Does Spinal Surgery in Elderly Patients (Over 80 Years-Old) Lead to More Early Post-Operative Complications Than Lower Limb Prosthetic Surgery?

Purpose: Patients and surgeons may be reluctant on spinal surgery over 80 years old, fearing medical complications despite the possible improvement on quality of life. However, fewer reservations for lower limb prosthetic surgery (LLPS) seem to be arisen in this population. Is spinal surgery after 80 years-old responsible of more complications than lower limb surgery? Methods: The consecutive files of 164 patients over 80 years that had spinal surgery or LLPS were analyzed. The data collected pre-operatively were demographic, clinical and post-operatively the number and types of medical complications and length of stay. Results: The mean number of medical complications was 1.11 ± 0.6 [0-6] for spinal surgery and 1.09 ± 1.0 [0-3] for LLPS, (p = 0,87). The length of stay in orthopedic unit was comparable between the two groups: 10.7 ± 4.9 days [2-36] for SS and 10.7 ± 3.0 days [5-11] for LLPS (p = 0,96). Conclusion: The global rate of peri-operative complications and the length of hospital stay were similar between spinal surgery and lower limb prosthetic surgery. These results may be explained by the rising cooperation between geriatric specialist and surgeons and the development of mini-invasive surgical technics, diminishing the early post-operative complication rates.

Association between Vitamin D Deficiency and Prognosis after Hip Fracture Surgery in Older Patients in a Dedicated Orthogeriatric Care Pathway

OBJECTIVES

Vitamin D deficiency is common in patients undergoing hip fracture surgery (HFS) and has been found to be associated with poor post-operative outcome in other settings. This study aimed to analyze the association between vitamin D status and prognosis after HFS.

DESIGN

Observational, prospective, single-center study.

SETTING AND PARTICIPANTS

All patients admitted in a peri-operative geriatric unit between 2009 and 2020 for HFS were included.

MEASUREMENTS

A moderate vitamin D deficiency was defined by a vitamin D level between 25 and 75 nmol/l and a severe deficiency by a vitamin D level <25 nmol/l. Primary endpoint was mortality 6 months after surgery. Secondary endpoints were bacterial infections and delirium during hospitalization. Odds ratio (OR) and 95% confidence interval (95%CI) were computed using logistic regression models with adjustment for confounders.

RESULTS

1197 patients were included (median age 87 years, IQR [82-91]). Median vitamin D level was 55 nmol/l (IQR [30-75 nmol/l]). Moderate and severe vitamin D deficiencies were reported in 53% and 21% of patients, respectively. There was no significant association between moderate or severe vitamin D deficiencies and 6-month mortality (OR 0.91, 95%CI [0.59-1.39], and OR 1.31, 95%CI [0.77-2.22], respectively), bacterial infection (OR 0.89, 95%CI [0.60-1.31] and OR 1.55, 95%CI [0.99-2.41], respectively), nor delirium (OR 1.03, 95%CI [0.75-1.40], and OR 1.05, 95%CI [0.70-1.57], respectively).

CONCLUSION

Vitamin D deficiency was not associated with mortality, bacterial infection or delirium after HFS. Our results suggest that comorbidities, functional status and post-operative complications are the main determinants of post-operative outcome after HFS.

Lack of Association Between Perioperative Medication and Postoperative Delirium in Hip Fracture Patients in an Orthogeriatric Care Pathway

OBJECTIVES

Units for perioperative geriatric care are playing a growing role in the care of older patients after hip fracture surgery. Postoperative delirium is one of the most common complications after hip fracture, but no study has assessed the impact of therapeutics received during a dedicated orthogeriatric care pathway on its incidence. Our main objective was to assess the association between drugs used in emergency, operating, and recovery departments and postoperative delirium during the acute stay.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

All patients ≥70 years old admitted for hip fracture to the emergency department and hospitalized in our unit for perioperative geriatric care after hip fracture surgery under general anesthesia between July 2009 and December 2019 in an academic hospital in Paris.

METHODS

Demographic, clinical, and biological data and all medications administered pre-, peri-, and postoperatively were prospectively collected by 3 geriatricians. Postoperative delirium in the unit for perioperative geriatric care was assessed by using the confusion assessment method scale. Logistic regression analysis was used to assess variables independently associated with postoperative delirium.

