaired swallowing should be first identified and dealt with as necessary. Anti-pneumoncoccal vaccination may be considered, but on current evidence, the value of systematic vaccination of residents has not yet been established.