Frailty, osteoporosis and hip fracture: causes, consequences and therapeutic perspectives

OBJECTIVE

The aim of this review of the literature is to report the factors which both contribute to the frailty syndrome and increase hip fracture risk in the elderly. This work is the fruit of common reflection by geriatricians, endocrinologists, gynecologists and rheumatologists, and seeks to stress the importance of detection and management of the various components of frailty in elderly subjects who are followed and treated for osteoporosis. It also sets out to heighten awareness of the need for management of osteoporosis in the frail elderly.

DESIGN

The current literature on frailty and its links with hip fracture was reviewed and discussed by the group.

RESULTS

The factors and mechanisms which are common to both osteoporosis and frailty (falls, weight loss, sarcopenia, low physical activity, cognitive decline, depression, hormones such as testosterone, estrogens, insulin-like growth factor-I (IGF-I), growth hormone (GH), vitamin D and pro-inflammatory cytokines) were identified. The obstacles to access to diagnosis and treatment of osteoporosis in the frail elderly population and common therapeutic pathways for osteoporosis and frailty were discussed.

CONCLUSION

Future research including frail subjects would improve our understanding of how management of frailty can can contribute to lower the incidence of fractures. In parallel, more systematic management of osteoporosis should reduce the risk of becoming frail in the elderly population.

[Evaluation of pulmonary function in the elderly. Intergroupe Pneumo Gériatrie SPLF-SFGG]

Aging is associated with a progressive decrease in lung function. As a consequence of aging, individual's reserve is diminished, but this decrease is heterogeneous between individual subjects. Many factors are involved in the overall decline in lung function. The prevalence of asthma in the elderly is estimated between 6 and 10%. Mortality due to COPD is increasing, especially among older subjects. Older subjects are at an increased risk of developing chronic diseases such as Parkinson's disease, which can have consequences for lung function. Under-nutrition is also common in the elderly and can produce sarcopenia and skeletal muscle dysfunction. The presentation of respiratory disorders may differ in the elderly, especially because of a lack of perception of symptoms such as dyspnea. The impact of bronchodilatators or corticosteroids on respiratory function has not been studied in the elderly. Drugs usually used for the treatment of hypertension or arrhythmias, which are often observed with aging, can have pulmonary toxicity. There is no difference between functional evaluation in younger and older subjects but it is more difficult to find predicted values for older patients. Performing pulmonary function tests in older patients is often difficult because of a higher prevalence of cognitive impairment and/or poor coordination. When assessing pulmonary function in the elderly, the choice of tests will be depend on the circumstances, with the use of voluntary manoeuvres dependent on the condition of the patient.

Cancer bronchique du sujet âgé

INTRODUCTION

In France, the average age for the diagnosis of bronchial carcinoma is 64. It is 76 in the population of over 70. In fact, its incidence increases with age linked intrinsic risk of developing a cancer and with general ageing of the population. Diagnosis tools are the same for elderlies than for younger patients, and positive diagnosis mainly depends on fibreoptic bronchoscopy, complications of which being comparable to those observed in younger patients.

STATE OF THE ART

The assessment of dissemination has been modified in recent years by the availability of PET scanning which is increasingly becoming the examination of choice for preventing unnecessary surgical intervention, a fortiori in elderly subjects. Cerebral imaging by tomodensitometry and nuclear magnetic resonance should systematically be obtained before proposing chirurgical treatment. An assessment of the general state of health of the elderly subject is an essential step before the therapeutic decision is made. This depends on the concept of geriatric evaluation: Geriatric Multidimensional Assessment, and the Comprehensive Geriatric Assessment which concerns overall competence of the elderly.

