Hashimoto's thyroiditis and coexisting disorders in correlation with HLA status-an overview.

Hashimoto's thyroiditis (HT), also known as chronic lymphocytic thyroiditis, is a frequent disorder of the thyroid gland caused by autoimmune-trigged lymphocytic infiltration and destruction of the thyroid gland. With the progressive destruction of the organ, the thyroid gland shrinks in size, thus commonly leading to hypothyroidism. Therapy of HT is mainly focused on managing the thyroid dysfunction by oral substitution of L­thyroxine. However, patients with HT often complain about a broad spectrum of symptoms, with some of them hardly explained by HT itself. Several other disorders are known to be associated with HT. The etiology of HT seems to be multifactorial, including environmental influences such as iodine supply, infections, and stress as triggers of immune modulation. In addition, also a genetic background based on changes of the human leukocyte antigen (HLA) status seems to be evident. The paper will provide an overview of diseases related to HT, including their correlation to certain HLA patterns. This presentation should give a broader view on HT-related disorders and facilitate detailed examination and management of patients with HT.

Abnormal liver findings as the first manifestation in a patient with brucellosis : Case report.

In January 2019, a 30-year-old woman admitted to our inpatient department presented with undulating fever, pain in several joints, and significantly elevated liver enzymes and lactate dehydrogenase. After extended examination, infection with Brucella melitensis with liver, musculoskeletal, and pulmonary involvement was diagnosed and treated. Diagnosis was based on clinical examination, laboratory findings including seroconversion as a proof of immune response, magnetic resonance imaging, three-phase bone scintigraphy, and F­18 FDG-PET (F-18 Flourdeoxyglucose positron emission tomography) illustrating the bone involvement and its normalization upon treatment. After treatment the patient showed a remarkable improvement of clinical symptoms within a short period. The patient remained symptom free and polymerase chain reaction (PCR) testing for brucellosis was negative, even at the follow-up examination 12 months after the end of the antibiotic therapy. The family members were also examined due to the similar travel history, and by this, brucellosis was also diagnosed in her husband but not in her children.

[Iodine-rich thermal water in cure and rehabilitation from the perspective of the thyroid gland]. / Kuranwendungen mit jodhaltigem Thermalwasser aus thyreologischer Sicht.

Excessive iodine intake should be avoided in certain thyroid disorders, such as Graves' disease, Hashimoto's thyroiditis and thyroid goiter with autonomous nodules. Regarding alimentary iodine intake broad information can be found in the literature or the internet. Cure and rehabilitation therapy is used in many clinical settings, such as chronic degenerative disorders of the musculoskeletal system, rehabilitation after trauma, after treatment of malignant tumors and many others. Iodine intake with iodine-rich thermal water during cure and rehabilitation is possible and the extent depends in particular on the route of application and the duration of treatment. Information on this topic can be hardly found in the literature. This article analyses iodine-rich cure and rehabilitation treatment with iodine-rich thermal water from the point of view of the thyroid gland. The positive and possible negative effects of treatment with iodine-rich thermal water on thyroid function are elucidated. Apart from an insight into the physiology and pathophysiology of iodine metabolism, the extent of iodine intake during cure and rehabilitation treatment is presented depending on the route of application and the clinical implications for certain thyroid disorders are discussed. An overview of cure and rehabilitation centers in Austria and neighboring countries is given. In addition, an algorithm for the clinical selection of patients unsuitable for high iodine intake and who should thus avoid an iodine-rich cure or rehabilitation treatment is presented in order to assist clinicians in optimally selecting patients for cure or rehabilitation treatment with iodine-rich thermal water.

Hemiagenesis of the thyroid gland detected by coincidence-what is the clinical relevance? : Case report and review of the literature.

Hemiagenesis of the thyroid gland (THA) represents a rare congenital anomaly. It is characterized by the absence of one thyroid lobe, and sometimes the isthmus as well. It can occur with all kinds of other thyroid pathologies that may be present in the remaining thyroid lobe. A case of a 21-year-old male patient is presented; he sought a thyroid consultation because of hair loss, fatigue, and problems concentrating, thus raising the suspicion of hypothyroidism. Thyroid function was normal, but sonography of the thyroid gland revealed THA of the left lobe and the isthmus. The current knowledge concerning the genesis and the clinical consequences of THA are discussed based on the current literature.

Bone Effects of Binge Alcohol Drinking Using Prepubescent Pigs as a Model.

