Ca&Bone

[Dear Colleagues and Readers!]

HORVÁTH CSABA

FEBRUARY 20, 2003

Ca&Bone - 2003;6(01)

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Ca&Bone

[National Fracture Prevention and Risk Reduction Programme]

SOMOGYI Péter, LAKATOS Péter, POÓR Gyula, HORVÁTH CSABA

[Prevention of fractures due to osteoporosis is of crucial importance given the high mortality associated with these fractures, especially with those of the hip and vertebrae. Patients with fractures often lose their independence or require institutionalization. Osteoporosis is a special disease in that even though its public health significance is well known only 10% of patients are medically treated.There are 900,000 patients with osteoporosis in Hungary, out of which about 130,000 to 150,000 are currently treated. In April 2003 a new fracture prevention programme was launched.The aim of the programme is to prevent subsequent fractures in patients with fractures of the distal radius, proximal humerus, hip and vertebrae by thorough examination, risk assessment and therapy if necessary in the osteoporosis centres and in the traumatological units associated with them.The National Fracture Prevention and Osteoporosis Risk Reduction Programme has been adapted from Glasgow, Scotland, and is the first of its kind that aims to cover a whole country.]

Ca&Bone

[Is there any association between the location of the parathyroid adenoma and the presence of nephrolithiasis in primary hyperparathyroidism?]

CSUPOR EMŐKE, TÓTH EDIT, MÉSZÁROS SZILVIA, FERENCZ VIKTÓRIA, SZŰCS János, LAKATOS Péter, HORÁNYI János, PERNER Ferenc, HORVÁTH CSABA

[INTRODUCTION - The majority of patients with primary hyperparathyroidism recurrently produce kidney stones, while the rest have other clinical manifestations (metabolic bone disease, acute pancreatitis, depression, etc.).The aim of this study was to examine whether there is any association between the clinical symptoms and the location of adenoma. PATIENTS AND METHODS - The records of 91 patients (10 males, 81 females, mean age: 61.9 years, range: 20-70 ys) operated for primary hyperparathyroidism between 1995 and 2000 were retrospectively evaluated. One patient was excluded from the study because of parathyroid cancer. Nephrolithiasis was noted in 55 cases and other clinical symptoms in 35 cases. The diagnosis of pHPT was confirmed by the surgery, which also determined the precise location of the adenoma. RESULTs - In the kidney stone group, the adenoma was located in the left inferior parathyroid gland in 50 cases (91 %), (χ2=67.5, p<0,00001), in the left superior parathyroid gland in 2 patients, while in 3 patients multiple hyperplasia was found. In the group without nephrolithiasis the adenoma was located in the right inferior parathyroid gland in 24 patients (69 %), (χ2=43.9, p<0,0001), while in 3 patients each it was detected in the left and right superior parathyroid gland, respectively. Multiple hyperplasia was also observed in 3 patients and ectopic location in 2 patients. CONCLUSION - The results raise the possibility that the clinical manifestation of the pHPT, i.e., whether it is or is not accompanied with nephrolithiasis, may be influenced by the location of the adenoma.This suggests that either the biological effects of the parathyroid hormone or its biologically active hormone fragments are different according to in which of the four glands it is produced.Therefore, we recommend that in patients with kidney stones where the preoperative imaging fails to reveal the location of the adenoma, during surgery the search for the adenoma should be started at the left inferior parathyroid gland.]

Ca&Bone

[Hypophosphatasia]

MÉSZÁROS SZILVIA, GYŐRI Gabriella, MAGDICS Mária, LAKATOS Péter, HORVÁTH CSABA

[INTRODUCTION - The authors describe a rare metabolic bone disorder causing a differencial diagnostic problem in a 44- year-old female patient. CASE REPORT - The patient has had a history of lower back and hip pain for 30 years, as a cause of which vitamin-D resistant rickets had been diagnosed and short-term vitamin-D therapy was applied several times. The laboratory tests of the patient (weight: 41 kg, hight: 142 cm) showed decreased levels of serum alkaline phosphatase and parathyroid hormone, normal serum calcium and ionized calcium, and an elevated phosphate concentration. On X-ray examination of the bones, calcified disci under the V. and XII. dorsal vertebrae, a pathologic curve of both femoral diaphyses and a Looser line among other degenerative changes were noted. CONCLUSION - The clinical, laboratory and radiological findings supported the authors’ diagnosis of hypophosphatasia. The clinical and diagnostic findings of hypophosphatasia may also be suggestive of hypoparathyreosis with consecutive disturbance of vitamin-D activation.The differenciation of the two disorders is essential for adequate treatment.]

