Natural course of hypogonadism diagnosed during hospitalization in aged male patients

Our aim was to assess short-term natural course of hypogonadism diagnosed during hospitalization for acute disease in aged male patients after discharge. A group of 43 hypogonadal males, aged 86.7±5.7 year, was studied. Serum concentrations of testosterone (T) and gonadotropins (follicle-stimulating hormone, FSH, and luteinizing hormone, LH) were measured in every patient both at admission and one month after discharge. Mean serum T at entry was 115.4±48.0 ng/dl. Hypogonadism was hyper-, hypo-, and normogonadotropic in 20 (46.5%), 20 (46.5%), and 3 (7.0%) patients, respectively. One month after discharge serum T concentrations increased significantly (230.9±135.6 ng/dl, p<0.001). At this point, more than half of the patients (n=27, 62.8%) showed normal serum T concentrations. Both gonadotropins, FSH (p<0.001), and LH (p=0.04) also increased one month after discharge. Approximately, half of the patients (13, 48.1%) who normalized serum T concentrations also showed normal serum gonadotropin concentrations. Patients who normalized their serum T concentrations one month after discharge showed significantly higher baseline values of T (134.7±33.9 ng/dl) than those who persisted with hypogonadism (n=16, 32.7%; 82.8±51.6 ng/dl, p<0.001). Lastly, serum T was the only independent predictor for achieving eugonadal status (OR 1.030; CI 95%, 1.010-1.050; p<0.001). In conclusion, about 63% of aged patients hospitalized for acute illness with hypogonadism discovered during hospitalization spontaneously normalize their serum T concentrations one month after discharge. Serum gonadotropin concentrations also increased after discharge. Serum T levels at admission was an independent predictor for the normalization of serum T concentrations.

Hypogonadism in aged hospitalized male patients: prevalence and clinical outcome

OBJECTIVE

Male hypogonadism is common in the elderly and has been associated with increased risk of mortality. Our objective has been to assess the prevalence of primary and central hypogonadism in elderly male patients admitted to the hospital because of acute illness. We also evaluated the relationships between gonadal dysfunction and in-hospital mortality.

PATIENTS AND METHODS

150 patients, aged ≥65 years, admitted during 2010 and 2011 in our geriatric unit, were studied. Serum concentrations total, bioavailable and free testosterone, as well as of follicle-stimulating hormone and luteinizing hormone were quantified in every patient. Hypogonadism was defined by the presence of serum testosterone levels lower than 200 ng/dl.

RESULTS

Hypogonadism was found in 80 patients (53.3 %). Serum gonadotropin concentrations were elevated in 43.7 % of these patients, whereas 41.3 % of hypogonadic patients showed normal and 15 % low gonadotropin concentrations. Respiratory tract infection and congestive heart failure were the main causes of hospitalization in hypogonadal men, whereas acute cerebrovascular disease was the main reason for admission in eugonadal patients. Of the 13 patients who died during hospitalization, 12 were hypogonadic. Patients who died showed significantly lower serum levels of total, free and bioavailable testosterone than those found in patients who survived.

CONCLUSION

Our results show that about half of patients admitted for acute illness have hypogonadism, mainly of non-hypergonadotropic type. Gonadal hypofunction is significantly related with in-hospital mortality. A low value of serum testosterone may be a predictor for mortality in elderly male patients.

Thyroid function tests and mortality in aged hospitalized patients: a 7-year prospective observational study

CONTEXT

Several alterations in thyroid function test (TFT) results have been associated with mortality in elderly patients.

OBJECTIVE

Our aim was to investigate the relationship between TFT results and all-cause and cardiovascular (CV) mortality in aged hospitalized patients.

DESIGN

A 7-year prospective observational study was conducted. TFTs were performed at hospital admission, and mortality was registered in the follow-up period.

PATIENTS

Participants were 404 patients aged >65 years admitted to the Department of Geriatrics, Hospital General, Segovia, Spain, for any reason during 2005.

MAIN OUTCOME MEASURES

The study evaluated the association between TFT results and mortality from all causes and CV diseases.

METHODS

TSH, free T₄, and free T₃ (FT₃) were measured on the first day of admission. In-hospital and total survival times, number of deaths, and all-cause and CV mortality were registered until the census date on January 1, 2012.

