[Single-port surgery and adnexal procedures: which indications in oncological surgery?]

OBJECTIVE

To show the interest of single trocar in order to perform uni- or bilateral salpingo-oophorectomies.

PATIENTS AND METHODS

A descriptive study monocentric.

RESULTS

A total of 79 unilateral or bilateral salpingo-oophorectomies were performed by single-port laparoscopy between January 2010 and September 2012 at the Institut Paoli-Calmettes (Marseille). There are three surgical indications: diagnostic, therapeutic and prophylactic. The median age was 50 years (22-78 years). The median BMI was 22.4 kg/m(2) (17.5 to 37.7 kg/m(2)). The median blood loss was 0cc (0cc-50cc). The median hospital stay of patient was one day (0-6 days). The conversion rate in this study was 8.8%.

DISCUSSION AND CONCLUSION

The single-port laparoscopic approach to perform uni- or bilateral salpingo-oophorectomies is a natural evolution of the conventional laparoscopy. If the cosmetic role seems obvious, its therapeutic value compared to traditional technique must be demonstrated by prospective studies with larger numbers.

The effects of abrupt antipsychotic discontinuation in cognitively impaired older persons: a pilot study

BACKGROUND

Antipsychotic use for behavioural and psychological symptoms of dementia (BPSD) is controversial. Guidelines advise to reduce antipsychotics given the adverse effects and limited efficacy, to limit dose and treatment duration as well as to undertake discontinuation.

METHODS

A pilot study with 40 hospitalised geriatric cognitively impaired patients, in which the effects of abrupt antipsychotic discontinuation were investigated, using neuropsychiatric inventory (NPI) scores before and one month after discontinuation. Withdrawal symptoms were monitored thrice a day with a checklist during five consecutive days.

RESULTS

Participants (n = 40) had a mean age of 84 years (range 67-95) and 53% were male. The total mean baseline NPI score was 21 (SD 12) with predominantly behavioural rather than psychological disturbances. After abrupt discontinuation, mild withdrawal symptoms were observed in 72% of the patients, with frequencies of symptoms peaking on day 2 (53%) and day 3 (48%). After one month, 31 patients (85%) were still off antipsychotics and improved on the majority of NPI domains, with a total mean NPI score decreasing from 18 (SD 13) to 12 (SD 8, p = 0.003). In the relapse group, there was no deterioration associated with the abrupt discontinuation and subsequent resumption of therapy with a total mean NPI score decreasing from 31 (SD 12) at baseline to 27 (SD 8) at one-month follow-up (p = 0.345).

CONCLUSION

Abrupt antipsychotic discontinuation appears to be feasible in older individuals with BPSD. Systematically performed discontinuation efforts in clinical practice are needed to differentiate between patients where antipsychotics have no added value and patients where the benefits outweigh the risks.

Removal of selected pharmaceuticals from domestic wastewater in an activated sludge system followed by a horizontal subsurface flow bed - analysis of their respective contributions

Seventy-three commonly administered pharmaceuticals from twelve different therapeutic classes were investigated at a municipal wastewater treatment plant in northern Italy featuring a conventional activated sludge system (full-scale) and a polishing horizontal subsurface flow bed (pilot plant). Removal of these micro-pollutants by the two systems was assessed in order to evaluate their respective contributions. Mean concentrations and standard deviations were calculated and found to differ for the compounds detected, ranging from few ng/L to over 1,165 ng/L in the secondary effluent and from 11 to 533 in the polished effluent. Eighteen compounds were consistently below the detection limit and the remaining 55 compounds were found at a minimum of one sampling point. Average removal efficiencies of both treatment steps and in treatment train as a whole are evaluated and discussed, highlighting the difficulties in predicting the fate of pharmaceuticals in both an activated sludge system and a horizontal subsurface flow bed. Comparison between the observed average removal efficiencies and those reported in the literature was also carried out for the pharmaceuticals of interest, and the discrepancies that emerged are discussed. The investigated constructed wetland did show efficacy in removing some of these compounds, and it contributed to the overall removal efficiency of each therapeutic class. Indeed, evaluation of the specific mass loadings of each class of PhC detected in the raw wastewaters, secondary and polished effluent evidences that the investigated constructed wetland is able to further reduce the load of micropollutants, which could become a necessity, especially where the receiving water body is an effluent-dominant river and mitigation measures of the discharge impact are required to protect and safeguard the aquatic environment.

