[Management of congestive heart failure in the elderly after hospitalization for acute decompensation Interest of a dedicated territorial geriatric network ; the GERICCO-78 study]

AIMS

Heart failure (HF) is the leading cause of hospitalisation in the elderly in France. Early rehospitalisations are common, often through an emergency department. The aim of this study was to assess the impact of a primary care-hospital coordination network, with interventions by coordination nurses (IDEC), on the rehospitalisations after a first hospitalisation for acute decompensation in frail elderly HF patients.

METHODS

From 01/10/2019 to 01/10/2021, 237 patients aged > 75 years with frailty criteria, hospitalised in 8 departments of 5 private or public hospitals in the Yvelines Sud health territory were followed by an IDEC (hospital visit, telephone contacts, home visit(s)) within 3 months of their return home. This prospective observational study analysed the rate of consultations to the emergency room, rehospitalisations (total and for acute HF), and the number of events avoided at 90 days after discharge.

RESULTS

The mean age of the patients was 87 years, 54% were women, 68% had a left ventricular ejection fraction > 40%, and 70% had atrial fibrillation. Non-cardiac comorbidities were very frequent. At 3-month follow-up, mortality was 9.3% (22/237), only 27 patients (11.3%) consulted the emergency room for acute HF, and the rehospitalisation rate for HF was 19.8%, without difference according to left ventricular ejection fraction. A consultation to the emergency room or a rehospitalisation for heart failure could be avoided for 10% of patients.

CONCLUSION

This study suggests that a primary care-hospital coordination network with dedicated coordination nurses is useful for the management of very elderly frail patients following hospitalisation for heart failure, limiting visits to the emergency room and rehospitalisations.

Topotecan preceded by oxaliplatin using a 3 week schedule: a phase I study in advanced cancer patients

Combinations of topoisomerase I (topo I) poisons and platinum derivatives have synergistic antitumoral effects. However, their clinical development is limited by supra-additive haematological toxicity. The aim of this study was to determine whether sustained doses of topotecan and oxaliplatin could be achieved using a synergistic sequence. 34 advanced cancer patients and 186 cycles were evaluable for toxicity over five dosing levels. Oxaliplatin at 85-110 mg/m(2) was given on day 1, followed by topotecan 0.5-1.25 mg/m(2)/day x 5 from day 1 to 5, every 3 weeks. Plasma pharmacokinetics (PK) of total and ultrafiltrable platinum, total and lactone forms of topotecan were determined in the first cycle. The dose-limiting toxicity (DT) was identified as grade 4 thrombocytopenia. The occurrence of grade 4 thrombocytopenia did not correlate with topotecan PK, but it did with the patient's characteristics. Severe thrombocytopenia was seen in 1/8 of patients without clinical or biological evidence of malnutrition, with a creatinine clearance higher than 1 ml/s, and no more than two previous chemotherapy regimens, while it was seen in 8/10 patients with one of these characteristics (P<0.004). In conclusion, the recommended doses of oxaliplatin 110 mg/m(2) and topotecan 1 mg/m(2)/day, every 3 weeks can be administered to patients with a favourable general status and pretreatment characteristics and a phase II study is worthwhile in ovarian cancer patients.

Decreased topotecan platelet toxicity with successive topotecan treatment cycles in advanced ovarian cancer patients

The dose-limiting toxicities of the DNA topoisomerase I inhibitor topotecan are hematological. We prospectively analyzed the platelet toxicity pattern in patients receiving topotecan to optimize the clinical management of topotecan hematotoxicity. Twenty-one advanced ovarian cancer patients, all pretreated with cisplatin and paclitaxel, were treated with 1.25 mg/m2/day topotecan as a 30 min infusion for 5 days, every 3 weeks. No prophylactic granulocyte colony stimulating factor (G-CSF) was given. No topotecan dose reduction was planned according to hematologic toxicity. One hundred and thirty-three topotecan courses were administered (median per patient 6; range: 1-15). Despite no dose reduction, the mean platelet nadir values were significantly less pronounced at cycle 2 than at cycle 1 (82 versus 46 x 10(3)/mm3, p=0.0007). Similar differences were found between cycle 1 and any following cycle. The percent of patients experiencing grade 4 thrombocytopenia decreased from 43% at the first cycle, to 15 and 19% at the second and third courses, respectively (p=0.058). We conclude that the currently recommended topotecan schedule is feasible in heavily pretreated ovarian cancer patients without prophylactic G-CSF. The severity of topotecan-induced thrombocytopenia is maximal at the first cycle but significantly decreases from the second cycle in the absence of dose reduction.

