SPECT imaging of the brain: regional cerebral blood flow before and after treatment of patients with primary fibromyalgia

Whether regional cerebral blood flow [rCBF] is affected by Duloxitine Hcl in Egyptian women with primary fibromyalgia [FM] and if it correlates with clinical findings. Thirty untreated women with FM [group I] and ten apparently healthy controls [group II] were studied with single photon emission computed tomography of the brain [brain SPECT] after IVI of Tc-99[m] HMPAO as a cerebral perfusion agent. The resting state [rCBF] was measured for the deep structures [thalamus and caudate] and cerebral cortices [anterior, lateral, posterior] of both sides. Fifteen patients[group Ia] received the conventional therapy of fibromyalgia and the other fifteen [group Ib] received a Duloxitine Hcl 60 mg daily for 3 months followed by measuring rCBF. There was a statistically highly significant lower [rCBF] in the thalamus and caudate nucleus in patients as compared to controls [p<0.01] but no such difference in the anterior, lateral and posterior cerebral cortices [p>0.05]. No significant difference clinically or radiologically was found comparing group Ia results before and after 12 weeks. There was a highly significant difference with fatigue and a significant difference as regard neck pain, headache, generalized body ache and morning stiffness when comparing group lb results before and after 12 weeks. The rCBF to thalamus and caudate nucleus showed a highly significant increase in group lb after 3 months. There was a significant difference in number of tender points, the duration of morning stiffness as well as thalamic and caudate blood flow comparing the change in Ia and lb. The decrease of regional cerebral blood flow to the thalamus and caudate nucleus in patients with primary FM may be the cause of their symptoms. Improvement of the symptoms by administration of duloxitine Hcl may be due to improvement of the cerebral blood flow

Effect of hypogonadism on bone mineral density in young males

A study of the relationship between bone mineral density and the level of testosterone in young hypogonadal males. The patients' group consisted of 20 hypogonadal men. A group of 20-euogonadal age matched men served as a control group. All were subjected to history taking, thorough clinical examination, measurement of serum testosterone levels with ELISA and assessment of bone mineral density [BMD] with dual energy X-ray absorptiometry [DEXA] for left femur, forearm and spine. The mean age of patients was 2 7.1 +/- 2.79 [years] with a mean body mass index [BMI] 24.23 +/- 4.67 kg/m[2]. Testosterone levels were highly significantly lower in patients vs. controls p<0.001. Patients showed highly significant reduction of BMD for left femur, forearm and spine than control group p<0.001. Testosterone levels and BMD were highly significantly lower in patients with delayed onset of puberty compared to those with normal onset puberty p<0.001. There was no significant difference in BMD or serum testosterone between patients with 1ry or 2ry hypogonadism p>0.05. A highly significant positive correlation was found between serum testosterone and T-score at all sites. Hypogonadal patients have lower serum testosterone level and lower BMD than age-matched controls. The more testosterone is deficient, the worse the BMD. Patients with history of delayed puberty have lower BMD than those with normal onset of puberty, and the more the delay the more the reduction in BMD. The spine is the most affected site with osteopenia in hypogonadal men

Serum interleukin-18 level and natural killer cell percentage in systemic lupus erythematosus: clinical correlation

To detect serum interleukin -18 level and natural killer cell percentage in patients with systemic lupus erythematosus and to find out their correlation with disease activity and their role in lupus renal disease. The study included 30 female patients with systemic lupus erythematosus [15 patients with lupus nephritis and 15 patients without renal disease]. 10 apparently healthy females with matched age represent the control group. All patients were subjected to full history taking, thorough clinical examination, assessment of disease activity using modified systemic lupus erythematosus disease activity index [SLEDAI], laboratory investigations especially serum interleukin-18 level, natural killer [NK] cell percentage, serum urea, serum creatinine and 24 hours urinary protein. Serum level of interleukin-18 [IL-18] was significantly increased and percentage of NK cells was significantly decreased in patients with systemic lupus erythematosus [SLE] when compared to controls. In patients with SLE, increased serum IL-18 level showed significant negative correlation with NK cell percentage while this correlation was significantly positive with SLEDAI. Serum IL-18 level was significantly higher and NK cell percentage was significantly lower in SLE patients with lupus nephritis compared to those with no renal disease. In patients with lupus nephritis, increased serum IL-18 level showed significant positive correlation to serum urea, serum creatinine and 24 hours urinary protein, while reduced percentage of NK cells showed significant negative correlation with serum creatinine. The findings of this study may indicate that increased serum IL-18 levels and reduced NK cell percentage may play a role in pathogenesis and activation of SLE and renal involvement in this disease. Further studies are recommended for IL-18 as a potential target in treatment of autoimmune diseases including SLE

Expression of some co-stimulatory molecules in systemic lupus erythematosus patients: association with clinical features