RESULTS

A total of 490 patients were included [mean (SD) age 87 (6) years]; 215 (44%) had postoperative delirium. The occurrence was not associated with therapeutics administered during the dedicated orthogeriatric care pathway. Probability of postoperative delirium was associated with advanced age [>90 years, odds ratio (OR) 2.03, 95% confidence interval (CI) 1.07-3.89], dementia (OR 3.51, 95% CI 2.14--5.82), depression (OR 1.85, 95% CI 1.14-3.01), and preoperative use of beta-blockers (OR 1.75, 95% CI 1.10-2.79).

CONCLUSIONS AND IMPLICATIONS

No emergency or anesthetic drugs were significantly associated with postoperative delirium. Further studies are needed to demonstrate a possible causal link between preoperative use of beta-blockers and postoperative delirium.

[A pragmatic approach to iatrogenic risk in the emergency room]

The links between the emergency department (ED) and drug-related harm are close. In practice, it is necessary to ask systematically if an iatrogenic accident is possible and to evaluate a new prescription carefully so as not to create iatrogenia during the visit to the emergency department. Any situation in which a nurse takes charge of an emergency room must be subject to precautions. Simple measures should be put in place during any hospitalisation of an elderly person.

Procalcitonin and C-Reactive Protein for Bacterial Infection Diagnosis in Elderly Patients After Traumatic Orthopedic Surgery

BACKGROUND

Biomarkers prove valuable for diagnosing postoperative bacterial infection, but data in elderly patients are scarce. Here we analyze how procalcitonin and C-reactive protein (CRP) perform for bacterial infection diagnosis after traumatic orthopedic surgery in elderly patients.

METHODS

We included all patients admitted to our perioperative geriatrics unit after traumatic orthopedic surgery. Patients on antibiotics, presenting preoperative bacterial infection, or without procalcitonin measurement were excluded. Clinical and biological data were collected prospectively. Medical charts were reviewed by three experts blinded to biomarker results to assess bacterial infection diagnosis. Areas under the curve and 90%-specificity thresholds were analyzed for baseline procalcitonin and CRP levels and relative variations.

RESULTS

Analysis included 229 patients (median age 86 years, hip fracture 83%), of which 40 had bacterial infection (pneumonia [n = 23], urinary tract infection [n = 8]; median delay to onset: 2 days post-admission). For bacterial infection diagnosis, the computed areas under the curve were not significantly different (procalcitonin-baseline 0.64 [95% confidence interval: 0.57-0.70]; procalcitonin-relative variation 0.65 [0.59-0.71]; CRP-baseline 0.68 [0.61-0.74]; CRP-relative variation 0.70 [0.64-0.76]). The 90%-specificity thresholds were 0.75 µg/L for procalcitonin-baseline, +62% for procalcitonin-variation, 222 mg/L for CRP-baseline, +111% for CRP-variation.

CONCLUSIONS

Diagnostic performances of procalcitonin and CRP were not significantly different. Baseline levels and relative variations of these biomarkers showed little diagnostic value after traumatic orthopedic surgery in elderly patients.

Fecal impaction is associated with postoperative urinary retention after hip fracture surgery

BACKGROUND

Postoperative urinary retention (POUR) is a common hip fracture (HF) complication. Although fecal impaction (FI) is one of the oft-cited causes of POUR in clinical practice, evidence regarding this association is scarce.

OBJECTIVE

The aim of this study was to determine whether FI was associated with POUR after HF surgery in older patients.

METHODS

All patients consecutively admitted after a HF surgery in a geriatric perioperative unit were included in this cross-sectional study. FI was systematically assessed by a digital rectal exam at admission and according to clinical suspicion during the hospital stay. The dependent variable was POUR, systematically screened according to the department protocol and defined as a bladder volume > 400 ml requiring catheterization. The association between FI and POUR was assessed by multivariable analysis.

RESULTS

A total of 256 patients were included (mean [SD] age 86 [6] years), 76% women): 108 (42%) presented FI and 63 (25%) POUR. The frequency of FI was higher with than without POUR (73% vs 32%, P<0.001). On multivariable analysis, after adjusting for age, sex, Cumulative Illness Rating Scale score and anticholinergic load, FI was the only factor independently associated with POUR (odds ratio 4.78 [95% confidence interval 2.44-9.71], P<0.001.

CONCLUSIONS

FI was the only independent factor associated with POUR after HF surgery in older adults. Further studies are needed to optimize perioperative geriatric care including FI and POUR assessment and management.

