Lege Artis Medicinae

[“BONE” IN THE VESSELS, “FAT” IN THE BONES? - THE THEORY AND CLINICAL SIGNIFICANCE OF VASCULAR CALCIFICATION]

SPEER Gábor, LAKATOS Péter

SEPTEMBER 20, 2005

Lege Artis Medicinae - 2005;15(08-09)

[Pathologist have recognized arterial calcification for over a century described also by Virchow in the 19th century. Vascular calcification, an active mechanism, involves a complex, regulated process of biomineralization resembling osteogenesis. Evidence indicates that proteins controlling bone mineralization are also involved in the regulation of vascular calcification. The atherosclerotic plaque calcification can be easily detected noninvasively with radiological methods currently available and it correlates with the amount of atherosclerotic plaque. Also, it serves as a surrogate measure for atherosclerosis, allowing preclinical detection of the disease. There are several examples for the relationship between hyperlipidaemia and increased loss of bone mass. It is not surprising that the base drugs for osteoporosis also have the characteristics for lowering vascular calcification and are antiatherogenous and antilipaemic drugs. The clinical importance ot these facts is that vascular calcification is associated with higher risk of cardiovascular events. In the summary, the authors review the four histopathological types of arterial calcification and the molecules and proteins involved in these processes.]

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Lege Artis Medicinae

[MARITAL STRESS, DEPRESSIVE SYMPTOMS AND CARDIOVASCULAR VULNERABILITY IN WOMEN]

BALOG Piroska, MÉSZÁROS Eszter

[INTRODUCTION - Marital stress and depression have proved to be independent biopsychosocial risk factors for cardiovascular disorders. At the same time their interaction increases cardiovascular vulnerability. The Stockholm Female Coronary Risk Study has shown that marital stress was statistically significantly associated with depressive symptoms, in both groups of healthy women and in patients, even after adjusting for age, educational level, menopausal status, body mass index, cigarette smoking, sedentary lifestyle and the severity of heart failure. METHODS - The aim of this study was to investigate the effect of marital stress on depressive symptoms and psychosocial vulnerability in women with coronary heart disease and in healthy women, cohabiting and currently working. Data were obtained from the Hungarostudy 2002, representing the Hungarian population over the age of 18, according to age, sex and county. RESULTS - The results have shown that an increase in marital stress contributes to an increase in psychosocial vulnerability (depression, anxiety, vital exhaustion, sleep complaints) in healthy women and in women with cardiovascular disorders as well. Higher depression has been related with higher marital stress as well. DISCUSSION - The relation between marital stress and depression seems to be independent from socio-cultural, economical differences: the same results have been found in Hungarian and Swedish women. This relation seems to be bidirectional: a bad marriage increases the prevalence rate of depressive symptoms and depression worsens marital quality. At the end we propose a conceptual framework for how marital stress and depression increases cardiovascular vulnerability in women, emphasizing circular causality.]

Lege Artis Medicinae

[THE INFLUENCE OF GASTROESOPHAGEAL REFLUX DISEASE AND ITS TREATMENT ON ASTHMATIC COUGH]

BÖCSKEI Csaba, VICZIÁN Magdolna, BÖCSKEI Renáta, HORVÁTH Ildikó

[INTRODUCTION - Gastroesophageal reflux is known to cause chronic cough and it is also implicated in worsening of asthma. We conducted a prospective study to examine the clinical significance of gastroesophageal reflux disease in asthmatic patients with chronic cough, to analyse the temporal relationship between reflux events and coughing and to assess the effect of esomeprazole treatment on respiratory symptoms and lung function in these patients. PATIENTS AND METHODS - 126 asthmatic patients with chronic dry cough were studied. Diagnosis of gastroesophageal reflux disease was based on typical symptoms and the effectiveness of therapeutic test or on pH monitoring, while control group consisted of the patients without gastroesophageal reflux (negative pH results). The study group patients received the proton pump inhibitor esomeprazole (40 mg/day for three months) and standard treatment for asthma was continued. During the study pulmonary function tests (forced expiratory volume in one second and peak expiratory flow) were evaluated four times and the reflux symptom scores as well, using a questionnaire. RESULTS - The results of pH monitoring showed that 64% of cough episodes were related to acid reflux and in 91% of reflux events preceded coughing. Esomeprazole treatment (40 mg/day for three months) not only diminished gastroesophageal reflux symptoms but also improved asthma outcome measures. Baseline pulmonary function values increased significantly together with a decrease in symptom scores and the use of rescue medication. In most patients included in the extended part of the study for another three months, the dose of inhaled steroids could be reduced with sustained therapy against gastroesophageal reflux. CONCLUSION - Our data shows that reflux events preceded coughing in most cases and that treatment of gastroesophageal reflux disease caused an improvement in different outcome measures of asthma suggest that gastroesophageal reflux disease worsens asthma and its treatment is of clinical importance in the effective management of these patients.]

