Medical information and surrogate designation: results of a prospective study in elderly hospitalised patients

OBJECTIVES: To determine the preferences of French elderly inpatients concerning medical information and surrogate designation in life-threatening situations. METHODS: Intention-to-act questionnaire was completed by two geriatricians during a patient interview in the week following admission in three geriatric units in France. The participants were elderly patients (> or =70 years) with adequate cognitive performance for decision making as assessed by the Mini Mental State Examination. The impact of socio-demographic factors, level of confidence in medical care, cognitive or physical disability on surrogate designation and amount of medical information expected were measured. MEASUREMENTS: Impact of socio-demographic factors, level of confidence in medical care, cognitive or physical disability on surrogate designation and amount of medical information expected. RESULTS: 426 consecutive elderly patients were recruited. 32.6% wanted to receive complete information about their care and 77% declared they would want to be informed if they were in a life-threatening situation. 4.5% reported they would not want any medical information. A family member was designated as surrogate by 73% of the patients. In 28%, a second surrogate was also designated, usually the family physician (22%) or a member of the hospital medical staff (10%). Polytomous logistic regression analysis was used to assess determinants of the amount of information expected and social and medical parameters. MMSE score, the presence of physical disability, a low level of confidence in medicine and the presence of children were identified as independent determinants of a high level of information expectation. CONCLUSION: Elderly hospitalised patients expressed a strong desire to receive extensive information and were willing to designate a surrogate in a life-threatening situation. The surrogate was usually a family member alone or with another person, usually a practitioner.     

Clinicopathological differences between hepatitis B viral genotype B- and C-related resectable hepatocellular carcinoma

Clinical and pathogenic differences exist between hepatitis B viral (HBV) genotypes B and C, and genotype C has a higher risk of hepatocellular carcinoma (HCC) development than genotype B. The aim of this study was to investigate whether HBV genotypes B and C influence the clinicopathological features of patients with resectable HCC. Stored serum samples from 193 patients with resectable HBV-related HCC were tested for HBV genotypes by a molecular method. Of 193 patients undergoing resection of HCC, 107 (55%) and 86 (45%) were infected with genotypes B and C, respectively. Compared with genotype C patients, genotype B patients were less likely to be associated with liver cirrhosis (33%vs 51%, P = 0.01). Pathologically, genotype B patients had a higher rate of solitary tumour (94%vs 86%, P = 0.048) and more satellite nodules (22%vs 12%, P = 0.05) than genotype C patients. Our results indicate that genotype B-related HCC is less associated with liver cirrhosis and has a higher frequency of solitary tumour as well as more satellite nodules than genotype C-related HCC. These characteristics may contribute to the recurrence patterns and prognosis of HBV-related HCC in patients with genotype B or C infection.     

Expression of microsomal prostaglandin E synthase 1 in rheumatoid arthritis synovium

OBJECTIVE: Microsomal prostaglandin E synthase 1 (mPGES-1) catalyzes the formation of PGE(2) from cyclooxygenase-derived PGH(2). Microsomal PGES-1 is induced by proinflammatory cytokines and is strongly linked to conditions that result in high PGE(2) biosynthesis. PGE(2) contributes to the pathogenesis of rheumatoid arthritis (RA), acting as a mediator of inflammation and promoting bone destruction. Induction of mPGES-1 in rheumatoid synoviocytes by proinflammatory cytokines has been demonstrated in vitro, indicating an important role in RA pathogenesis. Recent studies using mPGES-1-deficient mice demonstrated the importance of this gene in chronic inflammation. The aim of this study was to investigate the expression and localization of mPGES-1 in synovial biopsy specimens obtained from patients with RA. METHODS: Synovial tissue samples from 24 patients with RA were obtained, and immunohistologic analysis was performed using polyclonal antibodies against mPGES-1. Double immunofluorescence staining was performed with antibodies to CD3, CD19, CD20, CD68, CD163, and prolyl 4-hydroxylase. RESULTS: Intracellular mPGES-1 staining was observed in synovial membranes from all of the RA patients studied. Specifically, strong expression of mPGES-1 was detected in synovial lining cells. In sublining mononuclear and fibroblast-like cells, the extent of mPGES-1 staining was less than that in the synovial lining cells. In some patients, positive staining was observed in endothelial cells. With the double immunofluorescence technique, mPGES-1 production was detected in synovial macrophages and fibroblasts, while mPGES-1 expression was not observed in lymphocytes. CONCLUSION: The demonstration of mPGES-1 expression in synovial tissues from patients with RA suggests a role for mPGES-1 in the RA disease process. Microsomal PGES-1 might be a potential new target for treatment strategies to control PGE(2) synthesis in patients with RA, without the systemic side effects associated with cyclooxygenase inhibitors.     

Interferon-alpha reduces insulin resistance and beta-cell secretion in responders among patients with chronic hepatitis B and C

This study aimed at elucidating the effects of interferon (IFN)-alpha on glucose metabolism in patients with chronic hepatitis B and C infections. Twenty-eight biopsy-proven patients with chronic hepatitis B (ten cases) and hepatitis C (18 cases) were given IFN-alpha for a total of 24 weeks. The patients received a 75 g oral glucose tolerance test (OGTT), glucagon stimulation test, tests for type 1 diabetes-related autoantibodies and an insulin suppression test before and after IFN-alpha therapy. Ten of the 28 patients responded to IFN-alpha therapy. Steady-state plasma glucose of the insulin suppression test decreased significantly in responders (13.32+/-1.48 (S.E.M.) vs 11.33+/-1.19 mmol/l, P=0.0501) but not in non-responders (12.29+/-1.24 vs 11.11+/-0.99 mmol/l, P=0.2110) immediately after completion of IFN-alpha treatment. In the oral glucose tolerance test, no significant difference was observed in plasma glucose in either responders (10.17+/-0.23 vs 10.03+/-0.22 mmol/l) or non-responders (10.11+/-0.22 vs 9.97+/-0.21 mmol/l) 3 Months after completion of IFN-alpha treatment. However, significant differences were noted in C-peptide in both responders (2.90+/-0.13 vs 2.20+/-0.09 nmol/l, P=0.0040) and non-responders (2.45+/-0.11 vs 2.22+/-0.08 nmol/l, P=0.0287) before vs after treatment. The changes of C-peptide in an OGTT between responders and non-responders were also significantly different (P=0.0028), with responders reporting a greater reduction in C-peptide. No case developed autoantibodies during the treatment. In patients who were successfully treated with IFN-alpha, insulin sensitivity improved and their plasma glucose stayed at the same level without secreting as much insulin from islet beta-cells.     

