LOw-dose CT Or Lung UltraSonography versus standard of care based-strategies for the diagnosis of pneumonia in the elderly: protocol for a multicentre randomised controlled trial (OCTOPLUS).

INTRODUCTION Pneumonia is a leading cause of mortality and a common indication for antibiotic in elderly patients. However, its diagnosis is often inaccurate. We aim to compare the diagnostic accuracy, the clinical and cost outcomes and the use of antibiotics associated with three imaging strategies in patients >65 years old with suspected pneumonia in the emergency room (ER): chest X-ray (CXR, standard of care), low-dose CT scan (LDCT) or lung ultrasonography (LUS). METHODS AND ANALYSIS This is a multicentre randomised superiority clinical trial with three parallel arms. Patients will be allocated in the ER to a diagnostic strategy based on either CXR, LDCT or LUS. All three imaging modalities will be performed but the results of two of them will be masked during 5 days to the patients, the physicians in charge of the patients and the investigators according to random allocation. The primary objective is to compare the accuracy of LDCT versus CXR-based strategies. As secondary objectives, antibiotics prescription, clinical and cost outcomes will be compared, and the same analyses repeated to compare the LUS and CXR strategies. The reference diagnosis will be established a posteriori by a panel of experts. Based on a previous study, we expect an improvement of 16% of the accuracy of pneumonia diagnosis using LDCT instead of CXR. Under this assumption, and accounting for 10% of drop-out, the enrolment of 495 patients is needed to prove the superiority of LDCT over CRX (alpha error=0.05, beta error=0.10). ETHICS AND DISSEMINATION Ethical approval: CER Geneva 2019-01288. TRIAL REGISTRATION NUMBER NCT04978116

A systematic review assessing the under-representation of elderly adults in COVID-19 trials

Coronavirus disease (COVID-19) has caused a pandemic threatening millions of people worldwide. Yet studies specifically assessing the geriatric population are scarce. We aimed to examine the participation of elderly patients in therapeutic or prophylactic trials on COVID-19

Considerations for the optimal management of antibiotic therapy in elderly patients

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External validation of the Dat'AIDS score: A risk score for predicting 5-year overall mortality in people living with HIV aged 60 years or older.

OBJECTIVE To perform an external validation of the Dat'AIDS score for predicting 5-year overall mortality among people with HIV (PWH) aged 60 years or older. METHODS This was a multi-centre prospective cohort study at all sites participating in the Swiss HIV Cohort Study (SHCS). We calculated the Dat'AIDS score in PWH aged 60 years or older at their first visit between 1 January 2015 and 1 January 2020. People living with HIV-2 and those whose Dat'AIDS score could not be calculated were excluded. Patients were followed until 1 January 2020. The primary endpoint was all-cause mortality. Vital status was collected throughout the study period. We obtained population and score descriptive statistics and assessed the score's discrimination and calibration. RESULTS We included 2205 participants (82% male) of median [interquartile range (IQR)] age 62.0 (60.3-67.0) years, mostly with viraemia <50 copies/mL (92.7%). Median follow-up time was 15.9 years and median (IQR) CD4 cell count at enrolment was 586 (420-782) cells/μL. In all, 152 deaths were recorded during a total follow-up period of 7147 patient-years. The median (IQR) observed Dat'AIDS score was 3 (0-8). Discriminative capacities were good as the C-statistic was 0.73 (95% CI: 0.69-0.77) and consistent across all subgroups. Comparison of observed and expected survival probabilities showed good calibration. CONCLUSIONS External validation of the Dat'AIDS score in patients aged 60 years or older showed that it could be a useful tool not only for research purposes, but also to identify older patients at a higher mortality risk and to tailor the most appropriate interventions

Plasmodium falciparum Malaria and Atovaquone-Proguanil Treatment Failure

We noticed overrepresentation of atovaquone-proguanil therapeutic failures among Plasmodium falciparum–infected travelers weighing >100 kg. We report here 1 of these cases, which was not due to resistant parasites or impaired drug bioavailability. The follow-up of such patients should be strengthened

External validation of the Dat'AIDS score: A risk score for predicting 5-year overall mortality in people living with HIV aged 60 years or older