PERSPECTIVES

This is a global approach that allows precise definition and ranking of the patient's problems and their impact on daily life and social environment. Certain geriatric variables (IADL, BADL, MMSE, IMC etc) may be predictive of survival rates after chemotherapy or the incidence of complications following thoracic surgery. The main therapeutic principles for the management of bronchial carcinoma are applicable to the elderly subject; long term survival without relapse after surgical resection is independent of age. Whether the oncological strategy is curative or palliative, the elderly patient with bronchial carcinoma should receive supportive treatments. They should be integrated into a palliative programme if such is the case. In fact, age alone is not a factor that should detract from optimal oncological management.

CONCLUSIONS

The development of an individual management programme for an elderly patient suffering from bronchial carcinoma should be based on the combination of oncological investigation and comprehensive geriatric assessment.

Leptin a new biological marker for evaluating malnutrition in elderly patients

BACKGROUND

There is no single universally accepted biochemical marker of nutritional status in the elderly. Many markers are affected by non-nutritional factors.

OBJECTIVE

The purpose of this study was to determine the biological parameters best related to anthropometric markers of malnutrition in an elderly polypathological population, and determine cutoff values for these potential parameters to diagnose malnutrition.

DESIGN

This prospective study enrolled 116 elderly hospitalized patients and 76 elderly outpatients. Nutritional status (albumin, transthyretin, body mass index (BMI), skinfold thickness) and biological parameters (leptin, insulin-like growth factor-1 (IGF-1), IGF binding protein-1 (IGFBP-1), IGFBP-3, C-reactive protein (CRP), orosomucoid) were assessed. We defined malnutrition according to the lowest quartile of BMI and skinfold thickness measured in a large healthy elderly French sample population.

RESULTS

In this sample of elderly patients (age: 85+/-7 years old), leptin concentration was the only biological parameter significantly related to nutrition status. Independent correlations were found between leptin concentration and BMI, skinfold thickness and sex. The relationship between nutritional status and leptin concentration is significantly different in each sex: the more the patients are undernourished, the lower the leptin concentration in both sexes. The optimal leptin cutoff value for the diagnosis of malnutrition in this population was 4 microg/l in men (sensitivity 0.89, specificity 0.82) and 6.48 microg/l in women (sensitivity 0.90, specificity 0.83).

CONCLUSION

Leptin concentration is highly correlated with anthropometric data whereas albumin or transthyretin are known to be also influenced by morbidity and inflammatory conditions. Serum leptin concentration could be used for nutritional assessment in elderly patients with acute diseases.

Subcorneal pustulosis and Pyoderma gangrenosum associated with a biclonal gammopathy

Pyoderma gangrenosum and subcorneal pustulosis are two neutrophilic dermatoses. Their occurrence in the same patient is rare and may be related to an IgA dysglobulinemia. We report a case presenting these two conditions associated with a biclonal benign IgA and IgG gammopathy. A 67-year-old man exhibited typical pyoderma gangrenosum associated after three years duration with subcorneal pustulosis lesions, confirmed by cutaneous biopsy. Laboratory results showed a biclonal benign IgA and IgG kappa gammopathy. Therapeutic management was difficult: Pyoderma gangrenosum responded well to corticosteroids but subcorneal pustulosis management was harder and treatments were poorly effective.Pyoderma gangrenosum and subcorneal pustulosis are a part of the neutrophilic spectrum. Their association has been only reported in eleven patients. In eight cases, an IgA dysglobulinemia was associated suggesting its responsibility in the occurrence of both dermatoses. Treatments are various and not fully effective. If the Pyoderma gangrenosum usually responds to corticosteroids, the subcorneal pustulosis treatments are not well defined and often not efficient. Our case illustrates the dissociated evolution of these two dermatoses and their difficult global management. During the follow-up, a regular search for dysglobulinemia is required in order to detect malignant transformations.