BACKGROUND: Although chronic alcohol consumption in adults is an established risk factor for osteoporotic fractures, there is a huge gap in our knowledge about bone effects of binge drinking in adolescents. The aim of this pilot study was therefore to assess skeletal effects of binge alcohol drinking using prepubescent pigs as a large animal model. METHODS: Piglets aged 2 months were offered alcohol orally as a mixture of hard liquor and apple juice. Those with the highest propensity to drink alcohol were included in the experiment and received 1.4 g alcohol/kg bodyweight 2 times per week for 2 months (alcohol group); control piglets received apple juice in an identical manner. At the age of 4 months, the animals were euthanized; trabecular and cortical bone samples from the femur, the tibia, the humerus, and the fourth vertebral body harvested during necropsy were assessed by microcomputed tomography and dynamic histomorphometry. In addition, blood chemistry and blood alcohol determinations were performed. RESULTS: Blood alcohol levels assessed 1 hour after alcohol administration were 0.99‰ ± 0.15, 1.12‰ ± 0.2, and 1.14‰ ± 0.18 at the ages of 2, 3, and 4 months, respectively. In the alcohol group, serum calcium and phosphate levels were decreased. In the femur, trabecular number and connectivity density were lower in the alcohol than in the control group, and in the humerus and the fourth vertebral bodies, an opposite pattern was seen for trabecular number and connectivity density, respectively. Cortical density was higher in the humerus and trabecular density higher in the tibia of the alcohol group compared to the control group. Cortical porosity was lower in the humerus of the alcohol group. No significant differences were seen for trabecular thickness, trabecular separation, bone volume fraction, and static and dynamic histomorphometric parameters. CONCLUSIONS: In this pilot study, we have assessed skeletal effects of binge alcohol drinking by using prepubescent pigs as a promising large animal model. Binge drinking has bone effects that are site-specific. However, these data have to be verified in a larger study population.

Alcohol and bone.

Alcohol is widely consumed across the world in different cultural and social settings. Types of alcohol consumption differ between (a) light, only occasional consumption, (b) heavy chronic alcohol consumption, and (c) binge drinking as seen as a new pattern of alcohol consumption among teenagers and young adults. Heavy alcohol consumption is detrimental to many organs and tissues, including bones. Osteoporosis is regularly mentioned as a secondary consequence of alcoholism, and chronic alcohol abuse is established as an independent risk factor for osteoporosis. The review will present the different mechanisms and effects of alcohol intake on bone mass, bone metabolism, and bone strength, including alcoholism-related "life-style factors" such as malnutrition, lack of exercise, and hormonal changes as additional causative factors, which also contribute to the development of osteoporosis due to alcohol abuse.

[Osteoporosis: therapy in interface management]. / Osteoporose - Therapie und sektorenübergreifendes Management.

Osteoporosis is defined as a systemic bone disorder with decreased bone strength and an increased susceptibility for fragility fractures. In particular elderly people face an increased fracture risk. Fracture stabilisation by different methods of osteosynthesis and fast remobilisation has become standard procedures after a fragility fracture due to osteoporosis. However, only a small group of patients receive osteoporosis drug therapy with the aim to reduce the rate of further fractures. In literature this has been described as "osteoporosis care gap". In the past, various projects have been performed in order to overcome this problem of osteoporosis care after fragility fractures. The article presents the current problems in daily routine concerning the initiation of an osteoporosis therapy after a fracture. A simple concept of necessary procedures and questions is presented as a possible solution for the interface management of osteoporosis drug therapy after fragility fractures. In addition, current osteoporosis therapies are presented in the view of care for geriatric patients.

Stress ulcer prophylaxis, thromboprophylaxis and coagulation management in patients with hip fractures.

Hip fracture in older patients is a major health concern. 20-25 % of hip fracture patients will die in the first year after the trauma (Lane, Clin Orthop Relat Res 471(8):2711, 2013). Postoperative venous thrombosis and gastrointestinal stress-ulcer bleeding are frequent complications with a high case-fatality rate particularly in older patients. Thromboprophylaxis and stress ulcer prophylaxis are important and well established measures to decrease postoperative complications and the mortality rate in this high-risk population.The working group on orthogeriatrics of the Austrian Society on Geriatrics and Gerontology (ÖGGG) is composed of geriatricians who work as trauma surgeons, internists, anaestesists and nurses. A thorough literature search was done, using the terms "orthogeriatrics" and "hip fracture" in combination with "stress ulcer", "gastrointestinal bleeding" and "thrombosis", "thromboprophylaxis". The data was collected, discussed and evaluated in several adjustment meetings of the group and summarized in this article.

Treatment and prevention of postoperative complications in hip fracture patients: infections and delirium.

