Bone mineral density, vertebral fractures and body mass index in postmenopausal women with abdominal aortic calcification.

BACKGROUND: Evidence suggest that there are connections between osteoporosis and cardiovascular diseases. OBJECTIVES: The aim of the study was to analyze the relationship between radiological measurements of abdominal aorta calcifications (AAC) and bone mineral density (BMD) in postmenopausal women. METHODS: In this cross-sectional study were included 125 postmenopausal women 50-84 years of age. BMD of the spine and hip was measured by dual energy X-ray absorptiometry (DXA). AAC were assessed by lateral radiographs of lumbar spine (L1-L4), using the antero-posterior severity score (0-24). Vertebral fractures were evaluated from T4 to L4 using Genant's semiquantitative method. RESULTS: Forty-one (32.8%) patients had osteoporosis and 61 (48.8%) had AAC with a mean score of 3.1. Postmenopausal women with AAC were older and had significantly lower femoral neck and trochanteric BMD than subjects without AAC (all p < 0.01). There were no significant differences in the frequency of fractures between subjects with AAC and those without AAC (p > 0.05). In univariate analysis, age, height, weight, femoral and trochanter BMD were significantly associated with the severity of AAC score. In multiple regression analysis, femoral neck BMD, but not lumbar spine, trochanter BMD or age, was an independent predictor of AAC. CONCLUSIONS: Reduced femoral neck BMD is negatively associated with the presence of AAC in postmenopausal women. The association between BMD and AAC seems to be age-independent, which suggests a common pathogenesis for bone loss and vascular calcifications.

Relationship between VKORC1 single nucleotide polymorphism 1173C>T, bone mineral density & carotid intima-media thickness.

BACKGROUND & OBJECTIVES: The effects of vitamin K-dependent proteins in bone mineralization and vascular calcification and the implication of vitamin K epoxide reductase gene (VKORC1) 1173C>T polymorphism in warfarin sensitivity are well known. The main objective of the study was to investigate the relationship between VKORC1 1173C>T polymorphism, bone mineral density (BMD), and atherosclerosis (evaluated by intima-media thickness of the carotid artery and the presence of calcified plaques) in patients suspected to have osteoporosis or osteopenia and referred for BMD determination. METHODS: VKORC1 1173C>T polymorphism was evaluated in 239 consecutive patients referred by their physicians for BMD measurement (dual energy X-ray absorptiometry at L2-L4 lumbar spine, femoral neck and total hip). Ultrasonography of the carotid arteries was performed, intima-media thickness (IMT) was measured and the presence of atherosclerotic calcified plaques was recorded. RESULTS: In the patients with osteoporosis and osteopenia there was a higher frequency of TT genotype of VKORC1 1173C>T (P=0.04). The TT genotype was significantly more frequent in the osteoporotic group compared to the osteopenic group (P=0.01). The mean age and body mass index were lower in the patients with normal BMD and TT genotype (P=0.02, P=0.03). There was no correlation between the IMT and VKORC1 1173C>T genotype but the TT genotype had a significant association with the presence of calcified atherosclerotic plaques (P=0.05). This finding was not correlated with normal or pathologic BMD. INTERPRETATION & CONCLUSIONS: VKORC1 1173C>T polymorphism (TT genotype) was associated with osteoporosis and calcified plaques in the carotid artery in patients referred for BMD measurement. Different mechanisms are probably involved in these associations. TT genotype may serve as a potential genetic marker for the risk of OP and ATS.

Shoulder impingement syndrome: correlations between clinical tests and ultrasonographic findings.