[Early surgical treatment of cutaneous hemangiomas]

Infantile hemangioma appears after the birth as a vascular tumor, which is known for its characteristic evolution in 3 phases: rapid augmentation then stabilization and involution on several years with in the best cases, classical "restitutio ad integrum". Usual surgical attitude is abstention and surgery is proposed only in order to treat sequel. But some particular situations require early surgery for life-threatening lesions or in case of functional impairment. Surgery consists in these cases in a simple volumetric diminution of the tumor with no aim for esthetic improvement. Other kinds of hemangiomas require an early surgical treatment before their complete involution. In some particular locations, deformation or growth delay can occur due to the lesion's development. In some cases, hemangiomas present a delayed involution with minor regression capacity; these are mainly located on the median part of the face and have principally a subcutaneous development. Early surgery can be proposed in order to avoid definitive deformation or growth impairment of adjacent structures. It should be performed before school age and before occurrence of psychological difficulties. Surgery is indicated in a perspective of esthetic improvement. Surgical procedure consists first in modeling excision followed by simple repair technique as linear suture or purse string closure; complex surgical procedures inducing their own sequels are usually inappropriate.

[Invasive fungal dermatitis in extremely premature newborns: a specific clinical form of systemic candidiasis]

BACKGROUND

Fungal agents, chiefly Candida albicans, are the cause of rising morbidity and mortality in newborn infants weighing less than 1500 g. We studied the particular cutaneous effects during the course of these infections.

PATIENTS AND METHODS

This was a retrospective 3-year study in premature infants weighing less than 1500 g and hospitalized in the neonatal department of the Lille University Teaching Hospital. The patients included in the study presented sepsis with isolation of Candida in blood and/or urine culture.

RESULTS

Twelve infants were included (1.8%). The risk factors seen are those described in literature (broad-spectrum antibiotics, prolonged mechanical ventilation and parenteral nutrition, corticosteroids and central venous catheters). Infection occurred early (mean: D12) and affected extremely premature infants (mean: 25 weeks' amenorrhea) of low birth weight (mean: 758 g) generally born by vaginal delivery (9 of 12 infants). The sole fungal agent isolated was Candida albicans. In 10 of the 12 patients, a characteristic skin disorder was observed (erythema with erosion and desquamation). In 10 of the 12 patients, too, Candida was isolated from skin and/or mucosal samples.

DISCUSSION

Although it is now universally accepted that antifungal treatment should be initiated without delay for candidemia in septic newborn infants at risk, diagnosis of systemic candidiasis remains delicate. However, a specific pattern of skin involvement is very commonly seen that is atypical for candidiasis, but which in addition to its diagnostic value indicates early colonization with Candida (first 2 weeks of life). In this setting of immaturity of the skin and immune system, colonization and proliferation in skin and/or mucosa appear to constitute the first stage of systemic infection and we may speak of invasive cutaneous-mucosal candidiasis in extremely premature infants and initiate treatment designed to prevent the disease becoming systemic..

Activité de consultation de trois services de dermatologie hospitalo-universitaires français

BACKGROUND

We recently carried out a study concerning consultations by French dermatologists in private practice. We evaluated consultations at the dermatology departments of 3 university teaching hospitals in France.

MATERIALS AND METHODS

This was a 2-month prospective study conducted in 2003 at the dermatology departments of the university teaching hospitals of Amiens, Lille and Rouen. Each consultant completed a questionnaire covering the duration of the study. The following data were recorded: consultation date, function of the consultant, study centre, type of consultation, type of disease, and whether or not the patient was hospitalised after the consultation.

RESULTS

7296 files were examined during the study. 38% of the consultations were performed by part-time hospital consultants, 29% by dermatology interns, 18% by hospital practitioners, 9% by university professors and 6% by clinical heads or assistant heads. The most commonly encountered diseases were allergies (17%), cancer (16%), arteriovenous disease (15%) and infectious disease (11%). Three types of consultation were identified: emergency consultations without an appointment, consultations by appointment for a specific problem and consultations by appointment without a specific problem. The number of resulting hospital admissions ranged from 2 to 10% of consultations, depending on the type of consultation and the role of the consultant in question.

