Multiple sclerosis and hypogonadism: is there a relationship?

INTRODUCTION

Multiple sclerosis (MS) is a chronic autoimmune disease that affects the central nervous system and is widely recognized as a disease primarily affecting women. The relationship between MS and hypogonadism is complex and not fully understood, with recent evidence showing that hypogonadism may have a significant impact on the quality of life and disease progression of patients with MS.

OBJECTIVES

This review aims to provide an overview of the current knowledge regarding the relationship between MS and hypogonadism, including the mechanisms underlying this relationship; the effects of hypogonadism on patients with MS; and the potential benefits and drawbacks of testosterone replacement therapy for patients with MS and hypogonadism.

METHODS

This scientific review analyzed 19 articles that investigated the potential relationship among MS, testosterone levels, and hypogonadism. The articles were published between November 2008 and March 2022 and were identified through a comprehensive search of the PubMed database. The search terms used included "multiple sclerosis," "testosterone," "hypogonadism," and "MS and testosterone levels."

RESULTS

Of the 19 articles reviewed, 11 described a positive correlation between low testosterone levels and dysfunction within the hypothalamic-pituitary-gonadal axis in individuals with MS. These findings suggest that low testosterone levels may contribute to dysfunction within the hypothalamus-pituitary-gonadal axis, which plays a crucial role in regulating testosterone production. The results also showed a relationship between sexual dysfunction and low testosterone levels, as well as a positive correlative relationship between these factors.

CONCLUSION

The reviewed articles indicate a complex relationship among MS, testosterone levels, and the hypothalamic-pituitary-gonadal axis, with low testosterone levels potentially contributing to dysfunction in this axis and to sexual dysfunction. Further research is needed to better understand the effects of testosterone therapy on MS and sexual dysfunction in patients with MS.

Prostate cancer presentation and management in the Middle East

BACKGROUND

Although prostate cancer is a prevalent malignancy worldwide, its clinical presentation and management in the Middle East are not well-documented. This study aims to provide insights into the initial clinical presentation and management of prostate cancer in this region.

METHODS

A retrospective review was conducted on seven institutional databases from six Middle Eastern countries, including Türkiye, Lebanon, Iraq, Syria, Bahrain, and Jordan, to identify patients diagnosed with prostate cancer in 2021. Descriptive analysis was performed on the collected data to provide an overview of the demographic, clinical, and treatment variables.

RESULTS

A total of 1,136 patients were identified with a median age of 70 (range, 50-84). Most patients (78%) received their prostate cancer diagnosis after presenting with symptoms, as opposed to routine PSA screening. At the time of diagnosis, 35% of men had clinical T3 or T4 disease, 54% with Stage IV disease and 50% with Gleason score ≥ 8. Regarding treatment, 20% of non-metastatic and 22% of metastatic patients received no treatment.

CONCLUSION

Most men in this study sought prostate cancer evaluation due to symptoms and were subsequently diagnosed with advanced-stage disease, providing a foundation for future research aimed at understanding the underlying factors behind the observed trends and enabling informed interventions.

Modified GLIM Status as a Predictor of Morbidity and Mortality After Radical Cystectomy: A Propensity Matched Analysis

INTRODUCTION

To assess the modified Global Leadership Initiative on Malnutrition (mGLIM) status as a predictor of postoperative mortality and morbidity in patients undergoing Radical Cystectomy (RC).

METHODS AND MATERIALS

The American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) dataset was used to select patients who underwent RC between the years 2011 to 2020. A positive mGLIM status includes patients with preoperative albumin levels < 3.5 g/L or patients with ≥ 10% weight loss over 6 months or BMI ≤ 21 kg/m2. We compared prolonged length of stay, mortality, major morbidity and Clavien-Dindo complications between mGLIM positive and negative patients. A multivariable logistic regression model was also performed to control for possible confounders. Furthermore, a sensitivity analysis was performed by propensity score matching.