The course of older patients with hip fractures is often complicated by infections and delirium. Accurate care and high suspicion for these complications are essential, since these conditions are associated with an increase in mortality, length of hospital stay and nursing home placement, poorer mobility, and functional decline. Because of immunosenescence and higher infection rates, older patients need specific care, immediate diagnosis, and treatment of infections. Numerous guidelines of various medical societies outline the management of nosocomial infections, but there is a need of an individualized treatment plan because of comorbidities and polypharmacy. Hygiene measures have first priority to reduce the rate of infections. Treatment of geriatric syndromes like malnutrition, exsiccosis, gait disorders, falls, delirium, urine incontinence, and organ insufficiency are as important as immunization against pneumococci and influenza. Advanced age, cognitive impairment, hearing loss, peripheral vascular disease, prior delirium episodes, sight disorders, and polypharmacy are established risk factors for delirium; thus, older people with several chronic diseases are prone to delirium. A multifactorial approach, comprising standardized screening, oxygen support, intravenous fluid administration and augmented nutrition, monitoring of vital signs, pain treatment, optimized medication, and modification in perioperative management, significantly reduces delirium incidence during hospitalization for hip fracture. An interdisciplinary approach between surgeons and geriatricians may warrant optimized satisfaction of patients' needs.

Rehabilitation after hip fracture.

Low-trauma hip fracture in old age leads to impairment, increased need of care and mortality. Rehabilitation should start in the department for traumatology and accompany the patient through different settings until the pretraumatic status is reached. Besides the surgical procedure and the medical management of an aged person with complex disease and polypharmacy, the multidisciplinary rehabilitation process is an important factor for regaining ability for self-care and autonomous decisions. Pain management supports the process. The ideal setting is not clear yet. Besides established rehabilitation facilities for elderly people, including the departments for 'Akutgeriatrie/Remobilisation', the 'Outreach Geriatric Remobilisation' project offers new perspectives. It was designed to remobilise patients with multimorbidity in their own homes.

[Procedural organisation: surgical and anaesthesiological management in hip fractures]. / Ablauforganisation - unfallchirurgisches und anästhesiologisches Management bei Hüftfrakturen.

In patients with hip fractures, in order to reduce the high number of general complications and those associated with the specific treatment, the functional loss and cognitive impairment, implementation of co-ordinated, multidisciplinary treatment pathways, and rehabilitation, is mandatory. The imminent treatment of proximal femoral fracture consists of major orthopaedic surgery in most cases (total or partial hip arthroplasty, osteosynthesis). After the diagnosis of a hip fracture, an adequate pain medication should be initiated. The decision making for the fracture treatment includes fracture type, patient's age, cognitive function, mobility before the fall and functional demands of the patient in the context of patients life expectancy and goals of care. The anaesthesiological evaluation focuses on risk assessment. Medical abnormalities should be optimized within 24 to 48 h, or an increased perioperative risk due to comorbidities has to be accepted. The timing and the course of further preoperative diagnostic examinations and therapeutic interventions should be co-ordinated between the involved medical disciplines. After the operation a structured screening for delirium should be initiated and further evaluation of patient's nutrition, fall-associated medication, living conditions and osteoporosis treatment has to be performed.

[Diagnosis of osteoporosis in geriatric patients - possibilities and limitations]. / Diagnose von Osteoporose beim geriatrischen Patienten: Möglichkeiten und Grenzen.

Osteoporosis with its increased risk of low-trauma fractures has to be regarded as a disorder with significant influence on quality of life, increased morbidity and mortality in the elderly. Therapies of osteoporosis, in particular drug therapies aiming to reduce the fracture risk, are in general only initiated after diagnostic procedures prior to the start of osteoporosis therapy. Consequently, diagnosis of osteoporosis plays a key role in optimized patient care and management. Medical history, physical examination, planar X-ray, osteodensitometry and a range of laboratory parameters make up the key steps in the diagnostic work up of osteoporosis. In some clinical settings such as the investigation of possible occult fractures after falls, additional imaging methods including computed tomography, magnetic resonance imaging, and bone scintigraphy may be necessary to make up adequate diagnosis. However, it has to be questioned in which way all these diagnostic investigations can be effectively used in the diagnostic work up of geriatric patients. The article will give an overview of the different diagnostic methods with their possibilities and limitations and will present possible diagnostic work flows based on frequent clinical settings seen in geriatric patients.

[Calcium supplementation uncovering lactose intolerance - a case report]. / Abdominalschmerzen und Diarrhoe durch Kalziumsubstitution - Fallbericht einer Patientin mit Laktoseintoleranz.