Hip Fracture Leads to Transitory Immune Imprint in Older Patients

Background: Hip fracture (HF) is common in the geriatric population and is associated with a poor vital and functional prognosis which could be impacted by immunological changes. The objective here is to decipher immune changes occurring in the 1st days following HF and determine how phenotype, function, and regulation of innate and adaptive compartments adapt during acute stress event.

Methods: We included HF patients, aged over 75 years. For each patient, blood samples were taken at five different timepoints: four in the perioperative period (day 0 to hospital discharge) and one at long term (6–12 months). Phenotypical and functional analysis were performed longitudinally on fresh blood or cryopreserved PBMCs. Clinical data were prospectively collected.

Results: One-hundred HF patients and 60 age-matched controls were included. Innate compartment exhibits pro-inflammatory phenotypes (hyperleukocytosis, increase of CD14+ CD16+ proportion and CCR2 expression), maintaining its ability to produce pro-inflammatory cytokines. Adaptive compartment extends toward a transitory immunosuppressive profile (leucopenia) associated with an active T-cell proliferation. Furthermore, increases of LAG-3 and PD-1 and a decrease of 2-B4 expression are observed on T-cells, reinforcing their transitory suppressive status. Of note, these immune changes are transitory and sequential but may participate to a regulation loop necessary for homeostatic immune control at long term.

Conclusion: HF is associated with several transitory immunological changes including pro-inflammatory phenotype in innate compartment and immunosuppressive profile in adaptive compartment. A comprehensive assessment of immune mechanisms implicated in the patient's prognosis after HF could pave the way to develop new immune therapeutics strategies.

Hydroxychloroquine levels in patients with systemic lupus erythematosus: whole blood is preferable but serum levels also detect non-adherence

Background

Hydroxychloroquine (HCQ) levels can be measured in both serum and whole blood. No cut-off point for non-adherence has been established in serum nor have these methods ever been compared. The aims of this study were to compare these two approaches and determine if serum HCQ cut-off points can be established to identify non-adherent patients.

Methods

HCQ levels were measured in serum and whole blood from 573 patients with systemic lupus erythematosus (SLE). The risk factors for active SLE (SLEDAI score > 4) were identified by multiple logistic regression. Serum HCQ levels were measured in 68 additional patients known to be non-adherent, i.e. with whole-blood HCQ < 200 ng/mL.

Results

The mean (± SD) HCQ levels were 469 ± 223 ng/mL in serum and 916 ± 449 ng/mL in whole blood. The mean ratio of serum/whole-blood HCQ levels was 0.53 ± 0.15. In the multivariate analysis, low whole-blood HCQ levels (P = 0.023), but not serum HCQ levels, were independently associated with active SLE.

From the mean serum/whole-blood level ratio, a serum HCQ level of 106 ng/mL was extrapolated as the corresponding cut-off to identify non-adherent patients with a sensitivity of 0.87 (95% CI 0.76–0.94) and specificity of 0.89 (95% CI 0.72–0.98).

All serum HCQ levels of patients with whole-blood HCQ below the detectable level (< 20 ng/mL) were also undetectable (< 20 ng/mL).

Conclusions

These data suggest that whole blood is better than serum for assessing the pharmacokinetic/pharmacodynamic relation of HCQ. Our results support the use of serum HCQ levels to assess non-adherence when whole blood is unavailable.

Retrospective Evaluation of a Restrictive Transfusion Strategy in Older Adults with Hip Fracture

OBJECTIVES

To compare the association between a restrictive transfusion strategy and cardiovascular complications during hospitalization for hip fracture with the association between a liberal transfusion strategy and cardiovascular complications, accounting for all transfusions from the emergency department to postacute rehabilitation settings.

DESIGN

Retrospective study.

SETTING

Perioperative geriatric care unit.

PARTICIPANTS

All individuals aged 70 and older admitted to the emergency department for hip fracture and hospitalized in our perioperative geriatric care unit (N=667; n=193 in the liberal transfusion group, n=474 in the restrictive transfusion group) from July 2009 to April 2016.

INTERVENTION

A restrictive transfusion strategy (hemoglobin level threshold ≥8 g/dL or symptoms) used from January 2012 to April 2016 was compared with the liberal transfusion strategy (hemoglobin level threshold ≥10 g/dL) used from July 2009 to December 2011.

MEASUREMENTS

Primary endpoint was in-hospital acute cardiovascular complications (heart failure, myocardial infarction, atrial fibrillation or stroke).