Ca&Bone

[7th Congress of OROM]

SOMOGYI Péter

Ca&Bone

[Paget’s disease of the bones]

DONÁTH Judit

[The author provides a summary of the current knowledge on Paget’s disease. Recently, the greatest advances have been made in the fields of genetics and therapy.The incidence of the disease is far greater than the number of cases diagnosed. Current research focuses on proving the virus hypothesis of etiology as well as on genetic causes.Various new biochemical markers have become available, but serum alkaline phosphatase is still the most widely used parameter. Radiological studies remain the gold standard for the diagnosis of Paget’s disease. Clinical trials of the most recent bisphosphonates are ongoing.]

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Clinical Neuroscience

Alexithymia is associated with cognitive impairment in patients with Parkinson’s disease

SENGUL Yildizhan, KOCAK Müge, CORAKCI Zeynep, SENGUL Serdar Hakan, USTUN Ismet

Cognitive dysfunction (CD) is a common non-motor symptom of Parkinson’s disease (PD). Alexithy­mia is a still poorly understood neuropsychiatric feature of PD. Cognitive impairment (especially visuospatial dysfunction and executive dysfunction) and alexithymia share com­mon pathology of neuroanatomical structures. We hypo­thesized that there must be a correlation between CD and alexithymia levels considering this relationship of neuroanatomy. Objective – The aim of this study was to evaluate the association between alexithymia and neurocognitive function in patients with PD. Thirty-five patients with PD were included in this study. The Toronto Alexithymia Scale–20 (TAS-20), Geriatric Depression Inventory (GDI) and a detailed neuropsychological evaluation were performed. Higher TAS-20 scores were negatively correlated with Wechsler Adult Intelligence Scale (WAIS) similarities test score (r =-0.71, p value 0.02), clock drawing test (CDT) scores (r=-0.72, p=0.02) and verbal fluency (VF) (r=-0.77, p<0.01). Difficulty identifying feelings subscale score was negatively correlated with CDT scores (r=-0.74, p=0.02), VF scores (r=-0.66, p=0.04), visual memory immediate recall (r=-0.74, p=0.01). VF scores were also correlated with difficulty describing feelings (DDF) scores (r=-0.66, p=0.04). There was a reverse relationship bet­ween WAIS similarities and DDF scores (r=-0.70, p=0.02), and externally oriented-thinking (r=-0.77,p<0.01). Executive function Z score was correlated with the mean TAS-20 score (r=-62, p=0.03) and DDF subscale score (r=-0.70, p=0.01) Alexithymia was found to be associated with poorer performance on visuospatial and executive function test results. We also found that alexithymia was significantly correlated with depressive symptoms. Presence of alexithymia should therefore warn the clinicians for co-existing CD.

Clinical Neuroscience

Late simultaneous carcinomatous meningitis, temporal bone infiltrating macro-metastasis and disseminated multi-organ micro-metastases presenting with mono-symptomatic vertigo – a clinico-pathological case reporT

JARABIN András János, KLIVÉNYI Péter, TISZLAVICZ László, MOLNÁR Anna Fiona, GION Katalin, FÖLDESI Imre, KISS Geza Jozsef, ROVÓ László, BELLA Zsolt