To measure expression of the co-stimulatory molecules CD40L, CD40, CD28, CD80 and CD86 on peripheral blood lymphocytes in SLE patients and to correlate it with disease activity, levels of anti-ds-DNA antibodies and to detect their association with some clinical features of SLE. The study included 23 females with SLE diagnosed according to the 1982 revised criteria of the American College of Rheumatology for the diagnosis of SLE and 7 apparently healthy females with matched age to patients as a control group. Patients were attending the outpatient clinics of Rheumatology and Rehabilitation and Internal Medicine departments in Ain Shams University Hospitals. Patients were subjected to history taking, thorough clinical examination, disease activity was assessed using Systemic Lupus Erythematosus Disease Activity Index [SLEDAI]. The SLE cumulative organ damage was scored using the Systemic Lupus International Collaborating Clinics [SLICC] damage index. 14 patients were considered to have active disease with SLEDAI score > 4 and 9 patients had a score of 4 or less was in remission. The different clinical features of SLE patients were: 7 patients with renal disease, 6 patients with atherosclerosis presentation [myocardial infarction, anginal pain, and stroke], 6 patients with articular manifestations and 4 patients with skin manifestations. Patients and controls were subjected to laboratory investigations including: measurement of, hemoglobin level, anti-ds-DNA antibody titer, ESR, serum level of creatinine, lipid profile [cholesterol level, HDL cholesterol level, LDL cholesterol level, triglyceride level], level of proteinuria, expression of the activation markers CD25 for T cells and CD38 for B cells and the co-stimulatory molecules CD28, CD40 ligand [CD40L] on CD4 T cells and CD80, CD86, CD40 on CD19 B cells. Lymphocytes of SLE patients showed signs of increased activation as indicated by the highly significant increase in CD25 and CD38 expression on CD4 T cells and CD19 B cells respectively in patients compared to controls [t =2.9, t =4.7 respectively] and in patients with active disease compared to those in remission [t =5.3, t =3.1 respectively]. The expression of the co-stimulatory molecules CD40L and CD86 on T and B cells respectively was significantly increased in patients when compared to controls [t =2.1, t =3.9 respectively] and in active versus inactive SLE patients [t =8.1, t =5.3 respectively]. The highest increase in CD40L and CD86 expression could be detected in SLE patients with renal disease and atherosclerosis compared to those with articular or skin manifestations. In patients with SLE a highly significant positive correlation could be found between increased CD40L expression and SLEDAI [r=0.79], anti-ds-DNA antibody titer [r = 0.90], CD25 expression [r = 0.70], CD86 expression [r=0.82]. Among SLE patients, enhanced CD86 expression showed highly significant positive correlation with SLEDAI [r= 0.58], anti-ds-DNA antibody titer [r=0.76], CD38 expression [r= 0.75]. A significant positive correlation could be found between increased CD40L expression and serum creatinine level [r =0.81] on one hand, and serum cholesterol level [r = 0.94] on the other hand among SLE patients with renal disease and atherosclerosis respectively. The CD40L/CD40 and CD28/CD86-CD80 pathways of co-stimulatory molecules are interrelated in lymphocytes of patients with SLE; they may play an important role in immunopathogenesis of SLE. Increased expression of CD40L and CD86 on T and B cells respectively showed significant positive correlations with disease activity, anti-ds-DNA antibody titer and they also showed association with some clinical features of SLE especially nephritis and atherosclerosis clinical manifestations. Anti-co-stimulatory molecules monoclonal antibodies may be important therapeutic targets in SLE

Angiogenesis in rheumatoid patients: clinical, radiological and histopathological study

To evaluate angiogenesis and cartilage destruction in rheumatoid arthritis [RA] patients. This was performed using power Doppler ultrasonography [PDS] and detection of vascular endothelial growth factor [VEGF] in the serum and immunohistochemically. Eighteen Rheumatoid arthritis patients [group 1] and ten apparently healthy subjects [group 2] participated in this study. Full history taking, thorough clinical examination and routine rheumatological profile investigation were done. Serum VEGF was measured in all patients and controls using ELISA technique. The knee joints were examined with ultrasound and resistance index was measured with spectral ultrasonography. Histological examination for synovial membranes was done with hematoxylin and eosin, factor VIII and VEGF with immunohistochemical staining. There was a highly significant difference between RA patients and controls as regard sVEGF [582.22 +/- 84.89, 176 +/- 20.55 pg/ml], histological score [36.94 +/- 7.83, 2.72 +/- 1.2], factor VIII [3.16 +/- 0.618, 1.2 +/- 0.41], VEGF staining [3.03 +/- 0.89, 0.5 +/- 0.32] and PDS [3.027 +/- 0.58, 0.41 +/- 0.24] [p<0.001 in all parameters]. Also, there was a significant difference between patients and control as regard resistive index [RI] [0.72 +/- 0.19, 1.07 +/- 0.1] and synovial proliferation [3.055 +/- 0.7, 0.25 +/- 0.263] [p<0.05 in both parameters]. RA patients were classified according to VEGF staining into low, moderate and intense staining. There was a highly significant difference between patient subgroups regarding serum VEGF, synovial proliferation, PDS score [p<0.001] and a significant difference regarding histopathological score, factor VIII and RI [p<0.05 in all parameters]. There was a positive correlation between sVEGF and DAS score, synovial proliferation, ESR, PDS, VEGF staining and histological score, and negative correlation with RI. Also, there was a positive correlation between VEGF staining and histological score, sVEGF, PDS, synovial proliferation and negative correlation with RI. VEGF is a potent mediator of endothelial proliferation of angiogenesis, the expression of VEGF depending on the activity and plays a part of pathogenesis of RA and synovitis. PDS is a useful method demonstrating synovial vascularization and monitoring disease activity. RI is an objective tool to estimate the degree of inflammation in RA