OBJECTIVE: To perform an external validation of the Dat'AIDS score for predicting 5-year overall mortality among people with HIV (PWH) aged 60 years or older. METHODS: This was a multi-centre prospective cohort study at all sites participating in the Swiss HIV Cohort Study (SHCS). We calculated the Dat'AIDS score in PWH aged 60 years or older at their first visit between 1 January 2015 and 1 January 2020. People living with HIV-2 and those whose Dat'AIDS score could not be calculated were excluded. Patients were followed until 1 January 2020. The primary endpoint was all-cause mortality. Vital status was collected throughout the study period. We obtained population and score descriptive statistics and assessed the score's discrimination and calibration. RESULTS: We included 2205 participants (82% male) of median [interquartile range (IQR)] age 62.0 (60.3-67.0) years, mostly with viraemia <50 copies/mL (92.7%). Median follow-up time was 15.9 years and median (IQR) CD4 cell count at enrolment was 586 (420-782) cells/μL. In all, 152 deaths were recorded during a total follow-up period of 7147 patient-years. The median (IQR) observed Dat'AIDS score was 3 (0-8). Discriminative capacities were good as the C-statistic was 0.73 (95% CI: 0.69-0.77) and consistent across all subgroups. Comparison of observed and expected survival probabilities showed good calibration. CONCLUSIONS: External validation of the Dat'AIDS score in patients aged 60 years or older showed that it could be a useful tool not only for research purposes, but also to identify older patients at a higher mortality risk and to tailor the most appropriate interventions

Peritoneal Sclerosis in a Patient on Long-term Continuous Ambulatory Peritoneal Dialysis (CAPD). : An Autopsy Case.

若年性ネフロン癆による慢性腎不全でCAPD (continuous ambulatory peritoneal dialysis)導入し, 6年6ヵ月後に死亡した20歳男性の1剖検例を報告した。CAPD導入数カ月後, 腹膜炎による除水能低下を起こしたが, 約5ヵ月後に回復した。CAPD導入1年5ヵ月以降重症な腹膜炎罹患により除水能低下状態が遷延したが, 次第に回復した。しかし, 体液貯留傾向のため, 3年2ヵ月後より高張透析液を使用し除水量の増加を得たが, 3年9ヵ月後に不可逆的な除水能低下状態となった。一方, クレアチニンの透析排液/血漿濃度比(D/P)から見た溶質除去能は, その約半年後まで保たれており, 血清クレアチニン値の上昇は軽度であった。剖検にて腹膜の線維性肥厚と高度の内腔狭窄を伴う動静脈硬化を認め, 腹膜硬化症と診断した。本例の腹膜硬化症は, 頻回の腹膜炎と高張透析液の使用が主な原因と考えられた。腹膜機能を長期に維持するためには, 腹膜炎の予防と高張透析液の使用を最小限にすることが重要と考えられた。A 20-year-old man, treated with continuous ambulatory peritoneal dialysis (CAPD) for 6.5 years because of-end-stage renal disease due to juvenile nephronophthysis, died of ultrafiltration failure, and the morphological examination of peritoneum was carried out at autopsy. Nine episodes of peritonitis developed, and ultrafiltration transiently decreased after each episodes. At 2 years after the start of CAPD, severe peritonitis occurred, and then his body weight and blood pressure gradually increased. At 4 years after the beginning of CAPD, when hyperosmotic dialysate was frequently used, ultrafiltration was irreversively deteriorated. On the other hand, creatinine dialysate/plasma ratio remained within normal limits for about several months, and the increase in the level of serum creatinine was very little. The peritoneum obtained at autopsy revealed marked fibrous thickening as well as the conspicuous luminal narrowing of arteries and veins due to intimal thickening. The development of peritoneal sclerosis seemed to be related with the frequency and severity of peritonitis and the use of hyperosmotic dialysate

The specificities of pneumonia in elderly patients

The incidence of pneumonia increases with age. Making an accurate clinical diagnosis of pneumonia is difficult in very elderly adults because of certain clinical specificities, the presence of cognitive and behavioural disorders, and the decompensation of concomitant comorbidities. Roles for computed tomography (CT) and thoracic ultrasound look promising, especially in helping to diminish false-positive diagnoses of pneumonia, but evidence for the use of these imaging techniques will require reinforcement via pragmatic studies. Progress in the field of aetiological diagnosis has revealed evidence of the non-negligible roles played by viruses and bacterial–viral co-infections. A new concept of the physiopathology of pneumonias is emerging according to which the disease is a consequence of a homeostatic disequilibrium that affects the microbiota in the airways. Whether the changes in the microbiome are a cause or consequence of the development of pneumonia is a question for the future. Although the Pneumonia Severity Index (PSI) and CURB65 (confusion, uraemia, respiratory rate, blood pressure, age ≥ 65 years) remain the most frequently used pneumonia severity scores, it is important to remember that they are not a substitute for clinical judgment. With regards to treatments using antibiotics, few therapeutic trials have been carried out involving very elderly subjects, despite changes in numerous parameters, such as creatinine clearance, in this population. Indeed, most international guidelines are based on studies carried out on younger adults. Following the recommended guidelines for the management of pneumonia remains an important issue, notably with regard to the correct choice of antibiotic, in order to avoid the emergence of bacterial resistance. Some experts have drawn attention to the increased risk of Clostridium difficile-associated infection when treating bacteria using macrolides and they instead propose doxycycline for patients managed in outpatient units. Nevertheless, therapeutic trials to validate this proposition are eagerly awaited. Corticosteroids have a beneficial effect on the sub-group of patients with very significant inflammation. Using a procalcitonin (PCT) test or the C-reactive protein (CRP) marker may also help to guide treatment. Meta-analyses have shown that the treatment duration can be inferior to seven days in cases involving non-severe pneumonia. It is important that any decompensating organs accompanying the pneumonia are also treated. Finally, recent studies have shown increases in cardiovascular morbidity and mortality extending numerous years after the episode of pneumonia, and this should be remembered in the patient's long-term follow-up. Hospital discharge cannot be prescribed until the patient has met all the criteria for clinical stability, yet to the best of our knowledge, these have never been studied in very elderly populations of ≥ 85 years old. Age alone should not be a reason to refuse intensive care, and numerous other parameters should be evaluated, such as the patient's nutritional, functional and cognitive status, as well as his or her advance directives. It is imperative to discuss treatment plans with patients immediately they are admitted to hospital. Although vaccination is one of the quality criteria for pneumonia management, the possible preventive measures of good oral hygiene and attentiveness to swallowing disorders should not be forgotten