Although vertigo is one of the most common complaints, intracranial malignant tumors rarely cause sudden asymmetry between the tone of the vestibular peripheries masquerading as a peripheral-like disorder. Here we report a case of simultaneous temporal bone infiltrating macro-metastasis and disseminated multi-organ micro-metastases presenting as acute unilateral vestibular syndrome, due to the reawakening of a primary gastric signet ring cell carcinoma. Purpose – Our objective was to identify those pathophysiological steps that may explain the complex process of tumor reawakening, dissemination. The possible causes of vestibular asymmetry were also traced. A 56-year-old male patient’s interdisciplinary medical data had been retrospectively analyzed. Original clinical and pathological results have been collected and thoroughly reevaluated, then new histological staining and immunohistochemistry methods have been added to the diagnostic pool. During the autopsy the cerebrum and cerebellum was edematous. The apex of the left petrous bone was infiltrated and destructed by a tumor mass of 2x2 cm in size. Histological reexamination of the original gastric resection specimen slides revealed focal submucosal tumorous infiltration with a vascular invasion. By immunohistochemistry mainly single infiltrating tumor cells were observed with Cytokeratin 7 and Vimentin positivity and partial loss of E-cadherin staining. The subsequent histological examination of necropsy tissue specimens confirmed the disseminated, multi-organ microscopic tumorous invasion. Discussion – It has been recently reported that the expression of Vimentin and the loss of E-cadherin is significantly associated with advanced stage, lymph node metastasis, vascular and neural invasion and undifferentiated type with p<0.05 significance. As our patient was middle aged and had no immune-deficiency, the promoting factor of the reawakening of the primary GC malignant disease after a 9-year-long period of dormancy remained undiscovered. The organ-specific tropism explained by the “seed and soil” theory was unexpected, due to rare occurrence of gastric cancer to metastasize in the meninges given that only a minority of these cells would be capable of crossing the blood brain barrier. Patients with past malignancies and new onset of neurological symptoms should alert the physician to central nervous system involvement, and the appropriate, targeted diagnostic and therapeutic work-up should be established immediately. Targeted staining with specific antibodies is recommended. Recent studies on cell lines indicate that metformin strongly inhibits epithelial-mesenchymal transition of gastric cancer cells. Therefore, further studies need to be performed on cases positive for epithelial-mesenchymal transition.

Hypertension and nephrology

[About the care of patients with hyperuricaemia and gout]

[This consensus document is intended to provide guidance for the effective and efficient treatment of asymptomatic individuals with high uric acid levels and gout patients.]

Clinical Neuroscience

[What happens to vertiginous population after emission from the Emergency Department?]

MAIHOUB Stefani, MOLNÁR András, CSIKÓS András, KANIZSAI Péter, TAMÁS László, SZIRMAI Ágnes

[Background – Dizziness is one of the most frequent complaints when a patient is searching for medical care and resolution. This can be a problematic presentation in the emergency department, both from a diagnostic and a management standpoint. Purpose – The aim of our study is to clarify what happens to patients after leaving the emergency department. Methods – 879 patients were examined at the Semmel­weis University Emergency Department with vertigo and dizziness. We sent a questionnaire to these patients and we had 308 completed papers back (110 male, 198 female patients, mean age 61.8 ± 12.31 SD), which we further analyzed. Results – Based on the emergency department diagnosis we had the following results: central vestibular lesion (n = 71), dizziness or giddiness (n = 64) and BPPV (n = 51) were among the most frequent diagnosis. Clarification of the final post-examination diagnosis took several days (28.8%), and weeks (24.2%). It was also noticed that 24.02% of this population never received a proper diagnosis. Among the population only 80 patients (25.8%) got proper diagnosis of their complaints, which was supported by qualitative statistical analysis (Cohen Kappa test) result (κ = 0.560). Discussion – The correlation between our emergency department diagnosis and final diagnosis given to patients is low, a phenomenon that is also observable in other countries. Therefore, patient follow-up is an important issue, including the importance of neurotology and possibly neurological examination. Conclusion – Emergency diagnosis of vertigo is a great challenge, but despite of difficulties the targeted and quick case history and exact examination can evaluate the central or peripheral cause of the balance disorder. Therefore, to prevent declination of the quality of life the importance of further investigation is high.]

Clinical Neuroscience

[The role of sleep in the relational memory processes ]

CSÁBI Eszter, ZÁMBÓ Ágnes, PROKECZ Lídia

[A growing body of evidence suggests that sleep plays an essential role in the consolidation of different memory systems, but less is known about the beneficial effect of sleep on relational memory processes and the recognition of emotional facial expressions, however, it is a fundamental cognitive skill in human everyday life. Thus, the study aims to investigate the effect of timing of learning and the role of sleep in relational memory processes. 84 young adults (average age: 22.36 (SD: 3.22), 21 male/63 female) participated in our study, divided into two groups: evening group and morning group indicating the time of learning. We used the face-name task to measure relational memory and facial expression recognition. There were two sessions for both groups: the immediate testing phase and the delayed retesting phase, separated by 24 hours. 84 young adults (average age: 22.36 (SD: 3.22), 21 male/63 female) participated in our study, divided into two groups: evening group and morning group indicating the time of learning. We used the face-name task to measure relational memory and facial expression recognition. There were two sessions for both groups: the immediate testing phase and the delayed retesting phase, separated by 24 hours. Our results suggest that the timing of learning and sleep plays an important role in the stabilizing process of memory representation to resist against forgetting.]