OBJECTIVES: To compare the diagnosis of shoulder impingement syndrome (SIS) established by clinical and ultrasonographic examination and to evaluate the value of clinical tests for SIS as well as for rotator cuff pathology. METHODS: One hundred patients with periathrophatia scapulohumeralis entered the study, including 64 females and 36 males aged between 20-84 years (mean 56.8 and 57.5, respectively). Clinical and ultrasonographic examinations were carried out by independent observers, a rheumatologist and a musculoskeletal-trained sonographer. Clinical tests for SIS and for each of the tendons of the rotator cuff, as well as static and dynamic ultrasonographic examinations were performed for both shoulders. Findings were compared and statistically analyzed. RESULTS: The Hawkins test (72.2%) proved to be the most sensitive clinical test for the identification of SIS and the Neer test (95.3%) was the most specific one. When four tests were simultaneously positive, the specificity for the diagnosis was 98.5% but the sensitivity decreased to 40.3%. Jobe's test indicated supraspinatus involvement with a specificity of 90% but it was not able to disclose the type of lesions. The sensitivity and specificity of the tests aiming to elicit infraspinatus tendon pathology were of low value whereas those addressing subscapularis tendon involvement were rather of moderate value. SIS was clinically correctly diagnosed in 80.5% of cases, but its characteristic stages were poorly recognized (stage I 50%, stage II 70%, and stage III 30.7%). CONCLUSIONS: Although clinical tests are insufficient for clinical diagnosis, the examination of the patient still plays an important role in rotator cuff disorders. Ultrasonography should be used for all patients suffering from painful shoulder in order to improve the diagnosis.

Incidental Discovery of Multiple Myeloma, Presenting as an Amyloid Tumor with Plasmacytic Elements of the Thoracic Wall.

Multiple myeloma is characterized by monoclonal proliferation of bone marrow plasma cells causing multiple bone lesions and overproduction of a monoclonal protein (M-protein) that could deposit in tissues (amyloidosis). Dissemination of the multiple myeloma outside the bone is rare. We present a case of a 76 years old woman presenting with dry cough. Chest X-ray showed a giant tumor of the upper right lung. Contrast enhanced CT revealed a tumor that most probably originated from the structures of the thoracic wall. The transthoracic biopsy was inconclusive. The tumor was resected and the histopathological examination showed amyloid tumor of the thoracic wall with plasmacytic elements and lambda light chains deposits. A bone marrow aspiration was performed that found diffuse plasmacytic infiltrate of 20-60% and the serum proteins electrophoresis with immunofixation revealed elevated IgA and lambda light chains. The patient was diagnosed with IgA and lambda light chains multiple myeloma with consequent AL amyloidosis presenting as thoracic mass.

Focal nodular hyperplasia (FNH).

Focal nodular hyperplasia (FNH) is a benign tumour of the liver (hepatic tumour), which is the second most prevalent tumour of the liver (the first is hepatic hemangioma). It has a higher incidence in females, 20-40 years old, but also occurs in men and even in children. It is usually asymptomatic, rarely grows or bleeds, and has no malignant potential. This tumour was once often resected because it was difficult to distinguish from hepatic adenoma, but with modem multiphase imaging it is now diagnosed strictly by imaging criteria, and not resected. We present the case of a 78 years old man who presented to emergency room (ER) with a history of dry cough, chest pain and mild dyspnea. Chest X-ray showed ascension of the right hemidiaphragm, and a homogeneous round opacity of 6/6.2 cm in the right cardiophrenic angle. The first suspicion was of pulmonary tumor, but the final diagnosis was FNH, confirmed by CT scan. We discuss the differential diagnosis and prognosis of this entity. The particularities of the case are the presentation with respiratory symptoms and pulmonary mass, and the age of the patient.

Lyme disease.

Lyme disease (Borreliosis), also called the "disease of 1000 faces", is produced by a bacterium called Borrelia burgdorferi, transmitted by the Ixodes tick. The clinical picture is non-specific and polymorph, with multisystemic involvement. Diagnosis is most often one of exclusion, and certain diagnosis is based on the presence of Borellia antibodies. The treatment is done differently depending on the stage of the disease and the severity of injuries, being used antibiotics like Doxycycline, Amoxicillin, Erythromycin or Penicillin. Under treatment the disease quickly heals without sequel, in the early stages, but advanced stages are usually resistant to treatment and chronic injuries can occur. Symptoms get worse without treatment and become chronic. We present the case of a woman of 66-year-old with a complex history of disease, which began one year prior to admission, through multiple and nonspecific symptoms; she presented herself in numerous medical services (gastroenterology, rheumatology--where an immunosuppressive treatment was initiated, hematology) without determining a final diagnosis. She was admitted in our service with altered general state and worsening symptoms, predominantly fever, muscle pain, joint pain, the patient being immobilized in bed. After multiple investigations and the problem of differential diagnosis with multiple pathologies, we finally established the diagnosis of Lyme disease. The peculiarities of the case are represented by the severity of the clinical manifestations and fulminant disease evolution under the unjustified administration of immunosuppressive treatment, and atypical joint involvement regarding localization and evolution that raised the issue of differential diagnosis with osteosarcoma or bone tuberculosis.