A pharmacist-conducted medication review in nursing home residents: impact on the appropriateness of prescribing

Medication use in nursing homes is often suboptimal. This study investigated the impact of a pharmacist-conducted medication review on the appropriateness of prescribing for Belgian nursing home residents. We conducted a 6-month controlled, non-randomized study in two nursing homes (one intervention and one control nursing home). Sixty-nine residents completed the study in the intervention group (92 residents were included). For the control group, that were 79 residents (100 residents were included). Primary outcome was the appropriateness of prescribing, assessed by a set of validated quality indicators. At baseline, this study detected three main problems associated with the appropriateness of medication use: (i) the Medication Appropriateness Index (MAI) could be improved (continuation of no longer indicated medication was the most common problem), (ii) potential overuse was present in about half of the group, and (iii) potential underuse was present in about 30% of the sample. Despite this, our pharmacist-conducted medication review only modestly improved the appropriateness of prescribing. This may be attributed to the low implementation rate of the pharmacist recommendations.

Prevalence of orthostatic hypotension and relationship with drug use amongst older patients

INTRODUCTION

Orthostatic hypotension (OH) is said to be highly prevalent in older people. Drugs are often involved as causative factor. Nevertheless, few data are available about the prevalence of OH and its relationship with drugs in olders.

OBJECTIVES

To review data about (i) the prevalence and characteristics of OH in older patients; and (ii) the relationship between OH and drugs.

METHODS

Review of publications from Ovid (PubMed) from 1980 to May 2011 using the following key words: "orthostatic hypotension" combined with "elderly" or equivalent for the analysis of prevalence (first search) and "orthostatic hypotension" combined with "drugs" or equivalent to assess the relationship between OH and drugs (second search).

RESULTS

Fifty-one publications (of which 14 with original data) were retrieved from the prevalence search, 31 for the second search (8 with original data: 7 retrospective studies and 1 prospective cohort study) and 12 reviews or experts opinions. Prevalence of OH varies according to the characteristics of the subjects, the settings of the studies, and the procedures of blood pressure measurement. In acute geriatrics units, two studies reported a prevalence of over 30% and one study mentioned that 68% of the patients presented with at least one episode during the day. OH was associated with several geriatric problems: gait disorders, balance disorders, falls, cerebral hypoperfusion, transient ischemic attacks, cognitive impairment, acute myocardial infarct and systolic hypertension. OH can also be asymptomatic or with atypical presentation: falls, gait disorders and confusion. Psychotropic agents (antipsychotics, sedatives, antidepressants), and cardiovascular drugs (antihypertensive agents, vasodilators, diuretics) were associated with OH.

DISCUSSION

If the hypothesis of causality between drug treatment and OH is confirmed, the identification of the involved drugs could be of value for the prevention of OH and its complications. In this context, the Working Group Pharmacology Pharmacotherapy and Pharmaceutical Care of the Belgian Society of Gerontology and Geriatrics proposes to conduct a multicentre study to assess the prevalence of OH in Belgian acute geriatrics units and its relationship with drugs.

Clinical value of immunoscintigraphy in the rectal carcinomas: immunoscintigraphy of rectal carcinomas

BACKGROUND/AIM

The aim of this study was to evaluate the clinical reliability of the immunoscintigraphy with radiolabeled monoclonal antibodies for the detection of metastases and recurrences of rectal carcinomas.

METHODOLOGY

A total of 65 patients underwent immunoscintigraphy with radiolabeled monoclonal antibodies. Indication for that examination was suspicious rectal cancer or suspicious rectal cancer recurrence and/or metastases.

RESULTS

The method proved to have 92.7% sensitivity, specificity 83.3%, positive predictive value 90.5%, negative predictive value 87.0% and accuracy 89.2%. There was a statistically significant relationship between immunoscintigraphy findings and rectoscopy findings (rs=0.415, p=0.013), as well as significant relationship between immunoscintigraphy findings and US findings (rs=0.332, p=0.001). Tumor marker levels were in positive correlation with findings of immunoscintigraphy (rs=0.845, p=0.001), especially raised CEA level (rs=0.816, p=0.004). Patients with higher CA19-9 level had higher Duke's stage (p=0.025).