Lege Artis Medicinae

[BIVENTRICULAR PACING - A NEW TREATMENT OPTION IN CONGESTIVE HEART FAILURE]

BŐHM Ádám

[Cardiac resynchronisation therapy with biventricular pacing is a new treatment option in patients with moderate-to-advanced heart failure and left bundle branch block. Cardiac resynchronisation therapy leads to improved haemodynamics at diminished energy cost. Beneficial effects include reverse remodelling resulting in decreased heart size and ventricular volumes, improved ejection fraction and decreased functional mitral regurgitation. The haemodynamic improvements are associated with a significantly better quality of life, improved exercise tolerance and less frequent hospitalisation. Several randomised trials have evaluated the short- and longterm effect of biventricular pacing on haemodynamics and clinical parameters and recent preliminary data suggest that cardiac resynchronisation therapy can reduce the mortality. Despite major advances of lead and pacemaker techniques, the implantation of a biventricular pacemaker is still a challenging and complex procedure. To introduce the left ventricular pacing lead into the sinus coronarius may cause difficulties. Approximately one third of the patients do not respond to the therapy, therefore better pre-implant identification of the responders are needed. For patient selection and follow- up echocardiography has a major role.]

Lege Artis Medicinae

[TRAVEL MEDICINE IN GP PRACTICE]

FELKAI Péter, KOVÁCS Erzsébet

[The authors describe the basic ideas of travel medicine, as a newly introduced interdiscipline of the medical science in Hungary. Recently, this segment is considered to be the part of Insurance Medicine, on the other hand the methods and the practice of the travel medicine is based on the other medical specialities’ knowledge. Due to the growing number of travellers in our country as well as the consequences of the joining Hungary to EU, travel medicine could play an important role in the improvement of the Hungarian travellers’ attitude to their health care status, the prevention against the emerged infectious diseases, and in the medical assistance for the international tourism. Travel medicine also a good guideline for the fit-for-travel considerations, made by the GPs. Hungary with its advantageous geographical position appears to be an excellent stopover for any medical evacuation from East European or other surrounding countries. That is why we would like to establish a first travel medicine facility in central Europe. It is expectable that the Hungarian travellers require more and more information regarding to their health care possibilities and prevention during their trip. The first authentic person is being asked by the patients’ are GPs. The GP’s tasks are: diagnosis and the treatment of travel related diseases, the pre-travel advices. All the mentioned factors are a new challenge for the GPs in Hungary.]

Lege Artis Medicinae

[In the focus: cardiology]

PRÉDA István

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[Evaluation of quality of life following treatment with calcitonin nasal spray in patients with osteoporosis: preliminary results of the MERLIN study]

BORS Katalin, KÓSA József, BORBÉLY Judit, TABÁK Ádám, HORVÁTH CSABA

[INTRODUCTION - MERLIN (Management of Osteoporosis in Elderly with Calcitonin) is an open-label, multicenter, prospective, follow-up study conducted in Hungary, part of which is to assess the impact of treatment with Miacalcic, - an intranasal salmon calcitonin, on the quality of life (QoL) among patients with osteoporosis. In this paper we report the preliminary results of the MERLIN study. PATIENTS - The study initially involved 1949 senior patients (aged >65 years) to whom calcitonin was prescribed for osteoporosis according to the application instructions. Patients presented at outpatient clinics and consisted of two groups; they were either newly diagnosed or they had been receiving a therapy for osteoporosis other than calcitonin. METHODS - This latter group discontinued their previous treatment and all patients received 200 IU intranasal salmon calcitonin (SCT) once daily for three months. Patient and physician questionnaires were used to collect information on the patients' QoL (EQ-5D VAS) and their general well-being at baseline and at follow-up visits at week 4 and week 12. RESULTS - Calcitonin use was associated with improvements in all EQ-5D domains and component scores as well as in VAS. Patients with previously known osteoporosis who, switched to calcitonin therapy achieved better results (0,046 QALY), than the newly diagnosed patients (0,0405 QALY). CONCLUSIONS - We conclude that intranasal SCT 200 IU daily is safe and effective in improving QoL of both, male and female patients with low bone mineral density.The conclusions that can be drawn from this study are limited due to the lack of a control group and to the unblinded design. Further placebo-controlled studies are needed to confirm these results. Nevertheless, our study was the first in Hungary to evaluate the quality of life impact of an osteoporosis treatment, and hopefully it will be followed by more such studies directed to other osteoporosis treatments.]