Repeated administration of the 5-HT3 receptor antagonist granisetron reduces the incidence of delayed cisplatin-induced emesis in the piglet

We analyzed the effects of the 5-HT3 receptor antagonist granisetron on both acute and delayed phases of cisplatin-induced emesis in the conscious piglet. Animals that received a high dose of cisplatin (5.5 mg/kg i.v.) were observed continuously for 60 h. Seventeen piglets were treated with cisplatin only and acted as controls. In experimental animals, granisetron (administered before cisplatin) was administered either as a single initial injection (7 mg/kg), alone or in combination with dexamethasone (40 mg), or as multiple injections (1 mg/kg) given every 5 h during the first 30 h of the experiment (cumulative dose: 7 mg/kg). Two other groups of piglets were treated with dexamethasone (40 mg) alone or with multiple injections of ondansetron (7 injections at 3.5 mg/kg), respectively. The latency to the first emetic episode was significantly increased in all groups that received a 5-HT3 receptor antagonist, whatever the agent and the protocol of administration. Piglets treated solely with dexamethasone exhibited a latency similar to that of controls. The total number of emetic events during the 60 h was significantly reduced only in the group of piglets treated repeatedly with granisetron and in the group that received an initial dose (7 mg/kg) of granisetron in combination with dexamethasone. We observed that 3 out of 8 piglets treated repeatedly with granisetron did not vomit throughout the experiment. These results demonstrate that granisetron, when administered repeatedly, is efficacious against delayed emesis. They also suggest that serotonin may be involved in the production of the delayed phase of cisplatin-induced emesis.

The piglet as a suitable animal model for studying the delayed phase of cisplatin-induced emesis

In 46 weaned piglets we surgically implanted a cannula in the jugular vein and electrodes for ECG and EMG recordings. After a 4- to 5-day recovery, piglets were hydrated, then dosed with cisplatin (5.5 mg/kg i.v.) and recorded continuously for the next 60 h. Thirteen piglets (i.e., controls) received only cisplatin. Twenty-three other piglets received, 15 min before cisplatin, an i.v. injection of granisetron (0.25, 0.5, 2 or 7 mg/kg) or ondansetron (0.5, 2 or 7 mg/kg). Ten other piglets received, in addition to cisplatin, multiple injections of granisetron (1 mg/kg) and ondansetron (3.5 mg/kg). All control piglets exhibited both acute and delayed emesis. The first vomiting occurred with a latency of 2.13 +/- 0.82 hr after cisplatin administration; emetic intensity reached a peak (5 vomits/hr) within 2 hr and then decreased rapidly. No vomiting was observed between the 16th and 18th hr. The mean number of vomits during the first 16th was 18.4 +/- 2. Delayed emesis started at the 18th hr and lasted until the 58th hr. The mean number of vomits during the whole of the delayed phase was 9.6 +/- 2.4; the highest emetic intensity (1.2 vomit/hr) occurred between the 21th and the 22th hr. Pretreatment with a 5-HT3 receptor antagonist increased significantly the latency of the first emetic event in a dose-dependent manner. However, the severity of the acute phase was reduced significantly only with granisetron at the dose of 7 mg/kg, although the severity of the delayed phase remained unchanged, irrespective of the dose of granisetron. Three about five piglets treated repeatedly with granisetron did not vomit throughout the chemotherapy course. In contrast, no complete control was observed with repetitive injections of ondansetron. Cisplatin inducing both acute and delayed vomiting in the piglet without any lethality; this animal is a suitable model in which to study the pathogenesis of delayed emesis.