Sex hormones in relation to bone mineral density and bone turnover markers in rheumatoid patients

To study the changes in serum and salivary testosterone in rheumatoid arthritis [RA] patients and their implication on bone mineral density [BMD] and bone turnover markers. The above mentioned hormonal levels were measured in fifty post-menopausal RA women [thirty patients with glucocorticoid therapy and twenty treated with other drugs]. Bone turnover markers were also assessed namely Carboxy terminal cross linked telopeptide of type I collagen [ICTP] and carboxy terminal propeptide of type I procollagen [PICP] as well as their relation to BMD was assessed. Although serum and salivary testosterone were higher than controls, there was no significant difference between patients and controls. We observed significantly lower salivary testosterone level in RA on steroids as compared to those not taking steroids. Also salivary testosterone correlated with lumbar BMD and inversely with ICTP

Orthostatic hypotension in stroke patients

To assess the incidence of orthostatic hypotension [OH] in stroke patients undergoing rehabilitation and to determine clinical variables associated with it. Thirty patients with a first clinical stroke who underwent rehabilitation within one month of stroke onset were included in this study. They were 17 males and 13 females. Their age ranged from 49 to 68 years [mean +/- SD= 58.1 +/- 6.3]. Patients were subjected to full history taking, thorough clinical examination and investigations. Patients' blood pressure was measured in the supine position and on tilting at 90[0]. OH was defined as a drop in systolic blood pressure [SBP] of 20 mmHg or more. OH was present in 14 [46.7%] patients. Age was highly significantly associated [p<0.001] with OH and admission modified Barthel Index [MBI] score was significantly associated [p<0.05] with OH. There was a non-significant correlation with the site of stroke or the use of anti-hypertensives. OH was common in stroke patients undergoing inpatient rehabilitation especially in older patients who have a lower functional status

Musculoskeletal pain in obese Egyptians

Obesity is associated with musculoskeletal pain and osteoarthritis. This study compares the prevalence of work-restricting musculoskeletal pain in obese and general population and investigates changes in the incidence of and recovery from musculoskeletal pain after surgical or conventional obesity treatment. A random sample of 50 subjects from the general population was compared with 50 obese subjects. For the obese subjects, information about musculoskeletal pain was also collected 6 and 12 months after obesity surgery or the start of non-surgical treatment. In both sexes, work-restricting pain in the neck and back regions and in the hip, knee and ankle joints was more common in the obese subjects than in the control population. Operated obese women had a lower incidence of work-restricting pain in the knee and ankle joints as compared with the conventionally treated control group over 6 and 12 months. Among subjects reporting symptoms at baseline, the recovery rate for pain in the knee and ankle joints in obese men and pain in the neck and back and in the hip, knee and ankle joints in obese women improved in the surgical group as compared with the control group after 12 months. Obese subjects have more problems with work-restricting musculoskeletal pain than the general population. Surgical obesity treatment reduces the long-term risk of developing work-restricting musculoskeletal pain and increases the likelihood of recovering from such pain

Effects of physical exercise on HCV chronic active hepatitis patients

Infection with HCV shows a high prevalence in our country and often becomes chronic and proceeds to a state of chronic active hepatitis, a condition which is not easy to treat and almost always end up in liver cirrhosis as well as a high risk of hepatocellular carcinoma. The aim of the this work was to study the effect of regular physical exercise over a period of 6 weeks on some parameters usually used to evaluate the liver condition and the activity of the disease. Patients were randomized into 3 groups; Group I: 20 patients with chronic active hepatitis due to infection with HCV and showed a significant reduction in ALT and AST levels over the period of the exercise program. Group II: 20 patients with decompensated liver condition due to HCV infection with at least one of the manifestations of liver cell failure and exhibited a bad exercise tolerance with non-significant changes in their laboratory data. Group III: 20 patients with compensated HCV liver disease were not included in the exercise program and were considered as a control group. It was concluded that physical exercise was well tolerated by HCV chronic active hepatitis patients and may be of benefit while in decompensated patients physical exercise should be restricted as much as possible