RESULTS

The change to a restrictive transfusion strategy was associated with fewer acute cardiovascular complications (odds ratio=0.45, 95% confidence interval (CI)=0.31-0.67, p<.001), without any noticeable difference in in-hospital or 6-month mortality. The change also led to a reduction in packed red blood cell units used per participant (median 1, interquartile range (IQR) 0-2 in restrictive vs median 2, IQR 0-3 in liberal transfusion strategy, P<.001). In rehabilitation settings, the frequency of transfusion was greater with the restrictive transfusion strategy than the liberal transfusion strategy (18% vs 9%, P<.001).

CONCLUSION

A restrictive transfusion strategy in older adults with hip fracture was found to be safe and was associated with fewer cardiovascular complications but more transfusions in rehabilitation settings. Prospective studies are needed to confirm these findings.

Association between Cognitive Status before Surgery and Outcomes in Elderly Patients with Hip Fracture in a Dedicated Orthogeriatric Care Pathway

BACKGROUND

Dementia is associated with a worse prognosis of hip fracture, but the impact of a dedicated geriatric care pathway on the prognosis of these patients has not been evaluated.

OBJECTIVE

According to the cognitive status before surgery, our main objective was to compare mortality rate at 6 months; secondary outcomes were to compare in-hospital complications, the risk of new institutionalization, and the ability to walk at 6 months.

METHODS

Between 2009 and 2015, all patients (>70 years) admitted after hip fracture surgery into a dedicated unit of peri-operative geriatric care were included: patients with dementia (DP), without dementia (NDP), and with cognitive status not determined (CSND). Data are expressed as hazard ratio (HR) for multivariate cox analysis or odds ratio (OR) for multivariate logistic regression analysis and their 95% confidence interval (CI).

RESULTS

We included 650 patients (86±6 years): 168 DP, 400 NDP, and 82 CSND. After adjustment for age, sex, comorbidities, polypharmacy, pre-fracture autonomy, time-to-surgery, and delirium, there were no significant differences for 6-month mortality (DP versus NDP: HR = 0.7[0.4-1.2], DP versus CSND: HR = 0.6[0.3-1.4], CSND versus NDP: HR = 0.8[0.4-1.7]); but DP and CSND were more likely to be newly institutionalized after 6 months compared to NDP (OR DP = 2.6[1.4-4.9], p = 0.003, OR CSND = 2.9[1.4-6.1], p = 0.004). 92% of population was walking after 6 months (63% with assistance): no difference was found between the three groups.

CONCLUSION

In a dedicated geriatric care pathway, DP and CSND undergoing hip surgery have the same 6-month mortality and walking ability as NDP.

Elevated Neopterin Levels Predict Early Death in Older Hip-fracture Patients

Our society faces a major challenge concerning management of the health and socio-economic burden caused by acute physical stress in the older population (+ 75 years). In particular, hip-fracture surgery (HFS) represents a major health care preoccupation, affecting 1.6 million patients worldwide, resulting in a significant drop in life quality and autonomy. The trauma is associated with 20–30% one-year mortality in the elderly. In the present study, we aim to identify factors, which influence and/or predict the outcome of elderly hip- fracture patients (HFP) post-surgery.

Our objective was to identify biomarkers with a prognostic capacity of one-year mortality. We employed an observational cohort of HFP (n = 60) followed-up longitudinally during the first year post fracture. Clinical and biological data (n = 136), collected at arrival to hospital, were then compared to healthy controls (n = 42) and analyzed using a regularized logistic regression model with lasso penalty followed by 10-fold cross-validation of variables.

We show that plasmatic neopterin levels, a molecule released by IFN-γ-activated macrophages, is predictive of mortality in HFP (ROC-AUC = 0.859). Moreover, neopterin measured at arrival to the hospital correlated negatively with the time of survival after HFS.

Neopterin therefore represents a biomarker, which enables better follow-up of patients at risk of early death.

•

Neopterin level, measured at arrival to hospital, is a robust predictive marker of one-year mortality in HFPs.

•

Neopterin concentration correlated negatively with the time of survival after hip fracture surgery.

The growing incidence of hip fractures, due to demographically aging populations, represent an important burden for health care systems and for injured patients in terms of hospitalization, rehabilitation, needs for long-term care, change in autonomy and mortality. Hip fractures are associated with high rates of adverse outcome, but previous studies have not discovered methods to identify patients at high risk of pernicious clinical outcome or death. Here, we show that innate immune activation post hip fracture in older adults is associated with pernicious clinical outcome.