RESULTS

During the study, 323 patients (80%) died. Kaplan-Meier analysis showed that median survival time for all-cause mortality was significantly lower in patients in the first tertile of serum FT₃, in the first tertile of TSH, and in the first tertile of serum free T₄ concentrations. Multivariate adjusted Cox regression analysis showed that the history of cancer (hazard ratio, 1.60; 95% confidence interval, 1.12-2.28; P = .009), age (1.03; 1.01-1.06; P = .003), and FT₃ levels (0.72; 0.63-0.84; P < .001) were significant factors related to all-cause mortality. The cause of death was known in 202 patients. Of this group, 61 patients (30.2%) died of CV disease. Patients in the first tertile of TSH and FT₃ exhibited a significant higher mortality due to CV disease. In the adjusted Cox regression analysis, FT₃ was a significant predictor of CV mortality (0.76; 0.63-0.91; P = .004).

CONCLUSIONS

Alterations in TFT results during hospitalization are associated with long-term mortality in elderly patients. In particular, low FT₃ levels are significantly related to all-cause and CV mortality.

Fasting hyperglycaemia and in-hospital mortality in elderly population

BACKGROUND

Admission hyperglycaemia has shown to be a marker of poor clinical outcome. The prevalence of admission hyperglycaemia and its relationship with in-hospital mortality in elderly population has not been clearly defined. We assessed the prevalence and prognostic significance of admission fasting hyperglycaemia in aged patients.

METHODS

A total of 808 elderly patients were studied. Patients were classified into group I (serum glucose < 126 mg/dl), II (126-180 mg/dl) and III (> 180 mg/dl). Groups II and III were considered newly recognised fasting hyperglycaemia (NRFH) in non-diabetic patients.

RESULTS

NRFH was present in 18.6%. After excluding diabetic patients (n = 206, 25.5%), the distribution of patients (n = 602, 74.5%) was as follows: group I (n = 452, 55.9%), group II (n = 122, 15.1%) and group III (n = 28, 3.5%). In the whole cohort, median fasting glucose was lower in patients who survived [105 mg/dl (88-135)] than in those who died [127 mg/dl (93-159), p < 0.001]. This significant difference was maintained only when non-diabetic patients were considered [100 mg/dl (87-122) vs. 118 mg/dl (92-149), p < 0.001]. In-hospital mortality rate in groups I, II and III was 8.5%, 14.1% and 22.9%, respectively (p < 0.001). Mortality rate was 8.4%, 18.0% and 32.1% (p < 0.001) in groups I, II and III, respectively in non-diabetic population. Both low albumin and high glucose serum concentrations were the only independent risk factors for in-hospital all-cause mortality in non-diabetic patients.

CONCLUSIONS

In non-diabetic elderly patients admitted for acute disease, serum glucose concentration is an important, simple and independent predictor of hospital mortality.

Serum thyrotropin concentration is an early marker of normalization of low triiodothyronine syndrome in aged hospitalized patients after discharge

OBJECTIVES

To assess short-term spontaneous evolution of alterations in thyroid function tests in aged hospitalized patients after discharge.

METHODS

A group of 146 patients (mean age±SD 85.9±6.2 yr) was studied. Serum concentrations of TSH, free T4 (FT4), and free T3 (FT3) were evaluated in every patient both after admission and 1 month after discharge.

RESULTS

At entry, both serum TSH [median (interquartile range), 2.19mU/l (0.89-2.31)] and FT4 (mean±SD, 16.7±3.4 pmol/l) concentrations were into the normal range, whereas serum FT3 concentrations were low (3.3±0.7 pmol/l). After discharge TSH and FT4 concentrations remained normal and FT3 low. However, both serum TSH [2.53 mU/l (1.24-3.33); p<0.01] and FT3 (3.7±1.0 pmol/l; p<0.001) concentrations significantly increased. Most patients (no.=124, 84.9%) showed the euthyroid sick syndrome (ESS). After discharge, ESS diminished to 76 (52.1%) subjects. Patients who normalized thyroid function tests showed significantly lower TSH values at entry compared with those who persisted with altered thyroid function tests [1.27 mU/l (0.69-1.89) vs 1.69mU/l (0.96-2.91), p<0.05]. Logistic regression analysis showed that serum levels of TSH at admission was the only variable negatively related to normalization of thyroid function [odds ratio 0.730; confidence interval 95%, 0.567-0.940; p=0.01).