The place of CEUS in distinguishing benign from malignant cervical lymph nodes: a prospective study.

AIMS: The aim of the study was to evaluate the ability of contrast-enhanced ultrasonography (CEUS) compared to gray-scale B-mode and color Doppler ultrasound in differentiate benign versus malign superficial cervical lymph nodes. MATERIAL AND METHODS: In a prospective study ultrasonography (gray scale, color and spectral Dopller, and CEUS) was performed in 61 patients (33 men, 28 women; mean age of 51.2 years, range: 18-81 years), with cervical lymphadenopathy. The nodes were examined and biopsied or surgically removed. CEUS was performed with 2.4 ml intravenous bolus of contrast agent Sono Vue and the results were registered with a special software. RESULTS: Of all the nodes, 32 were benign and 29 were malignant (metastases). Solbiati index was higher in benign nodes (2.23 +/- 0.84 vs 1.50 +/- 0.48, p<0.05). Doppler parameters (vessel location, vascular pattern, pedicullum number, resistivity index, and pulsatility index) were significantly lower in benign nodes (p<0.001), and ROC analysis returned excellent results. For CEUS, derived peak intensity (DPI %) was higher in benign nodes (17.72 +/- 5.43 vs 11.76 +/- 4.88, p<0.05); regional blood volume (RBV) was also higher (849.8 +/- 467.1 vs 458.3 +/- 283.3, p<0.05). The time to peak (TTP, s) and area under the curve (AUC, cm2) were similar in both benign and malignant nodes. Enhancement pattern was the most accurate to characterize benign versus malignant nodes. Sensitivity and specificity were higher for DPI, RBV and enhancement pattern from CEUS, according to ROC analysis, compared to gray scale ultrasound, but lower than color Doppler. Analyzing the place of CEUS in lymph node evaluation we found that CEUS is most useful for the evaluation of the lymph nodes with uncertain aspect at gray scale and Doppler evaluation. CONCLUSIONS: ROC analysis confirmed the higher degree of diagnostic accuracy of CEUS in comparison with conventional techniques for some parameters such as enhancement pattern. Evaluation of nodal perfusion with this method can be helpful in the differentiation of benign from malignant nodes but requires further confirmation.

The utility of elastography and CEUS for the differentiation between benign and malignant cervical lymphadenopathy. Three cases report.

The differentiation between benign and malignant cervical lymph nodes is a frequent challenge for the clinician. We present the cases of three patients with cervical lymphadenopathy (inflammatory lymph node, lymphoma, and metastasis of laryngeal carcinoma) in which the use of elastography and contrast enhanced ultrasonography had substantial contribution to the correct final diagnosis.

Cardiac involvement in systemic sclerosis.

Primary myocardial involvement is common in systemic sclerosis and affects the prognosis of the disease when it is clinically evident. The exact mechanism leading to the myocardial fibrosis in systemic sclerosis remains unknown. Its detection depends, at least in part, on the sensitivity of the diagnostic methods used. The aim of this review is to analyze the types and mechanism of abnormalities in the heart in scleroderma and also summarize the diagnostic methods recommended for the most prevalent ones. The available literature describes the most frequent cardiovascular abnormalities in systemic sclerosis patients to be: myocardial dysfunction, pericarditis, rhythm and, most frequent, conduction abnormalities, pulmonary arterial hypertension. Key points regarding screening, diagnosis, and treatment remain to be determined more accurately. Novel diagnostic techniques and multicenter studies should improve our understanding of organ involvement in scleroderma, which will hopefully ultimately result in improved outcomes.

Assessing health related quality of life in diabetic patients.