A 44 yr-old female with osteoporosis had no relevant gastrointestinal symptoms and did not avoid any specific food. However, after prescription of a lactose-rich calcium supplementation, clinical symptoms suspicious for lactose intolerance occurred, which were thereafter confirmed by a lactose tolerance test. Lactose intolerance may present with only slight or subtle symptoms. Drugs containing lactose may induce or increase gastrointestinal symptoms in patients with lactose intolerance. In case of gastrointestinal symptoms occurring after the initiation of drugs containing lactose, the possibility of lactose intolerance should be considered and tested by lactose tolerance test or genetic testing for the LCT (-13910) polymorphism. Due to the prevalence of about 15-25% lactose intolerance in the Austrian population, lactose free drugs should be prescribed as widely as possible.

[Multiple liver lesions accompanied by eosinophilia - a case report of fascioliosis]. / Multiple Leberherde und Eosinophilie - ein Fallbericht einer Fasciola hepatica-Infektion.

Fascioliosis is a zoonotic disease caused by Fasciola hepatica (common liver fluke). Initial clinical symptoms are frequently non-specific. Even after the development of liver tumors, a range of different underlying disorders will have to be considered. The rare cause of a parasitosis is not always included in the differential diagnostic work up. We report on a 41-year-old truck driver from Middle East who was admitted at our hospital due to ongoing upper abdominal pain, fatigue, night sweat and nausea lasting for weeks. Diagnostic investigation showed leucocytosis, high erythrocyte sedimentation rate, elevated liver values and IgE as well as blood eosinophilia. Radiological findings of the computed tomography were bilateral pulmonary lesions 3 mm in size and multiple hepatic lesions up to 4.5 cm in diameter. Due to the suspicion of a malignant disease, a liver biopsy was planned but cancelled after parasitological serology (Western blot and ELISA) revealed IgG-antibodies against F. hepatica. Detailed history gave evidence of a recent parasitological infection during a stay in Turkey with consumption of vegetable which were grown and washed with water from the local river. Eggs of the parasite could neither be found in analysis of duodenal secretion nor in examination of fecal culture. However, confirmation for the infection with F. hepatica was proved with another positive serology. The treatment with Triclabendazole (Egaten(®)) for two days with a total dosage of 2000 mg was followed by a remarkable recovery of the patient's symptoms and decrease of eosinophilia in the blood count just one month after treatment and normalization after four months.

Effectiveness of respiratory-sinus-arrhythmia biofeedback on state-anxiety in patients undergoing coronary angiography.

AIM: This study is a report of a study conducted to evaluate the value of psychological assistance including respiratory-sinus-arrhythmia biofeedback training in its ability to reduce the level of anxiety in patients undergoing coronary angiography. BACKGROUND: Coronary angiography has been reported to cause anxiety and emotional stress. METHODS: Between March 2004 and January 2005, 212 patients undergoing routine elective coronary angiography for the evaluation of stable coronary artery disease were randomized into two groups. In the psychological support group (n = 106) a structured psychological conversation and respiratory-sinus-arrhythmia biofeedback training were offered prior to coronary angiography. In the control group (n = 106) standard care and information was provided without psychological support. State-anxiety was measured (scale 20-80) 1 day prior to and after coronary angiography, along with blood pressure and heart rate. FINDINGS: Prior to coronary angiography, state-anxiety was 54.8 +/- 11.5 (mean +/- SD) in the control group and 54.8 +/- 12.6 in the psychological support group. After coronary angiography, state-anxiety was 47.9 +/- 18.5 in the control group but 28.3 +/- 12.5 in the psychological support group (Wilcoxon rank sum test W = 7272, P < 0.001). Blood pressure was statistically significantly lower in the psychological support group prior to the intervention and the day after coronary angiography. CONCLUSION: Psychological support including respiratory-sinus-arrhythmia biofeedback is an effective and simple tool that could be used by nurses to reduce state-anxiety and emotional stress in patients undergoing coronary angiography.

An overview on bone manifestations in Gaucher disease.

Gaucher disease (GD), the most prevalent lysosomal storage disorder, affects multiple organ systems. Patients with non-neuronopathic (type 1) GD, the most common form of GD, present with hepatomegaly, splenomegaly, anemia, bleeding tendencies, thrombocytopenia, skeletal pathologies, growth retardation, and, in severe cases, pulmonary disease. The bone manifestations include bone infarcts, avascular bone necrosis, lytic lesions, osteosclerosis, fractures due to osteopenia or osteoporosis, and rarely acute osteomyelitis. Bone pain of varying intensity, fractures, and progressive joint collapses may cause impaired mobility and performances status, and increased morbidity. Enzyme replacement therapy and substrate reduction therapy have demonstrated to have beneficial effects on bone pain, bone crises, and the extent of osteoporosis. This review article gives an overview of the clinical appearance of bone pathology in GD, the possible pathophysiological mechanisms, diagnostic approaches, and the therapeutic effects of enzyme replacement therapy, substrate reduction therapy, and bone specific therapies as evaluated in current literature.