Early detection of macro vascular diseases of carotid and femoral arteries in patients with Rheumatoid arthritis

Rheumatoid arthritis [RA] is a multi-system disorder with inflammatory process associated with increased cardiovascular risk. The duplex scanning is a noninvasive technique to detect early atherosclerotic plaques and arterial wall changes either in symptomatic or asymptomatic patients. Early detection of asymptomatic vascular disorders allows early intervention and possibly retards the development of symptomatic cardiovascular diseases. A higher risk of cardiovascular morbidity and mortality persists among patients with an abnormal ankle brachial index [ABI] and it is useful to identify asymptomatic patients with established disease. To detect the early manifestations of atherosclerotic changes of carotid and femoral arteries in patients with rheumatoid arthritis. Twenty-four patients with chronic rheumatoid arthritis [six males and eighteen females] aged 26-65 years [45.7 +/- 14.7 years] with mean disease duration 11.12 +/- 6.4 years [2-18 year] were included in the study. All patients were on methotrexate, corticosteroids and nonsteroidal anti-inflammatory lines of treatment. Twenty apparently normal subjects were included in the study as controls. Patients with other types of collagen diseases or patients with ischemic peripheral manifestations, ischemic heart disease, diabetics or smokers were excluded from the study. Full history and thorough clinical examination, including full joints and vascular examination for all peripheral arteries and calculation of ankle brachial index [ABI] was done using pocket Doppler and sphygmomanometer. Patients and controls were subjected for Hb, WBC, platelet count, rheumatoid factor, blood sugar, ESR, levels of plasma cholesterol, triglyciride, HDL and LDL. Duplex study was performed on carotid and femoral arteries. The mean ABI in patients was 1.21 +/- 0.3, non-significantly lower than controls but still within the range of normal. There was a significant increase in the levels of cholesterol, triglyciride, LDL and HDL than controls and still within the range of normal. Duplex changes of carotid and femoral arteries were present in 18/24 [75%] of patients including hemodynamic changes, intimal thickness, plaques, stenotic segment. Duplex of carotid arteries detected hemodynamic changes in 12.5%, intimal thickness, plaques and stenotic segment in 25% of patients for each and detected intimal thickness of femoral arteries in 25% of patients. There was a significant negative correlation between the ABI and duration of disease [r = - 0.506, p<0.01] and a significant positive correlation between the intimal thickness and duration of disease [r =-0.807, p<0.001]. There was no relation between drug intake or type of drug and ABI or intima thikness and there was no relation between cholesterol, triglyciride, LDL or HDL levels and ABI or intimal thickness. There is increased risk of vascular disease in RA patients involving carotid and femoral arteries in the form of hemodynamic changes, intimal thickness, plaques and stenotic segment. Low ABI together with Duplex study are helpful for detection of subclinical ischemic changes in such high-risk patients. Normal levels of plasma cholesterol, triglyciride, HDL and LDL do not exclude underlying vascular changes. So we recommend ABI and Duplex examination for all RA patients and further studies are needed to elucidate non-traditional risk factors such as endothelial dysfunction, immune activation and impaired fibrinolysis in addition to oxidative stress

Erectile dysfunction: Current diagnosis and risk factors in Upper Egypt

Erectile dysfunction [ED] has taken an increasing importance in andrology and vascular practice. Recognizing the pathological pattern of ED assists in choosing the best method of treatment Normal erectile function needs good arterial inflow for adequate volume expansion of the cavernously sinusoids, sufficient to cause restriction of venous outflow and retention of the penile blood flow. Color flow Doppler analysis after intra-cavernous injection of vaso-active drugs has been reported to be a minimally invasive, accurate method, and considered to be the gold-standard technique for evaluating penile hemodynamics. It becomes one of the useful diagnostic methods for evaluation of ED. to diagnose types of erectile dysfunction and to evaluate the risk factors. From january to August 2006, 280 married patients with ED referred from andrology and vascular surgery clinics to radiology department, of Assiut University Hospital to be included and diagnosed according to International Index of Erectile Function. They aged from 21-63 years and age >40 were considered a risk factor. Full history and clinical examination [including vascular examination of peripheral blood vessels and examination of the external genitalia] was done. Pharmacodynamics color Doppler was done to all patients using Acuson XP/10 machine, and 7 MHz frequencies transducer. Gray scale and color Doppler imaging was performed to the penis to visualize the anatomic details of the corpora cavernosa, cavernosal arteries and surrounding structures. Vaso-dilating agent 20 micro g prostaglandin E1 [PGEI] was injected directly into the corpus cavernosma. Peak systolic velocity [PSV] and end diastolic velocity [EDV] of the cavernosal artery was measured. The resistivity index [Rl] was readily calculated by the machine and given. Description of sildenafil citrate [Viagra] 50 mg orally for six coitus times in all patients was done and they were objectively reevaluated. Patients with peripheral arterial diseases, Leriche syndrome or ischemic heart disease were excluded from the study. Patients mean age was 37.68 +/- 10.85 years and was from 4 months to 15 years and the mean duration of impotence was 3.92 +/- 4.06 years. History of risk factors as smoking was present in 47%, age > 40 years in 35% diabetes in 28%, and drugs induce impotence in 10% of ED patients. Normal Doppler-findings were present in 67.8% of ED patients and were diagnosed non-vasculogenic ED [psychogenic in 32.2 %, idiopathic in 28.5% and neurogenic in 7.1 % of ED patients]. .Abnormal Doppler findings were present in 32.2% of ED patients and were diagnosed as vascurlogenic ED [13.5% of total ED patients were venogenic, 10.5% were arteriogenic and 8.2% were combined ED]. vasculogenic ED patients were venogenic in 41.1%, arteriogenic in 33.3% and combined in 25.6% of them. Doppler study showed a significant decrease ii cavernously artery PSV and RI and a significant increase m EDV values in vasculobogenic group than those of total patients and non-vasculogenic group. Arteriogenic group showed a significantly lower PSV values and venogenic group showed a significantly lower. RI and significantly higher EDV values than those of non-vasculogenic group. No significant difference was present in-between non-vasculogenic groups regarding their Doppler values. Sildenafil citrate [Viagra] response was present in all patients and varies between grade II in 21.6% and grade III and lV in 78.4% of ED patiens. Vasculogenic and psychogenic ED got response in 100% of them. Idiopathic and neuogenic ED response was in 70% and 40% of them respectively. Erectile dysfunction could be vasculogenic or non-vasdogenic as psychogenic, idiopathic, or neurogenic. Pharmacodynamic color Doppler using PGE1 is diagnostic, safe and minimally invasive method to differentiate vasculogenic from nonvasculogenic typs. Risk factors concerned in ED are diabetes, smoking and some drugs. Sildenafil citrate can give good result with vasculogenic and psycogenic and to less extent with idiopathic and neurogenic ED