INTRODUCTION: The number of people with diabetes mellitus (DM) is increasing. For chronic illnesses such as DM, where there is no cure, it is important to establish that therapy really makes people feel better. The purpose of the study was to analyze the quality of life in a group of diabetic patients without major complications. SUBJECTS AND METHODS: The study group consisted of 50 patients, males and females, aged 60 (+/- 6), diagnosed with type 2 DM and followed up at an outpatient clinic. The Romanian version of the SF-36 questionnaire was used as a health survey tool to measure the quality of life (QOL) of patients in the study. RESULTS: Validity (coefficient alpha Cronbach) was > 0.7 for all scales except social functioning. QOL scores for study group were significantly lower compared with general population. Examining the effects of insulin use and QOL, there are no significant differences between patients following insulin therapy and patients with other therapeutic protocols. Role limitations due to emotional problems correlate with disease duration. Statistical analysis demonstrates a significant correlation between energy/fatigue scores and HbA1c. There are no other statistically significant correlations between SF-36 scores and other variables analyzed. DISCUSSIONS AND CONCLUSIONS: Patients with DM have statistically significant impairment of all aspects of QOL, not simply physical functioning. DM put a substantial burden on affected individuals by influencing physical, psychological and social aspects of QOL. The progressive nature of type 2 DM and the real risk for developing chronic complications certifies that insulin use will be a reality for most diabetic patients, but its use did not seem to have a negative impact upon QOL. Glycemic control becomes an important measurement for preventing long-terms complications and provides a better QOL to diabetic patient. This end-point should be a much more important target for healthcare interventions.

The role of contrast enhanced ultrasound in the assessment of superficial lymph nodes.

Evaluation of superficial lymphadenopathy is important for patients with pathologies like head and neck cancers or breast cancer, as it helps the assessment of patient prognosis and the selection of treatment method. Cervical lymph nodes are also common sites of involvement in lymphoma. Lymphomatous nodes are usually difficult to differentiate from metastatic nodes in clinical examinations. As the treatment for lymphoma and metastases is different, accurate differential diagnosis between the two conditions is important. Ultrasound is a useful imaging modality in evaluation of superficial lymphadenopathy because of its high sensitivity and specificity, especially when combined histopathology. With the use of power Doppler sonography, the vasculature of the lymph nodes can also be evaluated, which provides additional information in the sonographic examination of superficial lymph nodes. But there are still nodes that cannot be examined by Doppler or their vasculature cannot be visualized. So, in the last decade, contrast-enhanced ultrasound was more and more discussed as a non-invasive method for a more accurate differential diagnosis of cervical lymphadenopathy.

Markers of systemic involvement in chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is an important cause of morbidity and mortality worldwide. It is primarily a pulmonary disease, but it has various extrapulmonary manifestations such as muscular dysfunction and hypotrophy, cachexia or cardiovascular complications. That is why COPD may be considered a systemic disease. Principal mechanisms implicated in these extrapulmonary determinations are systemic inflammation, oxidative stress and neurohormonal activation. Circulating markers involved in these mechanisms can be detected in patients with COPD. We present some of the most important markers of systemic inflammation, oxidative stress and neurohormonal activation and also the clinical implications.

The role of heart rate variability in assessing the evolution of patients with chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (CPOD) is an important cause of morbidity and mortality. Cardiovascular involvement is the most common complication of the disease. Abnormalities of autonomic system, caused by this involvement, can lead to cardiac arrhythmias and sudden death. An important tool in assessing the dysfunction of the autonomic nervous system is the measurement of heart rate variability (HRV). In this article we systematically review the literature that addresses the role of heart rate variability as a maker of clinical evolution in patients with COPD. We focused on correlations between heart rate variability and pulmonary, muscular, cognitive and functional impairment. Heart rate variability has proven an important tool in assessing the cardiac function, the respiratory function, the muscular force, the cognitive capacity and the life quality of these patients. Until recently the problem of the cardiac autonomic dysfunction in patients with COPD could be identified only by invasive measures. At present the simple measuring of HRV is used as a noninvasive method in assessing the cardiac problems of these patients. HRV can be correlated with the severity of the disease, knowing that a dysfunction in autonomic nervous system can lead to potential fatal arrhythmias. Understanding the role of HRV in the evolution of COPD could be important in clinical practice and should be used more frequently.