CONCLUSIONS

About 35%of aged patients hospitalized for acute illness spontaneously normalize their thyroid function tests 1 month after discharge, mainly due to the correction of ESS. Serum TSH levels at admission seem to be the only variable negatively related to normalization of thyroid function at this time.

[Estimation of glomerular filtration rate in persons aged 69 years or older: agreement between distinct calculation methods]

MATERIAL

Estimation of glomerular filtration rate (eGFR) is the most widely accepted marker of renal function. Precise calculation is not routinely performed in clinical practice. Several methods have been developed for eGFR: creatinine clearance (CCr) calculation or the use of formulae derived from serum creatinine (sCr). The present study aimed to analyze the agreement between distinct methods of calculating eGFR.

MATERIAL AND METHODS

We performed a cross-sectional study between January and April, 2006 in 32 stable elders, aged 69 years or older, evaluated in a general nephrology unit. eGFR was calculated by CCr (considered the gold standard), Cockcroft-Gault (CG) and Modification of Renal Diet in Disease (MDRD) equations. The Mann Whitney U-test, Spearman's correlation coefficient and the Kappa coefficient were used to compare means and determine the concordance between methods.

RESULTS

The overall means+/-SD of GFRe for CCr were 36.14+/-16 ml/min (range 11.75-69.6); CG: 37.02+/-16 ml/min (range 13.3-72.3) and MDRD: 45.52+/-16 ml/min (range 19.2-75.36). Variations in eGFR on comparison of methods were CCr and MDRD: -9.37 ml/min (95% CI:-13.85, -4.9); CCr and CG:-2.54 ml/min (95% CI: -6.95, 1.80); MDRD and CG: 9.0 ml/min (95% CI: 5.96, 12). The correlation between the gold standard (CCr) and sCr-derived formulae was r=0.74 for MDRD (P<0.001) and r=0.77 for CG (P<0.001). The Kappa value for CCr and CG was 0.44 and was 0.35 for CCr and MDRD. When patients were classified by stage of chronic renal disease, discrepancies were found according to the method used: stage 5 (eGFR<15 ml/min) was diagnosed in 13.63% with CG while none were diagnosed with stage 5 with MDRD.

CONCLUSIONS

In the estimation of the renal function in the elderly, eGFRe levels can differ in the same patient according to the method used: in view of the degree of concordance between CG and CCr, this mathematical formula should be used in preference to MDRD.

Alterations in thyroid function tests in aged hospitalized patients: prevalence, aetiology and clinical outcome

BACKGROUND

Thyroid dysfunction is common in aged people and has recently been associated to mortality.

AIMS

Our aims have been (1) to assess the prevalence of alterations in thyroid function tests in hospitalized patients over age 60 years and (2) to study the relationship between thyroid functional status and mortality during hospitalization.

METHODS

We studied a group of 447 patients (62% women), aged 61-101 year, hospitalized during 2005. Thyroid dysfunction was assessed by measuring serum concentrations of thyrotrophin (TSH), free thyroxine (FT4), and free thriiodothyronine (FT3). Thyroid autoimmune status was evaluated through thyroid peroxidase (TPO) and thyroglobulin (TG) antibodies quantification.

RESULTS

Twenty-one patients (4.7%, 19 women) showed previously known thyroid dysfunction. 332 patients (74.3%) showed alterations in thyroid function tests. Euthyroid sick syndrome (ESS) was the derangement more frequently found (n = 278, 62.2%). After excluding ESS patients, 60 patients (13.4%) showed thyroid dysfunction: overt hypothyroidism, 14 (3.1%); subclinical hypothyroidism, 25 (5.6%); overt hyperthyroidism, 11 (2.5%), and subclinical hyperthyroidism, 10 patients (2.2%). Thyroid autoimmunity was positive in only 4.0% and 2.3% of patients, for TPOAb and TgAb, respectively. The presence of alterations in thyroid function tests was positively associated with the age of the patients and mortality during hospital stay (P < 0.001). Serum levels of FT3 were negatively related to death during hospitalization (OR 0.56; CI 95%, 0.38-0.81; P < 0.01).

CONCLUSIONS

About three quarters of patients admitted in our geriatric unit exhibited alterations in thyroid function tests. This finding was associated with elevated age and poor prognosis. The reduction of FT3 values was a powerful predictor for mortality during hospitalization in elderly patients.

[Laboratory manifestations associated with chronic renal failure: what degree of estimated glomerular filtration can be used for its detection in the elderly?]