Antiemetic treatment with oral granisetron in patients receiving moderately emetogenic chemotherapy: a dose-ranging study

The antiemetic efficacy and tolerability of four different oral doses of granisetron (0.25, 0.5, 1, and 2 mg twice daily [BID]) were compared in a randomized, double-blind, parallel-group, multicenter study involving 930 patients with malignant disease receiving moderately emetogenic chemotherapy over a 7- or 14-day period. On the first day of granisetron treatment, a statistically significant association between complete response and dose was seen (P = 0.001), with the maximum response (81.1%) achieved at a dose of 1 mg BID. The 24-hour complete response rate with granisetron 1 mg BID was significantly higher than with 0.25 mg BID (61.1%) or 0.5 mg BID (70.2%) (P < 0.009). The complete response rate for days 0 to 6 was significantly higher with granisetron at 1 mg BID (58.8%) than with 0.25 mg BID (43.7%) or 0.5 mg BID (53.6%) (P < 0.009). No advantage in terms of complete response rate was shown for 2 mg BID over 1 mg BID. Granisetron was well tolerated, and few patients required additional treatment with other antiemetics.

Evaluation of the bioequivalence of tablet and capsule formulations of granisetron in patients undergoing cytotoxic chemotherapy for malignant disease

Granisetron is a novel, highly specific 5-hydroxytryptamine receptor antagonist given prophylactically to patients undergoing chemotherapy. An open, randomized, crossover trial was performed with 37 patients (24 females and 13 males) undergoing cytotoxic chemotherapy for malignant disease to compare an oral tablet (1-mg tablet given twice daily) with a clinical-trial capsule (1-mg capsule given twice daily). Complete pharmacokinetic data were determined for 24 patients (14 females and 10 males). The concentration of granisetron in plasma was measured by HPLC; the limit of quantitation was 0.2 ng/mL. The bioavailability evaluation was based mainly on the area under the curve (AUC) (mean values: 52.1 ng.h/mL for the capsule and 54.2 ng.h/mL for the tablet) and the maximum concentration (Cmax) (mean values: 7.42 ng/mL for the capsule and 8.18 ng/mL for the tablet) measured at the steady state after 7 days of continuous therapy. Wide interpatient variability in plasma granisetron levels after oral administration was observed. The 90% standard confidence interval for the geometric mean ratio overlapped the critical range, 0.8-1.25. Point estimates for AUC and Cmax based on two one-sided t tests and log-transformed data showed that the upper limit of the confidence interval was not within 20% of the mean for the capsule; the corresponding power analysis values for AUC and Cmax were 0.89 and 0.81, respectively. Despite bioequivalence not being proven, any differences that exist between the two formulations are likely to be small. There was no difference in efficacy or safety between the two formulations assessed.

The isochromosome 18p syndrome: confirmation of cytogenetic diagnosis in nine cases by in situ hybridization

Nine cases are described of tetrasomy 18p resulting from the presence of an isochromosome 18p [i(18p)]. The initial diagnosis of i(18p) was by standard cytogenetic techniques and was confirmed by in situ hybridization with a biotinylated alphoid probe (L1.84) specific for the pericentric region of chromosome 18 and with a tritium-labeled chromosome 18 probe (B74) which hybridizes to the D18S3 locus situated at 18p11.3. The clinical features of the cases are summarized and shown to constitute a distinct and recognizable syndrome. Common features were low birth weight, a characteristic facies, neonatal hypotonia with subsequent limb spasticity, short stature, microcephaly, mental retardation, and seizure disorders. On the basis of size and cytogenetic banding a marker chromosome can be suspected to be an i(18p). In situ hybridization with the alphoid probe L1.84 provides confirmation of chromosome 18 origin. This more precise diagnosis will be an advantage in situations of pre- and postnatal diagnosis, since parents can be provided with a more confident prognosis for their child.

Isochromosome 17q in two cases of acute blast transformation in myeloproliferative disorders

Two cases of acute blast cell transformation in myeloproliferative disorders associated with a dicentric 17q isochromosome are reported. In both cases, the karyotypes also included a Philadelphia 9q;22q translocation, and in one case, an additional chromosome 8 (trisomy 8).

Ring chromosome 4

A mentally and physically retarded boy with a 46,XY,ring (4) (p16q35) chromosome complement is described. Chromosome banding showed that the amount of chromosome material deleted from the ring chromosome 4 was minimal, apparently no more than the telomeres. Chromosomal aberrations appear to be restricted to the production of double-sized dicentric rings, and aneuploidy. The mosiacism resulting from the behavioural peculiarities of ring chromosomes is described as dynamic mosaicism. It is suggested that the clinical features associated with this ring chromosome are more likely to be the result of the effects of a diploid/monosomy 4/polysomy 4 mosaicism than to the deficiency of the telomeric regions of the chromosome.