Gulistan Bahat Ozturk

Malnutrition in the elderly and its relationship with other geriatric syndromes.

BACKGROUND & AIMS Age related decline in food intake is associated with various physiological, psychological and social factors. Our aim was to assess the nutritional status of our elderly patients and its association with other geriatric syndromes. METHODS In this cross-sectional population based study, Mini Nutritional Assessment (MNA) test was used to evaluate nutritional status of 413 elderly patients who were admitted to our outpatient clinic in the last 12 months. MNA test results were compared with the laboratory findings and established geriatric syndromes. RESULTS Poor nutritional status was found in 44% of the patients (n=181: 13% malnutrition, 31% malnutrition risk). Malnutrition rate was higher among those with subsequent hospitalization (n=122, 25% vs 8%). Patients with poor nutritional status had lower blood haemoglobin, serum total protein and albumin, and revealed more chronic diseases and geriatric syndromes (6 ± 2 vs 3 ± 2, p<0.0001). Patients with depression, fecal incontinence, decreased cognitive function and functional dependence showed poor nutritional status according to MNA test results. CONCLUSIONS Malnutrition rate of our patients was comparable with the previous data. Malnutrition risk showed positive correlation with the number of existing geriatric syndromes. Depression, dementia, functional dependence and multiple co-morbidities were associated with poor nutritional status.

Fever of unknown origin: a report of 57 cases

Fever of unknown origin (FUO) is defined as the body temperature higher than 38.3 °C on several occasions and lasting longer than 3 weeks, with the aetiology remaining uncertain after 1 week of investigation. In this study, we reviewed 57 patients with FUO hospitalised in our inpatient department between 1998 and 2003. The median age of the patients was 44 years (17–84), and 26 were males (46%), while 31 were females (54%). In 24 patients (42%), infectious diseases such as tuberculosis (12 patients) and brucellosis (5 patients) were found under the aetiology of FUO. Inflammatory rheumatic diseases were the second most common cause of FUO (17 patients, 30%), while malignancies were found in 10 patients (18%). In six patients (10%), aetiology could not be identified. In conclusion, infectious diseases especially tuberculosis and brucellosis are the leading causes of FUO in our country.

Nutritional risk in hospitalized patients: impact of nutritional status on serum prealbumin

OBJETIVO: Falha no reconhecimento e acompanhamento do estado nutricional e a razao mais importante da desnutricao em pacientes hospitalizados. Este estudo objetivou avaliar o estado nutricional dos pacientes e comparar os resultados com os niveis sericos de pre-albumina. METODOS: Foram incluidos 97 pacientes no estudo, internados consecutivamente. O risco de desnutricao foi avaliado de acordo com dados antropometricos e com a Avaliacao Subjetiva Global e Triagem de Risco Nutricional 2002. Os estados nutricionais dos pacientes foram comparados com suas idades, sexo, indice de massa corporal, historico medico, perda de peso e analises bioquimicas, incluindo pre-albumina e tempo de permanencia hospitalar. RESULTADOS: De acordo com o Triagem de Risco Nutricional 2002, 57% dos pacientes estavam desnutridos ou em risco de desnutricao, apresentando boa correlacao com o Avaliacao Subjetiva Global (p<0,001, r=0,700). A analise multivariada mostrou correlacoes positivas entre desnutricao e idade, perda de peso, malignidade e proteina reativa-C (p=0,046, p=0,001, p=0,04 e p=0,002). Um escore ³3 no Triagem de Risco Nutricional 2002 foi associado a internacao prolongada (p<0,001). Houve correlacao entre pre-albumina serica e o estado nutricional, independente do numero de doencas cronicas e biomarcadores de inflamacao (p=0,01). A sensibilidade, especificidade, valor preditivo positivo, valor preditivo negativo e valor diagnostico da pre-albumina na avaliacao do risco de desnutricao foram de 94%, 32%, 0,67, 0,78 e 69, respectivamente. Apos sete dias de suporte nutricional, o risco de desnutricao caiu em 12% (p<0,001) e os niveis sericos de pre-albumina aumentaram em 20% (p=0,003). CONCLUSAO: Ao inves de refletir o estado nutricional global do paciente, niveis sericos baixos de sericos de pre-albumina podem ser vistos como um sinal de maior risco de desnutricao, exigindo uma avaliacao nutricional mais extensa. A analise serica de pre-albumina pode ser usada para o monitoramento de pacientes recebendo suporte nutricional.