Pressure ulcers are associated with 6-month mortality in elderly patients with hip fracture managed in orthogeriatric care pathway

Despite orthogeriatric management, 12% of the elderly experienced PUs after hip fracture surgery. PUs were significantly associated with a low albumin level, history of atrial fibrillation coronary artery disease, and diabetes. The risk ratio of death at 6 months associated with pressure ulcer was 2.38 (95% CI 1.31-4.32%, p = 0.044).

INTRODUCTION

Pressure ulcers in hip fracture patients are frequent and associated with a poor outcome. An orthogeriatric management, recommended by international guidelines in hip fracture patients and including pressure ulcer prevention and treatment, could influence causes and consequences of pressure ulcer. However, remaining factors associated with pressure ulcer occurrence and prognostic value of pressure ulcer in hip fracture patients managed in an orthogeriatric care pathway remain unknown.

METHODS

From June 2009 to April 2015, all consecutive patients with hip fracture admitted to a unit for Post-operative geriatric care were evaluated for eligibility. Patients were included if their primary presentation was due to hip fracture and if they were ≥ 70 years of age. Patients were excluded in the presence of pathological fracture or if they were already hospitalized at the time of the fracture. In our unit, orthogeriatric principles are implemented, including a multi-component intervention to improve pressure ulcer prevention and management. Patients were followed-up until 6 months after discharge.

RESULTS

Five hundred sixty-seven patients were included, with an overall 14.4% 6-month mortality (95% CI 11.6-17.8%). Of these, 67 patients (12%) experienced at least one pressure ulcer. Despite orthogeriatric management, pressure ulcers were significantly associated with a low albumin level (RR 0.90, 95% CI 0.84-0.96; p = 0.003) and history of atrial fibrillation (RR 1.91, 95% CI 1.05-3.46; p = 0.033), coronary artery disease (RR 2.16, 95% CI 1.17-3.99; p = 0.014), and diabetes (RR 2.33, 95% CI 1.14-4.75; p = 0.02). A pressure ulcer was associated with 6-month mortality (RR 2.38, 95% CI 1.31-4.32, p = 0.044).

CONCLUSION

In elderly patients with hip fracture managed in an orthogeriatric care pathway, pressure ulcer remained associated with poorly modifiable risk factors and long-term mortality.

Prognostic Value of Serum Procalcitonin After Orthopedic Surgery in the Elderly Population

Background

Orthopedic surgery is more and more frequent in the older patients and is associated with a high mortality rate. Although serum procalcitonin levels are associated with prognosis in young adults, data are still lacking in the elderly population, and especially after surgery. The main objective of this study was to determine the prognostic value of procalcitonin levels in a large geriatric orthopedic population, and we compared it with clinical variables and biomarkers.

Methods

This is a prospective study including patients admitted in our dedicated geriatric postoperative unit, after orthopedic surgery with immediate postoperative measured procalcitonin levels. Collected data included age, sex, medical history, functional status (activities of daily living [ADL]), fracture type, Cumulative Illness Rating scale (CIRS), postoperative complications, and biological data. The primary endpoint was the 30-day mortality.

Results

436 patients (age 85±6 years) were included. Hip fracture surgery was the most frequent (n = 310; 71%), and the 30-day mortality rate was 6.9%. Compared with C-reactive protein (CRP), albumin, CIRS, and ADL, procalcitonin had the highest area under the receiver operating characteristic curve for predicting 30-day mortality (0.74; 95% CI: 0.70-0.78). Using a cutoff at 1 µg/L, procalcitonin was more specific than CIRS to predict 30-day mortality (92 vs 77%; p < .001). In a multivariable analysis, procalcitonin level higher than 0.39 µg/L is a significant predictor of mortality within 30 days (odds ratio 3.84; 95% CI: 1.61-9.14, p = .002).

Conclusion

Elevated procalcitonin values were strongly and significantly associated with mortality within 30 days in older patients after orthopedic surgery.

Relapsing Polychondritis Can Be Characterized by Three Different Clinical Phenotypes: Analysis of a Recent Series of 142 Patients

OBJECTIVE

Relapsing polychondritis (RP) is a rare condition characterized by recurrent inflammation of cartilaginous tissue and systemic manifestations. Data on this disease remain scarce. This study was undertaken to describe patient characteristics and disease evolution, identify prognostic factors, and define different clinical phenotypes of RP.

METHODS

We performed a retrospective study of 142 patients with RP who were seen between 2000 and 2012 in a single center.