OBJECTIVE

A classification of chronic kidney disease (CKD) based on stages of glomerular filtration (GF) has recently been developed. Thus, chronic renal failure (CRF) is based on GF <60 ml/min. Our goal was to study the presence of typical manifestations of CRF in elderly individuals with a GF of <60 ml/min (stage 3-5) and to determine the cut-off value at which GF can be used to detect these manifestations.

MATERIAL AND METHODS

We performed a cross-sectional study in clinically-stable elderly patients attending the geriatrics and nephrology outpatient department. The estimated GF (GFe) was established with the Cockroft-Gault and abbreviated Modification of Diet in Renal Disease Study (MDRD) formulae. Because these patients had a GF of less than 60 ml/min, they were expected to show the manifestations associated with CRF (anaemia, metabolic acidosis, abnormal bone and mineral metabolism). We evaluated the occurrence of these manifestations and the GF cut-off at which they were detected. To do this, the population was divided into two groups: group A: patients with GFe > or = 30 ml/min (stage 3, N=48); and group B: patients with GFe <30 ml/min (stages 4-5, N=8).

RESULTS

Seventy percent of the patients had a GFe (MDRD) <60 ml/min (stage 3-5). Despite reduced GF, these patients did not show the typical manifestations of CRF. Group B showed higher plasmatic levels of creatinine, urea, uric acid, and potassium and required treatment with erythropoietin and calcium salts.

CONCLUSIONS

Many elderly people diagnosed with CKD with the current classification do not show manifestations of CRF. Estimation of the GF in elders should be generalized to correctly adjust medication to renal impairment rather than to classify elders into CKD stage.

Improving nasal tip projection and definition using interdomal sutures and open approach without transcolumellar incision

The object of this study was to maximally take advantage of the combination of two surgical techniques to manage the nasal tip. For this, an approach similar to the open tip approach without a transcolumellar incision was performed and the management of the alar cartilages with multiple combined sutures was carried out. This study represents more than two years of work where 57 primary and secondary rhinoplasty patients were operated on. In all of them, the nasal tip was managed by means of utilizing different types of sutures in the alar cartilages, according to the characteristics and needs of each patient. At the same time, an extensive lipectomy was performed on the nasal tip, if indicated. All of the nasal tip surgeries were performed with an open approach without transcolumellar incision. This approach has been previously described, is highly simple, and it eliminates the principal disadvantage of a transcolumellar scar that arises from the open approach technique. Although the scar is hardly noticeable in Caucasian patients, in non-Caucasians it could constitute an important undesirable effect. This approach permits us to manage the cartilages using sutures in many diverse types and variations in a more complete form, similar to which one could achieve using the classical open approach technique. The results are highly satisfactory and result in a definition and rotation of the nasal tip which would be difficult using the closed technique. Therefore, this study represents another alternative surgical technique in the surgical management of the nasal tip.

Digitization of photographic slides: simple, effective, fast, and inexpensive method

The technological evolution has changed multiple areas of plastic surgery, including photography. The photograph is one of the instruments used most by the plastic surgeon, and it cannot be eliminated by technological changes. The principal change in photography is that images can be scanned through digital cameras instead of slides. Despite the multiple advantages that digital photography represents, many surgeons are resisting the change. One of the main reasons for this resistance is the large quantity of photographic slides that need to be digitized to be used at scientific conferences as well as in publications. The methods and existing techniques for digitizing slides are costly and time-consuming, and there is risk for loss of definition and image brightness. The authors present a simple, effective, fast, and inexpensive method for digitizing slides. This method has been validated by various plastic surgeons and is effective for use in multimedia presentations and for paper printouts with publication quality.

Nasal angiocentric lymphoma: an entity that should be remembered

After four nasal aesthetic functional surgeries in a period of 18 months, a 46-year-old woman was evaluated who presented with moderate functional alteration, saddle-nose deformity, and total loss of the septal cartilage. Four months before presentation the patient sustained severe nasal trauma, resulting in depression of the nasal bridge without loss of function. Her problem was diagnosed initially as a consequence of an infected septal hematoma and loss of the septal cartilage. Based on this diagnosis, the patient was subjected, in an 18-month period, to four reconstructive surgeries by different specialists, without any improvement and with worsening of clinical presentation. During the authors' physical examination of the patient, she demonstrated marked nasal cutaneous retraction, atrophic nasal conchae with total loss of the septal cartilage, and a large loss of septal bone. Three nasal mucosa biopsies were acquired and the authors proceeded to carry out complete nasal reconstruction using external cranial table and rib cartilage. Histopathologically, a lesion was noted that was compatible with angiocentric lymphoma, for which treatment was administered according to this type of illness. The authors point out the importance of establishing an adequate diagnosis in the face of an apparently obvious clinical case, present cross-disciplinary treatment, and discuss the study protocol that should be used for this type of pathology. They present their reconstructive technique of the nasal structure using a combination of bone tissue and cartilage, the results, and the current state of the patient.