Uncomplicated diabetes does not accelerate age-related sarcopenia

Abstract Background: Diabetes is reported to accelerate sarcopenia (age-related loss of muscle mass and function). We aimed to assess muscle mass and strength in elderly diabetics, elderly non-diabetics, younger diabetics and healthy subjects, and to define correlates of muscle mass and strength in these subjects. Methods: Sixteen elderly diabetics, 16 younger diabetics, 16 elderly non-diabetics and 18 younger non-diabetics were included. Elderly and diabetic subjects were first evaluated with exercise testing. Isokinetic leg extension and flexion tests were performed using a Cybex 350 dynamometer. Muscle mass was calculated using bioelectric impedance analysis. Results: Muscle mass was similar between all groups; however, muscle strength was significantly lower in diabetic and non-diabetic elderly subjects compared with younger diabetic subjects and non-diabetics. Muscle strength was positively correlated with albumin, metabolic equivalent and hemoglobin, and inversely correlated with age, HbA1c, functional capacity and CRP. Independent correlates of muscle strength were age and hemoglobin. There was no clinically significant correlate of muscle mass. Presence or duration of diabetes was not associated with muscle mass or strength. Conclusions: Uncomplicated diabetes does not seem to accelerate aging-related muscle mass or strength loss. Exercise test parameters may be useful markers in the screening of sarcopenia.

Corticosteroid treatment normalizes QTc prolongation and improves heart block in an elderly patient with anti-Ro-positive systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a multisystemic disease which potentially involves various organs including the skin, joints, kidneys, liver, hematopoetic system, and serous membranes. It is rarely seen in elderly males. The most common cardiovascular involvement type is pericarditis. Anti-Ro antibodies may be associated with neonatal lupus which causes heart blocks. Recent literature indicates that anti-Ro antibodies may be associated with various rhythm and conduction disturbances in the adulthood. The most common finding associated with anti-Ro antibodies is prolonged corrected QT (QTc) interval. Herein, we present an elderly male patient with anti-Ro-positive SLE associated with prolonged QTc interval and AV blocks that significantly improved after corticosteroid treatment.

Kappa light chain myeloma with initial cutaneous involvement

Dear Editor, Cutaneous involvement in multiple myeloma (MM) is rare and generally develops as a consequence of direct spread from an underlying osteolytic lesion or solitary plasmacytoma of the bone in the late stages of the disease [1]. We present a 45-year-old woman with weight loss, weakness, neck and shoulder pain and skin lesions. Her skin lesions were nontender, nonpruritic violaceous papules (up to 8 mm), had firm consistency and smooth surfaces, and located on her trunk and abdomen (Fig. 1a). Laboratory examination revealed increased erythrocyte sedimentation rate (90 mm/h), macrocytic anemia (hemoglobin 9.5 g/dl, mean corpuscular volume 102.7 fl), increased blood–urea–nitrogen (14.28 mmol/l), creatinine (256.36 μmol/l) and uric acid (487.7 μmol/l) levels with decreased gammaglobulin (5 g/l) level. Serum albumin was 36 g/l. Creatinine clearance and daily proteinuria were 0.517 ml/s and 13.5 g. Abdominal ultrasonography showed enlarged kidneys with increased renal parenchymal echogenicity. Skin biopsy revealed a dense perivascular and nodular neoplastic plasma cell infiltration, beginning at the papillary dermis and extending through the deep dermis-subcutaneous fat border (Fig. 1b). Nodular and interstitial neoplastic plasma cell infiltration (40%) with monotypic kappa light chain expression was seen in bone marrow biopsy (Fig. 1c). Beta-2-microglobulin was 18.97 mg/l. There were monoclonal kappa light chain bands on both serum (1940 mg/l) and urine (415 mg/l, 11%) immunoelectrophoreses. Serum immunoglobulin levels were IgA 720 mg/l, IgG 3,820 mg/l, IgM 420 mg/l, kappa 1,940 mg/l, and lambda 1,100 mg/l. MM with skin involvement was diagnosed. No lytic lesions were seen on skeletal x-rays. Chromosomal analysis revealed 46,XX. Renal biopsy showed cast nephropathy (Fig. 1d). After three consecutive VAD protocols (parenteral vincristine, adriamycine, and oral dexamethasone), skin lesions disappeared. However, control bone marrow biopsy revealed poor response. Thalidomide 400 mg/day and dexamethasone 40 mg/day were given, but stopped due to peripheric neuropathy. The treatment was changed to high-dose dexamethasone. Plasma cell leukemia developed 14 months after the first diagnosis, and she died with pneumonia and sepsis. Although generally occurs with direct extension from an underlying bone lesion of the disease, cutaneous lesions of MM can also be seen distinct from a bony focus, and even as the initial manifestation of the disease. They appear in the form of papules or cutaneous and subcutaneous nodules; those that can be measured are 1–5 cm in diameter, with firm consistency, smooth surface, and a red or violaceous color. Rarely larger lesions like plaques can be seen. They are generally localized to trunk and abdomen [1]. A review of the literature reveals that patients with MM and cutaneous plasmacytoma show IgG monoclonal immunoglobulin in 56%, IgA in 24%, free light chain in 12%, IgD in 4%, and IgM in 4% [2]. Recently, BayerGarner et al. [3] reviewed their MM patients with various skin lesions. They found skin lesions in 284 patients out of 2,357. Only 14 patients had the diagnosis of cutaneous plasmacytoma, 10 IgG-producing tumors (4 λ, 6 κ), 1 IgA κ, 1 IgM κ, 1 κ-light chain, and 1 nonsecretory after chemotherapy. Cutaneous plasmocytoma in Bence-Jones protein secreting MM is even rarer and generally occurs in the late stages of the disease [4]. Histopathologic examination of the cutaneous plasmacytomas in MM revealed two patterns: nodular or diffuse interstitial infiltration [2], which was B. Saka (*) . N. Erten . G. Oztürk . C. Yılmaz . S. K. Besisik Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Millet Cad., 34270 Capa/Fatih/Istanbul, Turkey e-mail: sakab@medscape.com Tel.: +90-212-4142000 Fax: +90-212-5324208

