Spécificités des crises d’épilepsie chez le sujet âgé : proposition d’un score électro-radioclinique d’orientation

Diagnosis of epileptic seizure may be difficult in older patients because seizure manifestations are often unusual: confusion, paresis… and because there are multiple differential diagnoses (syncope, transient ischemic attack, transient global amnesia…). To promote and facilitate the diagnosis of seizures in the elderly, neurologists and gerontologists must work together and focus their strategy on two points: firstly, the knowledge of the specific presentation of seizures in elderly patients, and secondly, the adoption of a reasoning based on seizures and not epileptic syndromes. A multidisciplinary group worked on epilepsy of the elderly to elaborate an electro-clinical score which aims to help establish the diagnosis of epilepsy in elderly patients in different clinical settings. This electro-clinical score is based on a systematic review of scientific literature and the recommendations are explicitly linked to supporting evidence. Further, clinical validation of the electro-clinical score is required.     

Heart Rate as a Risk Factor for Cardiovascular Disease

Almost all the epidemiological studies that aimed to answer the question of the relationship between heart rate and all-cause or cardiovascular morbidity and mortality reported that a high heart rate was associated with a higher risk of all-cause mortality and cardiovascular events. This relationship has been found to be generally stronger in men than among women. The increase in the cardiovascular risk, associated with the acceleration of heart rate, was comparable to the increase in risk observed with high blood pressure. It has been shown that an increase in heart rate by 10 beats per minute was associated with an increase in the risk of cardiac death by at least 20%, and this increase in the risk is similar to the one observed with an increase in systolic blood pressure by 10 mm Hg. It has also been shown that heart rate recorded in elderly men has a strong predictive value in survival to a very old age. Taken together, these results indicate that the risk associated with accelerated heart rate is not only statistical significant but also clinically relevant and that it should be taken into account in the evaluation of the patients. Although the association between elevated heart rate and cardiovascular morbidity and mortality has been demonstrated in a large number of epidemiological studies, tachycardia has remained a neglected cardiovascular risk factor until very recently. For the first time, the recent guidelines of the European Society of Cardiology and the European Society of Hypertension indicate than an accelerated heart rate is considered as an independent risk factor and potentially as a target for pharmacologic therapies, especially in high-risk patients.     

Frailty in older population: a brief position paper from the French society of geriatrics and gerontology

Frailty in the older population is a clinical syndrome which evaluate a risk level. The Frailty syndrome defines a reduction of the adaptation capacity to a stress. It can be modulated by physical, psychological and social factors. The screening of the frailty syndrome is relevant for older people without disability for basic activities of daily living. The clinical criteria of frailty must be predictive of the risk of functional decline and adverse outcomes, consensual at the international level, and easy to perform in primary care as well as in the clinical researches.     

Laboratory evaluation of Fendona 6SC® treated bednets and Interceptor® long-lasting nets against Anopheles gambiae s.l. in Burkina Faso

Insecticide-treated bednets play a cornerstone role in the efforts to control malaria. Bednets entomological efficacy is the determinant factor of their use to control malaria. In this study, we compared under laboratory conditions, the efficacy of two long-lasting nets (PermaNet® versus Interceptor®) and two treatments kits K-O TAB® (deltamethrin) versus Fendona 6SC® (alpha-cypermethrin) against Anopheles gambiae s.l. malaria vectors. The efficacy of washed and unwashed bednets was assessed by contact bioassays using World Health Organization (WHO) cones. Three to five-days-old mosquitoes were exposed to the netting for 3 min; the median and 95 % knockdown time, the after 24 h mortality was recorded for each type of bednet. The mortality after 24 h was equivalent for the Fendona 6SC® treated bednets and the K-O TAB® treated bednets [79.4 % confidence limits (CL) (73.9–84.6) and 74 % CL (68.3–80.0), respectively]. However, the Fendona 6SC® treated bednets were superior in 50 % knockdown time to the K-O TAB® treated bednets [7.8 min, CL (6.5–9.0) and 15. 2 min, CL (14.0–16.4), respectively]. Washed Interceptor® and PermaNet® bednets showed similar efficacy in terms of 50 % knockdown times. Mortality after 24 h was similar from the fifth to the twentieth wash, but PermaNet® performed better than Interceptor® for the first four washes and for unwashed bednets. This study showed that Fendona 6SC® kit and the Interceptor® bednets have exhibited consistent comparable efficacy in the laboratory compared to the well known and in use K-O TAB® kit and PermaNet® bednets.     