RESULTS

Our cohort consisted of 12,760 patients who underwent RC. The matched cohort yielded 4864 matched patients. After propensity score matching, patients with a positive mGLIM status had higher odds of prolonged length of stay (OR = 1.99, 95%CI [1.75, 2.27]), mortality (OR 1.56, 95%CI [1.08, 2.26]), major morbidity (OR = 1.69, 95%CI [1.51, 1.90]), Clavien-Dindo class I and II (OR = 1.77, 95%CI [1.58, 1.99]), and lower odds of Clavien-Dindo class III (OR = 0.72, 95%CI [0.57, 0.92]) as compared to those with a negative mGLIM status (P < .018).

CONCLUSION

A positive mGLIM status is associated with prolonged hospital stay, morbidity, and mortality following RC. This indicates that the mGLIM criteria could serve as an independent predictor of morbidity and mortality in an attempt to optimize patient counseling and preoperative care.

The impact of AirSeal® on complications and pain management during robotic-assisted radical prostatectomy: a single-tertiary center study

PURPOSE

We aimed to compare perioperative outcomes, post-operative complications, and opioid use between AirSeal® and non-AirSeal® robotic-assisted radical prostatectomy (RARP).

METHODS

We retrospectively collected data on 326 patients who underwent elective RARP at our institution either with or without AirSeal®. The first 60 cases were excluded accounting for the institutions' learning curve of RARP. Patient demographics, oncologic, pathologic, and surgical characteristics between AirSeal® and non-AirSeal® cases were compared. Furthermore, outcomes of interest including operative time, length of stay, morbidity, and opioid use for pain management were compared between the two groups. Univariate linear and logistic regression models were developed.

RESULTS

The AirSeal® group consisted of 125 (38.3%) patients while the non-AirSeal® group consisted of 201 (61.7%) patients. No statistically significant difference was seen in terms of patient demographics, oncologic characteristics, surgical characteristics, and pathologic characteristics between the two groups. In addition, univariate linear regression showed that RARP with AirSeal® displayed shorter operative times by 12.3 min and a shorter length of hospital stay by 0.5 days compared to the non-AirSeal® group (p < 0.001). Furthermore, the AirSeal® group witnessed lower odds of Clavien-Dindo (CVD) Class > 2 complications (OR = 0.102) and a lower need for opioid use (OR = 0.49) compared to the non-AirSeal® group (p < 0.022).

CONCLUSION

RARP using AirSeal® is associated with shorter operative times, shorter length of hospital stays, lower odds of CVD > 2 complications, and lower odds of opioid use with respect to non-AirSeal® RARP. The efficacy and cost effectiveness of using the AirSeal® system during RARP should be further studied and evaluated by clinical trials.

The 5-item frailty index predicts 30-day morbidity and mortality in radical nephrectomy patients: A propensity matched analysis

PURPOSE

To assess the ability of the 5-item frailty index (5-IFi) score to predict 30-day morbidity and mortality post-radical nephrectomy (RN).

METHODS

ACS-NSQIP database was used to select patients who underwent RN from 2011 to 2020. 5-IFi score was calculated by assigning a point for each of the following comorbidities: chronic obstructive pulmonary disease or pneumonia, congestive heart failure, dependent functional status, hypertension, and diabetes. Patients were divided into 3 frailty groups 0, 1, and ≥2. Patient demographics, medical comorbidities, prolonged length of stay, and prolonged operative time were compared between different groups; mortality and morbidity using the Clavien-Dindo classification (CVD). Multivariable logistic regression models and propensity score matching were performed as a sensitivity analysis to control for possible confounders.