Use of cartilaginous autografts in nasal surgery: 8 years of experience

Although the cartilaginous autografts are one of the tissues more utilized in nasal surgery, a comparative study does not exist to determine which are better options and their precise indications. It is for this reason that a histopathologic analysis was carried out comparing the characteristics and properties of the four principal cartilages that are utilized in aesthetic functional surgery of the nose. Considering these particularities, the precise indications for the employment of the different cartilage as nasal autografts were determined. Of 1120 aesthetic functional rhinoplasties during a period of 8 years, 930 (83 percent) required cartilaginous autografts, 86 percent were primary, 11 percent were secondary, and 3 percent had two or more surgeries. Eighty-three percent of the grafts used were from nasal septum, 12 percent from the auricle, 3 percent from alar cartilages, and 2 percent from the rib. The anatomic sites in which they were employed consisted of the following: 64 percent between the medial crura, 28 percent as in Sheen's graft, 19 percent in the nasal dorsum, 8 percent as spreader grafts, 8 percent as in Peck's graft, and 3 percent in the rim to improve alar collapse. We followed at all times the previous indications for obtaining and placing the nasal autografts. Eighty-four percent of the patients were totally satisfied and only 8 percent required a second surgical procedure to achieve the results desired. Based on this study, it is recommended to utilize the cartilaginous autografts in nasal surgery considering three parameters: the physical and histologic characteristics of each cartilage, the anatomic site in which they are to be placed, and the effect desired with their application.

Cartilaginous behavior in nasal surgery: a comparative observational study

Cartilaginous autografts, either from the ribs, auricular concha, nasal septum, or even the alar cartilages, are some of the most widely used materials in nasal surgery. Nevertheless, no comparative study exists on these four cartilages in which their physicoelastic properties are analyzed based on their histological architecture and their function within the organism. The studies that do exist on structure and classification of cartilages differ widely. In this study, cartilage specimens obtained from the nasal septum, rib, auricular pavilion, and alar of 7 fresh cadavers were analyzed. They were subjected to special tincturing to be able to histologically observe their architecture, cellularity, intercellular substance, the relationship between cellularity and intercellular substance, the primary components of the matrix, and the distribution of fibers. Many similarities were found among the septal, costal, and alar cartilages. All three exhibit little cellularity and much intercellular substance. The intercellular substance is made up of homogeneously distributed collagen fibers. Auricular cartilage has many cells and little intercellular substance, being made up of irregularly distributed elastic fibers. On the basis of these findings, we propose a simpler classification and make recommendations for the use of these four cartilages in nasal surgery.

[Assessing quality of life in Parkinson's disease using the PDQ-39. A pilot study]

The aim of this pilot study was to analyze an adaptation of the PDQ-39, a Parkinson's disease (PD) quality of life questionnaire, for use in Spanish. Fifty patients were enrolled. Patient characteristics and medical histories were recorded, including scores on the following scales: Hoehn and Yahr (HY), PD unified (UPDRS), Schwab and England (SE), Intermediate Scale for Assessment of PD (ISAPD). Barthel Index (BI), Pfeiffer's SPMSQ, Global Deterioration Scale (GDS), Geriatric Depression Scale (GDS). Hospital Depression and Anxiety Scale (HDA) and the PDQ-39. Descríptive statistics were recorded, as well as Spearman's r and ANOVA results. The dimensions that correlated well with PD scale scores were mobility, daily life activities and cognitive deterioration. The dimension stigma correlated with complications on the UPDRS and the ISAPD. Emotional well-being correlated with subscale I of the UPDRS, the GDS and the HDA (r = 0.39-0.79, p < 0.01-0.001). Physical discomfort correlated only with depression and anxiety. Stage of disease and level of depression influenced most dimensions assessed by the PDQ-39. Some psychosocial factors that are important components of well-being are scarcely reflected by the clinical scales usually applied.