The use of ultrasonography in learning clinical examination - a pilot study involving third year medical students.

BACKGROUND: Physical examination is a crucial part in medical student curricula, but a decline in physical examination skills was noted in the last two decades. The benefic role of ultrasonography (US) as an adjuvant method for clinical examination was evaluated in many studies, but there are different approaches among countries and universities. The aim of this study was to evaluate the role of US in learning physical exam in 3rd year medical students. METHODS: One hundred and four 3rd year medical students were randomly enrolled. They were divided first in two equal groups (I and II, with and without US, by rotation) and then in smaller groups of 8-9 students. Pairs between smaller groups belonging to group I and II were randomly established in order to be trained and evaluated by the same instructor. We verified the influence of US on the correctness of thyroid palpation, lung percussion (inferior limit of the lung), and liver size estimation. They received no special training on US. After the learning sessions (four sessions, one hour each) a questionnaire was applied to each student. RESULTS: For thyroid palpation, there were no significant differences regarding the gland dimensions. For lung and liver palpation the results showed better results for some points in groups using US as adjuvant, but the most significant difference regarded the appreciation of self confidence (in favor of US-groups). The majority of the students using US appreciated as very useful the informations provided by US. Also, we found a clear improvement in detecting the upper limit of the liver comparing with the inferior limit of the lung, as result of better clinical skills. DISCUSSIONS AND CONCLUSION: The results from this pilot study proved the utility of US in learning clinical examination. The students can better understand the regional anatomy and can confirm immediately the physical findings. It is important for students to reach a certain level of knowledge regarding physical exam to better understand the role of US. Overall, we can state that use of US in the daily clinical examination teaching greatly improved the students' clinical examination abilities and that is a strong argument for integrating basic US into the medical school curriculum.

Rupture sinus of Valsalva in a patient with dextrocardia. Case report.

Ruptured sinus of Valsalva (RSOV) is a rare disease with a wide range of clinical manifestations, from asymptomatic murmur to cardiogenic shock and death. We present the case of a young woman known with dextrocardia and pulmonary agenesia; she was diagnosed with RSOV and during follow-up, with endocarditis. Her evolution was good despite the association of severe heart conditions and the refusal of surgical intervention.

Association between fatty liver disease and carotid atherosclerosis in patients with uncomplicated type 2 diabetes mellitus.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is a clinic-pathological syndrome closely associated with obesity, dyslipidemia, diabetes and atherosclerosis. Some authors suggest that NAFLD is, in fact, another component of the metabolic syndrome. AIM: To determine the prevalence of NAFLD in diabetes mellitus (DM) patients, and to evaluate the carotid artery status in these patients. METHODS: Fifty six patients with uncomplicated type 2 DM were enrolled. Hepatic steatosis (HS) and carotid atherosclerosis (intima-media thickness - IMT) were evaluated by ultrasonography. Plasma liver function tests and other biochemical blood measurements were determined. RESULTS: HS was found in 38 patients (67.8%) with DM. Subjects with HS had higher values for body mass index, diastolic blood pressure, mean blood pressure and triglycerides, and lower HDL cholesterol concentration, but there were no differences regarding IMT between DM patients with or without HS. Behavioral variables (smoking, diet, and sedentarism), fasting plasma glucose, and LDL cholesterol levels, also, did not significantly differ between subjects with and without HS. CONCLUSION: DM patients with HS in our study showed a cluster of cardiovascular risk factors but non-significant carotid atherosclerosis. The detection of HS by abdominal ultrasound should alert to the existence of a higher cardiovascular risk, but in DM this is still under discussion, the results being still unconfirmed.

Heart rate variability and diastolic dysfunction in patients with type 2 diabetes mellitus.