DISCUSSION

This study shows that in France, consultations at hospital dermatology departments differ greatly from those of dermatologists in private practice. The main diseases seen (cancer, arteriovenous disease, allergy, infectious dermatosis) accounted for the majority of hospitalisations in these departments. The organisation of hospital consultations is increasingly tending both towards treatment of highly specialised diseases through specifically oriented consultations and also towards the emergency treatment of certain forms of acute dermatosis.

Syndrome de Parkes-Weber familial

INTRODUCTION

Parkes-Weber syndrome is usually described as a sporadic form of osteohypertrophic angiodysplasia. However, family forms of Klippel-Trenaunay syndrome have been described. We report the first familial case of Parkes-Weber syndrome.

OBSERVATION

A boy born at 27 weeks and 6 days of amenorrhea with extensive plane angioma of the right lower limb, right lower part of the back and abdomen. We also noted hypertrophy of this member with venous dilatations. Arterial Doppler ultrasound of the right lower limb showed an aneurysmal varix between the vein and the common femoral artery, confirming a diagnosis of Parkes-Weber syndrome. His maternal first cousin, 10 years his senior, also presented Parkes-Weber syndrome of the right upper limb.

DISCUSSION

This is the first observation of a familial case of Parkes-Weber syndrome in first cousins. Vascular malformations are transmitted in autosomal dominant fashion in the majority of infected families but with incomplete penetrance and variable expressivity. Symptoms appeared to worsen from generation to generation. In each generation of this family, we noted the presence of hemangiomas or capillary malformations with aggravation in the third generation and onset of Parkes-Weber syndrome. Genetic investigation with linkage analysis for the various members in order to identify a predisposing locus yielded little of interest.

Four common glomulin mutations cause two thirds of glomuvenous malformations ("familial glomangiomas"): evidence for a founder effect

BACKGROUND

Glomuvenous malformation (GVM) ("familial glomangioma") is a localised cutaneous vascular lesion histologically characterised by abnormal smooth muscle-like "glomus cells" in the walls of distended endothelium lined channels. Inheritable GVM has been linked to chromosome 1p21-22 and is caused by truncating mutations in glomulin. A double hit mutation was identified in one lesion. This finding suggests that GVM results from complete localised loss of function and explains the paradominant mode of inheritance.

OBJECTIVE

To report on the identification of a mutation in glomulin in 23 additional families with GVM.

RESULTS

Three mutations are new; the others have been described previously. Among the 17 different inherited mutations in glomulin known up to now in 43 families, the 157delAAGAA mutation is the most common and was present in 21 families (48.8%). Mutation 108C-->A was found in five families (11.8%), and the mutations 554delA+556delCCT and 1179delCAA were present together in two families (4.7% each). Polymorphic markers suggested a founder effect for all four mutations.

CONCLUSIONS

Screening for these mutations should lead to a genetic diagnosis in about 70% of patients with inherited GVM. So far, a mutation in glomulin has been found in all GVM families tested, thus demonstrating locus homogeneity.

Clinical variants of the preprotuberant stage of dermatofibrosarcoma protuberans

BACKGROUND

Some cases of dermatofibrosarcoma protuberans (DFSP) do not protrude above the skin.

OBJECTIVES

To assess the prevalence of these DFSPs and further to describe their presentation and course.

METHODS

One hundred and forty-three patients were retrospectively collected. They were asked to complete a standardized questionnaire indicating the history and appearance of the DFSP from the first skin changes identified to the time of diagnosis.

RESULTS

Eighty-one DFSPs were described as protuberant ab initio, and 62 as initially nonprotuberant (npDFSP). The latter remained at this stage for a mean period of 7.6 years. Twenty-nine per cent of npDFSPs were 'morphoea-like', 19% were 'atrophoderma-like' and 42% were 'angioma-like'. Age at diagnosis was similar for both initial presentations. npDFSPs were most often misdiagnosed by physicians.