RESULTS

Cohort consisted of 36,682 patients whereby 5-IFi class 0, 1, and ≥2 included 11,564 (31.5%), 16,571 (45.2%), and 8,547 (25.3%) patients respectively. A multivariable analysis and propensity score matching revealed that patients with 5-IFi classes 1 and ≥ 2 were more likely to have a prolonged length of stay (OR = 1.11, 1.3, respectively) and to mortality (OR = 1.85 for frailty class ≥2); in addition to CVD class 1 & 2 (OR = 1.51, OR = 1.13, respectively), and CVD ≥ 4 (OR = 1.41, 1.86, respectively) as compared to 5-IFi class 0 (P < 0.001).

CONCLUSION

The 5-IFi score was found to be an independent predictor of prolonged length of stay, morbidity, and mortality after RN. This tool can play a major role in preoperative risk assessment and patient counseling based on individualized risks.

A novel nephrectomy-specific respiratory failure index using the ACS-NSQIP dataset

PURPOSE

Post-operative pulmonary failure is a major complication of nephrectomy that may lead to severe morbidity and mortality. Hence, we aimed to derive a nephrectomy-specific post-operative respiratory failure index.

METHODS

Our cohort was derived from The American College of Surgeons-National Surgical Quality Improvement Program database between 2005 and 2019. The outcome of interest was post-operative respiratory failure (PRF) defined as any incidence of unplanned intubation post-operatively or requiring mechanical ventilation post-operatively for a period > 48 h. A multivariable logistic regression model was constructed, and model calibration and performance were assessed using a ROC analysis and the Hosmer-Lemeshow test. Finally, we derived the nephrectomy-specific respiratory failure (NSRF) index and compared it to Gupta's index.

RESULTS

Seventy-nine thousand five hundred and twenty-three patients underwent nephrectomy between the years 2005 and 2019 of which nine hundred and sixty-two patients developed PRF. The final NSRF model encompassed ten variables: age, smoking status, American society of anesthesiology class, abnormal creatinine (≥ 1.5 mg/dL), anemia (< 36%), functional health status, chronic obstructive pulmonary disease, surgical approach, emergency case, and obesity (≥ 40 kg/m²). The NSRF ROC analysis provided C-statistic = 0.78, calibration R² = 0.99, and proper goodness of fit. In comparison, the C-statistics of Gupta's index was found to be 0.71 (p value < 0.001).

CONCLUSION

The NSRF is a procedure tailored index for predicting post-operative respiratory failure. It is a valuable tool in the pre-operative evaluation setting that can help identify high-risk patients who will require additional respiratory evaluation and preparation for their surgery.

Preoperative predictors of prolonged length of stay in radical cystectomy: a retrospective study using the American College of Surgeons-National Surgical Quality Improvement Program Dataset

Background

Radical cystectomy (RC) is considered a complex procedure that entails significant morbidity and mortality.

Objectives

We aimed to determine pre-operative patient characteristics that help predict a prolonged length of hospital stay (PLOS) following RC.

Design and Methods

The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was used to select patients who underwent RC between the years 2011 and 2020. Prolonged length of stay was defined as a hospital stay ⩾9 days. We compared patient demographics, pre-operative labs, surgical characteristics, and medical history between patients with or without PLOS. Multivariable logistic regression models controlling for pre-operative characteristics and propensity score matching for post-operative complications were conducted to control for possible confounders.

Results

The analysis yielded details of 19,158 RC patients of which 6007 (31%) patients had a PLOS. Patients with PLOS were more likely to have post-operative complications that could serve as predictors for the PLOS rather than their pre-operative characteristics. Hence, we matched our cohort for these complications. After matching, patient pre-operative characteristics that predict PLOS included female gender (Odds Ratio (OR) = 5.91), 10-year increase in age (OR = 1.15), non-White race (OR = 1.98), partially or totally dependent functional health status (OR = 2.86), bleeding disorders (OR = 4.67), congestive heart failure (OR = 1.59), pre-operative transfusion (OR = 3.03), and a 20-min increase in operative time (OR = 1.01) (p < 0.046).

Conclusion

Patient demographics and pre-operative factors can help predict PLOS in RC patients. These predictors could serve as tools for patient counseling and risk stratification.