Large artery stiffness and antihypertensive agents

Purpose of Review: Since in hypertensive populations, concentration on peripheral blood pressure only does not achieve 100% of blood pressure-attributable risk reduction, taking into consideration other hemodynamic parameters than peripheral blood pressure could perhaps improve cardiovascular prevention. The main purpose of this review is to analyse the scientific data in favour of considering arterial stiffness parameters as interesting intermediate cardiovascular endpoints in order to optimise risk assessment and risk reduction strategies. Summary: Aortic pulse wave velocity (PWV), a marker of aortic stiffness, has been shown to be a strong independent predictor of cardiovascular morbid events, cardiovascular and all-cause mortality in numerous studies in different populations. Furthermore, it has been shown in a therapeutic trial that the lack of aortic PWV attenuation despite significant drug-induced reduction in mean blood pressure was a significant predictor of cardiovascular death in subjects with end-stage renal disease. In essential hypertension, the Reason Study has shown that, despite a similar decrease in peripheral diastolic blood pressure, different effects on central hemodynamic parameters were observed between blockade of the renin-angiotensin system and atenolol. Novel therapeutic approaches available to reduce the increase of pulse pressure and arterial stiffness with age involve converting enzyme inhibitors in association with diuretic compounds; nitrate derivatives; agents acting on collagen cross-linking; and finally spironolactone and vasopeptidase inhibitors. Conclusion: These results support the hypothesis that measurement of aortic PWV could then help, not only in risk assessment strategies but also in risk reduction strategies by monitoring arterial stiffness under different pharmacological regimens.     

Prostate cancer with bladder neck involvement: Pathologic findings with application of a new practical method for tumor extent evaluation and recurrence-free survival after radical prostatectomy

Background: Recent studies have questioned the high risk for disease recurrence in cases of bladder neck involvement by prostate cancer (pT4 disease). Design: The study was based on 141 patients submitted to radical prostatectomy. PSA-recurrence was defined as 0.5 ng/ml or rising at three different examinations. Bladder neck invasion was correlated to Gleason score (<7 or 7), urethral or lateral positive surgical margins, tumor size (extensive or not extensive) using a new simple point-count method, race and preoperative PSA levels (<10 or 10 ng/ml). The mean and median follow-up periods were 17.2 and 15 months (range 3–55). Recurrence-free survival curves were constructed using the Kaplan–Meier survival method with tests of significant differences based on the log-rank statistic. Results: Bladder neck invasion was seen in 30/141 (21.27%) patients; 9 (6.38%) had also concomitant positive surgical margins in the sections. Extraprostatic extension was seen in 39/141 (27.65%) and seminal vesicle invasion in 18/141 (12.76%) patients. Patients with bladder neck invasion significantly correlated to Gleason score (P=0.04), preoperative PSA (P < 0.001), and tumor extension (P=0.04). No correlation was found to age (P=0.44), race (P=0.12) and positive urethral or lateral margins (P=0.32). The PSA-recurrence relative risk in patients with bladder neck invasion was 0.17 (P=0.68), with extraprostatic extension 0.53 (P=0.47) and with seminal vesicle invasion 5.76 (P=0.02). Conclusions: Bladder neck involvement correlates with pathologic unfavorable findings on radical prostatectomy specimens as well as to preoperative PSA levels. However, the PSA-recurrence risk associated with bladder neck involvement (pT4) was similar to extraprostatic extension (pT3a) and substantially lower than seminal vesicle invasion (pT3b). The findings favor a need for downstaging of bladder neck involvement in the next version of the TNM system. The method proposed for tumor extent evaluation is simple and accessible to all pathologists working in routine pathology laboratories.