La tomodensitométrie cardiaque dans la mise au point préopératoire d’une anomalie congénitale d’une artère coronaire

We report the case of a 81-year-old man presenting with stable exercise angina pectoris. The stress test is positive and the coronaro-angiographic evaluation demonstrates a coronary fistula between the left anterior descending (LAD) artery and the pulmonary artery trunk. The mid LAD presents a significant lesion after the origin of the fistula. A cardiac computed tomography is used before surgical treatment. Coronary artery fistulas are unusual congenital or acquired coronary artery abnormalities in which blood is shunt into a cardiac chamber, great vessel or other structure. Low-pressure structure is the most common site of drainage of the coronary fistula. The clinical presentation of coronary fistulas is mainly dependent on the severity of the left-to-right shunt. Various cardiac imaging modalities are used for diagnosis and anatomical exploration before surgical or percutaneous intervention if the closure of the fistula is indicated.     

Geographical variation in the prevalence of positive skin tests to environmental aeroallergens in the European Community Respiratory Health Survey I

BACKGROUND: Many studies have reported the prevalence of sensitization using skin prick tests. However, comparisons between studies and between regions are difficult because the number and the type of allergens tested vary widely. Using the European Community Health Respiratory Survey I data, the geographical variation of sensitization to environmental allergen as measured by skin tests was established. METHODS: Adults aged 20-44 years, living in 35 centres in 15 developed countries, underwent skin tests for allergy to nine common aeroallergens: Dermatophagoides pteronyssinus, timothy grass, cat, Cladosporium herbarium, Alternaria alternata, birch, Olea europea, common ragweed and Parietaria judaica. The age-sex standardized prevalence of sensitization was determined and centres with high (95% confidence interval above and excluding study median) and low prevalence (95% confidence interval below and excluding study median) of sensitization to each allergen and to any of the nine allergens were identified. RESULTS: There was substantial geographical variation in the prevalence of sensitization to each of the nine allergens tested and in the prevalence of sensitization to any allergen (lowest 17.1%, median 36.8% and highest 54.8%). Sensitization to D. pteronyssinus, grass pollen and cat were usually the most prevalent (median between centre 21.7%, 16.9% and 8.8%, respectively). Timothy grass sensitization was higher than that for any other pollen species. CONCLUSIONS: As expected, geographical variations of sensitization to environmental allergen were observed across centres. These findings were compatible for those observed with serum-specific IgE. Skin tests can be used to assess the geographical distribution of allergens in a multicentric epidemiological survey.     

Can T1-rho MRI detect acetabular cartilage degeneration in femoroacetabular impingement?: a pilot study

Advanced MRI cartilage imaging such as T(1)-rho (T1ρ) for the diagnosis of early cartilage degradation prior to morpholgic radiological changes may provide prognostic information in the management of joint disease. This study aimed first to determine the normal T1ρ profile of cartilage within the hip, and secondly to identify any differences in T1ρ profile between the normal and symptomatic femoroacetabular impingement (FAI) hip. Ten patients with cam-type FAI (seven male and three female, mean age 35.9 years (28 to 48)) and ten control patients (four male and six female, mean age 30.6 years (22 to 35)) underwent 1.5T T1ρ MRI of a single hip. Mean T1ρ relaxation times for full thickness and each of the three equal cartilage thickness layers were calculated and compared between the groups. The mean T1ρ relaxation times for full cartilage thickness of control and FAI hips were similar (37.17 ms (SD 9.95) and 36.71 ms (SD 6.72), respectively). The control group demonstrated a T1ρ value trend, increasing from deep to superficial cartilage layers, with the middle third having significantly greater T1ρ relaxation values than the deepest third (p = 0.008). The FAI group demonstrated loss of this trend. The deepest third in the FAI group demonstrated greater T1ρ relaxation values than controls (p = 0.028). These results suggest that 1.5T T1ρ MRI can detect acetabular hyaline cartilage changes in patients with FAI.     

Carriage of Candida species in the oral cavity in diabetic patients: relationship to glycaemic control

To study the possible relationship between the quality of glycaemic control in diabetes mellitus and the carriage of Candida species, the Candidal carrier status of 412 diabetic patients was examined using an oral rinse technique and correlated with measurements of random blood glucose and total glycosylated haemoglobin. Candida was isolated in 210 diabetics (51%) with 13 patients (6%) carrying more than one species. The positive isolates were: Candida albicans (89%), Candida krusei (2.8%), Candida glabrata (2.8%), Candida tropicalis (6.2%), Candida stellatoidea (2.8%) and Candida parapsilosis (0.5%). No association was identified between carriage rates and the type of treatment of diabetes, or with the quality of glycaemic control. As in non-diabetic subjects, the carriage rates were higher in diabetic patients wearing dentures. Thus, the oral carriage of Candida in diabetic patients was independent of glycaemic control but in certain sub-groups the carriage rates were higher, and involved uncommon candidal species.