A. Passeron

Apprentissage de la technique pour se relever du sol chez des patients âgés hospitalisés: Étude prospective en médecine interne

Resume Objectif Les chutes sont frequentes chez les personnes de plus de 65 ans et elles sont un motif frequent d’hospitalisation. Certains patients sont incapables de se relever seules malgre l’absence de blessure. Une station prolongee au sol est source de complications. Des exercices d’apprentissage pour se relever du sol existent mais ils n’ont pas ete evalues. Methodes Nous avons mis en place un tel apprentissage dans un service de medecine interne et l’avons evalue a court terme par une etude prospective d’observation menee sur 3 mois chez 29 patients. Chaque semaine, nous avons organise une seance collective d’apprentissage (J0) suivie d’une seance d’evaluation individuelle apres 48 h ou plus (entre le 2e et le 9e jour, J2-J9), menees selon un protocole ecrit. Resultats Vingt-quatre des 29 patients (16 % des patients de plus de 65 ans hospitalises dans le service) vus a J0 ont ete revus a J2-J9. Le nombre de malades capables de se relever sans aide etait de 2 sur 29 evaluables a J0 et de 11 sur 24 a J2-J9 (p = 0,003). Les progres significatifs concernaient les 2 premieres etapes, les plus delicates, du redressement : retournement au sol du dos sur le ventre (p = 0,003), et passage en quadrupedie (p = 0,006). Un Mini Mental Status (MMS) Conclusion Apprendre aux personnes âgees hospitalisees en medecine interne a se relever apres une chute semble efficace a court terme. Bien qu’il merite d’etre plus finement evalue, cet apprentissage est denue d’effets indesirables et nous semble pouvoir etre recommande.BACKGROUNDnFalls occur frequently among the elderly and often lead to hospitalization. Even if uninjured, some of them cannot get up again, and prolonged time on the floor and failed efforts to get up can cause complications. Training methods and exercises for getting up from the floor exist but have not been evaluated.nnnMETHODSnWe set up a training course to teach elderly patients to get up from the ground and assessed it over the short term by a prospective observational study of 29 patients over 3 months. Each week, a group training session took place, followed 2-9 days later by an individual assessment conducted according to a written protocol.nnnRESULTSnOf the 29 patients (16% of those older than 65 years admitted to our internal medicine department during this period) who received the training, 24 (80%) underwent the subsequent evaluation. Training was effective: before training, only 2 of 29 assessable patients were able to get up on their own, while at the reassessment, 11 of 24 succeeded (p=0.003). Significant improvement was observed for the first two-and most difficult-steps of the maneuver: rolling over from a supine to a prone position (p=0.003), and then moving up into a quadrupedal position (getting up onto all four limbs) (p=0.006). The only variable that appeared to predict a poor result was a Mini Mental Status (MMS) score lower than 26/30.nnnCONCLUSIONnTeaching elderly patients how to get up from the floor can be accomplished in an inpatient internal medicine department and appears to be effective in the short term. Although further studies involving more patients followed for a longer period are required to confirm and assess the actual benefits, this training is safe and can be recommended.

Bactériémie récidivante à entérocoque rapportée à l’infection d’un shunt porto-systémique intra-hépatique par voie transjugulaire

Resume La creation d’une anastomose porto-systemique intra-hepatique par voie transjugulaire ou TIPS est une procedure validee dans la prise en charge des complications de l’hypertension portale, en particulier hemorragiques. L’incidence des bacteriemies associees a un TIPS est faible, estimee a environ 2 % mais cette complication est souvent grave. Nous rapportons le cas d’une bacteriemie recurrente a enterocoque liee a l’infection de l’endoprothese hepatique avec regression du thrombus apres un mois d’antibiotherapie. Le schema therapeutique antibiotique peut etre similaire a celui des endocardites bacteriennes.

Recurrent Escherichia coli meningitis associated with aspergillar sphenoidal sinusitis.

Recurrent meningitis due to Escherichia coli is an extremely rare infection in adult patients. Most cases have been complications of neurosurgery. We report on the case of a 43-y-old man with 4 recurrent spontaneous episodes of E. coli meningitis related to aspergillar sphenoidal sinusitis. Surgical treatment of sinusitis cured the patient.

Activated partial thromboplastin time sensitivity to lupus anticoagulant in a patient with transient arthritis and lupus anticoagulant-hypoprothrombinemia syndrome

Dear Editor, A 23-year-old man presented with a five-day history of high fever and severe hip pain. Clinical examination evidenced hip arthritis and a joint effusion, while the patient was treated by antibiotics for pneumonia. Creactive protein level was 33.4 mg/l; cell blood count showed only a mild thrombocytopenia (133 G/l). Prothrombin time and activated partial thromboplastin time (aPTT) with kaolin (KPTT) were both prolonged; thrombin clotting time was normal. Measurement of clotting factor activities revealed an isolated prothrombin deficiency (23 %, Table 1). No correction of KPTT was observed on a mixture (1/1) with normal commercial plasma (Cryocheck, France). Lupus anticoagulanthypoprothrombinemia syndrome (LAHPS) was therefore suspected and both anti-phospholipid (aPL) and antiprothrombin (aPT) antibodies were searched for [1]. The two different coagulation tests used to detect lupus anticoagulant (LA) according to ISTH recommendations [2] were prolonged: aPTT using Automated APTT (Trinity Biotech, Ireland) and dilute Russell venom viper time (dRVVT) using LA1LA2 reagents (Siemens, Germany). The phospholipid dependence was confirmed by positive phospholipid-neutralizing assays for both tests with a dRVVT screen/confirm ratio at 1.77 and a ratio of aPTT with silica (LA sensitive reagent)/KPTT (LA unsensitive reagent) at 1.4. Anti-cardiolipin (aCL), anti-β2GPI (aβ2GPI) and aPT IgG and IgM were searched for by using commercial ELISAs (Orgentec Diagnostika, Mainz, Germany). High titres of aPTs were found (IgG 504 UA/ml, IgM 82 UA/ml, reference values <10 UA/ml) with neither aβ2GPI nor aCL antibodies. Altogether, these results confirmed the diagnosis of LAHPS [3]. To explain the origin of arthritis, systemic lupus erythematosus biological markers and microbiological tests were performed. An increased level of IgG directed against Chlamydia pneumoniae was observed between day 7 and two months after admission (160 and 260 UA/ml, respectively, for a threshold at 25 UA/ ml), suggesting reinfection. Unfortunately, the bacteria could not have been searched for at the site of arthritis as hypoprothrombinemia contraindicated joint puncture. However, cases of arthritis secondary to Chlamydia pneumoniae have already been reported [4], and a case of associated transient lupus anticoagulant has even been described [5]. After nine days of treatment with nonsteroidal anti-inflammatory drug, the patient was discharged at home without any further joint pain. A mirror effect was observed during the follow-up between prothrombin level that normalized at two months and aPT titres that concomitantly decreased (Fig. 1), as already described in quinidine-induced LAHPS [6]. At that time, dRVVT screen ratio became negative (1.13) while aPTT was L. Mauge (*) :M. Alhenc-Gelas : L. Darnige Department of Biological Haematology, European Hospital Georges Pompidou, AP-HP, Paris, France e-mail: laetitia.mauge@egp.aphp.fr