CONCLUSIONS

Nearly half the patients first identified their early DFSP-related skin changes as patches. Both this frequency and the long duration at this preprotuberant stage should prompt dermatologists to consider the diagnosis of DFSP earlier, in order to make surgical treatment easier.

Traitement par curiethérapie interstitielle du mélanome primitif cutané: 4 cas

BACKGROUND

Traditionally melanoma has been considered as a radioresistant tumor. However, recent observations regarding radiobiology and clinical response of melanoma have prompted physicians to re-evaluate the role of radiotherapy in the management of melanoma. Indeed, radiotherapy is frequently used in the treatment of metastatic melanoma but the role of this therapeutic approach in the primary tumor management is unclear. We report 4 cases of thick primary melanoma treated by interstitial brachytherapy.

CASE REPORTS

Four patients (3 men, 1 woman; age: 73, 74, 79, 84 years), three with lentigo maligna melanoma and one with nodular melanoma, were treated exclusively by interstitial brachytherapy. The thickness of the 4 tumors was more than 3 mm. This treatment was chosen either because of the impossibility of conservative surgery or because of a contraindication for general anesthesia. Median follow-up was 48 months [18 to 65 months] and we did not observe any local tumor relapse. The cosmetic and functional results of this therapy were excellent.

DISCUSSION

These four cases illustrate the possibility of obtaining good local control of thick primary melanoma by interstitial brachytherapy where surgery is impossible, although without challenging the standard surgical therapy for primary melanoma. Before our study, this treatment was used only in one study to treat melanoma patients. In this case however, interstitial brachytherapy was accompanied by surgery. Therefore, the findings reported here are the first to demonstrate the efficacy of this treatment when used as the sole treatment for primary melanoma. In conclusion, where surgery is difficult or impossible, interstitial brachytherapy may be used to treat primary melanoma with excellent local tumor control and a good cosmetic outcome.

[Giant keratoacanthoma of the eyelid]

The clinicopathologic case of a 76-year-old male with a giant tumor of the left eyelid is reported. Histopathological diagnosis was a keratoacanthoma. The lesion was treated with an injection of 5-Fluoro-Uracil and oral treatment with acitretin (Soriatane), causing the lesion to disappear quickly. Clinical and histopathological characteristics of keratoacanthoma are important to know because the differential diagnosis is epidermoid carcinoma. This treatment is original in that the surgical exeresis usually done in this kind of tumor would have been too mutilating for the eyelid in such a case.

Exanthème maculo-papuleux néonatal révélateur d’une septicémie à Klebsiella pneumoniae par infection maternofœtale

BACKGROUND

Neonatal exanthema of bacterial origin is caused very rarely by Gram-negative bacilli. We report a case of neonatal maculopapular exanthema evocative of Klebsiella pneumoniae septicemia resulting from maternofetal infection.

OBSERVATION

On the fourth day of life, a newborn infant presented incipient morbilliform maculopapular exanthema on the face. During delivery, the mother had presented hyperthermia and meconium was found in the amniotic fluid. Clinical examination of the newborn was normal. No clinically obvious site of entry of infection was seen. Laboratory tests revealed major inflammatory syndrome. Blood cultures were positive for K. pneumoniae, which was also found in blood cultures from the mother. Screening for other causes of infection was negative. Parenteral antibiotics for 10 days yielded favorable results with simultaneous resolution of the exanthema, normalization of laboratory values and negative blood cultures.

DISCUSSION

Exanthemas of infectious origin are not associated with any specific organism. The most common causative micro-organisms are Listeria monocytogenes, B streptococci, colibacilli, and more rarely, staphylococci. There have been reports of a number of cases of neonatal septicemia due to Gram-negative bacilli responsible for maculopapular exanthemas but the causative organism was not identified. To our knowledge, Klebsiella pneumoniae has never been incriminated in the appearance of this type of rash via maternofetal transmission. Consequently, the presence of neonatal exanthema should prompt screening for sepsis, even in the absence of other evocative signs, and in particular in settings of apyrexia.