Approach to Pain in the Elderly

Pain is the most common complained symptom in the elderly. Acute pain prevalence does not change with aging. However, chronic pain is much more prevalent in the elderly compared to young individuals. Despite these facts, pain in the elderly is commonly assessed and treated inadequately. The treatment goal of pain in the elderly is not always complete eradication of pain but decrease in pain allowing the improvement in activities of daily living and quality of life. Nonpharmacological-pharmacological approaches and anesthetic/invasive interventions can be used for pain treatment. During pharmacological treatment, the changes related to aging should be considered enabling increased side effects and drug-drug interactions. Generally, the stepwise guideline suggested by World Health Organisation for cancer pain is valid also for the treatment of chronic pain. Acetaminophen is the safest and mostly preferred analgesic in treating mild-moderate pain in the elderly. Metamizole is also free of gastrointestinal and thrombocyte related side effects. It is widely used in available countries for the pain in elderly with more intense and spasmolytic analgesic effect compared to other non-opioids. Nonsteroidal anti-inflammatory drugs can be used in moderate-severe pain. However, they should not be used in high doses and/or for a long time due to their severe side effect profile. Opioids are effective in all pain types and used in severe pain. The elderly is more prone to both analgesic effect and side effects of opioids. The most important side effects of opioids are respiratory depression, sedation, cognitive problems, emesis and constipation. Recently, they are being more suggested for the treatment of chronic non cancer pain in the elderly. If the pain is not controlled with these measures, the next step is the use of anesthetic/invasive modalities. In these cases, the elderly should be referred to centers specialized on pain. The aim of our study is to summarize the general approach to acute and chronic pain in elderly.

A case of paroxysmal nocturnal hemoglobinuria presenting with intra‐abdominal bleeding due to splenic rupture, developing renal infarct

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare disorder characterized by intravascular hemolysis, hemoglobinuria, and thrombosis. Thrombotic attacks are life threatening and are responsible for nearly 50% of PNH‐related deaths. Compared with thrombotic events, bleeding related to thrombocytopenia in PNH is quite rare. This report describes an atypical clinical presentation with problems in the diagnosis and management of a woman who presented with a splenic infarct followed by massive intra‐abdominal bleeding due to splenic rupture. She also developed a renal infarct during hospitalization after diagnosis.

Primary Biliary Cirrhosis and IgG-kappa Type Multiple Myeloma Both Respond Well to Vincristine, Adriamycin and Dexamethasone: Is There a Pathogenic Relationship?

Patients with primary biliary cirrhosis (PBC) are at increased risk for various malignancies including lymphoproliferative diseases. In this report, we describe a 52-year-old man with the simultaneous diagnosis of PBC and IgG-kappa multiple myeloma (MM). Serum cholestatic enzyme (alkaline phosphatase and gamma-glutamyltransferase) levels decreased after three courses of vincristine, adriamycin and dexamethasone treatment followed by six courses of melphalan and methylprednisolone, given for MM. Pruritus also disappeared. He did not show any progression during the next 24 months of clinical follow-up. The coexistence of PBC and MM is rare and the pathogenetic mechanism under this association remains unclear. Clinical improvement of both diseases in this patient after chemotherapy may indicate an association; however, absence of concurrency in previous large series increases the possibility of coincidence in this case. When compared with the previous single case reports, this case provided long-term results about response after chemotherapy.