Hypertension and nephrology

[Evaluation of arterial stiffness in children. Guidelines for the practice]

CSEPREKÁL Orsolya, KIS Éva, SZABÓ J. Attila, REUSZ György

[Assessment of early atherosclerosis and decreased arterial elasticity to recognise the cardiovascular dysfunction in high-risk patients has gained importance in the past decade. Since 1990, more than 630 papers have been published in the adult and pediatric literature. Methods of early risk assessment in adults are well determined in international recommendations. The aim of the present work is to review the suggestions of the American Heart Association helping us to find the most appropriate method for the non invasive methods of cardiovascular assessment of young adults and children. Furthermore, multicentric studies should be conducted to create a Framingham like score system for pediatric patients, to render cardiovascular risk assessment much easier for the every day routine.]

Ca&Bone

[Bone metabolism and body mass index in postmenopausal women]

TÁRCZY Csaba, TOLDY Erzsébet, SZERB János, VARGA László

[INTRODUCTION - In addition to several other causes constitutional factors play an important role in the development of osteoporosis.Various aspects of bone metabolism were examined to explain the differences in bone density between women with low and high body mass index (BMI). PATIENTS AND METHOD - One hundred and ninetytwo postmenopausal women were included in the study. Bone density was measured by forearm densitometry.To assess bone formation, serum osteocalcin levels were measured, while the rate of bone absorption was estimated from C-terminal telopeptide levels of collagen type I measured in urine and blood. RESULTS - The prevalence of osteoporosis was higher in women with low BMI than in those with normal or higher BMI. Bone metabolism - both formation and absorption - was increased in both groups, however, in women with low BMI this increase was more pronounced and bone metabolism tended to be shifted to absorption compared to patients with normal or higher BMI. CONCLUSION - Postmenopausal lean women have accelerated bone metabolism compared to obese women. This fact and the shift to absorption may be the main reasons for the higher frequency of osteoporosis found by densitometry in women with low BMI than in those with higher BMI.]

Lege Artis Medicinae

[Chlamydia pneumoniae in coronary arteries of young adults]

HORTOVÁNYI Eszter, ILLYÉS György, GLASZ Tibor, KULKA Janina, KÁDÁR Anna

[INTRODUCTION - An association of Chlamydia pneumoniae (C. pneumoniae) with coronary heart disease has been found with seroepidemiological methods. This organism was demonstrated in atheromatous plaques by electron microscopy, immunohistochemistry, and polymerase chain reaction. MATERIAL AND METHODS - To better understand the significance of the presence of C. pneumoniae in atheromatous plaques, we examined coronary artery segments from young adults (15-34 years) with and without atherosclerosis. 74 samples of left anterior descending artery were examined immunohistochemically for the presence of C. pneumoniae by the monoclonal antibody RR402. RESULTS - C. pneumoniae was identified in the atheroma in 11 of 17 cases (65%) and in preatheroma in 6 of 15 cases (40%), in fatty streak in 7 of 23 cases (30%) and in intimal thickening in 1 of 14 cases (7%). C. pneumoniae was not found in the intimal and medial layer of the normal-appearing coronary arteries. C. pneumoniae was detected in the adventitia in 51 cases (67%) of the coronary arteries: in the normal arteries and initial lesions in 27 of 42 cases (63%), and in the advanced lesions in 24 of 32 cases (75%). Correlation was observed between the C. pneumoniae positive cases and cigarette smoking. CONCLUSION - Our results suggest that C. pneumoniae may relate to the severity of atherosclerosis in the youth, thus may initiate atherosclerotic injury or facilitate its progression along with other risk factors.]

Ca&Bone

[Bone mineral density and diabetes mellitus - First results]

TÕKE Judit, TAMÁS GYULA, STELLA Péter, NAGY Erzsébet, NÁDASDI Ágnes, VARGA Piroska, KERÉNYI ZSUZSA

[INTRODUCTION - Data on bone mineral density (BMD) in diabetes mellitus are contradictory in the literature. Early studies described a decreased bone mineral density in type 1 diabetes mellitus (T1DM), but recent studies report no osteopenia in T1DM.The BMD may depend on the quality of treatment for diabetes mellitus and on the presence of chronic complications. In type 2 diabetes mellitus (T2DM) the BMD is not decreased, occasionally it can even be increased. PATIENTS AND METHODS - Bone mineral density was measured in 122 regularly controlled diabetic patients (T1DM: n=73, mean age: 43.6±11.1 years,T2DM: n=49, mean age: 61.8±9.8 years) by dual energy X-ray absorptiometry at the lumbar spine and at the femur. Results were compared to those of 40 metabolically healthy control persons with a mean age of 47.5±11.9 years.The patients’ carbohydrate metabolism was assessed by the average HbA1c level of the last three years.These values were 7.9±1.4 % in T1DM, and 7.5±1.7 % in T2DM. BMDs were classified based on the T-score and Z-score using the WHO criteria. RESULTS - There was no significant difference in T1DM or in T2DM compared to the reference group in the prevalence of either osteoporosis or of osteoporosis and osteopenia combined. CONCLUSION - BMD was not found to be decreased in patients with well-controlled metabolism compared to healthy controls.]