Maladie de Kikuchi-Fujimoto (série rétrospective multicentrique portant sur 91 cas et revue de la littérature)

La maladie de Kikuchi Fujimoto (MKF) est une cause rare d'adénopalhie principalement décrite en Asie. Dans cette étude réalisée en France, nous rapportons les caractéristiques, le traitement et l'évolution de 91cas de MKF confirmés hîstologiquemenUL'objectif principal était de décrire les caractéristiques de la MKF dans une population occidentale. Les objectifs secondaires étaient de comparer les formes associées à un Lupus Erythémateux Systémique (LES) de novo aux formes non associées à un LES, ainsi que des formes dites sévères de la maladie aux autres.Il s'agissait d'une analyse rétrospective des dossiers de patients avec MKF confirmée bistologiquement dans 13 centres hospitaliers français.91 patients ont été inclus. 70 patients (77%) étaient de sexe féminin avec un âge médian (+/- DS) au diagnostic de 30 +/-10,4 ans. L'origine ethnique se répartissait ainsi : caucasien (33%), Afro-caribéen (32%), nord africain (15,4%), asiatique (13%). Dix-huit patients avaient un antécédent de maladie systémique dont onze LES. L'atteinte ganglionnaire était cervicale (90%), souvent dans le cadre d'une polyadénopathie (52%) et associée à une bépato-splénomégalie dans 14,8% des cas. Les formes profondes définies par la présence d'une hépato-splénomégalie ou d'adénopathies profondes sur l'imagerie (TDM et/ou TEP-TDM) concernaient 18 % des patients. Les signes généraux étaient dominés par la fièvre (67%), une asthénie (74,4%), un amaigrissement (51,2%). Concernant les manifestations extra nodales, on observait une atteinte cutanée dans 32,9% des cas, des arthxo-myalgies dans 34,1% des cas, 2 cas de méningite aseptique et 3 cas de syndrome d'activation macrophagique. Les manifestations biologiques étaient dominées par une lymphopénie (63,8%), un syndrome inflammatoire (56,4%). Des FAN et des anti DNA natifs étaient présents respectivement chez 45,2% et 18% des patients prélevés. Huit patients avaient une infection virale documentée concomitante (8,8%). Une corticothérapie systémique était utilisée dans 32% des cas, l'hydroxycbloroquine dans 17,6% des cas et les immunoglobulines intraveineuses chez 3 patients. L'évolution était favorable chez tous les patients. Une rechute était constatée dans 21% des cas. Sur les 33 patients ayant des FAN au diagnostic, un LES était diagnostiqué de façon concomitante dans 10 cas, dans Tannée suivant le diagnostic dans 2 cas. 6 patients non pas présenté de LES, 4 patients ont été perdus de vue (suivi médian ; 19 mois [3-39]).La présence d'un amaigrissement, d'arthralgies, de lésions cutanées ainsi que la présence d'anticorps antinucléaires étaient associées à la survenue d'un LES (p<0,05). Le sexe masculin et la lymphopénie étaient associés aux formes sévères (p<0,05).Notre série présentant en majorité des patients d'origine européenne et africaine mettait en évidence une plus grande fréquence de formes profondes, sévères et associées au LES (n=23). Les patients de sexe masculin et ceux ayant une lymphopénie sont un groupe à risque élevé de forme sévère. La MKF peut compliquer un LES connu (48%) ou le révéler (52%), justifiant le suivi prolongé des patients. Une étude prospective est nécessaire pour mieux connaître les facteurs de risque d'évolution vers le LES.PARIS6-Bibl.Pitié-Salpêtrie (751132101) / SudocPARIS-Bib. Serv.Santé Armées (751055204) / SudocSudocFranceF