Cardiovascular autonomic neuropathy is a common form of autonomic dysfunction in diabetes mellitus (DM) and associates abnormalities in heart rate control and in vascular dynamics. This study evaluates the impact of diabetes mellitus on left ventricular diastolic dysfunction (LVDD) and heart rate variability in a group of type 2 diabetes mellitus without signs of cardiovascular disease. The study group consisted of 58 patients, aged 61 ± 8 years, diagnosed with type 2 DM. The subjects were selected from a series of 104 consecutive diabetic patients. All the subjects were on oral therapy or on diet for DM, and ECG was normal for all the subjects. The control group consisted of 45 healthy subjects, matched for age and sex. Heart rate variability was measured using a 24-h ECG monitoring system, and standard 2D and Doppler echocardiography was performed in all the subjects. There are significant differences between groups regarding disease duration, longer in patients with impaired relaxation (11.22 ± 9.17 vs. 8.31 ± 8.95 years), and disease control, worse in impaired relaxation group. Heart rate in impaired relaxation group is significantly higher than in controls, and higher, but not significantly, when compared with normal group (91 ± 10, vs. 88 ± 11 and 71 ± 11, respectively). Cardiac autonomic neuropathy was associated with LVDD in patients with type 2 DM, but without clinically manifest heart disease. Twenty-four-hour ECG monitoring and echocardiography can detect diabetic cardiomyopathy in early stages and should be performed in all subjects.

Is epicardial adipose tissue, assessed by echocardiography, a reliable method for visceral adipose tissue prediction?

INTRODUCTION: Epicardial adipose tissue is an ectopic fat storage at the heart surface in direct contact with the coronary arteries. It is considered a metabolically active tissue, being a local source of pro-inflammatory factors that contribute to the pathogenesis of coronary artery disease. The AIM of our study was to establish correlations between echocardiographic assessment of epicardial adipose tissue and anthropometric and ultrasound measurements of the central and peripheral fat depots. METHOD: The study was conducted on 22 patients with or without coronaropathy. Epicardial adipose tissue was measured using Aloka Prosound α 10 machine with a 3.5-7.5 MHz variable-frequency transducer and subcutaneous and visceral fat with Esaote Megas GPX machine and 3.5-7.5 MHz variable frequency transducer. RESULTS: Epicardial adipose tissue measured by echocardiography is correlated with waist circumference (p < 0.05), visceral adipose tissue thickness measured by ultrasonography (US) and is not correlated with body mass index (p = 0.315), hip and thigh circumference or subcutaneous fat thickness measured by US. CONCLUSIONS: Our study confirms that US assessment of epicardial fat correlates with anthropometric and US measurements of the central fat, representing an indirect but reliable marker of the visceral fat.

Relation between intima-media thickness and bone mineral density in postmenopausal women: a cross-sectional study.

CONTEXT AND OBJECTIVES: Controversy exists regarding the relationship between atherosclerosis and osteoporosis. The aim of this study was to determine the relationship between intima-media thickness (IMT) of the common carotid artery (CCA), presence of calcified atherosclerotic plaques and bone mineral density (BMD) evaluated by dual energy X-ray absorptiometry (DXA), in postmenopausal women. DESIGN AND SETTING: Cross-sectional study at Second Internal Medicine Clinic, Cluj-Napoca, Romania. METHODS: We studied the IMT (left and right CCA and mean IMT) and T-score (lumbar spine L2-L4, femoral neck and total hip) in 100 postmenopausal women (mean age 64.5 years). The presence of calcified atherosclerotic plaque and osteoporotic vertebral fractures was also noted. RESULTS: IMT in the left and right CCA and mean IMT were significantly associated with T-score measured for the lumbar spine L2-L4, femoral neck and total hip, with lower T-score, in the osteoporotic group than in the normal and osteopenic groups (P < 0.05). IMT had a significantly negative correlation with the lumbar spine T-score and femoral neck T-score; and mean IMT with lowest T-score. Mean IMT (P < 0.001), high blood pressure (P = 0.005) and osteoporotic vertebral fractures (P = 0.048) showed statistical significance regarding the likelihood of developing atherosclerotic plaque. CONCLUSIONS: In women referred for routine osteoporosis screening, the relationship between CCA, atherosclerosis and osteoporosis can be demonstrated using either cortical or trabecular BMD. Vertebral fractures may be considered to be a likelihood factor for atherosclerotic plaque development.