Non-invasive assessment of endothelial dysfunction in pre-menopausal systemic lupus erythematosus women at risk of atherosclerosis

To assess the endothelial dysfunction in patients with SLE by measuring endothelial reactivity in pre-menopausal female patients at risk of atherosclerosis without traditional cardiovascular risk factors. This study was conducted on 30 pre-menopause SLE patients and 25 age and sex- matched volunteers. All the patients and controls were free of traditional cardiovascular risk factors. We examined the endothelial function by brachial artery FMV, assessed by high resolution non-invasive ultrasound, where the diameter of the brachial artery is measured at rest and after reactive hyperaemia. The FMV of the brachial artery [endothelium dependent response] was significantly lower in patients than in control subjects [4.1 +/- 1.3 v13.2 +/- 2.0%; p<0.001]. Comparing the FMV with the different variables of the patients' group, we did not find any significant correlation between FMV and; patients' age, disease duration, systolic and diastolic blood pressure, Raynaud's phenomenon, vasculitis and ESR. While, there was a strongly significant difference in brachial artery FMV seen between 12 [40%] aCL positive patients compared to 18 [60%] patients with aCL negative and when compared with controls [4.0 +/- 0.7 v 11.3 +/- 0.6]%, p <0.001; 4.0 +/- 0.7 v 13.2 +/- 2.0%, p<0.001 respectively]. There was also a strongly positive correlation between SLEDAI disease activity score and baseline diameter and FMV [rs=0.42, p<0.001; rs= 0.44, p<0.001 respectively]. While there was a weakly positive statistical difference between FMV and the CRP [rs=-0.24, p=0.05]. The baseline value of FMV showed an inverse correlation with LDL cholesterol [r = -0.41, p<0.05]. When we compared the patients who had received corticosteroids, antimalarial, methotrexate and other medications with those who had not, we didn't find a significant statistical difference concerning the FMV. This study demonstrated that pre-menopausal patients with SLE free from cardiovascular risk factors and overt CVD have an altered endothelial reactivity which correlates positively with a CL positive subgroup of patients, SLEDAI disease activity score, serum CRP values, along with high LDL cholesterol concentration. This endothelial dysfunction indicates a higher susceptibility to the development of atherosclerotic disease

Correlation between subclinical common carotid artery atherosclerosis and plasma homocysteine level in rheumatoid arthritis

Objective: To detect subclinical morphologic atherosclerotic changes of common carotid artery in rheumatoid arthritis patients and to correlate it with plasma level of homocysteine, C-reactive protein and disease severity

Methodology: The study included twenty five rheumatoid arthritis females as a patient group, their age ranged from 42 to 66 years. Their disease duration was more than 5 years. Nine apparently healthy females served as a control group, their age ranged from 42 to 65 years. All patients and controls were chosen with exclusion criteria including: presence of hypertension, diabetes mellitus, renal insufficiency, history of any cardiovascular or cerebrovascular events, hyperlipidemia, using lipid lowering agents, smoking and intake of contraceptive pills. Patients were subjected to full history taking, thorough clinical examination, disease severity assessment using disease severity index, disease activity assessment using the modified disease activity score [DAS], physical activity assessment using Stanford Health Assessment Questionnaire [HAQ], laboratory investigations especially C-reactive protein and serum homocysteine level. Intima media thickness of the right common carotid artery and plaques were detected with B-mode ultrasound

Results: Seventeen patients [68%] out of 25 had increased intima media thickness of right common carotid artery [subclinical atherosclerosis]. Among them 6 showed atherosclerotic plaques and I 1 without atherosclerotic plaques. Intima media thickness and homocysteine level were significantly higher in patients as compared to controls. Age, disease duration, severity index, C-reactive protein, homocysteine level and intima media thickness were significantly increased in patients with sabclinical atherosclerosis as compared to those without atherosclerosis. Intima media thickness showed a significant positive correlation with age, disease duration, severity index, C-reactive protein and level of homocysteine

Conclusion: Our results suggest the presence of subclinical atherosclerosis in rheumatoid arthritis patients as indicated by increased intima media thickness of common carotid artery. Chronic inflammation may play an important role in development of this atherosclerosis. We also suggest that increased homocysteine level may be a non traditional risk factor for atherosclerosis in rheumatoid arthritis. B-mode ultrasound can be considered a useful tool for detection of early morphologic atheroscleroric changes in carotid artery despite absence of clinical manifestations for this atherosclerosis