CONCLUSIONS

We can conclude that immunoscintigraphy can be helpful in the detection of metastases and recurrences of colon carcinomas.

Clinical outcome of early glottic carcinoma in Serbia

OBJECTIVE

Proposed methods for treating early glottic carcinoma are cordectomy through laryngofissure, laser cordectomy, and radiotherapy. The aim of the study was to conduct comprehensive study to evaluate oncological and functional results of different treatment modalities for Tis and T1 glottic carcinoma, identify prognostic factors for the outcome of treatment and decide where we stand in applying worldwide standards of early glottic carcinoma treatment.

METHODS

Prospective study was conducted on 221 patients treated with Tis and T1 glottic carcinoma from 1998 to 2003 (72 patients were treated endoscopically with CO2 laser, 75 patients with cordectomy through laryngofissure and 74 with radiotherapy), with follow-up period from 38 to 107 months. Important demographic and clinical variables were analyzed. Voice quality after the treatment was assessed using multidimensional voice analysis.

RESULTS

Comparing oncological results of three modalities of treatment, there were no significant differences. Functional results of treatment were better after laser cordectomy and primary radiotherapy than following the open cordectomy. Five-year survival rate was almost identical in all three groups of patients, and important prognostic factors for survival were age and histological grade of the tumor.

CONCLUSION

Considering that the choice of treatment in our country is also greatly influenced by other paramedical factors, such as distance from treatment facility, reliability of follow-up, significant time delay of radiotherapy because of small number of radiology centers and strong patients' surgeon and treatment preference, we consider endoscopic laser surgery highly efficient and preferred choice of treatment for early glottic carcinoma.

Drug interactions and adverse drug reactions in the older patients admitted to the emergency department

PURPOSE

The aim of this study was to prospectively evaluate drug interactions and adverse drug reactions (ADRs) in the older patients admitted to the emergency department (ED) and to characterize risk factors.

METHODS

In 80 patients aged 65 years and older medication history and ED drug administration were analysed. Medical records were analysed for ADRs by an expert panel which also evaluated their avoidability and causality. An interaction program was used to search for potential drug interactions followed by assessment for clinical significance. Data were analysed using a logistic regression model. The significance level was set at alpha=0.05.

RESULTS

Eighty seven ADRs were identified in 37 patients; 18 were the result of an interaction (15 patients). Causality was assessed as definite (n=11), probable (n=62) and possible (n=24). The reason for admission was definitely and probably related to an ADR in 6 and 18 patients respectively. Only 17 (20%) of the ADRs were assessed as unavoidable, while 23 (26%) and 47 (54%) were classified as definitely and possibly avoidable, respectively. ADRs were related with female gender (p=0.023) and number of drugs (p=0.004), but not with high age (p=0.151). Clinically relevant interactions were related with older age (p=0.032) and number of drugs (p=0.003), but not with gender (p=0.380). None of the interactions with ED initiated medications were considered unjustified.

CONCLUSIONS

ADRs frequently occur in the older patients admitted to the ED and are an important cause of hospital admissions with a substantial contribution of adverse drug interactions.

Promoting access to innovation for frail old persons. IAGG (International Association of Gerontology and Geriatrics), WHO (World Health Organization) and SFGG (Société Française de Gériatrie et de Gérontologie) Workshop--Athens January 20-21, 2012

Frailty tends to be considered as a major risk for adverse outcomes in older persons, but some important aspects remain matter of debate.

OBJECTIVES

The purpose of this paper is to present expert's positions on the main aspects of the frailty syndrome in the older persons.

PARTICIPANTS

Workshop organized by International Association of Gerontology and Geriatrics (IAGG), World Health Organization (WHO) and Société Française de Gériatrie et de Gérontologie (SFGG).