RESULTS

Of the 142 patients, 86 (61%) were women. The mean ± SD age at first symptoms was 43.5 ± 15 years. Patients had the following chondritis types: auricular (89%; n = 127), nasal (63%; n = 89), laryngeal (43%; n = 61), tracheobronchial (22%; n = 32), and/orcostochondritis (40%; n = 57). The main other manifestations were articular (69%; n = 98), ophthalmologic (56%; n = 80), audiovestibular (34%; n = 48), cardiac (27%; n = 38), and cutaneous (28%; n = 40). At a mean ± SD followup of 13 ± 9 years, the 5- and 10-year survival rates were 95 ± 2% and 91 ± 3%, respectively. Factors associated with death on multivariable analysis were male sex (P = 0.01), cardiac abnormalities (P = 0.03), and concomitant myelodysplastic syndrome (MDS) (P = 0.004) or another hematologic malignancy (P = 0.01). Cluster analysis revealed that separating patients into 3 groups was clinically relevant, thereby separating patients with associated MDS, those with tracheobronchial involvement, and those without the 2 features in terms of clinical characteristics, therapeutic management, and prognosis.

CONCLUSION

This large series of patients with definite RP revealed an improvement in survival as compared with previous studies. Factors associated with death were male sex, cardiac involvement, and concomitant hematologic malignancy. We identified 3 distinct phenotypes.

Isolated cardiac troponin rise does not modify the prognosis in elderly patients with hip fracture

Perioperative myocardial infarction remains a life-threatening complication in noncardiac surgery and even an isolated troponin rise (ITR) is associated with significant mortality. Our aim was to assess the prognostic value of ITR in elderly patients with hip fracture.In this cohort study, all patients admitted between 2009 and 2013 in our dedicated geriatric postoperative unit after hip fracture surgery with a cardiac troponin I determination were included and divided into Control, ITR, and acute coronary syndrome (ACS) groups. The primary end point was a composite criteria defined as 6-month mortality and/or re-hospitalization. Secondary end points included 30-day mortality, 6-month mortality, and 6-month functional outcome.Three hundred twelve patients were (age 85 ± 7 years) divided into Control (n = 217), ITR (n = 50), and ACS (n = 45) groups. There was no significant difference for any postoperative complications between ITR and Control groups. In contrast, atrial fibrillation, acute heart failure, hemorrhage, and ICU admission were significantly more frequent in the ACS group. Compared to the Control group, 6-month mortality and/or rehospitalization was not significantly modified in the ITR group (26% vs. 28%, P = 0.84, 95% confidence interval [CI] of the difference -13%-14%), whereas it was increased in the ACS group (44% vs. 28%, P = 0.02, 95% CI of the difference 2%-32%). ITR was not associated with a higher risk of new institutionalization or impaired walking ability at 6 months, in contrast to ACS group.In elderly patients with hip fracture, ITR was not associated with a significant increase in death and/or rehospitalization within 6 months.

Quality of life in systemic lupus erythematosus: description in a cohort of French patients and association with blood hydroxychloroquine levels

Objectives

Benefits of hydroxychloroquine (HCQ) use on physician reported outcomes are well documented in systemic lupus erythematosus (SLE). We assess for the first time the association and predictive value of blood HCQ levels towards health-related quality of life (HRQOL) in SLE.

Methods

Data from the PLUS study (a randomized, double-blind, placebo-controlled, multicentre study) were utilized. Blood HCQ levels were quantified by high-performance liquid chromatography along with HRQOL assessments (Medical Outcomes Study-SF-36) at baseline (V1) and month 7 (V2).

Results

166 SLE patients’ data were analysed. Mean (SD) age and disease duration were 44.4 (10.7) and 9.3 (6.8) years. Eighty-seven per cent were women. Mean (SD, median, IQR) HCQ concentrations in the blood at V1 were 660 (314, 615, 424) ng/ml and increased to 1020 (632, 906, 781) ng/ml at V2 (mean difference 366 units, 95% confidence interval −472 to −260, p < 0.001). No significant correlations between HCQ concentrations with HRQOL domains at V1 or V2 were noted. There were no differences in HRQOL stratified by HCQ concentrations. HCQ concentrations at V1 or changes in HCQ concentration (V2-V1) were not predictive of HRQOL at V2 or changes in HRQOL (V2-V1).

Conclusions

No association of HCQ concentrations with current or longitudinal HRQOL were found in SLE.