RESULTS

Frailty is widely recognized as an important risk factor for adverse health outcomes in older persons. This can be of particular value in evaluating non-disabled older persons with chronic diseases but today no operational definition has been established. Nutritional status, mobility, activity, strength, endurance, cognition, and mood have been proposed as markers of frailty. Another approach calculates a multidimensional score ranging from "very fit" to "severely frail", but it is difficult to apply into the medical practice. Frailty appears to be secondary to multiple conditions using multiple pathways leading to a vulnerability to a stressor. Biological (inflammation, loss of hormones), clinical (sarcopenia, osteoporosis etc.), as well as social factors (isolation, financial situation) are involved in the vulnerability process. In clinical practice, detection of frailty is of major interest in oncology because of the high prevalence of cancer in older persons and the bad tolerance of the drug therapies. Presence of frailty should also be taken into account in the definition of the cardiovascular risks in the older population. The experts of the workshop have listed the points reached an agreement and those must to be a priority for improving understanding and use of frailty syndrome in practice.

CONCLUSION

Frailty in older adults is a syndrome corresponding to a vulnerability to a stressor. Diagnostic tools have been developed but none can integrate at the same time the large spectrum of factors and the simplicity asked by the clinical practice. An agreement with an international common definition is necessary to develop screening and to reduce the morbidity in older persons.

The advanced activities of daily living: a tool allowing the evaluation of subtle functional decline in mild cognitive impairment

OBJECTIVES

Assessment of advanced activities of daily living (a-ADL) can be of interest in establishing the diagnosis of Alzheimer's disease (AD) in an earlier stage, since these activities demand high cognitive functioning and are more responsive to subtle changes. In this study we tested a new a-ADL tool, developed according to the International Classification of Functioning, Disability and Health (ICF). The a-ADL tool is based on the total number of activities performed (TNA) by a person and takes each subject as his own reference. It distinguishes a total disability index (a-ADL-DI), a cognitive disability index (a-ADL-CDI), and a physical disability index (a-ADL-PDI), with lower score representing more independency. We explored whether these indices allow distinction between cognitively healthy persons, patients with Mild Cognitive Impairment (MCI) and patients with mild AD.

METHODS

Participants were on average 80 years old (SD 4.6; 66-90), were community dwelling, and were diagnosed as (1) cognitively healthy subjects (n=26); (2) patients with MCI (n = 17), or (3) mild AD (n = 25), based upon extensive clinical evaluation and a set of global, cognitive, mood and functional assessments. The a-ADL-tool was not part of the clinical evaluation.

RESULTS

The a-ADL-CDI was significantly different between the three groups (p<.01). The a-ADL-DI was significantly different between MCI and AD (p<.001). The tool had good psychometrical properties (inter-rater reliability; agreement between patient and proxy; correlations with cognitive tests). Although the sample size was relatively small, ROC curves were computed for the a-ADL-DI and a-ADL-CDI with satisfactory and promising results.

CONCLUSION

The a-ADL-CDI and a-ADL-DI might offer a useful contribution to the identification and follow up of patients with mild cognitive disorders in an older population.

Prioritization of chemicals in the aquatic environment based on risk assessment: analytical, modeling and regulatory perspective

The extensive and intensive use of chemicals in our developed, highly technological society includes more than 100,000 chemical substances. Significant scientific evidence has lead to the recognition that their improper use and release may result in undesirable and harmful side-effects on both the human and ecosystem health. To cope with them, appropriate risk assessment processes and related prioritization schemes have been developed in order to provide the necessary scientific support for regulatory procedures. In the present paper, two of the elements that constitute the core of risk assessment, namely occurrence and hazard effects, have been discussed. Recent advances in analytical chemistry (sample pre-treatment and instrumental equipment, etc.) have allowed for more comprehensive monitoring of environmental pollution reaching limits of detection up to sub ng L(-1). Alternative to analytical measurements, occurrence models can provide risk managers with a very interesting approach for estimating environmental concentrations from real or hypothetical scenarios. The most representative prioritization schemes used for issuing lists of concerning chemicals have also been examined and put in the context of existing environmental policies for protection strategies and regulations. Finally, new challenges in the field of risk-assessment have been outlined, including those posed by new materials (i.e., nanomaterials), transformation products, multi-chemical exposure, or extension of the risk assessment process to the whole ecosystem.