Determinants of hydroxychloroquine blood concentration variations in systemic lupus erythematosus

OBJECTIVE

Blood concentrations of hydroxychloroquine (HCQ) vary widely among patients with systemic lupus erythematosus (SLE). A pharmacokinetic/pharmacodynamic relationship has been found in different situations, and a very low blood concentration of HCQ is a simple marker of nonadherence to treatment. Therefore, interest in blood HCQ concentration measurement has increased, but little is known about factors that influence blood HCQ concentration variability. This study was undertaken to analyze determinants of blood HCQ concentrations.

METHODS

We conducted a retrospective analysis of patient data, including data from the Plaquenil Lupus Systemic (PLUS) study, to determine the association of epidemiologic, clinical, and biologic factors with blood HCQ concentrations. Data for nonadherent patients (blood HCQ concentration <200 ng/ml) were excluded.

RESULTS

To examine homogeneous pharmacologic data, we restricted the analyses of the PLUS data to the 509 SLE patients receiving 400 mg/day. We found no association of ethnicity or smoking with blood HCQ concentrations and no pharmacokinetic drug-drug interaction with antacids or with inhibitors or inducers of cytochrome P450 enzymes. On multivariate analysis, high body mass index (P = 0.008), no treatment with corticosteroids (P = 0.04), increased time between the last tablet intake and measurement of blood HCQ concentrations (P = 0.017), low platelet count (P < 0.001), low neutrophil count (P < 0.001), and high estimated creatinine clearance (P < 0.001) were associated with low blood HCQ concentrations. In 22 SLE patients with chronic renal insufficiency (median serum creatinine clearance 52 ml/minute [range 23-58 ml/minute]) who received 400 mg/day HCQ, the median blood HCQ concentration was significantly higher than that in the 509 patients from the PLUS study (1,338 ng/ml [range 504-2,229 ng/ml] versus 917 ng/ml [range 208-3316 ng/ml]) (P < 0.001).

CONCLUSION

We provide a comprehensive analysis of determinants of blood HCQ concentrations. Because this measurement is increasingly being used, these data might be useful for clinicians.

[Link between non hypoxemic chronic obstructive pulmonary disease and executive functioning in oldest old]

COPD (chronic obstructive pulmonary disease) may result in cognitive disorders (mainly executive) even without hypoxemia. The aim of this descriptive study was to highlight a deficit in task-switching in non-hypoxemic patient with COPD and mild cognitive impairment (MCI) or Alzheimer disease (AD). The main judgment criterion was patients' performances on the TMTA and B. COPD patients were recruited via the database (CogDisCo) of the geriatric medicine department at Pitié Salpêtrière hospital in Paris. 7 patients had Alzheimer's disease (AD), and 11 mild cognitive impairment (MCI): they were matched for age, sex, MMSE, education level with controls subjects without COPD. There was no significant difference between the two groups. However, patients with COPD and MCI required, on average, an extra 13 seconds compared with patient without COPD for the TMTA and 18 seconds for the TMTB. Patients with COPD and AD needed, on average, an extra 63 seconds for TMTA and 97 seconds for TMTB. The number of errors for the TMTB was the same in the both groups. This preliminary study does not show statistically significant results but the time for achieving TMT was longer in the population with COPD whether AD or MCI. These results encourage us to continue with prospective studies on larger samples.

[An essential multi-disciplinary approach in geriatric perioperative units]

A hip fracture, often a surgical emergency, is a geriatric as much as an orthopaedic pathology. A multi-disciplinary approach is essential especially in the management of complications. The geriatric perioperative unit of Pitié-Salpétrière-Charles Foix hospital has demonstrated the benefits of such a dedicated care pathway.

Lower vitamin D levels are associated with higher systemic lupus erythematosus activity, but not predictive of disease flare-up

Objectives

Growing evidence suggests that vitamin D plays a key role in the pathogenesis and progression of autoimmune diseases, including systemic lupus erythematosus (SLE). Recent studies have found an association between lower serum 25-hydroxyvitamin D (25(OH)D) levels and higher SLE activity. We studied the relationship between 25(OH)D levels and Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) score, and we assessed for the first time the role of vitamin D in predicting SLE flare-ups.

Methods

Serum 25(OH)D levels were measured in 170 patients with SLE who were prospectively followed up for 6 months (Plaquenil LUpus Systemic study, ClinicalTrials.gov number NCT00413361).

Results

The mean SLEDAI score was 2.03±2.43 and 12.3% patients had active disease (SLEDAI ≥6). The mean 25(OH)D level was 20.6±9.8 ng/mL. Deficiency (25(OH)D <10 ng/mL) was observed in 27 (15.9%), insufficiency (10≤25(OH)D<30) in 112 (65.9%) and optimal vitamin D status (25(OH)D≥30) in 31 (18.2%) patients. In multivariate analysis, female gender (p=0.018), absence of defined antiphospholipid syndrome (p=0.002) and higher creatinine clearance (p=0.004) were predictive of lower 25(OH)D levels. In multivariate analysis, lower 25(OH)D levels were associated with high SLE activity (p=0.02). Relapse-free survival rate was not statistically different according to the vitamin D status during the 6-month follow-up (p=0.22).

Conclusions

We found a low vitamin D status in the majority of patients with SLE, and a modest association between lower 25(OH)D levels and high disease activity. There was no association between baseline 25(OH)D levels and relapse-free survival rate.

Postoperative admission to a dedicated geriatric unit decreases mortality in elderly patients with hip fracture

Background

Elderly patients with hip fracture have a 5 to 8 fold increased risk of death during the months following surgery. We tested the hypothesis that early geriatric management of these patients focused on co-morbidities and rehabilitation improved long term mortality.

Methods and Findings

In a cohort study over a 6 year period, we compared patients aged >70 years with hip fracture admitted to orthopedic versus geriatric departments in a time series analysis corresponding to the creation of a dedicated geriatric unit. Co-morbidities were assessed using the Cumulative Illness Rating Scale (CIRS). Each cohort was compared to matched cohorts extracted from a national registry (n = 51,275) to validate the observed results. Main outcome measure was 6-month mortality. We included 131 patients in the orthopedic cohort and 203 in the geriatric cohort. Co-morbidities were more frequent in the geriatric cohort (median CIRS: 8 vs 5, P<0.001). In the geriatric cohort, the proportion of patients who never walked again decreased (6% versus 22%, P<0.001). At 6 months, re-admission (14% versus 29%, P = 0.007) and mortality (15% versus 24%, P = 0.04) were decreased. When co-morbidities were taken into account, the risk ratio of death at 6 months was reduced (0·43, 95%CI 0·25 to 0·73, P = 0.002). Using matched cohorts, the average treatment effects on the treated associated to early geriatric management indicated a reduction in hospital mortality (−63%; 95% CI: −92% to −6%, P = 0.006).

Conclusions

Early admission to a dedicated geriatric unit improved 6-month mortality and morbidity in elderly patients with hip fracture.

[Surgical emergencies in elderly patients]

Surgical emergencies represent a diverse combination of common and particularly severe pathologies in elderly patients. This severity is due in part to concurrent comorbidities and sometimes atypical clinical presentations, causing delay in diagnosis and treatment.

Scurvy in hospitalized elderly patients

OBJECTIVES

The aim of this study was to systematically screen hospitalized elderly patients for clinical symptoms of scurvy and to confirm the diagnosis with biological measures.

SETTINGS

Geriatric acute care ward.

MEASUREMENTS

Scurvy symptoms (one or more among perifollicular hyperkeratosis, petechiae or bruises, haemorrhagic features caused by venous puncture, severe gingivitis). We compared associated diseases, nutritional status, need for assistance for feeding, serum albumin, transthyretin, B9 and B12 vitamins, iron status and Serum Ascorbic Acid Level (SAAL) and outcome (in-hospital mortality) between scurvy and scurvy free patients.

RESULTS

18 patients with clinical symptoms of scurvy (scurvy group) were identified out of 145 consecutive patients (12%). They were compared to 23 consecutive control patients with no clinical symptoms of scurvy (scurvy-free group). SAAL was significantly lower (1.09 +/- 1.06 vs 4.87 +/- 4.2 mg x L-1, p < .001) and vitamin C deficiency more frequent (94 vs 30 %, p < .001) in the scurvy group. Moreover, in scurvy group, coronary heart disease (39 vs 9 %, p=.028), need for assistance for feeding (56 vs 13 %, p=.006) and in-hospital deaths (44 vs 9 %, p=.012) were more frequent.

CONCLUSION

Ninety-four percent of patients with clinical symptoms of scurvy had vitamin C deficiency. Our results suggest that in hospitalized elderly patients, clinical symptoms allow scurvy diagnosis. Scurvy could be a frequent disease in elderly patients admitted to acute geriatric ward.